Patient involvement and institutional logics: A discussion paper.

The research into patient involvement is seldom concerned with the significance of cultural and structural factors. In this discussion paper, we illustrate our considerations on some of the challenges in implementing the ideal of patient involvement by showing how such factors take part in shaping the ways in which the intentions to involve patients are converted to practical interventions. The aim was to contribute to the approach dealing with contextual and structural factors of significance for patient involvement. With the idea of "institutional logics," borrowed from the Danish scholar, Erik Riiskjaer, we first demonstrate, with examples from our own research, how patient involvement is interpreted differently within the different logics. Then, we show how the different interpretations of patient involvement meet and conflict in mutual competition as the ideals are sought to be converted to practical interventions. At last, we argue that an adequate theoretical model for the development in the future health care system should be expanded with a "patient logic."

Laborist to Obstetrician/Gynecologist-Hospitalist: An Evolution or a Revolution?

The laborist model offers the best approach to standardize care and improve patient safety on the labor unit, improve physician well-being, and decrease physician dissatisfaction/burnout. The concept of the laborist was based on the hospitalist model. The laborist is free of the stresses of a private practice, works a constant and controllable schedule, and can have work shift limitations, thereby eliminating the issue of fatigue and impairment, and improving patient safety while decreasing the potential for adverse outcomes that may result in a liability action. This is what is being demanded both by patients and generation Y physicians.

Evaluación de un programa de educación médica continua: ¿en qué medida los médicos incorporaron en su práctica clínica las conductas recomendadas? / Continuing medical education programme evaluation: ¿did doctors incorporate recommended behaviors in their clinical practice?

Introducción: La Sociedad Argentina de Pediatría desarrolla desde 1992 un programa de actualización con modalidad de educación a distancia (PRONAP). Todos los años se publican temas nuevos y se implementa un cuestionario para explorar el grado de satisfacción de los participantes y recoger opiniones sobre cada uno de los componentes del programa. El propósito de este trabajo es conocer si los médicos están utilizando en su práctica clínica las conductas o recomendaciones promovidas por el PRONAP. Sujetos y métodos: En los cuestionarios de 2008, 2009 y 2010 se incluyó una pregunta de autoevaluación, con cuatro opciones de respuesta, para indagar en qué medida se estaban aplicando en la práctica clínica 24 conductas específicas vinculadas a los temas desarrollados en el programa. Resultados: Se remitieron 22.899 cuestionarios y se recibieron 19.721 respuestas (86%). Los profesionales decían haber incorporado frecuentemente las siguientes conductas: observar en los lactantes pequeños la capacidad de establecer contacto visual (48,8%) e indagar regularmente si a sus pacientes se les habían realizado las pruebas de cribado para hipoacusia (48%). Respecto a las conductas más novedosas, menos del 10% de los profesionales decían que ya las practicaban, y resultaron ser la inclusión del tema de tatuajes y piercings en toda entrevista con adolescentes (6,8%) y la indicación de ácido fólico a todas las adolescentes (6,5%). Conclusiones: Los resultados permitirían afirmar que el PRONAP está influyendo en la práctica clínica, pero es sabido que al utilizar encuestas de opinión autoadministradas o preguntas de autoevaluación, siempre queda la duda sobre la autenticidad de las respuestas

Introduction: Since 1992, Argentina Society of Pediatrics develops an update program (PRONAP) distance education mode. Every year new issues are published. At the end of each year implements a survey to explore the degree of satisfaction of the participants and their assessment of each of the components of the program. The purpose of this work was to do an evaluation of results of the PRONAP. Subjects and methods: Questionnaires from 2008, 2009 and 2010 included a question of self-assessment to investigate the application of 24 recommended behaviors. Results: 22,899 questionnaires were sent and are receiving 19,721 responses (86%). The behaviors that the professionals say that they added frequently, almost always, in clinical practice are: in small infants observe the capacity to establish eye contact (48.8%), and regularly inquire if their patients the tests conducted of screening for hearing loss (48%). Most innovative behaviour, less than 10% of professionals already practicing it, they were: to include the topic of tattoos and piercing in interviews with adolescents (6.8%), and to indicate folic acid to all young woman (6.5%). Conclusions: The results would claim that the PRONAP is influencing clinical practice but it is well known that in selfmanaged questionnaires always have doubt about the authenticity of the answers

Profiles about practice settings of American College of Obstetricians and Gynecologists fellows.

Selection of a practice setting affects duty hours, practice autonomy, institutional relationships, administrative responsibilities, personal finances, and professional satisfaction. To identify national trends in practice settings reported by the College, we evaluated responses by Fellows (and Junior Fellows) in active practice from six College surveys on professional liability issues between 1992 and 2012. Although half of Fellows remained in an independent private practice, a decline was observed among solo health care practitioners (from 32% in 1992 to 19% in 2012). Direct employment increased either in hospital systems (from 5% to 15%) or as academic faculty (from 9% to 12%). The proportion of Fellows employed by either health maintenance organizations (from 4% to 2%) or the government (2%) remained low. We anticipate that practice settings will be increasingly influenced by health care reform, team-based care with use of nonphysician clinicians, physician age, and increasing subspecialization. Future surveys of Fellows about their practice settings, preferably required at the time of Maintenance of Certification, will aid in evaluating practice settings and their influence on quality of care, cost containment, and health care provider satisfaction.

[The practice of Dutch child and adolescent psychiatry - developments over the last fifteen years]. / De Nederlandse kinder- en jeugdpsychiatrie in de praktijk; ontwikkelingen in de afgelopen vijftien jaar.

BACKGROUND: The child and adolescent psychiatry (cap) section of the Dutch Association for Psychiatry intends to keep track of the extent to which CAP is practised and to monitor the way in which it functions. The CAP has conducted three surveys since 1996. This paper reports on the 2012 survey. AIM: To investigate the composition (i.e. age and gender) of specialists working in child and adolescent psychiatry, to find out how much time these psychiatrists really spend on child and adolescent psychiatry and what type of work they actually do; furthermore, to make a list of specific questions such as 24-hour availability, and to note opinions regarding the planned transfer of child and adolescent mental health care facilities to town councils. METHOD: A survey was conducted and an analysis was made of the data collected. RESULTS: The number of specialists practicing child and adolescent psychiatry in the Netherlands, expressed in full-time equivalents, has more than doubled since 1996 (from 183 in 1996 tot 389 in 2012). Compared to 1996, many more of these psychiatrists spend nearly all their time on CAP. The percentage of these specialists working only in private practice remains the same as in 1996 (19%) , although the percentage was lower in 2003 (135). Whereas in 1996 specialists in child and adolescent psychiatry worked mainly as psychotherapists, in 2012 they were working in a broader field, including assessment and pharmacotherapy. CONCLUSION: Dutch CAP has grown substantially over the past 15 years. Growth in psychiatry in general has been even more marked. Considering the current composition of the population, there is only a relatively limited amount of specialised psychiatric help available for people under the age of 20. The impending transfer of CAP mental health care facilities to town councils is a matter of deep concern to professionals and to psychiatrists in particular. Only if CAP investigations continue over the coming years will it become clear that this deep concern is entirely justified.

Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifestyle for physicians?

Over the last 5 years, a new obstetric-gynecologic hospitalist model has emerged rapidly, the primary focus of which is the care and safety of the laboring patient. The need for this type of practitioner has been driven by a number of factors: various types of patient safety programs that require a champion and organizer; the realization that bad outcomes and malpractice lawsuits often result from the lack of immediate availability of a physician in the labor and delivery suite; the desire for many younger practicing physicians to seek a balance between their personal and professional lives; the appeal of shift work as opposed to running a busy private practice; the waning amount of training that new residency graduates receive in critical skills that are needed on labor and delivery; the void in critical care of the laboring patient that is created by the outpatient focus of many physicians in maternal-fetal medicine; the need for hospitals to have a group of physicians to implement protocols and policies on the unit, and the need for teaching in all hospitals, not just academic centers. By having a dedicated group of physicians whose practice is limited mostly to the care of the labor and delivery aspects of patient care, there is great potential to address many of these needs. There are currently 164 known obstetrician/gynecologist hospitalist programs across the United States, with 2 more coming on each month; the newly formed Society of Obstetrician/Gynecologist Hospitalists currently has >80 individual members. This article addresses the advantages, challenges, and variety of Hospitalist models and will suggest that what may be considered an emerging trend is actually a sustainable model for improved patient care and safety.

Better off alone? Why physicians don't merge.

The era of the small medical practice is over. How many times have we heard that? It was widely proclaimed back in the 90s, in the wake of the Clinton administration's healthcare reform proposal. But 15 years have passed, and there are stillplenty of physicians working in solo and small group practices. Despite all the predictions that small practices could not survive in an environment of "big healthcare," they persist. A report published recently by the U.S. Centers for Disease Control and Prevention estimated that as of 2003-2004 more than 35% of office-based physicians were in solo practice, and roughly 66% practiced in groups of five or fewer. This article examines why, in spite of the challenges of being in solo and small group practices, many physicians still prefer the status quo and resist forming or joining larger groups.

Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery.

BACKGROUND: Others have reported significant changes in red blood cell (RBC) transfusion practice during the past two decades during knee, hip, prostate, and carotid surgery. Similar data for patients undergoing major spine surgery, however, are not available. STUDY DESIGN AND METHODS: After institutional review board approval, adult patients undergoing elective major spine surgery were stratified into one of two transfusion-related groups: 1) 1980 to 1985 (i.e., before human immunodeficiency virus screening, early practice group; n = 699) or 2) 1995 to 2000 (i.e., late practice group; n = 610). RESULTS: Patients in the late practice group were older, had greater numbers of preoperative coexisting diseases (e.g., hypertension, cardiac dysrhythmias, coronary artery disease, prior myocardial infarction, diabetes mellitus, renal disease, cerebrovascular disease, and asthma), and were exposed to longer operations (p < 0.01 for each variable). Over time, allogeneic RBC administration significantly decreased, whereas autologous and intraoperative autotransfusion significantly increased. Compared to the early practice group, all perioperative Hb concentrations were significantly lower than the late practice group, yet no significant difference in major morbidity or mortality was observed between groups. CONCLUSION: In this retrospective analysis, significantly lower acceptable perioperative Hb concentrations were observed in older patients having substantially worse baseline comorbidity and exposed to longer major spine operations, without significant change in the incidence of perioperative morbidity or mortality.

Internal medicine specialists' attitudes towards working part-time: a comparison between 1996 and 2004.

BACKGROUND: Although medical specialists traditionally hold negative views towards working part-time, the practice of medicine has evolved. Given the trend towards more part-time work and that there is no evidence that it compromises the quality of care, attitudes towards part-time work may have changed as well in recent years. The aim of this paper was to examine the possible changes in attitudes towards part-time work among specialists in internal medicine between 1996 and 2004. Moreover, we wanted to determine whether these attitudes were associated with individual characteristics (age, gender, investments in work) and whether attitudes of specialists within a partnership showed more resemblance than specialists' attitudes from different partnerships. METHODS: Two samples were used in this study: data of a survey conducted in 1996 and in 2004. After selecting internal medicine specialists working in general hospitals in The Netherlands, the sample consisted of 219 specialists in 1996 and 363 specialists in 2004. They were sent a questionnaire, including topics on the attitudes towards part-time work. RESULTS: Internal medicine specialists' attitudes towards working part-time became slightly more positive between 1996 and 2004. Full-time working specialists in 2004 still expressed concerns regarding the investments of part-timers in overhead tasks, the flexibility of task division, efficiency, communication and continuity of care. In 1996 gender was the only predictor of the attitude, in 2004 being a full- or a part-timer, age and the time invested in work were associated with this attitude. Furthermore, specialists' attitudes were not found to cluster much within partnerships. CONCLUSION: In spite of the increasing number of specialists working or preferring to work part-time, part-time practice among internal medicine specialists seems not to be fully accepted. The results indicate that the attitudes are no longer gender based, but are associated with age and work aspects such as the number of hours worked. Though there is little evidence to support them, negative ideas about the consequences of part-time work for the quality of care still exist. Policy should be aimed at removing the organisational difficulties related to part-time work and create a system in which part-time practice is fully integrated and accepted.

Hospitalists: in-house docs can ease some vexing problems, but first you've got to win over the skeptics.

In-house physicians can alleviate many headaches, such as keeping the ED staffed and making sure a doctor is on hand when a patient's regular physician is unavailable. Success depends on resolving turf wars between hospitalists and other docs, dearly defining duties and workload, and designing pay to reward both volume and quality.

Child and adolescent psychiatry in The Netherlands: patterns of practice 7 years later.

OBJECTIVE: The aim of the study was to investigate capacity, demographic composition, and patterns of practice of Dutch child and adolescent psychiatrists, and to compare these findings with the results of a similar investigation in 1996. METHOD: A postal survey was sent out to all Dutch child and adolescent psychiatrists. RESULTS: In comparison with 1996, there is an increase in Dutch child and adolescent psychiatry (CAP) capacity. CAP has moved towards being a predominantly female specialty, usually practised as a mono-specialism, rather than combined with adult psychiatry. CAP as a rule is practised within institutions, rather than in private practice. CONCLUSION: The threat of a stark decline in Dutch CAP capacity starting in the year 2006, predicted in 1996, is lifted. The consequences of the findings are discussed in a European perspective.

Health care market trends and the evolution of hospitalist use and roles.

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.

Hospitalists: Evolution, evidence, and eventualities.

Hospitalists are physicians who spend at least 25% of their professional time serving as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge. The hospitalist movement is only about 5 years old, yet at least 7000 hospitalists practice today and an estimated 19,000 will ultimately practice, approximately the current number of emergency medicine physicians. The emerging positivist literature on hospitalists' impact is the subject of this review. It traces the nature and evolution of the hospitalist movement; summarizes empirical evidence about costs, clinical outcomes, patient satisfaction, and education; and appraises whether the hospitalist model is indeed novel. The review concludes by outlining research questions about the hospitalist model's viability over time, the mechanisms by which it produces benefits, and especially hospitalists' longitudinal effect on continuity of patient care. A literature "scorecard" might rank evidence to date on costs as positive, evidence on clinical outcomes and education as nonnegative, and evidence on patient satisfaction and continuity of care as inconclusive. Above all, longitudinal research must illuminate whether hospitalists' advantages comeat the cost of the doctor-patient relationship.

From bedside to boardroom - nursing shared governance.

A brand-new nursing shortage is revitalizing shared governance. This innovative organizational model gives staff nurses control over their practice and can extend their influence into administrative areas previously controlled only by managers. But nursing shared governance is hard to define. Its structures and processes are different in every organization; and its implementation is like pinning Jell-O to a wall. Is it appropriate for every situation? Is it worth the price? And can it really measure up to its glowing reputation? This article presents an overview of nursing shared governance, looking at themes and experiences from its rich 25-year tradition. The author identifies its essential elements, provides guidance for professionals who wish to embark on the journey, and describes the current status of shared governance as of 2004.