Violence against doctors: a medical(ised) problem? The case of National Health Service general practitioners

Violence against doctors provides an illuminating context for studying medicalisation and its limits in the management of deviance. The paper examines the emergence of such violence as a policy issue in England, with particular reference to general practitioners (GPs) in the National Health Service. Recent guidance exhorts doctors to exercise ‘zero tolerance’ with respect to acts of violence. The emphasis is on risk management and protecting victims rather than on resolving the perpetrators’ problems. The paper argues that this policy frame is consistent with recent claims from criminologists that there is a new ‘turn’ in penal policy, away from rehabilitation and addressing the needs of individual offenders. However, responses of individual GPs, obtained through a postal questionnaire sent to c.1000 GPs and in‐depth interviews with a sub‐sample, suggest that doctors are not ‘zero tolerant’ in responding to attacks. But nor are they medical imperialists seeking to include all perpetrators within their professional jurisdiction. Rather, they exercise professional discretion about behaviours which often fall into a ‘grey area’ between ‘illness’ and ‘crime’, and about individuals who are not clearly categorisable as either ‘sick’or‘bad’.     

Preparing tomorrow's doctors: the impact of a special study module in medical informatics

BACKGROUND: In response to the call for more informatics teaching in the medical curriculum, an elective special study module has been offered to first-year students at Queen's University since 1997. OBJECTIVES: To assess the impact of a medical informatics course in terms of the use of skills acquired and attitudes held about information technology (IT) in medicine. METHODS: A postal structured questionnaire was sent to all 30 students who took the medical informatics special study module in 1997 and to all 29 students who took the module in 1998, plus an age and sex-matched group of controls in each year. Main outcome measures included attitudes to the role of IT in medicine and declared frequency of use of various software packages. RESULTS: Compared with the control group, those taking the module felt less confident initially with computers. There was a high level of positive attitude to computers in medicine following the course, in both study and control groups. There was a significantly greater use of word-processing (P=0.001) and presentation packages (P=0.0005) amongst third-year students compared with second-year students, but there was no significant difference in this regard between those taking the module and controls. CONCLUSIONS: Students' use of computer technology and IT skills, is more influenced by the demands of the overall curriculum than by undertaking a single module in medical informatics. A special study module may, however, provide valuable support by performing a 'remedial function'. The authors found the module a useful first step in the process of introducing medical informatics to the core curriculum.     

医务社会工作人才建设在构建和谐医患方面的作用

医务社会工作人才建设是现代社会人才建设体系的重要组成部分,是维系现代健康照顾体系协调发展的必要途径,在医疗纠纷不断增多、医患关系冲突加剧的当今社会,医务社会工作人才建设发挥了非常重要的作用。文章从意义、理论支持、问题发现、原因分析、提出建议几个方面展开了详细的阐述和说明。     

Practices of reading and writing: the constitutive role of the patient record in medical work

This paper contributes to a reappraisal of the sociological significance of the medical record. Building upon re-evaluations of the notion of ‘representation’ in ethnomethodological and science and technology studies, it attempts to portray the medical record as an artefact which mediates the social relations that act and work through it. Through practices of reading and writing, it is argued, the medical record figures as a fundamental, constitutive element of medical practice. To address some of the dimensions that are involved, three case fragments are discussed. The way the medical record enters into the process of ‘medical decision making’ in the doctor-patient interaction, and into that interaction itself, is discussed first. Subsequently, some aspects of how the record mediates medical work as it is performed in the wards of a hospital are outlined. A third instance of its prominent role demonstrates how practices of reading and writing tend to produce particular renderings of patients’ histories - including notions of how medical work is structured.     

The changing body work of abortion: a qualitative study of the experiences of health professionals

‘Body work’ has emerged at the nexus of sociologies of work and bodies as a means of conceptualising work focusing on the bodies of others. This article utilises this analytical tool in the context of contemporary abortion work. Abortion provision in Britain has seen significant change in the last 25 years, paralleling developments in medical methods, and the option for women under nine weeks' gestation to complete the abortion at home. These shifts raise questions around how abortion work is experienced by those who do it. We apply the conceptual lens of body work to data drawn from in‐depth interviews with 37 health professionals involved in abortion provision, to draw out the character, constraints and challenges of contemporary abortion work. We explore three key themes: the instrumental role of emotional labour in facilitating body work; the temporality of abortion work; and bodily proximity, co‐presence and changes in provision. By drawing on the conceptual frame of body work, we illuminate the dynamics of contemporary abortion work in Britain and, by introducing the idea of ‘body work‐by‐proxy’, highlight ways in which this context can be used to expand the conceptual boundaries of body work.     

The deleterious consequences of privatization and outsourcing for hospital support work: the experiences of contracted-out hospital cleaners and dietary aids in Vancouver, Canada

This article is based on the findings of the Hospital Support Workers Study, which includes in-depth interviews with 70 hospital housekeepers and dietary aids in Vancouver, British Columbia, Canada. As a result of provincial government legislation in 2003, all hospital-based support work in the Vancouver region was privatized and contracted out to three multinational corporations. The outsourcing of hospital support services is part of a larger global trend toward neoliberal policy reform in health care. This article presents the perceptions of hospital support workers about the consequences of contracting out on their work conditions, training, turnover rates and other issues that directly affect their quality of work and have important implications for patient health and well-being. The findings suggest serious negative consequences for the health care system as a result of the privatization and contracting out of hospital support services.     

The contribution of migration to changes in the distribution of health over time: five-year follow-up study in Northern Ireland

A number of recent studies have highlighted the potential contribution of migration to increasing inequalities in health between areas with different levels of deprivation. Some of these studies have reported that increasing inequalities between areas can, at least partly, be explained by selective migration. Both mortality and morbidity have been used as indicators of health status, but many of the studies focusing on morbidity have suffered from specific methodological problems, including the use of self-reported health measured after migration had occurred, thereby ignoring the possible effect that migration itself may have on health and the reporting of health. This study used general practice records assessed prior to movement, an arguably more objective measure of health status, from 40 general practices, to determine whether selective migration influenced the distribution of health in Northern Ireland between the years 2000 and 2005. Evidence of selective migration was found in the study, with migrants often having significantly different levels of health to non-migrants. However, overall migration within this cohort did not substantially alter the distribution of health through time, partly because the migrants out of the deprived and affluent areas were replaced by in-migrants with similar levels of health. The absence of an effect of migration in this instance should not be used, however, to conclude that migration effects are unimportant in assessing changes in inequalities through time. Rather, migration should be viewed in the context of the underlying population dynamics, which at the time of this study were characterised by a process of urban regeneration. Varying population movements, operating at different times and locations, require that the effects of migration be considered in all studies which examine changes in the spatial distribution of health.     

The power of place: space and time in women's and community health centres in South Australia

This paper focuses on the importance of time and space in an Australian medical setting. It draws on research findings from a one year project that aimed to explore community perspectives of, and experiences of medical services in three South Australian women's and community health centres. Both qualitative and quantitative methods of data collection and analysis were used in order to address these objectives. A significant finding was the way in which participants described the organisation and experience of time and space in these centres and how this impacted on their health and well being and that of the community. In analysing these spatio-temporal dimensions and the underlying philosophical structures of women's and community health centres, this paper argues that experiences associated with space and time have a positive effect on health status by: diminishing barriers to health services, improving quality of care, increasing community participation, providing safe places for social interaction and strengthening people's sense of belonging or attachment to a particular community and place. Based on these findings, the authors conclude that the spatio-temporal dimensions of health care provision have empowering and positive impacts on a community's health, a significant finding that has implications for the maintenance and future funding of this style of health service.     

Specialist training and medical research in developing countries of tropical Africa: a case for the establishment of postgraduate medical schools

Developing countries like developed ones need highly skilled medical personnel, referred to as 'specialists'. In the case of developing countries, the training of these specialists abroad is expensive to the sponsoring governments, imposes a lot of hardship on the doctors and, above all, the coursecontent of such training takes little or no cognizance of the environment in which these doctors would later practise. The developing countries also cannot afford the loss of years in valuable services which the training abroad entails.
Attempts are now being made to train specialists wholly or partly at home, in some developing countries. The approach is still not much divorced from what obtains in Britain and North America, that is, one of being trained on the job, with the onus for self-education being placed on the prospective students. Such students in most developing countries of tropical Africa have little or no facilities for further education outside their places of work.
It is proposed that purpose-designed postgraduate medical schools may provide a temporary solution to specialist training in developing countries of tropical Africa. Such schools would in addition provide highly skilled medical service as well as obviate the need and the expense for the setting up of government sponsored medical research and training institutes.     

The challenge of contributing to policy making in primary care: the gendered experiences and strategies of nurses

This paper explores nurses’ experiences as members of primary care organisations set up to develop and commission health services for local communities. Nurses, alongside GPs and other health professionals, were given a place on the governing bodies (boards) of Local Health Groups – a move widely welcomed by the nursing profession as long overdue recognition of the important contribution nurses and nursing could bring to the policy arena. Nurse board members faced a number of challenges in their attempts to contribute to and influence local health policy. This ethnographic study (which involved non‐participant observation of 33 board meetings and interviews with 29 board members including nurses) suggests that medical authority and control, and hierarchical power relations between doctors and nurses on the board, were seen by nurses as significant obstacles to their participation in this new policy arena. In response to their perceived lack of power and subordinate status, nurses employed a number of strategies to negotiate their participation as board members – these included ‘getting it right’, ‘achieving the right balance’, ‘self‐presentation’ and ‘unassertiveness’. These strategies reflected and reproduced gendered identities and relations of power and raise important questions regarding the influence of nurses and nursing within policy making.     

Upstairs, downstairs: Medical students in their first clinical year and their previous experience of work in hospitals

In a study of Edinburgh students in their first clinical year it was found that a sizeable proportion had had some prior experience of hospital life and work from vacation jobs--such as being porters, auxiliary nurses and so on. Students' retrospective accounts of such experience are reported. The most salient aspect of hospitals seen from this vantage point concerned the division of labour between grades of staff, and the hierarchical organization of hospital personnel. Students saw the experience primarily as a chance to see medicine 'from the other side'. It is suggested that such experiences can be drawn on in the teaching of sociology to undergraduate students.     

The role of national culture in shaping health workforce collaboration: Lessons learned from a case study on attitudes to interprofessional education in Malta

The World Health Organisation identifies interprofessional education (IPE) as a key element for preparing a collaborative workforce. However, global implementation remains challenging due to individual, professional and organisational barriers. A qualitative case study explored the concept of introducing an undergraduate IPE programme at the Faculty of Health Sciences, University of Malta. A combination of in-depth interviews and focus groups were conducted with a sample of sixty-four academics,health and education policy makers and newly qualified health professionals. The findings suggest that while participants support the notion of IPE, they identify multiple barriers that would challenge implementation. This includes particular cultural norms and values which participants perceived would conflict with IPE. These findings were interpreted through Hofstede’s theory of cultural dimensions as a means of theorising about the role that culture could play in implementing such an approach. This study contributes to the health policy debate by highlighting the potential impact of national culture in the planning, development and delivery of collaborative initiatives. It also highlights new insights for European small states and other countries by providing a lens through which culture needs to be taken into account in the transfer of innovation across health systems.     

How is medical decision‐making shared? The case of haemophilia patients and doctors: the aftermath of the infected blood affair in France

Objective This article looks at how users and doctors in France have rethought the question of shared decision‐making in the clinical field of haemophilia following a major crisis – that of the infected blood affair. Design We did a qualitative survey based on semi‐structured interviews in three regions of France. Setting and participants The interviews covered 31 clinical doctors of haemophilia and 31 users: 21 adult males with severe haemophilia (21/31), infected (14/21) or not (7/21) with HIV, the infected wife of one of the latter (1/31) and nine parents of young patients with severe haemophilia (9/31), either HIV positive (6/9) or negative (3/9). Results and conclusions The results show the infected blood affair to be a major individual and collective ordeal. It has caused users and doctors to rethink their roles within clinical relationships and to develop new ways of sharing medical decision‐making. Prior to the crisis, the dominant model was based upon a distinction between the medical aspect, governed by the doctors, and the psychosocial aspect, which involved the patients and their families. Since the crisis, medicoscientific knowledge has been shared between users and doctors. This general trend nevertheless permits the existence of different patient, family and doctor profiles which in turn correspond to different notions of what a clinical decision should be. Some users remain attached to the idea of complementarity between doctors and patients (new partnership model), whilst others put doctors and patients on an equal footing (negotiation model). On the doctors’ side, whilst some still prefer the initial model for therapeutic decision‐making, the majority have reassessed their perceptions and viewpoints. A certain number believe that decisions should be made by both doctor and patient in accordance with scientific procedures (decision‐making controlled by scientific standards) or regulatory procedures (decision‐making controlled by legal standards). Yet others feel that multiple points of view are acceptable within the decision‐making process (decision‐making model as interactivity).     

Risk and the politics of boundary work: preserving autonomous midwifery in the Netherlands

Midwives’ position in maternal and newborn care (MNC) in the Netherlands is unique: unlike many other countries, they have retained the authority over risk assessment and referral. We studied why and how midwives formally gained their position as gatekeepers, a role formally granted in 1987 by the Study Group for the Revision of the Kloosterman List (SGKL), a group of representatives from all professions and organisations involved in Dutch MNC. We analysed the minutes of the SGKL’s meetings and conducted interviews with eight key-informants who were involved in the SGKL’s decision process. We used theories of professional boundary work and cultural theories of risk to analyse the negotiations regarding the authority over risk assessment and referral in MNC that occurred between the representatives of midwives, general practitioners, and obstetricians in the SGKL. Our study offers new insights into professional boundary demarcation and the contest for control of risk management that occur at the political level of MNC. We show that beliefs regarding risks associated with childbirth and concern with the protection of professional interests can differ not only between but also within professions that seek to police and extend their boundaries. Negotiations are shaped by a dynamic interaction between these beliefs and interests, creating the possibility for otherwise unexpected transprofessional coalitions and redefining boundaries in unexpected ways. Our findings offer the possibility to view disputes in MNC as occurring between beliefs and interests, instead of between professional groups. These insights can reframe policy discussions in MNC and point to the need for further analysis of the boundary work that occurs in political and regulatory arenas.     

The effects of work organization on the health of immigrant manual workers: A longitudinal analysis

This analysis uses a longitudinal design to examine the associations of work organization and health outcomes among Latino manual workers. Participants included 247 Latino workers who completed baseline and 1-year follow-up interviews and clinical examinations. Health outcome measures were epicondylitis, rotator cuff syndrome, back pain, and depressive symptoms. Independent measures were measures of job demand, job control, and job support. Workers commonly experienced rotator cuff syndrome (6.5%), back pain (8.9%), and depressive symptoms (11.2%); fewer experienced epicondylitis (2.4%). Psychological demand was associated with rotator cuff syndrome; awkward position and decision latitude were associated with back pain. Decreased skill variety but increased decision latitude was associated with elevated depressive symptoms. Work context factors are important for health outcomes among vulnerable workers. Further research is needed to expand upon this work, particularly cultural perspectives on job support.