State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case

The relationships amongst the health professions and between them and the state are rapidly changing. I argue that analysis of these relationships has to take into consideration: the fact that medicine played an intermediary role (through medical dominance in health care) between the state and the other health occupations; the permeability of the boundaries of the state and the professions; and the dual nature of professional organizations (as sites of intra-occupational conflict and as possible vehicles of extra-occupational control). In Ontario the medical profession partially 'mediated' the relationships between 'non-physician' health occupations and the state through medical control over other health care occupations. National/provincial health insurance brought the state into the health care system as an actor and forced a reconsideration of its relationships with medicine and with the other health care occupations. The state came to be directly involved in 'rationalizing' health care. This involvement meant curbing the power of medicine and modifying the relationships between medicine and the para-medical occupations. State influence is partly constructed through a particular kind of professional organization, namely, the professional College. These changing relationships are illustrated by historical and recent developments regarding medicine, nursing and chiropractic in Ontario.     

Psychiatric disorders and gynecological oncology: a review of the literature

The widespread use of complementary and alternative medicine techniques, often explored by patients without discussion with their primary care physician, is seen as a request from patients for care as well as cure. In this article, we discuss the reasons for the growth of and interest in complementary and alternative medicine in an era of rapidly advancing medical technology. There is, for instance, evidence of the efficacy of supportive techniques such as group psychotherapy in improving adjustment and increasing survival time of cancer patients. We describe current and developing complementary medicine programs as well as opportunities for integration of some complementary techniques into standard medical care.     

Internal medicine in the current health care environment: a need for reaffirmation

Managed care has substantially changed the environment of health care delivery for general internists and internist-subspecialists. In the current system, one may wonder whether detailed and thoughtful workups still have a role when the direction of medical practice increasingly prizes a high volume of brief encounters. However, the very forces that drive managed care make the role of internist in the care of adults even more central. The internist's unique training and clinical approach should lead to both medically effective and cost-effective health care for adults. This type of health care will be increasingly important as the U.S. population ages and an increasing number of Americans have chronic, multisystem disease. Over the past century, internal medicine has evolved from a consultative model to a discipline that encompasses total adult care, from prevention to diagnosis and treatment of acute and chronic illness and from outpatient care in the office to inpatient care in the intensive care unit. However, the leadership role of internists in the medical care of adults is now being threatened by family medicine and by fragmentation within internal medicine itself. Managed care organizations and the general public must be shown why internists are better able than family physicians to meet the health care needs of adults. Furthermore, as the marketplace becomes more competitive, the issue of when care given by a subspecialist is superior to that given by an internist has become more prominent. The rapidly developing "hospitalist" movement also threatens the traditional role of the internist as the caregiver for adults in health and disease. Given the historic flexibility of internal medicine and the assumption that appropriate roles can be defined for family physicians, subspecialists, and hospitalists, internists will continue to play a central role in providing the best care for adults in the new world of health care delivery.     

Expression of carboxymethylcellulase on the surface of Escherichia coli using Pseudomonas syringae ice nucleation protein

Geriatric assessment is a means to collect health and functional data of an individual older person in a standard way. It has been developed on the secondary care level in the specialties of geriatric and rehabilitative medicine. Transferring geriatric assessment into primary care may improve health outcomes of older people, especially as it facilitates preventive diagnostic and therapeutic intervention. Yet, it is not possible to use geriatric assessment, as it is carried out in secondary care, under primary care conditions. Several adaptations will be necessary. An assessment instrument will have to be developed which takes epidemiological features of the older population into account. It will have to be tailored to the specific conditions of health delivery in primary care. Moreover, to achieve effectiveness and acceptance by health care providers and users, we see the necessity of creating an algorithmic assessment instrument which allows the use in different health situations with different levels of diagnostic detail. A primary care assessment for older people then would need to be evaluated according to its effectiveness of improving health outcomes. Potential negative effects on health beliefs may be worth considering. The final task lies in the implementation of a primary care assessment instrument into our existing health delivery format.     

Applying behavioral research to incontinence

Historically, treatment strategies for urinary incontinence (UI) have not been offered by primary care practitioners. This is despite the fact that prevalence for UI in women of all ages has been reported to be as high as 30 percent and that there are interventions, specifically behavioral treatments, that can be integrated in a primary care practice. However, most practitioners have not been trained in identification of UI, causes and approaches that can be incorporated into a successful treatment program. The authors have implemented a program to address the problem of UI. This article outlines their successful application of a behavioral therapy protocol in two diverse practices: gynecological and internal medicine.     

Viability and recovery of peripheral blood mononuclear cells cryopreserved for up to 12 years in a multicenter study

Polish physicians-philosophers tried to find a compromise between medicine as a science and medicine as a healing art. They stated that clinical practice should be transformed into science, bearing in mind that there would be no medicine without the existence of the sick. A perfect physician is a good and wise person and not exclusively a proficient expert. Polish physicians exercised a science that they called philosophy of medicine. It included logic, psychology, and medical ethics. The Polish school claimed that the history of medicine and philosophy of medicine are necessary for future doctors. The historical and philosophical approach makes it possible to recognize the subject of medicine (health, disease, and the sick) and its aim (treatment, restoration of health or just alleviation of suffering). The ethics teaches what values are pursued by medicine, what moral duties a doctor has, and what role model to follow to become a good physician. Placing the sick in the focus of medical interest, the Polish school taught future physicians to see in them suffering fellow men who should be embraced with care, compassion, and Christian charity. Such an approach to the ethical aspect of medical philosophy became incorporated into an education towards humane values, responsibility for ones' life and health in the spirit of the ethics of care.     

Antiretroviral therapy for HIV infection. Heartening successes mixed with continuing challenges

Probably nothing in the field of medicine has changed as rapidly over the last decade as antiretroviral (ARV) therapy for HIV infection. New insights into pathogenesis, new tests for measuring virus levels in plasma, and availability of powerful new drugs have combined to transform the care of persons with HIV infection into a field infused with real hope. However, ARV therapy remains complex, expensive, and not universally effective or available. This article focuses on a general approach to the use of ARV agents.     

Visions and revisions: viewpoints on nuclear medicine & health care reform. Part 1: Outcomes research

Although health care reform movements and the strategies that medical societies use to meet the challenges existed long before President Bill Clinton's September 1993 presentation of his reform bill, these strategies have since come into the foreground of medical reform discussions. Medical groups are carefully eying outcomes research as a method to both pinpoint their most effective procedures and to point up the effectiveness of their practice in overall patient care. Practice guidelines promise a way to sift out the optimal procedures and suggest them to all nuclear medicine physicians--to both unify the specialty and perhaps help protect practitioners in malpractice cases. Discussions of the specialty physician workforce question the need and practicality of any policy that substitutes generalists for specialists. And vigilance over the several pieces of legislation currently sifting through Congress alert members of specialty societies about political developments and how to influence congressmen. The question remains, are these strategies being employed in such a way as to best pull a specialty like nuclear medicine through the gantlet and optimize health care provision in the US? This four-part series will explore this question.     

Market influences on internal medicine residents' decisions to subspecialize

BACKGROUND: Managed care reduces the demand for internal medicine subspecialists, but little empirical information is available on how increasing managed care may be affecting residents' training choices. OBJECTIVE: To determine whether increased managed care penetration into an area where residents train was associated with a decreased likelihood that residents who completed general internal medicine training pursued subspecialty training. DESIGN: Secondary logistic regression analysis of data from the 1993 cohort of general internal medicine residents. SETTING: U.S. residency training sites. PARTICIPANTS: 2263 U.S. medical school graduates who completed general internal medicine residency training in 1993. MEASUREMENTS: The outcome variable (enrollment in subspecialty training) was derived from the Graduate Medical Education Tracking Census of the Association of American Medical Colleges (AAMC). Health maintenance organization (HMO) penetration (possible range, 0.0 to 1.0; higher values indicate greater penetration) was taken from the Interstudy Competitive Edge Database. Individual and medical school covariates were taken from the AAMC's Student and Applicant Information Management System database and the National Institutes of Health Information for Management Planning, Analysis, and Coordination system. The U.S. Census division was included as a control covariate. RESULTS: 980 participants (43%) enrolled in subspecialty training. Logistic regression analyses indicated a nonlinear association between managed care penetration into a training area and the odds of subspecialization. Increasing managed care penetration was associated with decreasing odds of subspecialization when penetration exceeded 0.15. The choice of subspecialty training increased as HMO penetration increased from 0 to 0.15. CONCLUSIONS: Local market forces locally influenced the career decisions of internal medicine residents, but the influence was small compared with the effects of age and sex. These results suggest that market forces help to achieve more desirable generalist-to-specialist physician ratios in internal medicine.     

Complementary medicine--health policy and health care costs

Complementary medical methods are increasingly offered by physicians as well as other members of the health services and numerous therapists and they are sought and used by a majority of the population. From the point of view of health care authorities the question of acceptance or admission of methods and offering persons is raised. Unfortunately Switzerland lacks an uniform federal curriculum for practitioners of natural cures of other therapists in complementary medicine. Therefore, in order to control the steadily increasing wild growth of complementary medical offerings, several states (Kantone) have introduced examinations for the registration of such paramedical practitioners. Whether complementary (paramedical) medicine will really reduce costs of health care remains unproven so far. According to several surveys most alternative methods are used in addition to "school medicine" (academic medicine). Health insurance companies should subject reimbursement of costs to the fulfillment of standards regarding efficacy, appropriateness and economy equal to all other medications and therapies.     

Moving behavioral medicine to the front line: A model for the integration of behavioral and medical sciences in primary care.

Psychologists have an unprecedented opportunity to influence primary medical care systems where chronic conditions, somatic symptoms, and health-threatening behaviors are prevalent. The authors developed a new model to incorporate behavioral medicine expertise into existing primary care practice with the purpose of delivering integrated, comprehensive, and efficient health care through physician training and direct patient care services. This model moves psychologists from isolated referral settings to the front line of medical care, where a broader impact on the outcomes and costs of health care can be achieved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Folk medicine, experience therapy, a component of modern therapeutics?

Empirical medicine has three main supporting pillars: physical treatment, dietetics and phytotherapy. In this area of medicine, a number of therapeutical methods have been evolved which stand up to investigations employing scientific criteria, and which, in consequence, have become officially recognized by medical science. Examples are: diet rich in bulkage, digitalis, products of Papaver somniferum (Poppy) and salicylates. The acceptance of phytotherapeutic agents into the drug armamentarium of scientific medicine presupposes the availability of test methods suitable to demonstrate their effectiveness. Quite a number of remedies that have always been firmly anchored in empirical medicine, but which was applied regularly only by the nature healer, have suddenly, in the light of new test methods, been shown to be effective medicines; thus, for example, onions and garlic are good for thrombotic processes and hyperglycaemia, carminatives for sphincter spasms in the gastrointestinal tract, and alcohol is an appetite-stimulating stomachic. This fact, the limited applicability of the information obtained from animal experiments, and the further fact that even test results obtained in human subjects cannot be applied on a world-wide basis, exhort us to take care not to subscribe to an all-too apodictic classification of therapeutic measures into effective and noneffective. A further point for consideration is that the administration even of what is only a supposed remedy, can trigger or promote healing simply on the strength of the action of the physician. Scientific thinking is an indispensible precondition of the physician's activity--to consider it as the beginning and end of all things medical, however, is simply to demonstrate a narrowness of outlook.     

Research and teaching in social and preventive medicine and in public health

Both public health and social and preventive medicine are characterised by the common goal of promoting, maintaining and improving health and preventing disease, and both are concerned with a population-related, preventive and environmental perspective. But whereas public health is interdisciplinary and goes far beyond the medical focus, social and preventive medicine is medically based and forms a bridge between public health and medical practice. Research in a department of social and preventive medicine serves to support preventive and medico-social activities in medical practice as well as in public health. This is illustrated by results from research conducted at the author's department during the last twenty years. Examples are research in support of smoking cessation activities, and research used for the planning of care for the elderly. Both the research and the teaching activities of the department take into account the population focus of public health as well as the focus on individual medicine in clinical practice.     

Instructional intranets in graduate medical education

Changes in medicine, medical education, and technology have influenced graduate medical education (GME) and have altered many traditional concepts of resident training. Three issues in particular have led to changes. The first is the shortage of time that academic and community physicians have to devote to medical teaching because of the demands to bring in revenue through clinical practice. The second is the limited exposure that residents have to various medical conditions due to a shift in training venues from hospitals to ambulatory care settings. Last is residents' lack of training in using information technologies. The resultant deficits the exist in GME make it more difficult for residents to practice medicine in the most efficient manner. Hence, there is a need for health care professionals' education to address the coming demands of the 21st century. Instructional computer technology can be useful in bridging this gap. Intranets, internal organizational networks, are private versions of the World Wide Web that are often available only to members of a particular organization. This paper reviews changes in medicine and medical education, describes how instructional intranets can be incorporated into GME, and discusses the impact intranet and Internet technologies can have on GME.     

The feminization of the medical profession in Israel

Two factors have caused major changes in the gender composition of the Israeli medical profession in recent years: (i) a wave of immigration from the former USSR, which increased the doctor population by approximately 70% and which included a majority of women physicians, and (ii) the entry of more Israeli women into medical school. This report presents the current gender status of the Israeli medical profession, regarding students and physicians, and the choice of medical specialty and academic seniority, and compares gender differences in Israel with those in other countries. Traditional patterns of specialization persist in Israel, with women still concentrated in primary care (family medicine, paediatrics and psychiatry). In addition, women still face obstacles in entering the more prestigious (mainly surgical) specialties. Whilst the number of women in academic medicine has increased over the last decade, women are still concentrated in the lowest echelons of academic medicine. However, the steady trend towards the feminization of medicine will inevitably lead to an increase of women in all areas of the medical profession. Because cross-cultural studies have repeatedly revealed that women doctors have a more humanistic and personalized approach to patient care, a higher ratio of women in the profession should have a qualitative effect in this direction, despite the bureaucratic and fiscal constraints incumbent upon practising doctors. As more women become role models for medical students, their approach will influence the education of the doctors of the future.     

Protective effect of GV150526A on the glutamate-induced changes in basal and electrically-stimulated cytosolic Ca++ in primary cultured cerebral cortical cells

Medical care in the United States continues to face tremendous financial pressures. Public and private health policy claim to encourage primary care and preventive services, but also discourage services that have not been demonstrated to be effective and/or cost-effective. This article suggests a model to illustrate the conceptual relationship between traditional American medical care and "evidenced-based" medicine. It further examines how the lack of an adequate research base makes a move to purely evidence-based care premature for primary care and prevention services. The paper defines a new conceptual statistic, the uncertainty index, as the proportion of non-refuted current practice that is also not corroborated by research evidence. The greater the uncertainty index, the less appropriate is a clinical model restricted to evidence-based care. Specific theoretical barriers to outcomes research in prevention are discussed and simple criteria to determine the desirable components of care are suggested. The need for theoretical and empirical research into primary care and prevention, especially for children, is emphasized. Care that is of low risk, not of extremely high cost, and that is generally believed useful by the community of practitioners is particularly desirable in the absence of data refuting its value.     

The origins, benefits, harms, and implications of emergency medicine clinical policies

Emergency physicians desire to provide their patients with care that is of the highest quality and is cost effective. Any tool that promotes these aims is good and should be used. Clinical policies have been proposed as a new method of prompting physicians to provide better care. While there is no direct evidence that emergency medicine clinical policies improve care, there is indirect evidence that they may be useful. ACEP has initiated a process for the development and evaluation of selected clinical policies. We anxiously await information that sheds light on the value of policies in enhancing the clinical practice of emergency medicine.     

Predoctoral training in collaborative primary care: An exam room built for two.

Psychologists have discovered new training and practice opportunities by collaborating with family physicians. This article describes a collaborative practicum experience in which predoctoral psychology students teamed with family medicine residents to provide care for family medicine outpatients. Psychology students improved their clinical skills and reported learning valuable collaborative skills. Family medicine residents increased their postpracticum mental health diagnoses and their mental health referrals and changed their attitudes about providing mental health care. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Institutional influences on the primary cesarean section rate in Utah, 1992 to 1995

OBJECTIVES: Our purpose was to evaluate institutional and organizational influences on cesarean section rates in Utah and to adjust such rates for differences in patient acuity. STUDY DESIGN: Data on cesarean section rates were derived from the Utah Hospital Discharge Database and adjusted for patient acuity by correcting raw cesarean rates for those patients undergoing cesarean section meeting regional gestational age transport criteria. RESULTS: When analyzed by means of 1-way analysis of variance, the following factors had a significant negative correlation (P < .05) with cesarean section rate: presence of a newborn intensive care unit and maternal-fetal medicine subspecialists, presence on the medical staff of obstetrician-gynecologist(s) as opposed to family physicians only, delivery volume >1500/y, urban location, and 24-hour in-house anesthesiology. When cesarean rates were corrected for acuity, facilities with maternal-fetal medicine specialists and a newborn intensive care unit had significantly lower rates (P < .001) and more uniform rates than otherwise similar institutions. CONCLUSIONS: More medically sophisticated physicians and institutions have lower cesarean rates when patient acuity is taken into account.     

Rehabilitation psychology in primary care: Preparing for a changing health care environment.

Restructuring of health care delivery systems has deemphasized tertiary and specialty services with a resultant increase in primary medical care. These reform efforts are anticipated to continue, highlighting the need for rehabilitation psychologists to expand beyond tertiary care settings to sustain the growth and prosperity of their profession. New models of service delivery and training are needed to help them transition into the new health care environment. A recently developed model for integrating behavioral medicine into primary care may serve as a guide. In this paper we discuss a model for integrating behavioral science into the medical management of primary care patients. The model is applicable to the functions and philosophy of rehabilitation psychologists. A discussion of the new model and its relation to rehabilitation psychology is provided along with implications for predoctoral training and strategies for overcoming barriers to primary care integration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)