Health Care Providers, Institutions, and Patients: Changing Patterns of Care Provision and Care Delivery: Volume 17

There is a growing consensus that there are often excessive medical interventions in terminally ill patients. This problem is usually seen as stemming from physician decisions in applying new technology in a context in which financial costs have been borne by third parties. We believe this is, at best, a partial explanation for the phenomenon. The tendency to escalate commitment—to persist in failing courses of action—has been found by social scientists to occur in a wide variety of decision contexts. In ethnographically examining health care interventions in terminally ill patients, we found that a wide range of rational calculus, psychological, social, organizational, and contextual factors interact over time to contribute to excessive persistence. Intervention decisions reflect a complex, fluid interplay between patients, health care providers, institutions, and an array of external stakeholders. Effective revisions of current patterns of care practices must address the nature and complexity of the sources of the problem. We suggest a series of strategies including a new medical specialty to deal with these issues.

Older adults with memory problems (especially those diagnosed with dementia) consume a great number of health services. However, little is known about the special needs of memory-impaired, noninstitutionalized older adults who seek treatment from primary care physicians (PCPs) for memory problems. The study outlined in this chapter investigated the interrelationships among level of education, residence, physical and mental status, and the use of PCPs for memory problems. A probability-based (random-digit dialing) survey of households with individuals more than 60 years of age occurred in six Southern states: Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee (N = 1,368). We developed two multivariate logistic regression models. The first estimated the additive effects of sociodemographic and health status characteristics on the likelihood of service utilization. The second model inserted two multiplicative terms: the “instrumental activities of daily living (IADL)” by “memory impairment” and the “low education” by “memory impairment” interaction terms. Three main findings emerged from the analyses: (1) rural/urban differences in use of PCPs approached statistical significance, (2) for lower educated older adults, the odds of using a PCP declined steadily as their number of memory impairments increased, and (3) as older adults experienced increases in IADL limitations and memory impairments, their likelihood of service use declined. The chapter ends with a discussion on program planning, policy, and practice initiatives in light of the findings.

Changes in the health care system are threatening the independence and professionalism of health care providers. One such proposed policy change related to professional licensure is creating a specific challenge for the nursing profession. This article examines how the licensure challenge affects aspects of autonomy, independence, and integrity of the nursing profession with special emphasis on one group of nurses—that of nurse practitioners. The impact of the PEW Commission's study is analyzed as well as the concern for potential loss of individual licensure for nurses. Nursing groups have responded to the PEW Commission study to prevent such deregulation of the nursing profession.

Despite waves of budget cuts and structural reorganizations, physicians in most of Europe have not been subject to managerial controls like those that have emerged in the United States and to a lesser degree in Britain. This paper examines one of the most dramatic instances in which physicians resisted managerial and governmental control and explains recent changes in this pattern. From 1982 through 1992, Dutch hospital specialists successfully blocked efforts by governmental regulators, insurers, and hospital managers to control the specialists' activities so as to reduce hospital costs, integrate care activities, and assure quality. Gradually the specialists began to lose their budgetary and operational autonomy and signed agreements with hospitals and insurers to integrate the specialists' fees into hospital budgets. These new fiscal arrangements increase the hospital managers' economic control over specialists and create possibilities for the enhancement of other types of managerial control. The organizational and political forces behind these changes are analyzed, along with their implications for future patterns of professional control in the Netherlands and for the integration of professional and managerial functions within Dutch hospitals.

Prenatal genetic testing is fast becoming standard practice in the medicalized arena of pregnancy in American health care provision. The interest of this paper, using empirical research data from participant observation and semistructured interviews of genetic counselors, geneticists, perinatologists, and obstetricians, is to explicate the provision of genetic care by the care-givers themselves, paying close attention to the ways they deal with the inherent uncertainties and ambiguities in medical genetics, especially prenatal genetic testing. Ambiguity and uncertainty are omnipresent in prenatal genetic testing, most obviously through the absence of an individual to examine in conjunction with test results. The test is for fetal abnormalities. Rarely are test results able to be interpreted with a clear, straightforward definition of what type of individual the fetus could eventually be. Through analysis of genetic intake meetings, departmental meetings, and quarterly interdepartmental meetings, the way providers order their work is elucidated; it reveals two work ideologies implemented to handle ambiguity and uncertainty: assessing the patient and tailoring the information to the patient. These work ideologies are examined through a social worlds/arenas theory and a sociology of work lens informed by symbolic interactionism. Analyzing providers' interpretations of their clinical practices allows an explication of their (re)construction of genetic medical knowledges through the individual providers' social worlds.

This study developed a two-stage model of decision making used by healthcare providers when considering combination antiretroviral therapy for HIV-positive patients. Provider interviews and patient medical records from 10 HIV-positive patients were utilized. Four providers (two nurse practitioners and two physicians' assistants) situated in two managed care HIV clinics were studied. Newly diagnosed HIV patients were observed while interacting with their health care provider. Following the interactions, healthcare providers were given a semistructured private interview about the factors that influenced their treatment decisions. It was hypothesized that providers, when they made their treatment decisions, would initially evaluate biomedical markers followed by an evaluation of patient characteristics associated with treatment adherence. It was found that providers developed basic decision-making principles and perceived some decisions as relatively easy and others as much harder. The easiest decisions conformed to biomedical guidelines while the harder ones had substantial behavioral and nonmedical components. These were hard decisions because they were perceived as making treatment regimen adherence much more problematic. It was also found that the providers' high level of decisionmaking responsibility combined with their relatively low authority contributed to their decision-making uncertainty.

Gender bias in medical knowledge and practice is an issue of longstanding significance for women's health scholars and activists alike. This paper assesses the current status of medical education, where gender bias has the potential to influence the culture and process of medical care, and focuses on three areas of concern: the presence and participation of women as medical students and faculty, the problem of gender bias in the content of medical curricula and training programs, and the friendliness for both men and women of the climate and environment of medical education. Significant change has occurred over the past several decades in the admission of women into medicine; yet, women remain under represented in positions of leadership and decision authority. In the 1990s, the content of the medical curriculum began to be evaluated in terms of gender, and a number of the resulting changes were implemented. Additionally, recent attention has been placed on improving the gender friendliness of medical school policies and resources. While these developments signal a decrease in gender bias and greater equality in medical education, the ability of the medical profession to continue to address these issues is being challenged by the increasingly powerful private health care economy.

In recent decades, consumers and providers have become increasingly frustrated with the health care system. Concerns with the “bottom line” have replaced concerns about patients and providers. In response, new models of patient-centered care being developed are encouraging participatory relationships. Patients are empowered when their values, preferences, and needs become the center of health care decisions. In this article, I illustrate how empowerment has been translated into health care settings. The data come from a qualitative study of 14 feminist women's health centers, which were established in the 1970s and had more than 20 years experience providing community services. I discuss three primary strategies they used for empowering patients: (1) education and information to increase knowledge and demystify medical procedures, (2) breaking down institutional barriers between providers and clients, and (3) providing an environment of dignity and respect. These strategies are particularly well-suited for community-based health care. This study also contributes to the dialogue on defining “quality” of care and strategies for rethinking the dominant, medical model of health care delivery in this country.

By its very nature, the field of medical sociology has considerable potential for incorporating a consideration of gender in its research. After approximately a generation of the women's movement, women's studies, and the study of gender in sociology, now is an appropriate time to assess the impact of feminism on the mainstream of the field. Such an assessment is distinct from a feminist critique of medical sociology, with its implication that the field has many shortcomings, and also from a review of the growing sociological study of women's health (e.g., Auerbach and Figert 1995) and their role in providing as well as receiving care. Instead, my purpose is to examine representative research in mainstream medical sociology for evidence of the extent and nature of feminism's influence. Overall, I argue that by the 1990s mainstream medical sociology has been significantly affected by feminism, but that this effect is qualified in important ways.

The inclusion of race/ethnicity, socioeconomic status, and sex/gender in biomedical and epidemiologic research often constitutes routine and taken-for-granted practices that are based on particular notions of bodily “differences” and their roles in health and illness. Such practices legitimate constructions of race, class, and gender as attributes of atomistic individuals—rather than as intersectional dimensions that structure social relationships—and render invisible how relations of power contribute to the stratification of well-being and disease. This paper offers applications of two theoretical perspectives to illuminate these arguments. Firstly, epidemiologic research exemplifies in many ways Foucauldian notions of biopower and Panopticism. It individualizes bodies and bodily differences; at the same time, it disindividualizes power, embedding it within the diffuse and pervasive acts of biomedical knowledge production and subsequent imperatives of self-judgment and surveillance. Secondly, epidemiologic research embodies processes of racial, class, and gender formation, and constitutes a kind of racial, class, and gender project. Such projects mediate between the discursive definitions of bodily differences and the institutional forms in which those definitions are routinized and standardized. As such, biomedical knowledge production is an active participant in the construction and institutionalization of social meanings of “difference”. However, my contention is not that we should abandon the epidemiologic use of racial, class, and gender categories. Instead, race, class, and gender must be reconceptualized as social relations of power that are located not just in the biological bodies of individuals but in the social spaces between them, producing and stratifying the distribution of health and illness.

Telemedicine has been touted as a solution to the problems of access to health care experienced by rural and other isolated populations. Few studies exist, however, that explain the differential use of telemedicine by patients. Patient utilization of this technology is likely to be predicted by both those factors that affect the adoption of new ideas, on the one hand, and those factors that affect the utilization of health care, on the other. These include (1) propensity factors such as education and ethnicity; (2) enabling factors such as income and health insurance, and (3) need characteristics such as the severity of the illness as well as factors that impact (4) accessibility. Data were collected from samples of patients who had experienced telemedicine in one of two rural locations in Texas. A second sample of patients who had not experienced telemedicine was drawn from these same locations for comparative purposes. Models were developed to differentiate among patients who would elect to use telemedicine for each of six hypothetical medical conditions versus the alternatives of consulting their local physician without the presence of telemedicine or travel to see a specialist. Separate models were developed for those patients who had previous experience with telemedicine and for those without such previous experience. Prior experience was associated with a greater willingness to use telemedicine for all but the most serious of medical conditions. Predisposition factors had the greatest impact on the more serious conditions (e.g., problem pregnancy and cancer), and enabling conditions as well as access factors were more likely to affect the less serious conditions (e.g., cough and rash).

A new medical model has emerged due to the public's increasing awareness and acceptance of alternative medicine. As a result, alternative practitioners have joined with physicians in a variety of professional settings to explore ways to integrate Western medical techniques with alternative medical techniques and ideology. For example, clients with chronic lower back pain may receive treatments in an integrative clinic from the physician, chiropractor, and massage therapist. Yet, they are also encouraged to make changes in their daily routines at work and home to lessen the stress on their back. Thus, practitioners use both Western and alternative techniques in accordance with a key component of alternative ideology: the belief that individuals must take responsibility for their health.Political and cultural changes have made integrative medicine possible, yet there are some key issues that activists need to resolve as they develop this new model of medicine. Many alternative practitioners are interested in working with physicians, because it brings legitimacy to their work. Yet, it is important to understand why some physicians are now interested in working with alternative practitioners. Political changes, such as the rise of managed care, have eroded physicians' authority. Consequently, some physicians are searching for new ways to practice medicine without these structural constraints. Other physicians are drawn to the connection that alternative ideology makes between spirituality and medical practice, reflecting a new cultural emphasis on spirituality. Finally, physicians and alternative practitioners need to develop a team approach where all practitioners have equal power and maintain the ideological integrity behind their techniques. These elements are critical for integrative medicine to be successful and effective.

Measures of health status and prior service use have been considered promising predictors of future health expenditures, particularly when used for risk-adjustment models in capitation payment systems. While the use of health status as a future predictor has its difficulty in terms of measurement accuracy and implementation costs, using prior utilization as the base for the calculation of future health expenditures also has its concerns. Based on a three-stage cross-lagged model in a longitudinal study design, this study showed that prior utilization has both a direct and an indirect effect on subsequent utilization. However, the real net effect of prior utilization on subsequent utilization can be overestimated by 25%, if the effect of health status is not taken into account.