Is the American health care delivery system ready for change?

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and on-site visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. In a series of reports that began in the July issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. In this final report, the implications of the German and Dutch systems for reform of the U.S. health care system are discussed.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

Ropes course training for youth in a rural setting: “At first I thought it was going to be boring ...”

Outdoor structured activities, such as Ropes Challenge Courses, are typically utilized as interventions for youth coming from urban settings. Evaluation of such programs is scanty at best. In this instance, the course experience is used as a prevention tool for high risk youth in a remote, rural setting of high unemployment, alcohol problems, and low income. The authors discuss the effectiveness of this approach, and the intended and unintended consequences for the rural community at large. The evaluation design relies on extensive qualitative methodology as well as quantitative methods to capture the unique nature of this rural project.     

Freud's “Anna O.”: Social work's Bertha Pappenheim

The story of Anna O. has loomed large in psychoanalytic history, but few social workers know that the young woman, who was so influential in the development of Freud's thinking, became a pioneer social worker in Germany. The story of the transformation of the troubled young woman, who was actually Joseph Breuer's patient, is the focus of this paper. In addition, some of the facts of the case are discussed as social constructions. Anna O./ Bertha Pappenheim participated in the creation of the talking cure and eventually went on to be a leading feminist, developer of social programs for women, and social reformer.     

Psycho-social impacts of terrorism and organized crime: The counterfinality of the practico-inert

The phrase, the counterfinality of the practico-inert is from Sartre with reference to implications of modern technology as a shorthand for that enormous properly human and anti-natural power of dead human labor stored up in our machinery — an alienated power, which turns back on and against us in unrecognizable forms and can symbolize the massive dystopian horizon of organized crime as well as individual terrorist praxis (Jean-Paul Sartre (1948).Situations II. Paris: Gallimard).     

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.