The levers of influence

Physicians often determine the demand for health care services, as well as control the clinical processes aimed at improving health outcomes at the individual and population level. Given their important role in enhancing health status and improving the health care delivery system, it is critical that physician executives master the tools necessary to positively influence physician behavior. But changing behavior is far more complex than "doing it or not doing it." The Nike slogan "just do it" is motivating, but over-simplified. The roots of human change include: consciousness-raising, emotional arousal, commitment, helping relationships, self-reevaluation, reward, and environmental control. A model to effectively influence behavior is presented and includes setting clear expectations, measuring and monitoring performance, providing feedback, and rewarding and recognizing improvement. If all else fails, try discipline. This five-step approach is based on the science of human behavior and working with physicians in diverse settings, ranging from academic medical centers to small practices.     

How to shape positive relationships in medical practices and hospitals

Managing workplace conflict is one of the most important, stressful, and time-consuming tasks faced by today's medical leaders. Poorly managed workplace conflict can alienate patients, demoralize staff, increase turnover, damage relationships with valued referral sources and third party carriers concerned about patient satisfaction, and lead medical practices to costly "corporate divorces." Physician executives cannot solve the problems caused by disruptive doctors simply by bolstering their own conflict management skills or by policing offenders. The larger contexts within which inappropriate workplace behavior occurs must also be assessed and addressed. The true leadership challenge is to intervene in ways that help to foster a "culture" of appropriate interpersonal dynamics throughout your organization. This requires learning to think and to intervene systematically.     

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.     

Is there a relationship between burnout and objective performance? A critical review of 16 studies

Previous research has suggested that high levels of burnout lead to impaired functioning on the job. However, as this research has usually relied on self-reported performance, it is imperative to examine whether this association is also confirmed when using “objective” performance data (e.g., supervisor reports). This study reviewed previous research on the associations between burnout (exhaustion, depersonalization, and personal accomplishment) and various types of objective performance. A systematic literature search identified 16 studies dealing with the burnout-performance relationship. These studies showed the wide variety of approaches that are used to study burnout and objective performance. Using data from these 16 studies, a meta-analysis was conducted to obtain mean correlations. The meta-analytical correlations between exhaustion and in-role behaviour (based on five studies), organizational citizenship behaviour (OCB; five studies), and customer satisfaction (two studies) were -.22, -.19, and -.55, respectively, underlining the practical relevance of burnout research for organizational performance. The evidence for the relationships between depersonalization, personal accomplishment, and performance was inconclusive. Future research should focus on valid indicators of job performance, should more often employ longitudinal designs and large samples, and should consider the theoretical basis for the study expectations more extensively.     

The Opinions of Minorities About Preparing for Work: Report of the Second NCDA National Survey

A report of the 1989 NCDA survey of the perceptions of American adults of their career planning, the nature of their workplaces, and the availability of and utility of occupational information is presented. The survey, which was administered by the Gallup Organization, included an oversampling of Hispanics, African Americans, and Asian-Pacific Islanders. Although the results for all groups including Whites are presented, the emphasis is upon the perceptions of minority groups.     

Bandwidth selection for local linear regression smoothers

Summary. The paper presents a general strategy for selecting the bandwidth of nonparametric regression estimators and specializes it to local linear regression smoothers. The procedure requires the sample to be divided into a training sample and a testing sample. Using the training sample we first compute a family of regression smoothers indexed by their bandwidths. Next we select the bandwidth by minimizing the empirical quadratic prediction error on the testing sample. The resulting bandwidth satisfies a finite sample oracle inequality which holds for all bounded regression functions. This permits asymptotically optimal estimation for nearly any regression function. The practical performance of the method is illustrated by a simulation study which shows good finite sample behaviour of our method compared with other bandwidth selection procedures.     

Melanie klein's work: An adaptation in practice

Kleinian theory seems both intimidating and alien to many American psychotherapists. This paper offers an entry into Klein's work. The theory is approached by emphasizing three areas especially valuable in clinical practice: mourning and manic defenses, schizoid relationships, and envy and idealization. A detailed presentation of an individual psychotherapy case is offered as an illustration of how her ideas may be integrated into a broader objectrelations treatment perspective.     

Preparation,support, and satisfaction of adoptive families in agency and independent adoptions

Information gathered from over 1000 adoptions in the fourth year of a prospective study of adoptions finds satisfaction levels to be quite high, with those families adopting through private agencies to feel best prepared and satisfied. Differences by adoption auspice are detailed and discussed.The senior authors are Co-Principal Investigators of the California Long-range Adoption Study. This research was supported by the Child Welfare Research Center, Family Welfare Research Group, University of California at Berkeley, through a grant from the Children's Bureau, Administration for Children and Families, Department of Health and Human Services. The authors wish to thank the families for their participation. Please address correspondence to Mary Berry at the Center for Child Welfare, UTA School of Social Work, P.O. Box 19129, Arlington, Texas 76019.     

UNDERSTANDING AND TREATING POST-TRAUMATIC STRESS DISORDER SYMPTOMS IN FEMALE PARTNERS OF VETERANS WITH PTSD

Studies of post-traumatic stress disorder have focused primarily on veterans, generally ignoring their female partners (wives or girlfriends). recently, clinicians have begun to identify PTSD-like symptoms in these female partners, but the literature describing this phenomenon has been limited. This paper addresses the fact that women in long-term relationships with veterans suffering from PTSD commonly experience PTSD-like psychiatric symptoms themseoves. These wonem's symptoms and issues they face in their relationships with their veteran partners are described. Conceptual explanations of and causal factors for these women's symptoms are presented, followed by discussion of treatment approaches and issues.