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.     

IOM/UNFPA project on emigration dynamics in developing countries

The author briefly reviews a special section of papers in this issue of International Migration. The papers focus on aspects of a project on emigration dynamics in developing countries.     

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.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.     

Mirror, mirror on the wall: reflections from failure to establish a truly uniform national health care policy

When the author gazed into the proverbial mirror and asked if the U.S. health care system was the fairest of them all, it shattered. In this article, Thompson tells why the system is broken and what failure to fix it means to physician executives. He suggests that we, as Americans, must reinvent ourselves by realigning our value systems and and stifling our obsession with profit before trying to reinvent health care.     

Analgesia produced in women by genital self-stimulation

This study investigated the relative effectiveness of specific genital regional self-stimulation in elevating pain thresholds. Anecdotal reports in humans suggest that sexual activity and orgasm decrease a wide variety of human responses to pain and touch, but the phenomenon has not been evaluated objectively. Two types of self-stimulation, pressure and pleasurable, were applied by 10 women to the anterior vaginal wall, the posterior vaginal wall, and the clitoris. Significant increases in pain thresholds but not tactile thresholds occurred when pressure stimulation was applied to the anterior wall of the vagina or when "pleasurable" self-stimulation was applied to any of the three areas. Tactile thresholds were not significantly affected by any genital stimulation condition. However, there was a significant increase in tactile threshold but not pain thresholds in the distraction control condition. On the basis of these findings, we conclude that (a) a sensation of pleasure evoked by genital stimulation can elevate pain thresholds, (b) these pleasurable stimuli were not general "distractants" because they elevated pain thresholds but not tactile thresholds differentially, and (c) genital pleasurable stimuli activate an analgesic process that is distinct from a distraction process.