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.     

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.     

Portraits of emigration: sour milk and honey in the promised land

This article analyzes the moral tones of public emigration stories through an exploratory analysis of newspaper stories published between 1990 and 1993 in a region in Poland with a century-old tradition of out-migration. Media stories are fertile ground for examining values and myths because they negotiate between the micro-level process of individuals constructing meanings and the macro-level process of political economies producing meanings. I identified two sets of contradictory stories: (1) stories about the sending country cast emigrants as either home builders or home wreckers, and (2) stories about the receiving country depicted America as either Horatio Alger's land of possibility or a morally degenerate place where greed corrupts the soul. To explain these contradictions, I compare the institution of migration to (post)modern culture and note that both contribute to social diversity and structural differentiation which lead to value inconsistencies.     

Is there evidence to show that fetal alcohol syndrome can be prevented?

Fetal Alcohol Syndrome (FAS) is currently the major cause of mental retardation in the Western world. Since FAS is not a natural phenomenon and is created by mixing alcohol and pregnancy, the solution to decreasing the incidence of all alcohol-related birth defects is therefore entirely preventable. To date, little is known about the effectiveness of prevention programs in reducing the incidence of FAS. Therefore, it is the intention of this article to review the effectiveness of prevention programs in lowering the incidence of FAS. The present review revealed that prevention programs, to date, have been successful in raising awareness of FAS levels across the groups examined. However, this awareness has not been translated into behavioral changes in "high risk" drinkers as consumption levels in this group have decreased only marginally, indicating prevention programs have had minimal or no impact in lowering the incidence of FAS. Urgent steps must now be taken to fully test prevention programs, and find new strategies involving both sexes, to reduce and ultimately eliminate the incidence of FAS.     

Do male dropouts benefit from obtaining a GED, postsecondary education, and training?

The authors use longitudinal data from the National Longitudinal Survey of Youth to investigate whether the wage trajectories of male high school dropouts are affected by the acquisition of the General Educational Development (GED) credential, by postsecondary education, and by training. The authors show that acquisition of the GED results in wage increases for dropouts who left school with weak skills, but not for dropouts who left high school with stronger skills. College and training provided by employers are associated with higher wages for male dropouts.     

A comparative assessment of public opinion toward immigrants and immigration policies

"This article is part of a larger study of public attitudes toward immigration in seven countries that historically and currently have had different policies and practices vis-a-vis immigration. The countries involved are Australia, Canada, France, Germany, Great Britain, Japan and the United States. The time frame for which most of the public opinion data will be reported is from 1970 through 1995. The data have been collected from national surveys that were conducted in each of the countries."     

Multilevel mediation modeling in group-based intervention studies

This article proposes and evaluates a method to test for mediation in multilevel data sets formed when an intervention administered to intact groups is designed to produce change in individual mediator and outcome variables. Simulated data of this form were used to compare ordinary least squares (OLS) and two multilevel estimators of the mediated effect. OLS and multilevel standard error approximations were also evaluated and recommendations given for optimal estimator choice. These methods were applied to data from an existing substance use intervention to show the impact multilevel mediation modeling can have on the conclusions drawn from real-world evaluation studies.     

Terrorist Population Dynamics Model

A system that includes a number of terrorist cells is considered. The cells can consist of one or more terrorists. The current number of terrorist cells is further denoted by N(t), where t is a current time counted from any appropriate origin. The objective is to find the evolution of the system in terms of N(t) and some interpretable parameters, such as the initial number of the terrorist cells N0=N(0), the cell disabling rate constant lambda (or the cell half-life t1/2), and the rate of formation of new cells P. The cost-effectiveness analysis, performed in the framework of the model, reveals that the effectiveness of disabling a terrorist cell is getting worse after 2-3 half-lives of a cell, which shows that if the anti-terrorist actions have not reached their goal during that time, the respective policy should be considered for revision, using the risk assessment consideration. Another important issue raised concerns balancing the efforts related to counterterrorism actions inside the system and the efforts protecting its borders. The respective data analysis is suggested and illustrated using simulated data.     

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.