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PubMed1994

Sexual behavior, sexual swelling, and penile evolution in chimpanzees (Pan troglodytes).

Functional relationships between the penis, vagina, and cervix during copulation in the chimpanzee were studied. In 11 adult males, penile length during full erection ranged from 10.0-18.0 cm (mean +/- SD = 14.4 +/- 2.02). In 19 parous adult females examined during the early follicular phase of the cycle, or during lactation, vaginal depth (from the introitus to the os cervix) ranged from 9.8-16.5 cm (mean +/- SD = 12.6 +/- 1.69). However, when the sexual skin was maximally swollen, vaginal depth increased by up to 52% in some cases and ranged from 15.2-20.1 cm (mean +/- SD = 16.9 +/- 1.68). Under such conditions males vary in their ability to achieve maximal depth of intromission. Observations made on 6 females after natural matings revealed that in some cases males had deposited copulatory plugs in contact with the cervix, while in others plugs were lower down in the vagina. Direct observations under fluoroscopy using an artificial "penis" loaded with radio-opaque medium showed that the filiform tip can make contact with the os cervix. However, expulsion of radio-opaque medium under these conditions failed to demonstrate any immediate transfer of fluid through the cervix into the uterus. These studies indicate that, aside from its functions as a visual signal, the female chimpanzee's sexual skin swelling adds considerably to the distance males must negotiate during copulation to place spermatozoa at the cervical os. Evolution of the male's elongated, filiform penis may therefore be the result of sexual selection, to negotiate the long vagina of the female and to penetrate copulatory plugs deposited during previous copulations.

Animals↗
PubMed1996

Strategies for managing uncertainty and complexity.

OBJECTIVES: To identify strategies involved in the diagnosis and treatment plans of primary care problems that are uncertain and complex. METHODS: In this exploratory study we observed primary care physicians encountering standardized patients who portrayed typical primary care problems involving uncertainty and complexity. First, we analyzed 10 tapes of nine physicians with a range of clinical experience (first-year residents through faculty physicians) interacting with four standardized patient cases (headache, back pain, hypertension, and abdominal pain). We analyzed the 10 tapes to determine the regular occurrence of physician behavior patterns that we later described as strategies. Then, using a written questionnaire, 19 general internal medicine faculty physicians from our hospital and from an affiliated hospital rated the perceived importance of these strategies for clinical practice in general. Finally, we checked the incidence of the strategies: (1) across a range of six cases (headache, back pain, hypertension, abdominal pain, fatigue, and well-adult care) using six first-year residents (a total of 19 encounters), and (2) across different levels of clinical experience using the standardized patient case of headache involving eight physicians (first-year residents through faculty physicians). RESULTS: Nine strategies were identified, and each was rated as important to primary care clinical practice. The strategies were: (1) defines the context of the diagnosis and explains the signs and symptoms as part of the expected spectrum of the disease; (2) eliminates alternative diagnoses by dealing with patient fears, giving reasons in the context of the patient's belief system; (3) describes the prognosis in terms of the likely course of the disease and expectations of treatment; (4) negotiates key problems or issues that are important to both patient and physician; (5) negotiates the plan and ensures patient understands, and is willing and able to comply, given his/her particular context; (6) keeps diagnostic options open by making provisional diagnoses while keeping alternatives in mind; (7) is circumspect and takes action to minimize the possibility of missing other critical diagnoses; (8) plays for time by allowing signs and symptoms to develop to help clarify the diagnosis; and (9) plans for contingencies by providing appropriate if/then statements concerning situations requiring further action. The strategies were used in each of the six cases, and by physicians with all levels of clinical experience. CONCLUSIONS: The nine strategies led to the generation of a construct we termed "strategic medical management," which refers to the management (diagnosis and proposed treatment) of uncertain and complex medical problems in primary care. The construct provides a more elaborated framework in which to view clinical decision making and integrates recent ideas concerning doctor-patient communication into this process. Strategic medical management appears to be based on tacit knowledge that is seldom explicity articulated or taught. It has potential implications for enhancing instruction and assessment in medical education.

Clinical Competence↗
PubMed1998

[Performance-related income budget. A means for reorganizing hospital financing].

Performance-related budgets are the result of negotiated performance units per hospital multiplied by state-wide negotiated prices. Such hospital budgets contain profit chances and loss risks. Exceeding the contractual fixed amount leads to price reductions, falling below that amount leads to lower reimbursement. A consistent pricing system for basic and department performance units could solve the present problem of cost separation in Germany. A step in this direction is the definition of hospital department groups and the construction of an average department treatment case, which could be priced on an average cost base. In the long run, more flexibility according to pricing and budgeting can be developed. Competitive insurance companies should be free to find their own budgets so that a hospital can have several independent contractors.

Budgets↗
PubMed2003

Understandings of environmental quality: ambiguities and values held by environmental professionals.

The terms used to describe and negotiate environmental quality are both ambiguous and value-laden. Stakeholders intimately and actively involved in the management of forested lands were interviewed and found to use ambiguous, tautological, and value-laden definitions of terms such as health, biodiversity, sustainability, and naturalness. This confusing language hinders public participation efforts and produces calls to regulate and remove discretion from environmental professionals. Our data come from in-depth interviews with environmental management professionals and other stakeholders heavily vested in negotiating the fate of forested lands. We contend that environmental science and management will be more effective if its practitioners embrace and make explicit these ambiguous and evaluative qualities rather than ignore and disguise them.

Attitude↗
PubMed2004

Posture, head stability, and orientation recovery during vestibular regeneration in pigeons.

Compensatory behavior such as oculomotor, gaze, and postural responses that occur during movement largely depend upon a functioning vestibular system. In the present study, the initial loss and subsequent recovery of postural and head stability in pigeons undergoing vestibular regeneration were examined. Adult pigeons were trained to manipulate a straight run chamber to peck an illuminated key for fluid reward. Six behavioral measures assessing performance, posture, and head stability were quantified. These included run latency, steps (walking), path negotiation (lane changes), gaze saccades, head bobs, and head shakes. Once normative values were obtained for four birds, complete lesion of all receptor cells and denervation of the epithelia in the vestibular endorgans were produced using a single intralabyrinthine application of streptomycin sulfate. Each bird was then tested at specific times during regeneration and the same behavioral measures examined. At 7 days post-streptomycin treatment (PST), all birds exhibited severe postural and head instability, with tremors, head shakes, staggering, and circling predominating. No normal trial runs, walking, gaze saccades, or head bobs were present. Many of these dysfunctions persisted through 3-4 weeks PST. Gradually, tremor and head shakes diminished and were replaced with an increasing number of normal head bobs during steps and gaze saccades. Beginning at 4 weeks PST, but largely inaccurate, was the observed initiation of directed steps, less staggering, and some successful path negotiation. As regeneration progressed, spatial orientation and navigation ability increased and, by 49 days PST, most trials were successful. By 70 days PST, all birds had recovered to pretreatment levels. Thus, it was observed that ataxia must subside, coincident with normalized head and postural stability prior to the recovery of spatial orientation and path navigation recovery. Parallels in recovery were drawn to hair cell regeneration and afferent responsiveness, as inferred from present results and those in other investigations.

Animals↗
PubMed2002

Pricing and reimbursement of drugs in Sweden.

The Swedish public health care system is financed mainly by taxes. The major part of drug costs is paid by the drug reimbursement system. Sweden has, as most other countries, seen a large increase in the expenditures on drugs in recent years. The responsibility for the cost of drugs in Sweden has recently been decentralized to the county council level. The reimbursement system of drugs currently covers all drugs with a price approved by the National Social Insurance Board, unless the government specifically decides against such coverage. Two groups of drugs were recently excluded from coverage: drugs for obesity and impotence. The price level of drugs in Sweden is close to the average of the European countries. Economic evaluations are currently not mandatory in Swedish price and reimbursement negotiations but are nonetheless important, particularly in negotiations for drugs expected to command large price premiums. The Swedish pricing and reimbursement system has recently been under investigation, and new reforms are expected in the near future.

Journal Article↗
PubMed2004

The risk-adjusted vision beyond casemix (DRG) funding in Australia. International lessons in high complexity and capitation.

Hospitals throughout the world using funding based on diagnosis-related groups (DRG) have incurred substantial budgetary deficits, despite high efficiency. We identify the limitations of DRG funding that lack risk (severity) adjustment for State-wide referral services. Methods to risk adjust DRGs are instructive. The average price in casemix funding in the Australian State of Victoria is policy based, not benchmarked. Average cost weights are too low for high-complexity DRGs relating to State-wide referral services such as heart and lung transplantation and trauma. Risk-adjusted specified grants (RASG) are required for five high-complexity respiratory, cardiology and stroke DRGs incurring annual deficits of $3.6 million due to high casemix complexity and government under-funding despite high efficiency. Five stepwise linear regressions for each DRG excluded non-significant variables and assessed heteroskedasticity and multicollinearlity. Cost per patient was the dependent variable. Significant independent variables were age, length-of-stay outliers, number of disease types, diagnoses, procedures and emergency status. Diagnosis and procedure severity markers were identified. The methodology and the work of the State-wide Risk Adjustment Working Group can facilitate risk adjustment of DRGs State-wide and for Treasury negotiations for expenditure growth. The Alfred Hospital previously negotiated RASG of $14 million over 5 years for three trauma and chronic DRGs. Some chronic diseases require risk-adjusted capitation funding models for Australian Health Maintenance Organizations as an alternative to casemix funding. The use of Diagnostic Cost Groups can facilitate State and Federal government reform via new population-based risk adjusted funding models that measure health need.

Australia↗
PubMed2006

Discussing patient management online: the impact of roles on knowledge construction for students interning at the paediatric ward.

The objectives of this study are to explore the use of asynchronous discussion groups during medical students' clinical rotation in paediatrics. In particular, the impact of role assignment on the level of knowledge construction through social negotiation is studied. Case-based asynchronous discussion groups were introduced to enhance reflection and critical thinking on patient management and treatment, and to offer an exercise in evidence-based medical practice. Groups of approximately 4-5 students were asked to discuss 4 authentic cases during clinical rotation in paediatrics. 49 students interning at the paediatric ward participated in this study. With respect to role assignment, differences between groups (1) with a student or an instructor as moderator and (2) with or without a developer of alternatives for patient management were explored. A content analysis was performed to explore the different levels of social construction of knowledge. The results of multilevel logit analyses show a significant difference in knowledge construction through social negotiation between conditions with a student moderator and conditions where the instructor is moderating, but only when a developer of alternatives is involved. No significant difference was revealed between student-moderated and instructor-moderator groups without a developer of alternatives. It can be concluded that when both the moderator and developer role are assigned to students, their contributions are more likely to reflect a high level of knowledge construction.

Adult↗
PubMed2004

The importance of meta-ethics in engineering education.

Our shared moral framework is negotiated as part of the social contract. Some elements of that framework are established (tell the truth under oath), but other elements lack an overlapping consensus (just when can an individual lie to protect his or her privacy?). The tidy bits of our accepted moral framework have been codified, becoming the subject of legal rather than ethical consideration. Those elements remaining in the realm of ethics seem fragmented and inconsistent. Yet, our engineering students will need to navigate the broken ground of this complex moral landscape. A minimalist approach would leave our students with formulated dogma--principles of right and wrong such as the National Society for Professional Engineers (NSPE) Code of Ethics for Engineers--but without any insight into the genesis of these principles. A slightly deeper, micro-ethics approach would teach our students to solve ethical problems by applying heuristics--giving our students a rational process to manipulate ethical dilemmas using the same principles simply referenced a priori by dogma. A macro-ethics approach--helping students to inductively construct a posteriori principles from case studies--goes beyond the simple statement or manipulation of principles, but falls short of linking personal moral principles to the larger, social context. Ultimately, it is this social context that requires both the application of ethical principles, and the negotiation of moral values--from an understanding of meta-ethics. The approaches to engineering ethics instruction (dogma, heuristics, case studies, and meta-ethics) can be associated with stages of moral development. If we leave our students with only a dogmatic reaction to ethical dilemmas, they will be dependent on the ethical decisions of others (a denial of their fundamental potential for moral autonomy). Heuristics offers a tool to deal independently with moral questions, but a tool that too frequently reduces to casuistry when rigidly applied to "simplified" dilemmas. Case studies, while providing a context for engineering ethics, can encourage the premature analysis of specific moral conduct rather than the development of broad moral principles--stifling our students' facility with meta-ethics. Clearly, if a moral sense is developmental, ethics instruction should lead our students from lower to higher stages of moral development.

Engineering↗
PubMed1996

Cardiac surgery in a fixed-reimbursement environment.

Hospital and physician services in Canada are funded by public (government) sources. This article will describe the practice of cardiac surgery in this setting. Federal legislation has prescribed the principles of accessibility, universality, comprehensiveness, portability, and public administration for essential healthcare services in Canada. Provincial and territorial governments are responsible for the provision of services, receiving federal tax and cash transfers that supplement provincial/territorial funds for hospital, physician, and community health services. Hospitals negotiate annually for global budgets. Physicians work as independent contractors in hospitals (and communities) and are usually paid as specified by fee-for-service contracts negotiated at intervals with governments. Cardiac surgical services have been planned conjointly with government. Forty-two centers in Canada serve a population of 28 million. All but three of these centers are located in tertiary teaching hospitals; all but one do more than 200 pumps annually. The rate of cardiac operations is 80 per 100,000 population. In Ontario, the Provincial Adult Cardiac Care Network makes recommendations to governments about the distribution of the 7,600 pumps annually (population, 11 million), rationalizing waiting lists based on an urgency rating scale. Patients requiring emergent/urgent operations are well served. The average waiting time for an elective cardiac operation is 10.5 weeks. The waiting list mortality is less than 0.5%. The Provincial Adult Cardiac Care Network also determines the placement of new programs and participates in creating hospital funding formulas developed from a combination of resource and acuity intensity weighting. Most surgeons hold full-time academic appointments but are funded largely by practice income. Surgical fees average $2,000 (Canada) per case. Overhead, including malpractice insurance, is approximately 45%. All Canadian patients enjoy reasonably timely access to good cardiac surgical care. Further constraints on physician compensation and (academic) hospital funding will compromise this balance.

Adult↗
PubMed1983

Cost effectiveness of operator features in equipment design.

In design negotiation, the attribution of credible values to the incorporation or deletion of operator features allows engineers the freedom to judge the overall effect of human factors recommendations in relation to the achievement of a design specification. Likewise in the development phase, product planners frequently need more precise statements about productivity, training needs and general operational performance than, "it will be greater/less, worse/better than...". The method described utilises measured and synthetic data, learning theory and Markov processes to calculate the likelihood of operator task failure. These failure rates are then treated via filter factors derived from the application of the Nominal Groups Technique to give a global statement of the likelihood of operator failure resulting in unscheduled calls for service. Using the relationship between the cost of service calls and the overall life cost of developing, manufacturing, marketing and supporting a leased product, it is then possible to place credible values on the design features in question. Thus during the design process it becomes feasible to calculate the likely effects of human factors recommendations and modifications in relation to manufacturing costs, and thereby facilitate rational assessment of their implementation on a sound economic basis. This technique has been used to considerable effect, and represents a useful additional tool for the human factors practitioner in the design negotiation process. Further developments and refinements are planned, and it is anticipated that a similar technique will shortly be available to enable assessment of the effectiveness of product training programmes and job aids.

Journal Article↗
PubMed1984

Paradox in psychotherapy: a cybernetic perspective.

Recent uses of the term "paradox" in the field of psychotherapy have distracted attention from the concept's broader implications. All therapy can be seen as paradoxical because of the recursive nature of self-evaluation. Using agoraphobic problems as illustrative, and starting from the notion that the core issue for the agoraphobic is a demand for absolute control of his environment, we argue that therapy requires the bonding of two observers--the therapist and the "client-as-observer". Negotiations issuing from this bond are crucial to outcome, even when behavioral techniques, often considered to have automatic effects, are used. Behavior therapy, like all other psychotherapy, is not simply action--it is action contextualized by a specific, negotiated social contract.

Agoraphobia↗
PubMed1996

Physician-patient interaction in reproductive counseling.

OBJECTIVE: To review the scientific and clinical bases for effective patient counseling in contraceptive care. DATA SOURCES: All articles and chapters in the Annotated Bibliography of Doctor Patient Communication of the Task Force on Doctor and Patient of the American Academy on Physician and Patient were searched and included. This is an expert-derived data base based on MEDLINE review from 1969 to 1994 and including expert-selected additions from PsychLit and a variety of other social science data bases, books, and reviews. METHODS OF STUDY SELECTION: Expert consensus was used from the Committee on Bibliography of the American Academy on Physician and Patient. TABULATION, INTEGRATION, AND RESULTS: The doctor-patient interaction is the main determinant of the accuracy and completeness of patient data, diagnostic accuracy, efficiency in the encounter, compliance, patient understanding of problems, and patient and physician satisfaction. Yet this critical skill is inadequately taught and practiced, with serious consequences for patient care and physician job satisfaction. Use of the 14 structural elements (preparing the environment, preparing oneself, observation, greeting, introduction, detecting and overcoming barriers to communication, surveying problems, negotiating a priority problem, developing a narrative thread, establishing the life context of the patient, establishing a safety net, presenting findings and options, negotiating plans, and closing) and three functions (gathering information, developing a therapeutic relationship, and patient education) and their associated behaviors improves encounter results significantly. Other helpful activities are patient activation, facilitating partnership, review of findings and plans, eliciting and responding to patients' attitudes and emotions about contraception and fertility, and use of empathy and positive regard. CONCLUSIONS: The use of scientifically derived, empirically validated interview skills substantially improves outcomes in contraceptive and other patient education and counseling. Use of appropriate structure and functions of the encounter, patient participation and partnership, review of patient understanding and reactions, and relating to the patients' attitudes and emotions about the subject each improve the outcomes of contraceptive care.

Contraception↗
PubMed1991

Dapiprazol prevents U50,488H-mediated suppression of preparatory components of drinking behavior in rats.

In a previous study, we found that the kappa opioid agonist U50,488H (U50) suppresses both appetitive and consummatory components of drinking behavior in rats trained to negotiate water in a straight runway. U50 also activates diuresis. Kappa opioid mechanisms could therefore play a dissipative role in the body's water balance. Since naloxone inhibits diuresis, but not hypodipsia produced by U50, these effects are probably mediated also by nonopioid mechanisms. In rats trained to negotiate water in a straight runway, we have studied the influence on the hypodipsic effects of U50 of the selective alpha-1 adrenoceptor antagonist dapiprazol (DAP), which we found to inhibit U50-mediated diuresis. When given alone, DAP (3 and 6 mg/kg IP) influenced neither running for water nor water intake; neither did it prevent the suppression of water intake produced by U50 (8 mg/kg IP) across the test. However, it did antagonize the U50-mediated slowing of running for water. Alpha-1 adrenoceptors thus appear to play a role in U50's effects on diuresis and the appetitive, but not consummatory, aspects of drinking.

3,4-Dichloro-N-methyl-N-(2-(1-pyrrolidinyl)-cycloh↗
PubMedDate not supplied

Conflict behaviors of maltreated and nonmaltreated children.

Maltreated and nonmaltreated children (ages 3-7 years) were paired for brief play sessions involving a single desirable object. Facial, verbal, and physical actions used while negotiating access to the object were examined. Results showed that the maltreated-nonmaltreated pairs were able to engage in a negotiation process resulting in approximately equal sharing of the object. The differences found between maltreated and nonmaltreated children primarily suggested that maltreated children were somewhat hesitant to engage their partners. Results also showed that children's scores on a facial expression recognition task predicted greater responsiveness to their partners' indication of reluctance to relinquish the object.

Aggression↗
PubMed1994

Enhancing multi-agency collaboration in the management of child sexual abuse.

Conflict naturally occurs when multiple organizations with different mandates interact to deliver services to children who have been sexually abused. In this article, the authors review the underlying sources of conflict that impair interorganization functioning, and dysfunctional techniques used to manage such conflict. As an alternative to dysfunctional conflict management strategies, the authors develop a model for managing conflict which builds on concepts from the operations and negotiations literature. The approach the authors advocate involves the three steps of problem characterization, acknowledgement of relevant goals and interests, and negotiation when interests are in conflict. The benefit of this approach, and difficulties encountered when employing it, are discussed.

Child↗
PubMed1992

Funding consultation-liaison psychiatry via Medicare screening.

Despite offering many benefits to patients, the hospital, and the hospital staff, an academic psychiatric consultation service is difficult to fund. By screening Medicare patients for psychiatric complications and comorbid conditions, the consultation-liaison (C-L) service can generate incremental revenue for the hospital by moving patients from lower-paying to higher-paying Diagnostic Related Groups (DRGs). The C-L service chief can negotiate with the hospital to obtain a portion of these incremental funds to support the C-L service. Concurrent psychiatric disorders that move patients to more complex DRGs include substance abuse, substance dependence, drug-induced delirium, drug-induced organic affective syndrome, and psychotic depression. This paper presents a method of calculating the incremental hospital revenue generated by such screening along with the results of applying the method to selected DRGs at a west coast teaching hospital. Implementing this program at that hospital in fiscal year 1989 would have resulted in screening 142 Medicare patients (2.2% of Medicare admissions), discovering an estimated 25 patients with comorbid psychiatric conditions, and generating $51,800 in incremental hospital revenue. In creating a screening program, a C-L service chief must be prepared to negotiate issues with the medical records department, referring physicians, and the hospital administration.

Academic Medical Centers↗
PubMed1989

Introduction of information during the initial medical visit: consequences for patient follow-through with physician recommendations for medication.

While negotiation of treatment decisions in the medical visit has long been recognized as an important interviewing skill, limited work has been done to investigate how doctors and patients negotiate what information is relevant in understanding the patient's problem. In this research we tested how the introduction of information reflecting both the patient's and physician's perspective is related to the patient's adherence to physician recommendations for medication. Introduction of information was defined as bi-directional if patients independently offered information or behavior as frequently as they provided the information or exhibited behavior that physicians requested. Thirty random samples of audiotaped dialogue were used to construct estimates of introduction of information during the history, examination, and consultation phases of initial ambulatory care visits of 45 older male patients. The data demonstrate that bi-directional introduction of information during the examination segment explains more than half of the variance in patient adherence to physician recommendations for new medication. These findings support the idea that physician willingness to allow patients to contribute input may contribute to the partnership's arrival at treatment decisions that have meaning for both.

Adult↗