A guerra dos mundos ou as relações institucionais entre a homeopatia e a medicina científica / War of Worlds or The institutional relations between Homeopathy and Scientific Medicine

O Objetivo deste trabalho é tratar da Homeopatia e da Medicina Científica, e de sua convivência institucional, considerando principalmente o cenário posterior à década de 1980, quando de sua assimilação pela Medicina Oficial brasileira. O que se pretende demonstrar, fundamentalmente, é que a Medicina Científica e a Homeopatia são essencialmente diferentes, e acima de tudo demonstrar que este caso particular de relações institucionais deve ser entendido sob pelo menos duas perspectivas, de uma epistemológica, e de outra sociológica. Essas duas perspectivas são essenciais para entender a moderna relação institucional entre Homeopatia e Medicina Científica, que acontece num contexto de assimilação institucional da Homeopatia pela Medicina Oficial. Ainda que essa integração nunca possa vir à ser concretizada completamente, essa assimilação é resultado de uma grande mudança no universo simbólico das culturas ocidentais, principalmente dos conceitos e valores ligados ao imaginário da saúde. Neste novo contexto simbólico, a ciência como instituição é ressignificada e e devidamente recontextualizada, em termos de cultura popular e senso comum (universo simbólico da vida cotidiana), de modo que passa a poder acomodar os mais diversos tipos de conhecimentos em seu universo. É sob a perspectiva do processo de racionalização e desencantamento do mundo que essas instituições são analisadas e a compreensão dos universos simbólicos mantidos por cada grupo é o objetivo central desse trabalho.(AU)

This study deals with Homeopathy and Scientific Medicine and focus its institutional relationship, especially considering the latter scenario to the 1980s decade, after its assimilation by brazilian Official Medicine. It intends to demonstrate that Scientific Medicine and Homeopathy are fundamentally and essentially different things and, above all, demonstrate that this particular case of institutional relations should be understood in, at least, two perspectives: epistemological, and sociological. These perspectives are essential to understand the modern relationship between Homeopathy and Official Medicine -­ which takes place in a context of institutional assimilation of homeopathy by the Official Medicine (although this integration could never come to be fully realized). This assimilation is the result of a change in the symbolic universe of western cultures, especially the concepts and values linked to the health imaginary. In this new symbolic context, science, as an institution, is resignified and recontextualized in terms of popular culture and common sense (the symbolic universe of everyday life), allowing to accommodate all different types of knowledge in this new resigninified universe of science. Its from the process of rationalization and disenchantment of the worlds perspective that these institutions are analyzed, and the understanding of the symbolic universes maintained by each group is the central objective of this work.(AU)

Integration of primary health services: being put together does not mean they will work together.

BACKGROUND: This paper reports on an Australian experience of co-locating a range of different primary health services into one building, with the aim of providing integrated services. It discusses some of the early challenges involved with moving services together and reasons why collaborative and integrated working relationships to improve the clients' journey, may remain elusive. METHODS: Ethnographic observational data was collected within a GP plus site as part of day-to-day interactions between the research officer and health professionals. This involved observations of team processes within and across teams at the site. Observations were thematically analysed using a social anthropological approach. RESULTS: Three main themes arose from the analysis: Infrastructural impediments to collaboration; Territorialism; and Interprofessional practice (IPP) simply not on the agenda. The experience of this setting demonstrates that dedicated staff and resources are needed to keep IPP on the agenda of health service organisations. This is especially important where organisations are attempting to implement new models of collaborative and co-located services. Furthermore, it shows that establishing IPP within newly co-located services is a process that needs time to develop, as part of teams building trust with each other in new circumstances, in order to eventually build a new cultural identity for the co-located services. CONCLUSIONS: Co-located health service systems can be complex, with competing priorities and differing strategic plans and performance indicators to meet. This, coupled with the tendency for policy makers to move on to their next issue of focus, and to shift resources in the process, means that adequate time and resources for IPP are often overlooked. Shared interprofessional student placements may be one way forward.

Psychosomatic medicine and psychiatry residents: a pan-Canadian survey.

BACKGROUND: Psychosomatic medicine (PM) is recognized as a psychiatric subspecialty in the US, but continues to be considered a focused area of general psychiatric practice in Canada. Due to the unclear status of PM in Canada, a national survey was designed to assess the perception of and training experiences in PM among psychiatry residents. METHODS: Residents enrolled at one of 13 psychiatry programs in Canada participated in the study. Logistic regression analyses were conducted to assess the effect of PM training experiences and career interest in PM on the perception of PM, controlling for number of months already completed in PM, training level, and residency program. RESULTS: The response rate was 35%, n = 199. 68% of respondents identified PM as a definite subspecialty, with the majority of respondents believing that PM was as important a subspecialty as child (53%), forensic (67%) and geriatric psychiatry (75%). Eighty percent of the respondents believed a PM specialist should complete more than 3 months of additional training to be competent/qualified. There was significant heterogeneity in training experiences across programs, with a differential effect of certain training components-seminar, journal club-associated with a more favorable perception of PM as a subspecialty. CONCLUSIONS: The above results challenge the notion that PM represents only a focused area of general psychiatric practice in Canada. PM appears to require additional training beyond residency for trainees to feel competent and qualified. Results from this survey suggest Canada should follow the US lead on recognizing PM as a subspecialty.

Norwegian priority guidelines: estimating the distributional implications across age, gender and SES.

OBJECTIVE: Targeting hospital treatment at patients with high priority would seem to be a natural policy response to the growing gap between what can be done and what can be financed in the specialist health care sector. The paper examines the distributional consequences of this policy. METHOD: 450000 elective patients are allocated to priority groups on the basis of medical guidelines developed by one of the regional health authorities in Norway. Probit models are estimated explaining priority status as a function of age, gender and socioeconomic status. RESULTS: Women and older people are overrepresented among patients with low priority. Conditional on age, women with low priority have lower income and less education than women with high priority. Among men below 50 years, patients with low priority have less education than patients with high priority. CONCLUSION: Targeting hospital treatment at patients with high priority, though sensible from a pure medical perspective, may have undesirable distributional consequences.

Topical anaesthesia in children: reducing the need for specialty referral.

OBJECTIVE: The management of wounds in children is stressful, not only for the child, but also for parents and staff. In our Emergency Department (ED), we currently do not have a paediatric sedation policy, and thus children requiring suturing, not amenable to distraction and infiltrative anaesthesia, are referred to specialty teams for general anaesthesia. We proposed that the introduction of a topical anaesthetic gel (lidocaine, adrenaline, tetracaine - LAT) might help to reduce the number of referrals, by allowing the ED staff to perform the procedures, in combination with nonpharmacological approaches. METHODS: We carried out a retrospective review of ED records of all children aged 14 years or less attending with wounds, over an 8-month period, from 01 May 2007 to 31 January 2008. RESULTS: Two hundred and one (50.6%) patients presented before the introduction of LAT gel, whereas 196 (49.3%) patients presented afterwards. A total of 39 (19.4%) patients were referred for specialty review pre-LAT, whereas only 19 (9.7%) patients were referred in the LAT group. Of these, 31 (15.4%) pre-LAT and 15 (7.7%) LAT group required general anaesthesia. There is a significant difference between these two groups, using Fischer's exact test, P=0.018. CONCLUSION: We have found that the introduction of topical anaesthetic gel in ED has significantly reduced the number of children with wounds referred to specialty teams for general anaesthesia. This has important implications for patient safety and hospital resources.

Integrated musculoskeletal rehabilitation care at a comprehensive combat and complex casualty care program.

OBJECTIVE: The purpose of this study is to describe the musculoskeletal rehabilitation model used to care for combat and severely wounded or ill US military service members at an integrated Comprehensive Combat and Complex Casualty Care center located at Naval Medical Center San Diego. METHODS: Through a collaborative and iterative process, providers from the various services included at the Comprehensive Combat and Complex Casualty Care program developed a description of the integration of services provided at this location. RESULTS: After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers. CONCLUSION: The complex nature of combat wounded and polytrauma patients requires an integrated and interdisciplinary team that is innovative, adaptable, and focused on the needs of the patient. This article presents a description of the model and the experiences of our musculoskeletal rehabilitation team; it is our hope that this article will assist other centers and add to the small but emerging literature on this topic.

Do socio-economic factors, elderly population size and service development factors influence the development of specialist mental health programs for older people?

BACKGROUND: Despite the increase in the proportion of older people in the population, little is known about factors that facilitate the development of specialist mental health services for older people. METHODS: The relationship between the presence of specialist mental health programs for older people and elderly population size, proportion of older people in the population, gross national domestic product (GDP), and various parameters of health funding, mental health funding and mental health service provision was examined in an ecological study using data from the World Health Organization. RESULTS: The presence of specialist mental health programs for older people was significantly associated with higher GDP, higher expenditure on healthcare and mental healthcare, the presence of a national mental health policy and a national mental health program, the availability of mental health care in primary care and the community, and higher density of psychiatric beds, psychiatrists, psychiatric nurses, psychologists and social workers. CONCLUSION: The challenge will be to persuade policy-makers in low and medium income countries, where the increase in the elderly population is most rapid, to develop specialist mental health services for older people.

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia.

BACKGROUND: This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada. METHODS: A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND(R)/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7-9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic. RESULTS: Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57). CONCLUSION: A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

Greek medical students' career choices indicate strong tendency towards specialization and training abroad.

The aim of the study was to investigate the career choices, location preferences and criteria among medical students in Greece. We applied a questionnaire-based analysis using a sample of 591 students of four out of seven Greek Medical Schools. The sample included students of all academic years. The vast majority of students wish to specialize (97.6%), while general practice gathered a very low percentage (1.7%). The scientific challenge (61.4%) and interaction with patients (60.6%) seem to be the major influencing factors for most of the students' specialty preferences, whilst less common variables influencing career choice are the high demand/supply ratio for certain health services (40.4%), the income potential (31.4%), the active tempo (26.2%) and prestige (15%). 70.3% of those asked consider the possibility of specializing abroad. The low concern of Greek medical students for general practice reveals today's drastic deficiency in Greek primary health care. Such a situation will escalate, unless targeted strategies to produce more general practitioners are adopted. Furthermore, the results reflect a lower education and organizing level urging students to specialize abroad. The National Health System (NHS) should be reformed towards a rationalistic distribution of the medical specialties and medical workforce.

Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science.

People in remote Aboriginal communities in the Northern Territory have greater morbidity and mortality than other Australians, but face considerable barriers when accessing hospital-based specialist services. The Specialist Outreach Service, which began in 1997, was a novel policy initiative to improve access by providing a regular multidisciplinary visiting specialist services to remote communities. It led to two interesting juxtapositions: that of 'state of the art' specialist services alongside under-resourced primary care in remote and relatively traditional Aboriginal communities; and that of attempts to develop an evidence base for the effectiveness of outreach, while meeting the short-term evaluative requirements of policy-makers. In this essay, first we describe the development of the service in the Northern Territory and its initial process evaluation. Through a Cochrane systematic review we then summarise the published research on the effectiveness of specialist outreach in improving access to tertiary and hospital-based care. Finally we describe the findings of an observational population-based study of the use of specialist services and the impact of outreach to three remote communities over 11 years. Specialist outreach improves access to specialist care and may lessen the demand for both outpatient and inpatient hospital care. Specialist outreach is, however, dependent on well-functioning primary care. According to the way in which outreach is conducted and the service is organised, it can either support primary care or it can hinder primary care and, as a result, reduce its own effectiveness.

Building legitimacy and the early growth of health networks for the uninsured.

An integrated system of health care for serving the uninsured population of one community was followed from formation through early growth. Funding was provided through the Health Resources Services Administration's Community Access Program to bring together a diverse set of health care providers to form a collaborative network managed by a central administrative entity. Legitimacy building was critical for explaining how the network evolved and the effectiveness of the network in sustaining itself and building a patient base. Based on the study's results, conclusions are drawn that contribute to theory on network legitimacy in health care. In addition, lessons learned are offered that may help other communities address the health needs of the uninsured through collaborative health care networks.

The impact of accessibility on the use of specialist health care in Norway.

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.