Psychosocial versus biomedical risk factors in Kevorkian's first forty-seven physician-assisted deaths

This article examines biomedical and psychosocial data on the first forty-seven cases of physician-assisted suicide (PAS) of Kevorkian as collected by means of both a physical autopsy and a preliminary psychological autopsy. The following patterns emerge: 1) The physical condition of these PAS patients was not typical of the conditions that lead to death in the United States. 2) Consistent with the above findings, our pilot data indicate that only 31.1 percent of these patients were terminal. While 73.9 percent were described as reporting pain, only 42.6 percent were revealed at autopsy to have a specific anatomical basis for their pain. However 36 percent were described as depressed, 66 percent as having some disability, and perhaps of key importance, 90 percent expressed a fear of dependency. Most important, our pilot data suggest the possibility of large gender differences, since 3) 68.1 percent of these forty-seven PAS's are women and only 31.9 percent are men. This represents the reverse of the gender pattern for completed suicides in the United States in 1995, resembling instead the approximate pattern for unsuccessful suicide attempts. 4) Approximately 75 percent of both men and women in the above sample were described as reporting pain. Men were almost twice as likely to have had an anatomical basis for the pain and three times as likely to be terminal. Our pilot data indicate PAS women are more likely to be described as depressed and twice as likely to have had a history of previous unsuccessful suicide attempts. 5) Kevorkian's patients were older than the typical unaided suicides in America. Reported pain decreases with age as does depression; however anatomical basis for pain increases slightly with age, and no age effect emerges for terminality. 6) Approximately two-thirds of those physician-assisted suicides were at middle SES levels. History of disability was the biggest risk factor for the low SES patients and fear of dependency for the high SES patients.     

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.     

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.     

The Determinants of Expenditure on Children's Personal Social Services

¹ Peter C. Smith, Centre for Health Economics, University of York, York YO1 5DD, UK. E-mail: pcsl{at}york.ac.ukAbstract Summary This paper reports the results of a statistical study of thedeterminants of expenditure on children's social services intwenty-five local authorities in England. The study was commissionedas part of the Government's review of Standard Spending Assessmentsfor Personal Social Services. The study combined data from avariety of sources, including local authority registers, toinfer the distribution of expenditure between 1,036 small areaswith populations of about 10,000. Multilevel statistical techniqueswere used, and suggested that the principal determinants ofexpenditure are children in lone parent families, children infamilies of income support claimants, children living in flats,children with limiting long-standing illness, and populationdensity. As well as these results, the study yielded importantinsights into potential improvements for Standard Spending Assessmentmethodology.     

Homeless mothers and depression: misdirected policy.

This paper is a critique of recent service-intensive shelter programs for homeless mothers and the policies that underlie these shelters. We first document the process by which mental health problems and family homelessness became so closely but mistakenly linked. We then demonstrate empirically that shelter programs for homeless families nonetheless presume that mental health problems are part of the causal nexus of family homelessness and indiscriminately deliver mental health services to homeless mothers. Simultaneously, shelter programs encourage the isolation of their residents from what they presume to be their "problematic" social networks. We show that, while mental health services had little impact on depression levels among homeless mothers, isolation from social networks did increase depression among homeless mothers. Our findings suggest that policy should put more emphasis on rapid reintegration into the community through providing housing, and it should put less emphasis on providing services.     

Marriages and fertility among Turkish and Moroccan women in Belgium: results from census data

The patterns of family formation and fertility behavior of Turkish and Moroccan women in Belgium are changing rapidly. The census data (1991) indicate a fertility decline. The reasons are changes in the nuptiality patterns, contraceptive behavior, and migratory flows. The changes are not identical in both communities. Young cohorts postpone their marriage, but this is most prominent among Moroccan women. On the other hand, young Turkish women have a clear preference for smaller families. The changes also differentiate according to migrant "generation" and level of education. The changes are not restricted to Belgium but are also observed in the countries of origin.     

Treatment of noncustodial fathers: Gender issues and clinical dilemmas

This article addresses issues involved in the treatment of fathers who do not have custody of their children. It reviews literature on demographic trends and discusses fathers' reactions to loss of child custody. Assessment and treatment guidelines are offered so that clinical practice may become more responsive to the needs of the population. Gender concerns, particularly as they relate to transference and countertransference, are also discussed.     

Character-Based Determinants of Trust in Leaders

Trust is a prominent determinant of effective interpersonal relationships, group process, and organizational development. However, for leaders and managers, trust building is often problematic. The aim of this article is to contribute to a growing understanding of the way in which individual managers can develop trust in organizations, particularly those defined by medium to high risk. The article presents a theoretical and empirical analysis of the nature of trust at work. Building on the results of an earlier study, use is made of the facet-theoretical approach to generate a definitional framework of trust, which focuses on the characteristics of the trusted person that contribute to the development of trust. Using items developed on the basis of a mapping sentence, hypotheses regarding the relations between the definitional framework and empirical observations were tested through smallest space analysis (SSA) of data collected from a sample of 398 bank and hospital employees. The results demonstrate strong support for the definitional system and show a clear association with results of prior research that identify perceptions of ability, integrity, fairness, and openness as key determinants of trust. The empirical structure clearly reflects the attitudinal nature of interpersonal trust at work and the items empirically distinguish distinct character-based components of trust.