Non-medical Providers Research Articles

Do Mexico City pharmacy workers screen women for health risks when they sell oral contraceptive pills over-the-counter?

Context In Mexico, oral contraceptives (OCs) are available to women over-the-counter in pharmacies. While past research has suggested that nonmedical providers, such as pharmacy workers, are capable of screening women for contraindications to OCs, little is known about their practices. Methods After selecting a 10% random sample of all pharmacies in Mexico City (n = 108), we surveyed the first available pharmacy worker to learn more about pharmacy workers' screening practices when selling OCs over-the-counter to women. Results While nearly all of the pharmacy workers surveyed had sold OCs without a prescription, only 31% reported asking women any questions before selling pills. Among those who asked questions, the most commonly asked questions were about other medications a woman was taking, about blood pressure and about alcohol intake. Pharmacy workers did not ask these questions consistently to all clients. Conclusion Training pharmacy workers might be one strategy to improve screening of women for pill contraindications. However, pharmacy workers may lack the time and motivation to carry out such screening. An alternative strategy might be to better inform women to self-screen for pill contraindications.

NON-PHYSICIAN ASSISTED SUICIDE: THE TECHNOLOGICAL IMPERATIVE OF THE DEATHING COUNTERCULTURE

This article reports on the 2nd Self-Deliverance New Technology Conference (NuTech), held in November 1999, in Seattle,Washington. Right-to-die activists from six countries met to demonstrate a number of devices for non-medical assisted death and to share preliminary findings on their use. The author attended all sessions of the private conference and received confidential memoranda and papers. An overt observer-as-participant method was used. Five devices for non-medical assisted death were demonstrated. These included three systems for breathing inert gas, a customized plastic bag for asphyxiation called the Exit Bag, and a closed circuit breathing system called the Debreather. Seven deaths out of eight trials were reported for the Debreather and four deaths were reported using the Exit Bag. Additionally, a non-quantified number of deaths using inert gas delivery systems were described by various conference delegates. The systems demonstrated by the NuTech group are designed to induce death quickly and painlessly. In general, they leave negligible, if any, post-mortem evidence of their use.The compulsion to use technology to cause death, the "technological imperative," has emerged as part of underground care of dying persons. This imperative raises serious challenges to the health care professions, legislators, and policy makers, particularly because it has led to a sophisticated, expanding movement of non-medical death providers.

NON-PHYSICIAN ASSISTED SUICIDE: THE TECHNOLOGICAL IMPERATIVE OF THE DEATHING COUNTERCULTURE

This article reports on the 2nd Self-Deliverance New Technology Conference (NuTech), held in November 1999, in Seattle,Washington. Right-to-die activists from six countries met to demonstrate a number of devices for non-medical assisted death and to share preliminary findings on their use. The author attended all sessions of the private conference and received confidential memoranda and papers. An overt observer-as-participant method was used. Five devices for non-medical assisted death were demonstrated. These included three systems for breathing inert gas, a customized plastic bag for asphyxiation called the Exit Bag, and a closed circuit breathing system called the Debreather. Seven deaths out of eight trials were reported for the Debreather and four deaths were reported using the Exit Bag. Additionally, a non-quantified number of deaths using inert gas delivery systems were described by various conference delegates. The systems demonstrated by the NuTech group are designed to induce death quickly and painlessly. In general, they leave negligible, if any, post-mortem evidence of their use.The compulsion to use technology to cause death, the "technological imperative," has emerged as part of underground care of dying persons. This imperative raises serious challenges to the health care professions, legislators, and policy makers, particularly because it has led to a sophisticated, expanding movement of non-medical death providers.

CRITICAL CARE AND PERIOPERATIVE MEDICINE: How Goes the Flow?

The specialty of anesthesiology is at a crossroad. Do anesthesiologists stay in the illusionary safe harbor of the operating room and allow critical care anesthesiologists to float alone? How can in-fighting with other medical and nonmedical providers be avoided, while maintaining or expanding the historic and hopefully future roles of anesthesiologists as hospital-based physicians? A different tact is required to redefine the scope of the practice with broadened training to provide increased expertise in the evolving medical marketplace. This approach would include solid training in business, informatics, data management, and critical thinking on outcomes. This paradigm shift may be challenging, and requires redirection, reallocation of assets, re-education, and a new mindset. If successfully applied, however, it presents a means to strengthen the respected position of the specialty and to promote the medical care and practice of perioperative specialists in the rapidly changing landscape of modern medicine. Regarding the question of turf and ownership of the ICU, the authors suggest pursuing the higher ground of an excellent scope of practice, which facilitates the care and activities of surgical and primary care colleagues. These colleagues, administrators, and governmental agencies will have to be re-educated to support training and provide equitable remuneration. Appropriately trained anesthesiologist-intensivists can complement many other care providers, while providing a wide range of services with an economy of care, whether in a semiclosed or closed ICU setting.

Treatment Options for Depression: Women and Primary Service Providers

A substantive quantitative research literature base exists exploring aspects of treatment for depression. Major themes to emerge from this literature include the use of general practitioners (GPs) in preference to psychiatrists for treatment and the negative public attitudes toward the use of pharmacological treatment strategies for depression. The study reported in this paper utilises a qualitative methodology to explore the experiences and attitudes of women currently being treated for depression. Specifically the paper focusses on the women's attitudes toward psychological versus medical treatment options for the disorder. Attitudes toward treatment modalities of medical and non-medical primary service providers are also investigated. Several significant findings emerged from the study. Women interviewed expressed a sense of personal responsibility for both the occurrence and management of depression.Consequent to this belief psychosocial interventions were critical to 'getting well'. Medication was viewed positively by all women, not as a treatment for depression, rather as a means of relieving the extreme symptoms of the illness, therefore providing space for psychosocial interventions. Medical and non-medical service providers expressed an acceptance of the need for integrating psychological and pharmacological treatment strategies though all providers acknowledged their lack of skills in incorporating treatments outside of their professional training. The study provides insight into the belief structures which influence participants' behaviours, presenting a less polarised view of attitudes toward psychological and pharmacological interventions than suggested by the current quantitative literature.

Health services, coordination and the Internet

The on-going specialization of medical services requires socioeconomic coordination of different health services. The GP is the key to improve this primary coordination. To qualify referral decisions by the GP an Internet-like information system (VisInfo) has been implemented in Denmark. This VisInfo contains information on (1) alternative periods of waiting, (2) medical guidelines for specific treatments, (3) clinical home pages, and (4) links to non-medical providers of health services (NGOs). VisInfo was originally implemented in the Counties of Funen, Northern Jutland and Vejle in 1993–1995. A number of other counties are implementing similar information systems whereof the County of Frederiksborg, recently has implemented the first real Internet-system. Provisional experiences with the VisInfo strategy is presented on (1) the general user interest, (2) elaborations of the strategy, and (3) organization. Based on the BlackSeaDiab Action Plan and the BlackSea TeleDiab project, the potential for dissemination of medical informatics in the Black Sea Region through an adaption of the VisInfor strategy is discussed.

Health Professionals' Perceptions About Induced Abortion in South Central and Southeast Asia

Although the legal status and the availability of induced abortion are highly variable in South Central and Southeast Asia, findings from a 1996 survey of 232 knowledgeable health professionals indicate that women of all socioeconomic levels obtain abortions, and many procedures take place in settings that may increase the risks to the woman’s health. Overall, the vast majority of nonpoor urban women seeking abortions are believed to go to medically trained providers; however, roughly one-third to one-half of poor women in both urban and rural areas turn to a wide range of nonmedical providers or induce their abortion themselves. Of all women having abortions in these countries, about one-third are thought to experience medical complications, and only about half of these are hospitalized for treatment; thus, an estimated one in seven women having an abortion are hospitalized for the treatment of complications. The estimated abortion rate of 30 abortions per 1,000 women aged 15‐44 suggests that each year, 3% of women in South Central and Southeast Asia have an abortion; therefore, according to the survey results, about 1% are likely to suffer medical complications.

The acute care nurse practitioner in collaborative practice.

Nurse-physician relationships remain, for the most part, hierarchical in nature. A hierarchical structure allows the person at the top, most notably the physician, the highest level of authority and power for decision making. Other health care providers are delegated various tasks related to the medical plan of care. One role of nonmedical health care providers, including nurses, is to support the medical plan of care and increase the productivity of physicians. Medical centers have house staff, usually interns and residents, who work collaboratively with the attending physicians in care delivery. At one medical center, a shortage of medical house staff for internal medicine prompted the development and evaluation of an alternative service. The alternative service utilized master prepared, certified nurse practitioners on a nonteaching service to provide care for selected types of medical patients. Physicians consulted with nurse practitioners, but retained decision-making authority concerning patient admission to the service. This paper describes the development and evaluation of an alternative service based on a collaborative practice model and the role of nurse practitioners working under such a model. Discussion includes suggestions for process guideline development for organizations that want to improve collaborative practice relationships between unit nursing staff, nurse practitioners, and physicians.

Legal ramifications of homeopathy.

The article addresses four regulatory challenges faced by practitioners of homeopathy: (1) medical practice acts, which prohibit the unlicensed practice of "medicine," (2) scope of practice limitations, which restrict nonmedical providers' ability to diagnose and treat disease; (3) prohibitions against "unprofessional conduct;" and (4) malpractice rules. The article concludes with suggestions for regulatory reform.

Paediatric trauma in the rural developing world: low cost measures to improve outcome

We reviewed 181 injured children admitted to a rural African hospital from 1987 to 1990 to ascertain factors influencing survival and functional outcome. Burns were the most common (39 per cent), occurred in the youngest patients, and were due to domestic scalding in 54 per cent of cases. Of the patients, 65 per cent presented more than 24 h after injury and 81 per cent presented without any previous treatment. Major disability occurred in 14 per cent of survivors and was associated with Injury Severity Score (ISS), extremity injury, and delayed presentation. Mortality was associated with the ISS. The mean ISS was 6.3. An ISS of 20–25 was associated with 75 per cent mortality. Trauma caused 8 per cent of hospital deaths in the 5–19 years age group. To reduce the mortality and disability from paediatric trauma in the rural developing world, we recommend (i) prevention strategies targeting domestic burns in younger children, (ii) increased attention to care of extremity injuries and burns, and (iii) increased use of non-medical health care providers in more remote areas.

The political economy of medical underemployment in Mexico: Corporatism, economic crisis and reform

There seem to be periods in human history when a worldwide phenomenon affects countries at the most varied levels of economic development. In recent decades one of these phenomena has been the appearance of fundamental manpower imbalances in the health field. Such imbalances have adopted many forms, from geographic maldistribution to functional disparities among various personnel categories [3]. Of all these forms, probably the most prevalent has been the increase in the supply of physicians beyond the needs of the population, the capacity of the health care system to absorb them, or both. It is indeed a challenge to social, political and economic theory to explain the processes through which widely differing national circumstances can lead to such a similar result. While the problem itself of increased physician supply is shared by many countries, the social response has varied substantially across them. Some societies have been able to cope with the excess of physicians by diverse mechanisms, such as the reduction of working hours, the displacement of nonmedical providers, the growing medicalization of life, the encouragement of medical out-migration, or even the deliberate and planned export of physicians. In other countries, however, it has been impossible to fully utilize the increased supply of doctors. Probably the worst outcome has been the coexistence of underemployed physicians with large groups of people who lack ready access to medical services. This is the most extreme contradiction facing today the health care systems of many Latin American countries, Mexico among them. A survey carried out in 1986 revealed that 23 500 of the 81000 active physicians living in the 16 major cities of Mexico were unor underemployed [14]. At the same time, official statistics placed at 9.3 million (or 11% of the national population) the number of people without permanent health services (Ref. 7, p. 74). How did Mexico arrive to this state of affairs, which is obviously opposite

A New Physician Supply Policy Is Needed

THE PUBLICATION of Estimates of Physician Requirements for 1990 for the Specialties of Neurology, Anesthesiology, Nuclear Medicine, Pathology, Physical Medicine and Rehabilitation, and Radiology: A Further Application of the GMENAC Methodology (p 2623) covering six specialties that were not included in the original GMENAC report is a reminder that the findings of Dr Alvin Tarlov and his legion of collaborators remain on the nation's health agenda. There are many important questions about the future supply of physicians that warrant attention by members of the profession and its leaders. These include the determination of whether an oversupply threatens or is already here; the criteria for reaching a judgment about the adequacy of the supply; the extent to which factors on the demand side, eg, pressures to reduce reimbursement or the growing number of the elderly, will affect physicians' work loads; conflicts with nurse practitioners and nonmedical providers over turf; the rate

Economic and legal analysis of medical ethics: The case of restrictions on interprofessional association.

In the last decade, the antityrust authorities have stricken one after another of the ethical rules of professional societies. Underlying this pokicy is the widelyaccepted notion that ethics are simply devices designed by the professions to limit competition and thereby to benefit their pecuniary interests. The antitrust assault does not consider the longstanding, nearly universal consumer support for controls on the activities of certain professions. In this paper, the narrow view ofcompetition adopted by the courts is assailed. Focusing on the case ofrestrictions on interactions between physicians and other nonmedical health care providers, some procompetitive effects of medical ethics are analyzed. Generally, professional ethics can only change the form of competition but not eliminate it. A proper legal policy requires recognition of the consumer concern with the form of competition and therefore requires a careful balancing of the beneficial competitive effects against any attendant limits on intraprofessional competition.