Structure Of Medical Practice Research Articles

Physician moral injury in the context of moral, ethical and legal codes

After 40 years of attributing high rates of physician career dissatisfaction, attrition, alcoholism, divorce and suicide to ‘burnout’, there is growing recognition that these outcomes may instead be caused by...

Medical Professionalism In An Organizational Age: Challenges And Opportunities.

The structure of medical practice is undergoing an extraordinary transformation. The percentage of physicians salaried and employed by hospitals and health care groups has increased dramatically. Growing numbers of patients are using health information technologies that facilitate transparency and enable patients to use the internet and health tracking devices to better manage their health care. This article aims to start a dialogue on how these changes may affect the key responsibilities of medical professionalism: putting patient interests first, maintaining and enhancing physicians' medical competence, and sustaining trust in the doctor-patient relationship. We identify several potentially effective strategies. They include policies to promote an institutional culture committed to professionalism and to enlarge physicians' role in institutional leadership. We also address how the principles of professionalism might guide physician compensation formulas, policies governing transparency, and best practices for strengthening the relationships between physicians and newly empowered patients.

A model of medical practice for contextual knowledge sharing in collaborative healthcare

The dynamics of knowledge use in the context of care is complex and particularly challenging when knowledge is shared across boundaries in collaborative healthcare. The process is reliant on contextual features that support perceptions of shared information, and usually occurs within a complex structure of medical practice shaped by a wide range of factors, including local work patterns, organizational contexts, and patients' circumstances that vary across settings. Consequently, designing computational systems to support contextual knowledge sharing among clinicians working across boundaries remains a challenge. In particular, very few mechanisms exist for representing the notion of practice for computational design. This paper presents an approach for formalising and representing medical practice for cross-boundary knowledge sharing in healthcare. The approach is based on the practice theoretic paradigm, and draws upon a view of context as an interaction problem, representing practice as a context parameter for the design of cross-boundary collaborative healthcare systems.

Consultation Etiquette: A Proposed Set of Guidelines

Too often, actions and decisions affecting patient care are determined by expediency, cost-effectiveness, and time constraints. At risk of sacrifice are ethics and professionalism, pillars essential to the very structure of medical practice. In particular, there appears to be an erosion of consultation etiquette-exchanges between physicians and patients as well as among physicians. While methods to maximize efficiency are essential to medical practice, they should not come at the expense of etiquette. To improve patient care and strengthen relationships between patients and physicians, as well as relationships between referring and consulting physicians, a set of guidelines for improving consultation etiquette is proposed.

Drawing Blood: Technology and Disease Identity in Twentieth-Century America

Reviewed by: Drawing Blood: Technology and Disease Identity in Twentieth-Century America Joel D. Howell Keith Wailoo. Drawing Blood: Technology and Disease Identity in Twentieth-Century America. Henry E. Sigerist Series in the History of Medicine. Baltimore: Johns Hopkins University Press, 1997. xii + 288 pp. $39.95. As a marker of destiny, a carrier of familial traits—indeed, as the very “river of life”—human blood has long been invested with profound cultural significance. Yet today, as we near the end of the twentieth century, physicians often claim to make medical decisions based on precise, objective, scientific measurements of the blood. Does history matter? Is our reading of blood still grounded in cultural understandings? In this excellent book, Keith Wailoo suggests that the answer to both questions is “Yes.” His analysis uses ideas about the blood as windows onto a changing century to illuminate relationships among different types of physicians, among different medical institutions, and, perhaps most important, between people who have come to be labeled (or not labeled) as having a disease of the blood. As Wailoo shows throughout the book, there has always been a complex relationship between diseases and technology (and by this term he means far more than simply the physical artifacts). On the one hand, a disease such as anemia came to be constructed as something to be best explained by the use of technology. On the other hand, the use of that technology gave legitimacy to the people who could (and would use) those tools. Technology was used to help create identities for both patient and physician in ways that were flexible enough to serve the needs of many different constituents, often at the same time. Wailoo’s astute reading is relevant to the use of diagnostic technologies in general, not only those used to study blood. A particular strength of the book vis-à-vis the history of technology is the attention paid to technologies that were thought applicable at the time, whether or not we now hold them to be useful. Wailoo takes a number of diseases as emblematic. Countless nineteenth-century family physicians employed “moral management” for their female patients diagnosed with chlorosis. At one time a central disease concept, chlorosis disappeared from center stage by the 1920s, which reflected both a change in the structure of medical practice and a shift in attitudes toward diseases of women—the latter shift reflecting what Wailoo terms “medicine’s enduring desire to define, through technology, a legitimate female identity” (p. 45). Splenic anemia localized anemia to a particular organ, an abdominal organ that had been of relatively little interest until early twentieth century surgeons (the dominant medical specialists of the age) found it to be within easy grasp, and used it to label a new anemia as one susceptible to surgical intervention. Aplastic anemia led medical professionals to look more closely at the industrial world that was increasingly their patients’ workplace. They were forced to grapple with “medical” issues that included legal and social values—if industrial practices caused aplastic anemia, should the workplace be made safer, or should “susceptible workers” be removed? In other words, did the illness indicate a problem with the patient, or with the environment? The development of a cure for pernicious anemia highlighted newly formed relationships between universities [End Page 585] and pharmaceutical industries. Sickle-cell anemia forced those who studied it to deal with issues of race and racial identity. Earlier in the century, Emmel’s blood test was used to label people as members of a specific race; a change to hemoglobin electrophoresis may have led to different formulations for the disease, but the meaning of the technology was no less embedded in a specific social context. In the final chapter, Wailoo considers how federal support of medical research has changed the world of blood and blood diseases. He examines leukemia and the formation of the specialty of hematology-oncology, as well as how the technology that enabled easier diagnosis of the sickle-cell trait forced patients and caregivers to confront new social dilemmas. He weaves each of these stories into a world that was changing not only outside medicine but also within, as physicians (and technicians...

The effects of capitation payment on the organizational structure of medical group practices.

This study explores the effects of capitation payment on the structural elements used by medical group practices to control physician-directed use of resources and the quality of patient care. Forty-five medical groups located in the highly competitive Minneapolis/St. Paul metropolitan area were studied. The range of capitation payment in these medical group practices is from 2% to 87%. Although the practices vary considerably in the extent to which they have developed these control mechanisms, it does not appear that capitation payment is a major factor influencing that pattern. It appears that many of these medical group practices either use less formal mechanisms than those included in this study to control resource use and the quality of care or use none at all. In either event, the data suggest that the effects of capitation payment on the structure of medical practices may be overestimated.

Vagina dentata revisited: gender and asymptomatic shedding of genital herpes.

Medical research on genital herpes indicates that women shed herpes asymptomatically. This paper examines the medical understanding of asymptomatic shedding of herpes among women as partial knowledge, meaning biased and incomplete, based upon folk models of male and female sexual bodies and upon the structure of medical practice. The focus on women's sexual anatomy as dangerous to men and the lack of a medical specialty on male reproductive/sexual health results in blaming women for transmission of sexual diseases.

Professional and popular medicine in France, 1770-1830: the social world of medical practice

List of tables, maps, and illustrations Preface Acknowledgments Introduction Part I. Professional Medicine: 1. The regular medical network at the end of the Old Regime 2. The medical profession in the early nineteenth century Part II. Popular Medicine: 3. Irregulars: itinerants 4. Irregulars: sedentary empirics 5. Folk healers: maiges and witches Part III. Toward a Social Interpretation: 6. The structure of medical practice: an overview Afterword Appendices Notes Glossary and note on French money Index.

Lessons from Elderly Physicians: Reflections on Practice, Changes in Medicine, and Retirement

To gain perspective on changes in medicine and learn about the later stages of physicians' careers, we surveyed Rhode Island physicians age 65 years or older. Despite their concerns about changes in the structure of medical practice and the doctor-patient relationship, these physicians reported satisfying careers and expressed few professional regrets. Those elderly physicians who remained in practice did so because they enjoyed patient care and the intellectual stimulation of medicine. They also felt a responsibility to their patients and wished to remain active professionally. Those who retired cited "hassles, "high costs associated with practice, and their personal health as important reasons.

Medicine as a dependent tradition: historical and ethical reflections.

MEDICINE AS A DEPENDENT TRADITION: HISTORICAL AND ETHICAL REFLECTIONS RICHARD VANCE* In 1982, Howard Brody noted that medical ethics is now in its third generation [I]. The metaphor is a helpful reminder of important changes in the relatively short history of modern medical ethics. The first generation was characterized by physicians' attitudes and reflections on ethical issues. The second generation consisted of careful analyses of ethical issues by professional ethicists. The third generation, clearly the most important phase of medical ethics to date, is marked by Edmund Pellegrino and David Thomasma's A PhilosophicalBasis ofMedicalPractice [2] and Robert Veatch's A Theory ofMedicalEthics [S]. Both books involve systematic presentation ofmedical ethics. In many ways, these two books have defined the arena within which future work in medical ethics will be done. Despite marked differences in style and perspective, they share important purposes. They attempt not only to define what medical practice ought to be in a liberal pluralistic society but also to describe what moral foundations the medical profession does and should have [2, pp. 170-191, 260-280; 3, pp. 324-330]. In addition, both systems attempt to resolve a number of peisvasive tensions 'n modern medicine. The authors agree that these tensions arise from the conflict between the traditional assumptions and structure of medical practice, on the one hand, and the liberal presuppositions of modern society, on the other [2, pp. 10, 38; 3, p. 3]. The conflict is manifested in the institutional struggle of medicine to remain a classical craft and in the tensions so widely recognized in the doctor-patient relationship . Physicians also experience this conflict at a personal level as they try to decide what place medicine ought to have in their lives. The author is indebted toJohn Sykes, Robert W. Prichard, and James M. Gustafson for numerous helpful comments and criticisms during the preparation of this essay. ?Department of Pathology, Wake Forest University Medical Center, Winston-Salem, North Carolina 27103.© 1985 by The University of Chicago. AU rights reserved. 0031-5982/85/2802-0429$01 .00 282 I Richard Vance · Medicine as a Dependent Tradition Should medicine be a craft or a business? a vocation or ajob? a constellation of virtues or a role? The efforts of Pellegrino, Thomasma, and Veatch to resolve these tensions are not new. Seeking resolutions of this sort has been a persistent theme in all three generations ofmedical ethics [4-7]. What is new about the third generation is the systematic approach to these problems. Therefore, neither system considers the tensions that pervade modern medicine to be inevitable or ineradicable. If such were the case, the best medical ethics might be able to do would be to help preserve those tensions in nondestructive ways. After the efforts of two generations of medical ethicists, such a conclusion would be both disconcerting and unappealing. However, Pellegrino, Thomasma, and Veatch do not avoid important issues simply because they are unpalatable. Indeed, the only adequate reason they ignore this possibility is, I believe, a deeply held conviction: if tensions are present, they can (at least in principle) be resolved. To say the least, Pellegrino, Thomasma, and Veatch are not the first to depend on such an assumption. However, these common purposes and presuppositions do not ameliorate important differences in their interpretations of contemporary tensions or in their suggested solutions. For Pellegrino and Thomasma, the tensions are resolved by establishing the unique and fundamental importance ofclinical experience and by developing a language that can articulate it coherently [2, pp. 47-65]. The tensions are not so much tensions as they are a collection of unfortunate incongruities that can be eliminated by the proper synthetic categories [2, pp. 10, 17, 19]. For Veatch, the tensions are the result of paternalistic and presumptuous motives on the part ofthe medical profession and need to be eliminated by making medical practice more thoroughly contractual and egalitarian [3, pp. 10-11]. Pellegrino and Thomasma move an uncertain medical practice in the direction of a coherent, reconstructed profession that can show our liberal pluralistic society the fundamental coherence that underlies important aspects of human experience [2, pp. 22—27, 31—32]. Veatch moves the profession of medicine into the arena...

The impact of the laboratory's multiparametric analyzer on the medical technology and health expenditure in Japan

The use of an automatic analyzer for blood chemistry has become widespread since the latter half of the 1970s. This medical equipment conserved while improving accuracy. This technology has had a greater impact upon the structure of medical practice, management of medical institutions and medical economics, than previous diagnostic tests such as the X-ray, electrocardiograph and manual laboratory tests. This report analyzes the nationwide use of blood chemistry automatic analyzer, based on statistics from the Ministry of Health and Welfare. First, attempts are made to evaluate the significance of the provision of the multiple-channel auto-analyzer. Second, we review the impact of this technology on medical care and its background in three phases: (1) medical institutions, (2) clinical Laboratory Test Centers and (3) national medical expenditure and the response of the government. These phenomena are common to the fruits of the technological revolution centered on ME (Medical Engineering or Medical Electronics), such as CT, ultrasonograph, hemodialyser. The rational utilization of this equipment will require the cooperative efforts of both economists and medical technologists.

Drug Development, Regulation, and the Practice of Medicine

IN LESS than five decades, the revolution has transformed therapeutics. The purpose of this report is to propose and examine the hypothesis that the process by which drugs are now developed and regulated has become a prototype for wider changes in the structure of medical practice. Patients, Physicians, Government, and Industry Before therapeutic drugs achieved their present economic importance, such development of useful new therapies as did occur (eg, quinine, digitalis, morphine, hypnotics, local and general anesthetics, cholinergics and anticholinergics, amyl nitrite, anthelmintics, antiscorbutics, hormones, and vitamins) stemmed mainly from the academic and professional communities. The main change of the past 50 years is the nearly total transfer of the responsibility for developing new drugs to the pharmaceutical industry, supervised by government. Industry's participation developed because of the enormous increase in the cost and complexity of drug development, 1 and because of the profitability of the process. Government's entry

Medicine and the computer. The promise and problems of change.

Abstract Rapid advances in the information sciences, coupled with the political commitment to broad extensions of health care, promise to bring about basic changes in the structure of medical practice. Computing science will probably exert its major effects by augmenting and, in some cases, largely replacing the intellectual functions of the physician. As the "intellectual" use of the computer influences in a fundamental fashion the problems of both physician manpower and quality of medical care, it will also inevitably exact important social costs — psychologic, organizational, legal, economic and technical. Only through consideration of such potential costs will it be possible to introduce the new technology in an effective and acceptable manner. To accomplish this goal will require new interactions among medicine, the information sciences and the management sciences, and the development of new skills and attitudes on the part of policy-makers in the health-care system.

The Teaching of Preventive Medicine

Many years ago Perkins1defined health as "a state of relative equilibrium of body form and function which results from its successful dynamic adjustment to forces tending to disturb it." The term preventive medicine connotes the science and art of promotion of physical and mental health, the prevention of disease, the prevention of progression of disability, and prolongation of efficient and healthful living. When preventive medicine is practiced for groups and communities, it is usually referred to as public health. The graduate instruction of public health as presented in a school of public health, as well as graduate teaching of occupational and aerospace medicine, will be omitted from this discussion. The AMA "Essentials of Approved Residencies" states2: Preventive medicine embraces a broad spectrum of professional activity in the present-day highly organized and complex structure of medical practice which has been differentiated into closely related yet discretely identified specialty

THE PEDIATRICIAN AND THE PUBLIC

Dear Dr. Park: It is pretty generally agreed that medical practice in this country has been based on the premise of free choice of physician by the patient, and maintenance of a satisfactory, direct, doctor-patient relationship without the intervention of a third party. At present the opponents of tax-supported, government-controlled medical care are convinced that some form of voluntary, prepaid medical insurance constitutes the best means of protecting our free choice of physician and direct doctor-patient relationship principles. Some 40 years ago the beginnings of voluntary, prepaid medical care plans were made in this country. These beginnings were made in the Pacific Northwest. They had their origin here because of the peculiar demands of the local, hazardous industries of lumbering, mining and fishing. Contract practice came into being, and received tremendous impetus from the Industrial Insurance Law which was passed in Washington in 1917. Competition for contracts became so intense during the depression period which started in 1929 that vicious methods threatened the structure of medical practice in the State, and it seemed likely that most of the physicians would be relegated to practicing as salaried individuals under a form of health insurance. It was at this time that the various county medical service bureaus in the State of Washington were revived or organized. In Pierce County (Tacoma) a Bureau had been in continuous operation since 1917, and in King County (Seattle) one had been in operation from 1917 to 1925. These bureaus had been organized primarily to contract for work under the State Industrial Insurance Law, and to guarantee a free choice of physician to the workers who belonged to the Bureau. In May 1933 the King County Medical Service Bureau Society was instrumental in organizing the King County Medical Service Bureau to compete with existing contract groups, and to block a proposal by an insurance company for selling insurance and hiring physicians to render necessary medical care.

Basal-Cell Carcinoma at Trauma Site

After 40 years of attributing high rates of physician career dissatisfaction, attrition, alcoholism, divorce and suicide to ‘burnout’, there is growing recognition that these outcomes may instead be caused by moral injury. This has led to a debate about the relative diagnostic merits of these two terms, a recognition that interventions designed to treat burnout may be ineffective, and much perplexity about how—if at all—this changes anything. The current research seeks to develop the construct of moral injury outside military contexts, generate more robust validity tests and more fully describe and measure the experiences of persons exposed to moral harms. Absent from the literature is a mechanism through which to move from the collective moral injury experience of physicians to a systematic change in the structure of medical practice. To address this, after providing a brief history, definitions and contrasts between burnout, moral distress and moral injury, we review the interplay of moral and ethical codes in the context of moral injury. We conclude by suggesting that professional associations can potentially prevent moral injury by providing protections for physicians within their codes of ethics.