Toward a common understanding of self-assessment

Self-assessment and its role in self-regulation and lifelong learning lack clarity. A goal of this Journal of Continuing Education in the Health Professions issue is to begin to clarify our current understanding of self-assessment and what it entails, as seen through an educational lens. The purpose of this summary article is to synthesize briefly the definitions of self-assessment proposed by the authors, their perspectives on external and internal factors influencing and/or inherent in self-assessment, and common messages for educational research and practice. Among the seven authors, there appears to be unanimity in conceptualizing self-assessment within a formative, educational perspective, and seeing it as an activity that draws upon both external and internal data, standards, and resources to inform and make decisions about one's performance. Multiple external sources can and should inform self-assessment, perhaps most important among them performance standards, eg, clinical practice guidelines, and use of formal practice audit and feedback approaches. Equally important, internal factors or capacities also influence one's ability to self-assess and self-monitor, such as reflection, mindfulness, openness, curiosity. In summary, these articles aid in our appreciation of the complexity of self-assessment as a formative activity and identify multiple implications for educational practice and research.     

Toward a better understanding of hospital occupancy rates.

This article starts out with the premise that a "uniform occupancy rate" for hospitals is not a meaningful concept because the ability of individual hospitals to maintain a certain occupancy rate consistent with a specified "protection level" depends upon several factors. These factors include hospital size, the number of nonsubstitutable patient facilities, the percent of nonurgent (elective) beds, the number of hospitals serving an area, and the relative variation (fluctuation) in the demand for services faced by the hospital. A regression analysis with observed, overall occupancy rate as the dependent variable, and measures that attempt to represent the factors just mentioned as independent variables, tends to substantiate this line of reasoning. However, inasmuch as the status of the independent variables (that is, whether or not they can be regarded as justifiable or uncontrollable) depends largely on the circumstances of each case, the regression model cannot be used as a standard-setting tool. Nonetheless, it offers valuable guidelines for hospital management, planners, and regulators in such areas of decisionmaking as the location and size of hospitals, and acceptable occupancy standards.     

Toward understanding elders' health service utilization

Providing appropriate health services to the elderly is emerging as one of the major challenges of this decade. Using the theoretical framework developed by Andersen and Aday, this study attempts to improve our understanding of those factors which inhibit or facilitate elders' use of health services. The data come from a 1974 statewide random probability sample of 1,625 noninstitutionalized elders 65 years of age or older living in Massachusetts. Regression analysis is used to study the effects of predisposing, enabling, and need characteristics on the use of five health services: hospitals, physicians, dentists, home care, and ambulatory care. The model explains from 5% to 27% of the variance in health service utilization. Need characteristics, in general, account for most of the explained variance.Drs. Branch and Jette and Ms. Polansky are with the Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School, 643 Huntington Avenue, Boston, Massachusetts 02115; Dr. Jette is also with the Massachusetts General Hospital's Institute of Health Professions; Dr. Evashwick and Ms. Rowe are with the Department of Health Services and Long Term Care Gerontology Center, School of Public Health and Community Medicine, University of Washington; and Dr. Diehr is with the Department of Biostatistics, School of Public Health and Community Medicine, University of Washington. Work for this project was supported in part by a grant from the Massachusetts Department of Public Health while the first author was with the Center for Survey Research, a facility of the University of Massachusetts and the Joint Center for Urban Studies of M.I.T. and Harvard University; in part by Grant 90-A-1350/2 from the Administration on Aging of H.E.W. to the Harvard School of Public Health; and in part by Grant 90-AT-2159 from the Administration on Aging of H.E.W. to the Harvard Medical School.     

Toward a transdisciplinary understanding and a global control of emerging infectious diseases

The Franceville International Centre for Medical Research (CIRMF) organized a first international symposium on infectious diseases, environments, and biodiversity. Over 200 international experts gathered in Gabon to forecast and work to prevent the emergence of infectious diseases. This symposium aimed to strengthen the regional and international fight against the emergence of infectious diseases with high-level scientific debates. Toward this goal, it brought together experts in human and animal health, the environment, and ecology, including biologists, climatologists, microbiologists, epidemiologists, public health professionals, and human and social sciences specialists. National, regional and international participants were present to debate on the challenges related to the emergence of infectious diseases and on the responses to be implemented. The symposium was very successful, and plans for a second symposium of this kind to be held in the near future in another high-biodiversity area are already underway.     

Toward understanding the patient's perception of quality

Patients often don't have the technical competence to judge the quality of medical care. Therefore, they rely on different criteria than do professionals in assessing quality. They perceive quality as a gestalt of experiences influenced by such issues as empathy, integrity, and appearance of competency. Patients do not complain about service quality when it is appropriately provided. But to satisfy the consumer, providers must go beyond being reliable, polite, and honest. They must provide prompt services, be approachable, and provide individualized attention. To ultimately delight consumers, however, providers must meet the unarticulated needs of the patient.     

Toward understanding and caring for latchkey children

Several recent articles published in the popular press have presented contrasting accounts of the emerging social phenomenon of latchkey children. In this paper, we examine available empirical evidence in light of a contextual model of human development and, on this basis, offer preliminary suggestions for the care of latchkey children.The authors wish to express their appreciation to James Garbarino for his critical reading of an earlier version of this article.     

Increasingly ruth: Toward understanding sex reassignment

Both the clinician and the patient present accounts of a 44-year-old male's search for a comfortable gender identity. The juxtaposition of these two perspectives illustrates many of the dilemmas inherent in the therapy of gender dysphoria. Ruth underwent sex reassignment surgery in 1976—one year after the assumption of a full-time female gender role. Six months after surgery, she made a serious suicide attempt. At age 50, she has now consolidated her feminine gender identity and has become a thoughtful, unusually honest, articulate person. The physician's “objective” and the patient's retrospective perspectives provide evidence of the psychodynamic nature of transsexualism and the limitations of evaluation criteria for sex reassignment surgery.     

Toward a rational, value-based drug benefit for Medicare

A major challenge facing Congress is what changes, if any, to make to Medicare Part D. With the apparent failure of the Democrats' attempt to remove the prohibition on government intervention in drug price negotiations, the party's next steps are unclear. One suggested option is a plan administered by the Centers for Medicare and Medicaid Services (CMS), to compete with private plans and facilitate a transition to a more rational structure. We discuss issues surrounding the design of such a mechanism and how it might provide a transition toward a more rational and sustainable drug benefit in the longer term.     

Toward a better understanding of the “advanced maternal age”; factor

Women over the age of 30–35 are presumed to encounter more adverse pregnancy outcomes because of their reduced reproductive efficiency. In the vast majority of studies of advanced maternal age and pregnancy outcome, however, researchers have failed to control for important contextual differences surrounding the pregnancy and childbirth experiences of younger and older women. These contextual differences can account for a considerable portion of the differential results mistakenly ascribed to reproductive age. In this article are reviewed research findings that identify three such hidden factors: older women's increasing likelihood of chronic diseases that adversely affect pregnancy outcome; the altered medical management of middle‐aged women's pregnancies and labors, with resultant iatrogenically caused complications; and demographic characteristics suggesting that midlife pregnancy in the past has been associated with poverty or subfertility and today is associated with healthy middle‐class postponers.     

Toward understanding the clinical aspects of geriatric case management

Despite the prominence of complex psychosocial problems in aging clients, geriatric case management has generally emphasized the provision of concrete resources and services as its primary function. However, some of the literature as well as the findings of this study, point to competent case management as being contingent on interventions that successfully address key psychosocial problems. This paper presents a qualitative study involving experienced geriatric care managers. Psychosocial problem and intervention categories are identified as well as overarching themes with significant implications for practice. The paper argues that a grounded, thorough, well-explicated and generalizable model for clinically-focused geriatric case management practice is necessary; it also suggests additional research towards the development of such a model.     

Introducing client-centered reproductive health services in a Pakistani setting

Pakistan is a high-fertility country with elevated levels of maternal mortality and unmet need for family planning. Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor indicators. The authors designed an intervention to address some of these issues and implemented it on a quasi-experimental basis in Bhalwal Tehsil of the Sargodha district of Punjab. The intervention introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. It introduced the concept of SAHR (an acronym for salutation, assessment, help, and reassurance), to inculcate a client-centered approach to care that acknowledges explicitly and addresses a client's gender and power relations within her family and household. Results of the intervention indicate significant effects on providers' behavior related to SAHR elements. The changes provide demonstrable evidence that the public sector can shift toward client-centered services in reproductive health care in a challenging setting.     

Toward understanding youth suicide in an Australian rural community

Australia has one of the highest rates of youth suicide in the western world, especially among rural men. This paper discusses the social construction of this issue in Australia and explores the issue through interviews with 30 young people and 12 key informants from a rural town in NSW. Findings suggest that young people struggle to deal with conflict in social relationships, that community discourses shape young people's understandings and that suicide is talked about in reference to depression. Implications for youth suicide prevention in Australian rural communities are discussed.     

Goal setting dynamics that facilitate or impede a client-centered approach

Background: Client-centred goal setting is central to the process of enabling occupation. Yet, there are multiple barriers to incorporating client-centred goal setting in practice. We sought to determine what might facilitate or impede the formation of client-centred goals in a context highly supportive of client-centred goal setting

Methods: We used conversational analysis to examine goal-setting conversations that took place during a pilot trial of Occupational Performance Coaching for stroke survivors. Twelve goal-setting sessions were purposively selected, transcribed, and analyzed according to conventions for conversation analysis.

Results: Two main types of interactions were observed: introductory actions and goal selection actions. Introductory actions set the context for goal setting and involved sharing information and seeking clarification related to goal requirements and clients’ occupational performance competencies. Goal selection actions were a series of interactions whereby the goals were explored, endorsed or dropped.

Conclusion: Client-centred occupational performance goals may be facilitated through placing goal-setting in the context of life changes and lifelong development of goals, and through listening to clients’ stories. Therapists may improve consistency in adoption of client-suggested goals through clarifying meaning attached to goals and being attuned to power dynamics and underlying values and beliefs around risk and goal attainability.