How to fire a physician

How does one fire a physician? In a word, carefully! Most of the legal protections for other employees apply just as well to physicians. And physicians have access to an expanded realm of protections because of the nature of their profession and because of its role in the health care delivery system. The ordinary employee cannot raise antitrust; the fired physician may very well raise just that issue. And yet the need to terminate a physician will sometimes, even though rarely, occur. How can the organization be certain that it has treated the physician fairly, has documented any and all offenses in a defensible fashion, and has generally followed accepted practices in all aspects of dealing with the physician? The author provides some guidelines for dealing with the problem or the incompetent physician.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.     

Occupational status and mobility among undocumented immigrants by gender

Immigration has long been a national and state concern. The 1989 Legalized Population Survey (LPS-1) collected data on illegal immigrants to the US who subsequently became legalized aliens under the provisions of the 1986 Immigration Reform and Control Act. These data are used in a study assessing whether undocumented male and female immigrants improve their earnings and occupational status over time and the extent of variation in occupational status and mobility by gender and region. The data indicate that both undocumented men and women, on average, improved their earnings and occupational status between their first jobs in the US and their jobs just before applying for legalization under the 1986 Immigration Reform and Control Act. However, the earnings, occupational status, and occupational mobility of men were greater than for women.     

A tobacco and alcohol use profile of San Francisco's Chinese community

Relatively little is known about Asian American tobacco and alcohol use patterns. This is particularly true of Chinese living in the United States--either U.S.-born or non-U.S.-born Chinese. This article presents data from a research project studying tobacco and alcohol use patterns in San Francisco's Chinese community. Data were secured both from focus groups and a self-report telephone survey of a random sample of 1,808 Chinese residents in San Francisco. This results indicate that the prevalence of both tobacco and alcohol use is lower for San Francisco's Chinese population than for the general population. Moreover, those persons who report smoking tend to be different from those who report consuming alcohol. The study concludes that specific, culturally relevant tobacco and alcohol prevention programs should be designed to better reach this target population.     

Quality. A tightrope for the '90s

How accurately can you measure quality of care in health care? Recently, HMOs and other types of managed care organizations have been in the process of defining quality in quantitative terms. Physicians who utilize fewer resources and who care for more patients per-unit-of-time are valued as providing better care than colleagues who may work at a slower (more expensive?) pace. The pressure to evaluate or treat greater numbers of patients in shorter periods of time can produce adverse consequences. And numbers do not necessarily take into account the quality of the care delivered. There is clearly a middle road. Physicians must take care of a sufficient number of patients with a given problem to gain and maintain expertise and mastery. But they must also guard against the insidious pressure for the procedure to become the end in itself.     

The medical practice as business organization

Medical practices historically have not been examined in terms of their organizational structures and of the appropriateness of their structures for survival as business entities. In this paper, we propose a model for the typical medical practice and discuss its fit with current organizational theory. It is apparent that the medical practice organization does not fit with the demands of a rapidly changing and complex environment. To survive and grow, the medical practice organization must align itself with others that have an interest and stake in the health care system, develop teamwork among physicians, bridge the gap between physicians and others in the organization, and recognize that the work done in the organization depends on other components of the organization.     

Mandatory seat belt laws in the states. A study of fatal and severe occupant injuries

This study examines the impact of mandatory seat belt laws on fatal and incapacitating injury rates in the states. Annual data for all 50 states for the period 1975-1991 are used. Pooled time series analysis is employed. The general conclusion that emerges from this analysis is that seat belt laws significantly impact state fatal injury rates. Primary enforcement and all-seat coverage provisions appear to be particularly effective in reducing fatality rates.     

The health status of elderly people and the new direction of health services

The projected increase of people in Japan aged 75 years and older in the years to come implies the increase of the disabled elderly. Thus, the core of societal preparation for the aging of the population is generally considered to be the expansion of services for the disabled elderly. However, gerontological studies on the health status of the elderly conducted in Japan show that the prevalence of disability is quite low and even decreasing. Relative to the services for the disabled elderly, preventive services for the healthy elderly have long been overlooked. In 1994, the Metropolitan Tokyo Government organized a task force to develop a new health education program as the preventive health service for the healthy urban elderly. A preliminary plan outlining the health education program--consisting of propagation with a booklet, on-the-job training of practitioners, and development of new curricula and teaching materials--was proposed by the authors for discussion within the task force. Although the inquiry has just begun and the plan is still nascent, it seems adequate to fit the needs for preventive health services in the near future.     

Going to Pieces: Paul Monette and the Fragments of the Tribe

Author of the highly acclaimed Borrowed Time: An AIDS Memoir (1988) and winner of the 1992 National Book Award for his autobiography Becoming a Man: Half a Life Story, Paul Monette died of complications from AIDS in Los Angeles on February 12, 1995. His most recent work, Last Watch of the Night: Essays Too Personal and Otherwise (1994), is his third volume in a trilogy of autobiographical writing on growing up gay, coming-out, and living with AIDS. A graduate of Phillips Academy and Yale University, Monette received a number of awards for his writing and his work as an outspoken voice in the battle against AIDS, including the National Book Award, three Lambda Literary awards, the PEN Center West Freedom to Write Award, and three honorary doctorate degrees, from Wesleyan University, the City University of New York, and the State University of New York at Oswego. A memorial service was held for Monette on Sunday, February 19, 1995, at the Directors Guild of America on Sunset Boulevard in Los Angeles. Paul Monette was 49.     

Marketing and the medical specialist in the managed care environment

Marketing means more than just communicating or advertising to potential patients; marketing means identifying your customers and working to meet or exceed their expectations. There are five key areas of a marketing plan: (1) Establish the foundation, beginning with your mission statement; (2) Assess your marketing environment by internal and external research; (3) Target your efforts, looking at image and perception; (4) Develop your particular mix of product, price, place of distribution, and promotion; and (5) implement and evaluate your marketing process. This article discusses the importance of a marketing plan for the medical specialist and highlights the features unique to a practice working in a system of capitated reimbursement. Applying these principles will help to demonstrate added value, protect the fundamental role of the patient-physician relationship, ensure that our efforts are aligned with professional missions and goals, and ultimately increase profitability and professional success.