Health Risk Assessment of a Modern Municipal Waste Incinerator

During the modernization of the municipal waste incinerator (MWI, maximum capacity of 180,000 tons per year) of Metropolitan Grenoble (405,000 inhabitants), in France, a risk assessment was conducted, based on four tracer pollutants: two volatile organic compounds (benzene and 1, 1, 1 trichloroethane) and two heavy metals (nickel and cadmium, measured in particles). A Gaussian plume dispersion model, applied to maximum emissions measured at the MWI stacks, was used to estimate the distribution of these pollutants in the atmosphere throughout the metropolitan area. A random sample telephone survey (570 subjects) gathered data on time-activity patterns, according to demographic characteristics of the population. Life-long exposure was assessed as a time-weighted average of ambient air concentrations. Inhalation alone was considered because, in the Grenoble urban setting, other routes of exposure are not likely. A Monte Carlo simulation was used to describe probability distributions of exposures and risks. The median of the life-long personal exposures distribution to MWI benzene was 3.2·10^–5 g/m³ (20th and 80th percentiles = 1.5·10^–5 and 6.5·10^–5 g/m³), yielding a 2.6·10^–10 carcinogenic risk (1.2·10^–10–5.4·10^–10). For nickel, the corresponding life-time exposure and cancer risk were 1.8·10^–4 g/m³ (0.9.10^–4 – 3.6·10^–4 g/m³) and 8.6·10^–8 (4.3·10^–8–17.3·10^–8); for cadmium they were respectively 8.3·10^–6 g/m³ (4.0·10^–6–17.6·10^–6) and 1.5·10^–8 (7.2·10^–9–3.1·10^–8). Inhalation exposure to cadmium emitted by the MWI represented less than 1% of the WHO Air Quality Guideline (5 ng/m³), while there was a margin of exposure of more than 10⁹ between the NOAEL (150 ppm) and exposure estimates to trichloroethane. Neither dioxins nor mercury, a volatile metal, were measured. This could lessen the attributable life-long risks estimated. The minute (VOCs and cadmium) to moderate (nickel) exposure and risk estimates are in accord with other studies on modern MWIs meeting recent emission regulations, however.     

Distribution of Exposure Concentrations and Doses for Constituents of Environmental Tobacco Smoke

The ultimate goal of the research reported in this series of three articles is to derive distributions of doses of selected environmental tobacco smoke (ETS)-related chemicals for nonsmoking workers. This analysis uses data from the 16-City Study collected with personal monitors over the course of one workday in workplaces where smoking occurred. In this article, we describe distributions of ETS chemical concentrations and the characteristics of those distributions (e.g., whether the distribution was log normal for a given constituent) for the workplace exposure. Next, we present population parameters relevant for estimating dose distributions and the methods used for estimating those dose distributions. Finally, we derive distributions of doses of selected ETS-related constituents obtained in the workplace for people in smoking work environments. Estimating dose distributions provided information beyond the usual point estimate of dose and showed that the preponderance of individuals exposed to ETS in the workplace were exposed at the low end of the dose distribution curve. The results of this analysis include estimations of hourly maxima and time-weighted average (TWA) doses of nicotine from workplace exposures to ETS (extrapolated from 1 day to 1 week) and doses derived from modeled lung burdens of ultraviolet-absorbing particulate matter (UVPM) and solanesol resulting from workplace exposures to ETS (extrapolated from 1 day to 1 year).     

Attracting qualified physicians to underserved areas. Part 2. Pay physicians more to practice in underserved areas.

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part I of this article, which appeared in the November/December issue of The Physician Executive, reviewed the efficacy of these approaches. The second part explores a more pragmatic option: to simply improve the working conditions and pay substantially more to physicians who practice in "less desirable" locations. Although this idea is consistent with economic principles, drawbacks must be considered, such as: (1) the American taxpayers' reluctance to finance a more costly health care delivery system for the poor; (2) the inherent conceptual difficulties of a capitated Medicaid HMO serving as the linchpin for organizing, financing, and delivering care for the underserved; and, (3) many providers being expected to react in a fairly litigious manner to such an approach.     

Physician anger, Part 2. More on the dance of anger.

This article is a follow-up to an interview with Charles Dwyer, PhD, which appeared in the 1999 March/April issue of The Physician Executive. He described how physician executives can change the perceptions of today's beleaguered physicians and help them cope with change. We then asked him for some hands-on strategies to deal with physician anger, fear, and resentment. After much contemplation on providing a list of "fixes" that will restore each of us to a state of greater satisfaction, Dr. Dwyer concludes that there are no generalizable solutions because there are too many variables that come into play in each organization, individual, or group. Attending to the self can provide both individual rescue from these turbulent times and the best hope for changes in the system from which patients and health care providers can benefit. If physicians are to regain their power and maintain, or even improve, their quality of life, clearly changes are called for. And these are changes that require persistent effort and uncomfortable adjustments.     

Conflict management, Part 1. Conflict management checklist: a diagnostic tool for assessing conflict in organizations

Complex interpersonal conflicts are inevitable in the high speed, high stakes, pressured work of health care. Poorly managed, conflict saps productivity, erodes trust, and spawns additional disputes. Well managed, conflict can enhance the self-confidence and self-esteem of the parties, build relationships, and engender creative solutions beyond expectations. Just as thoughtful differential diagnosis precedes optimum treatment in the doctor-patient relationship, management of conflict is greatly enhanced when preceded by careful assessment. In the first of two articles, the authors present a diagnostic approach, the Conflict Management Checklist, to increase self-awareness and decrease anxiety around conflict.     

What physician executives and health care organizations should expect from each other

Today, interest in defining the role of the physician executive and ensuring this individual is effectively integrated into the organization is high for good reason--the ranks of physician executives are growing. What attributes should health care organizations look for when hiring physician executives and what should they should expect of them once they are on the job? Physician executives should: (1) have demonstrated clinical and management skills; (2) have a comfort level with participatory decision-making; (3) have superb interpersonal skills; and (4) be a champion of the patient. Physician executives should expect the following support from their organizations: (1) varied roles and responsibilities; (2) mentoring by other senior executives; (3) lifelong learning opportunities; and (4) complete support of the management team.     

Improving performance in a contracted physician network

Health care organizations face significant performance challenges. Achieving desired results requires the highest level of partnership with independent physicians. Tufts Health Plan invited medical directors of its affiliated groups to participate in a leadership development process to improve clinical, service, and business performance. The design included performance review, gap analysis, priority setting, improvement work plans, and defining the optimum practice culture. Medical directors practiced core leadership capabilities, including building a shared context, getting physician buy-in, and managing outliers. The peer learning environment has been sustained in redesigned medical directors' meetings. There has been significant performance improvement in several practices and enhanced relations between the health plan and medical directors.     

What are Research Expectations? A Comparative Study of Different Academic Disciplines

This paper is intended to assist professors, administrators, librarians and other members of university level committees that must consider research expectations and research quality in academic fields that they lack. While this is not a problem for field experts, it is a difficulty when people are asked to make decisions in areas of study other than their own. This is commonly the case for senior university professors, librarians and administrators in regards to university wide decisions. The paper investigates this gap, through a study of 27 academic fields in 348 highly regarded universities. We find that there are almost always statistically significant differences in activity between academic fields, regardless of the metric one considers. However, it is possible to understand these differences by comparing the distribution of a known academic field to that of a field that one is not familiar with. Tables and information are provided to assist in the comparison of different fields of study on metrics such as: departmental publications and researcher level metrics of publications, citations, H-index, and total number of co-authors. The information can also be used to support decisions associated with promotion to senior posts such as endowed chairs and professorships. Information regarding specific universities and researchers are included in the data supplement.