Culture and Politics of Health Care Work – serie

We are on the verge of the nation's worst nursing shortage in history. Dedicated nurses are leaving hospitals in droves, and there are not enough new recruits to the profession to meet demand. Even hospitals that were once very highly regarded for the quality of their nursing care, such as Boston's Beth Israel Deaconess Medical Center, now struggle to fill vacant positions. What happened? Dana Beth Weinberg argues that hospital restructuring in the 1990s is to blame. In their attempts to retain profit margins or even just to stay afloat, hospitals adopted a common set of practices to cut costs and increase revenues. Many strategies squeezed greater productivity out of nurses and other hospital workers. Nurses' workloads increased to the point that even the most skilled nurses questioned whether they could provide minimal, safe care to patients. As hospitals hemorrhaged money, it seemed that no one—not hospital administrators, not doctors—felt they could afford to listen to nurses.Through a careful look at the effects of the restructuring strategies chosen and implemented by Beth Israel Deaconess Medical Center, the author examines management's efforts to balance service and survival. By showing the effects of hospital restructuring on nurses' ability to plan, evaluate, and deliver excellent care, Weinberg provides a stinging indictment of standard industry practices that underestimate the contribution nurses make both to hospitals and to patient care.

"At present nursing homes are designed... like outmoded zoos. Residents are kept in small rooms, emotionally isolated. Occasionally they are visited by family members who reach through the bars and offer them treats. Aides keep their bodies clean and presentable.... America invests huge amounts of money to maintain the body while leaving the person to languish, cut off from all they love."—From Nobody's HomeAfter caring for his mother at the end of her life, Thomas Edward Gass felt drawn to serve the elderly. He took a job as a nursing home aide but was not prepared for the reality that he found at his new place of employment, a for-profit long-term-care facility. In a book that is by turns chilling and graphic, poignant and funny, Gass describes America's system of warehousing its oldest citizens.Gass brings the reader into the sterile home with its flat metal roof and concrete block walls. Like an industrial park complex, it is clean, efficient, and functional. He is blunt about the institution's goal: keep those faint hearts pumping and the life savings and Medicaid dollars rolling in. With 130 beds in the facility, the owner grosses about three million dollars annually. As a relatively well-paid aide, Gass made $6.90 an hour.Seventeen of the twenty-six residents on Gass's hall were incontinent, and much of his initiation to the work was learning to care for them in the most intimate ways. One of the many challenges was the limited time that he had available for each of his charges—17.3 minutes per day by his calculation. Even as he learned to ignore all but the most pressing demands of the residents, he discovered the remarkable lengths to which aides and their patients will go to relieve the constant ache of loneliness at the nursing home.With Americans living longer than ever before, elder care is among the fastest growing occupations. This book makes clear that there is a systemic conflict between profit and extent of care. Instead of controlling costs and maximizing profits, what if long-term care focused on our basic need to lead meaningful and connected lives until our deaths? What if staff members dropped the feigned hope of forestalling the inevitable and concentrated on making their charges comfortable and respected? These and other questions raised by this powerful book will cause Americans to rethink how nursing homes are run, staffed, and financed—as well as the circumstances under which we hope to meet our end.

South African nurses care for patients in London, hospitals recruit Filipino nurses to Los Angeles, and Chinese nurses practice their profession in Ireland. In every industrialized country of the world, patients today increasingly find that the nurses who care for them come from a vast array of countries. In the first book on international nurse migration, Mireille Kingma investigates one of today's most important health care trends. The personal stories of migrant nurses that fill this book contrast the nightmarish existences of some with the successes of others. Health systems in industrialized countries now depend on nurses from the developing world to address their nursing shortages. This situation raises a host of thorny questions. What causes nurses to decide to migrate? Is this migration voluntary or in some way coerced? When developing countries are faced with nurse vacancy rates of more than 40 percent, is recruitment by industrialized countries fair play in a competitive market or a new form of colonialization? What happens to these workers—and the patients left behind—when they migrate? What safeguards will protect nurses and the patients they find in their new workplaces? Highlighting the complexity of the international rules and regulations now being constructed to facilitate the lucrative trade in human services, Kingma presents a new way to think about the migration of skilled health-sector labor as well as the strategies needed to make migration work for individuals, patients, and the health systems on which they depend.

The number of women practicing medicine in the United States has grown steadily since the late 1960s, with women now roughly at parity with men among entering medical students. Why did so many women enter American medicine? How are women faring, professionally and personally, once they become physicians? Are women transforming the way medicine is practiced? To answer these questions, The Changing Face of Medicine draws on a wide array of sources, including interviews with women physicians and surveys of medical students and practitioners. The analysis is set in the twin contexts of a rapidly evolving medical system and profound shifts in gender roles in American society. Throughout the book, Ann K. Boulis and Jerry A. Jacobs critically examine common assumptions about women in medicine. For example, they find that women's entry into medicine has less to do with the decline in status of the profession and more to do with changes in women's roles in contemporary society. Women physicians' families are becoming more and more like those of other working women. Still, disparities in terms of specialty, practice ownership, academic rank, and leadership roles endure, and barriers to opportunity persist. Along the way, Boulis and Jacobs address a host of issues, among them dual-physician marriages, specialty choice, time spent with patients, altruism versus materialism, and how physicians combine work and family. Women's presence in American medicine will continue to grow beyond the 50 percent mark, but the authors question whether this change by itself will make American medicine more caring and more patient centered. The future direction of the profession will depend on whether women doctors will lead the effort to chart a new course for health care delivery in the United States.

Frontline health care workers have always been especially vulnerable to the perpetual tides of health care 'reform,' but in the mid-1990s in New York City, they bore the brunt of change in a new way. They were obliged to take on additional work, take lessons in recalibrating their attitudes, and, when those steps failed to bring about the desired improvements, take advantage of training programs that would ostensibly lead to better jobs. Such health care workers not only became targets of pro-market and restructuring policies but also were blamed for many of the problems created by those policies, from the deteriorating conditions of patient care to the financial vulnerability of entire institutions.In Never Good Enough, Ariel Ducey describes some of the most heavily funded training programs, arguing that both the content of many training and education programs and the sheer commitment of time they require pressure individual health care workers to compensate for the irrationalities of America's health care system, for the fact that caring labor is devalued, and for the inequities of an economy driven by the relentless creation of underpaid service jobs. In so doing, the book also analyzes the roles that unions—particularly SEIU 1199 in New York—and the city's academic institutions have played in this problematic phenomenon.In her thoughtful and provocative critique of job training in the health care sector, Ariel Ducey explores the history and the extent of job training initiatives for health care workers and lays out the political and economic significance of these programs beyond the obvious goal of career advancement. Questioning whether job training improves either the lives of workers or the quality of health care, she explains why such training persists, focusing in particular on the wide scope of its "emotional" benefits. The book is based on Ducey's three years as an ethnographer in several hospitals and in-depth interviews with key players in health care training. It argues that training and education cannot be a panacea for restructuring—whether in the health care sector or the economy as a whole.

"Nursing, everyone believes, is the caring profession. Texts on caring line the walls of nursing schools and student shelves. Indeed, the discipline of nursing is often known as the 'caring science.' Because of their caring reputation, nurses top the polls as the most-trustworthy professionals. Yet, in spite of what seems to be an endless outpouring of public support, in almost every country in the world nursing is under threat, in the practice setting and in the academic sector. Indeed, its standing as a regulated profession is constantly challenged. In our view, this paradox is neither accidental nor natural but, in great part, the logical consequence of the fact that nurses and their organizations place such a heavy emphasis on nursing's and nurses' virtues rather than on their knowledge and concrete contributions."—from the IntroductionIn a series of provocative essays, The Complexities of Care rejects the assumption that nursing work is primarily emotional and relational. The contributors-international experts on nursing- all argue that caring discourse in nursing is a dangerous oversimplification that has in fact created many dilemmas within the profession and in the health care system. This book offers a long-overdue exploration of care at a pivotal moment in the history of health care. The ideas presented here will foster a critical debate that will assist nurses to better understand the nature and meaning of the nurse-patient relationship, confront challenges to their work and their profession, and deliver the services patients need now and into the future.Contributors: Sanchia Aranda, University of Melbourne and Peter MacCallum Cancer Centre; Rosie Brown, University of Melbourne; Sean Clarke, University of Pennsylvania and University of Montreal; Suzanne Gordon; Marie Heartfield, University of South Australia; Tom Keighley, Royal College of Nursing; Diana J. Mason, American Journal of Nursing; Lydia L. Moland, Babson College; Sioban Nelson, University of Toronto; Dana Beth Weinberg, Queens College, CUNY

Although the United States spends 16 percent of its gross domestic product on health care, more than 46 million people have no insurance coverage, while one in four Americans report difficulty paying for medical care. Indeed, the U.S. health care system, despite being the most expensive health care system in the world, ranked thirty-seventh in a comprehensive World Health Organization report. With health care spending only expected to increase, Americans are again debating new ideas for expanding coverage and cutting costs. According to the historian Paul V. Dutton, Americans should look to France, whose health care system captured the World Health Organization's number-one spot.In Differential Diagnoses, Dutton debunks a common misconception among Americans that European health care systems are essentially similar to each other and vastly different from U.S. health care. In fact, the Americans and the French both distrust "socialized medicine." Both peoples cherish patient choice, independent physicians, medical practice freedoms, and private insurers in a qualitatively different way than the Canadians, the British, and many others. The United States and France have struggled with the same ideals of liberty and equality, but one country followed a path that led to universal health insurance; the other embraced private insurers and has only guaranteed coverage for the elderly and the very poor.How has France reconciled the competing ideals of individual liberty and social equality to assure universal coverage while protecting patient and practitioner freedoms? What can Americans learn from the French experience, and what can the French learn from the U.S. example? Differential Diagnoses answers these questions by comparing how employers, labor unions, insurers, political groups, the state, and medical professionals have shaped their nations' health care systems from the early years of the twentieth century to the present day.

Legally mandated nurse-to-patient ratios are one of the most controversial topics in health care today. Ratio advocates believe that minimum staffing levels are essential for quality care, better working conditions, and higher rates of RN recruitment and retention that would alleviate the current global nursing shortage. Opponents claim that ratios will unfairly burden hospital budgets, while reducing management flexibility in addressing patient needs.Safety in Numbers is the first book to examine the arguments for and against ratios. Utilizing survey data, interviews, and other original research, Suzanne Gordon, John Buchanan, and Tanya Bretherton weigh the cost, benefits, and effectiveness of ratios in California and the state of Victoria in Australia, the two places where RN staffing levels have been mandated the longest. They show how hospital cost cutting and layoffs in the 1990s created larger workloads and deteriorating conditions for both nurses and their patients—leading nursing organizations to embrace staffing level regulation. The authors provide an in-depth account of the difficult but ultimately successful campaigns waged by nurses and their allies to win mandated ratios. Safety in Numbers then reports on how nurses, hospital administrators, and health care policymakers handled ratio implementation.With at least fourteen states in the United States and several other countries now considering staffing level regulation, this balanced assessment of the impact of ratios on patient outcomes and RN job performance and satisfaction could not be timelier. The authors' history and analysis of the nurse-to-patient ratios debate will be welcomed as an invaluable guide for patient advocates, nurses, health care managers, public officials, and anyone else concerned about the quality of patient care in the United States and the world.

In its early years, Israel's dominant ideology led to public provision of health care for all Jewish citizens-regardless of their age, income, or ability to pay. However, the system has shifted in recent decades, becoming increasingly privatized and market-based. In a familiar paradox, the wealthy, the young, and the healthy have relatively easy access to health care, and the poor, the old, and the very sick confront increasing obstacles to medical treatment.In Circles of Exclusion, Dani Filc, both a physician and a human rights activist, forcefully argues that in present-day Israel, equal access to health care is constantly and systematically thwarted by a regime that does not extend an equal level of commitment to the well-being of all residents of Israel, whether Jewish, Israeli Palestinians, migrant workers, or Palestinians in the Occupied Territories. Filc explores how Israel's adoption of a neoliberal model has pushed the system in a direction that gives priority to the strongest and richest individuals and groups over the needs of society as a whole, and to profit and competition over care.Filc pays special attention to the repercussions of policies that define citizenship in a way that has serious consequences for the health of groups of Palestinians who are Israeli citizens-particularly the Bedouins in the unrecognized villages-and to the ways in which this structure of citizenship affects the health of migrant workers. The health care situation is even more dire in the Occupied Territories, where the Occupation, especially in the last two decades, has negatively affected access to medical care and the health of Palestinians. Filc concludes his book with a discussion of how human rights, public health, and economic imperatives can be combined to produce a truly equal health care system that provides high-quality services to all Israelis.

"With Lous Heshusius as a guide, pain patients can learn much about the perils of a modern health-care odyssey. Health professionals can learn how an articulate middle-class female white patient thinks (with all that thinking entails) when her world is irreversibly altered by pain. She does not promise happy endings. Chronic pain is like that. From the rare intersection in this text between patient narrative and physician response, however, readers may construct a dialogue on pain in our time that cannot fail to bring plentiful opportunities for personal insight and professional enlightenment."—from the Foreword by David B. MorrisChronic pain, which affects 70 million people in the United States alone—more than diabetes, cancer, and heart disease combined—is a major public health issue that remains poorly understood both within the health care system and by those closest to the people it afflicts. This book examines the experience of pain in ways that could significantly improve how patients and practitioners deal with pain. It is the first volume of a new collection of titles within the acclaimed Culture and Politics of Health Care Work series called How Patients Think, intended to give voice to the concerns of patients about their own medical care and the formulation of health policy.Since surviving a near-fatal car accident, Lous Heshusius has suffered from chronic pain for more than a decade, forcing her to give up her career as a professor of education. Inside Chronic Pain, based in part on the pain journal Heshusius keeps, is a stunning memoir of a life lived in constant pain as well as an insightful and often critical account of the inadequacies of the health care system—from physicians to hospitals and health insurance companies—to understand chronic pain and treat those who suffer from it. Through her own frequently frustrating experiences, she shows how health care providers often ignore, deny, or incorrectly treat chronic pain at immense cost to both the patient and the health care system. She also offers cogent suggestions on improving the quality and outcome of chronic pain care and management, using her encounters with exceptional medical professionals as models.Inside Chronic Pain deals with pain's dramatic and destructive effects on one's sense of self and identity. It chronicles the chaos that takes place, the paralyzing effect of severe pain, the changes in personality that ensue, and the corrosive effects of severe pain on the ability to attend to day-to-day tasks. It describes how one's social life falls apart and isolation takes over. It also relates moments of happiness and beauty and describes how rooting the self in the present is crucial in managing pain. A unique feature of Inside Chronic Pain is the clinical commentary by Dr. Scott M. Fishman, president of the American Pain Foundation. Fishman has long tried to improve the lives of patients like Heshusius. His medical perspective on her very human narrative will help physicians and other clinicians better understand and treat patients with chronic pain.

Kaiser Permanente is the largest managed care organization in the country. It also happens to have the largest and most complex labor-management partnership ever created in the United States. This book tells the story of that partnership-how it started, how it grew, who made it happen, and the lessons to be learned from its successes and complications. With twenty-seven unions and an organization as complex as 8.6-million-member Kaiser Permanente, establishing the partnership was not a simple task and maintaining it has proven to be extraordinarily challenging.Thomas A. Kochan, Adrienne E. Eaton, Robert B. McKersie, and Paul S. Adler are among a team of researchers who have been tracking the evolution of the partnership between Kaiser Permanente and the Coalition of Kaiser Permanente Unions ever since 2001. They review the history of health care labor relations and present a profile of Kaiser Permanente as it has developed over the years. They then delve into the partnership, discussing its achievements and struggles, including the negotiation of the most innovative collective bargaining agreements in the history of American labor relations. They conclude with an assessment of the Kaiser partnership's effect on the larger health care system and its implications for labor-management relations in other industries.

Changing the Course of AIDS is an in-depth evaluation of a new and exciting way to create the kind of much-needed behavioral change that could affect the course of the global health crisis of HIV/AIDS. This case study from the South African HIV/AIDS epidemic demonstrates that regular workers serving as peer educators can be as—or even more—effective agents of behavioral change than experts who lecture about the facts and so-called appropriate health care behavior. After spending six years researching the response of large South African companies to the epidemic that is decimating their workforce as well as South African communities, David Dickinson describes the promise of this grassroots intervention—workers educating one another in the workplace and community—and the limitations of traditional top-down strategies.Dickinson's book takes us right into the South African workplace to show how effective and yet enormously complex peer education really is. We see what it means when workers directly tackle the kinds of sexual, gender, religious, ethnic, and broader social and political taboos that make behavior change so difficult, particularly when that behavior involves sex and sexuality. Dickinson's findings show that people who are not officially health care experts or even health care workers can be skilled and effective educators. In this book we see why peer education has so much to offer societies grappling with the HIV/AIDS epidemic and why those interested in changing behaviors to ameliorate other health problems like obesity, alcoholism, and substance abuse have so much to learn from the South African example.

Throughout history, physicians have played a vital role in medical discovery. These physician-scientists devote the majority of their professional effort to seeking new knowledge about health and disease through research and represent the entire continuum of biomedical investigation. They bring a unique perspective to their work and often base their scientific questions on the experience of caring for patients. Physician-scientists also effectively communicate between researchers in the "pure sciences" and practicing health care providers. Yet there has been growing concern in recent decades that, due to complex changes, physician-scientists are vanishing from the scene.In this book, leading physician-scientists and academic physicians examine the problem from a variety of perspectives: historical, demographic, scientific, cultural, sociological, and economic. They make valuable recommendations that—if heeded—should preserve and revitalize the community of physician-scientists as the profession continues to evolve and boundaries between doctors and researchers shift.Contributors: James M. Anderson, MD, PhD, University of North Carolina at Chapel Hill School of Medicine; Ann J. Brown, MD, MHS, Duke University School of Medicine; Barry S. Coller, MD, Rockefeller University; Fabio Cominelli, MD, PhD, Case Western Reserve University; Paul E. DiCorleto, PhD, Cleveland Clinic and Case Western Reserve University School of Medicine; Mark Donowitz, MD, The Johns Hopkins University School of Medicine; Stephen G. Emerson, MD, PhD, Haverford College; Gregory Germino, MD, The Johns Hopkins University School of Medicine; Stephen J. Heinig, Association of American Medical Colleges; Margaret K. Hostetter, MD, Yale University School of Medicine; Reshma Jagsi, MD, DPhil, University of Michigan Medical School; Kenneth Kaushansky, MD, MACP, University of California, San Diego School of Medicine; David Korn, MD, Harvard University and Harvard Medical School; Timothy J. Ley, MD, Washington University School of Medicine; Philip M. Meneely, PhD, Haverford College; David G. Nathan, MD, Harvard Medical School; Philip A. Pizzo, MD, Stanford University School of Medicine; Jennifer Punt, VMD, PhD, Haverford College; Andrew I. Schafer, MD, Weill Cornell Medical College and New York-Presbyterian Hospital; Alan L. Schwartz, MD, PhD, Washington University School of Medicine; Roy L. Silverstein, MD, Cleveland Clinic; Nancy J. Tarbell, MD, Massachusetts General Hospital and Harvard Medical School

How Patients ThinkAt age twenty-one, Chloë Atkins began suffering from a mysterious illness, the symptoms of which rapidly worsened. Paralyzed for months at a time, she frequently required intubation and life support. She eventually became quadriplegic, dependent both on a wheelchair and on health professionals who refused to believe there was anything physically wrong with her. When test after test returned inconclusive results, Atkins's doctors pronounced her symptoms psychosomatic. Atkins was told not only that she was going to die but also that this was her own fault; they concluded she was so emotionally deranged that she was willing her own death.My Imaginary Illness is the compelling story of Atkins's decades-long battle with a disease deemed imaginary, her frustration with a succession of doctors and diagnoses, her immersion in the world of psychotherapy, and her excruciating physical and emotional journey back to wellness. As both a political theorist and patient, Atkins provides a narrative critique of contemporary medicine and its problematic handling of uncertainty and of symptoms that are not easily diagnosed or known. She convincingly illustrates that medicine's belief in evidence-based practice does not mean that individual doctors are capable of objectivity, nor that the presence of biomedical ethics invokes ethical practices in hospitals and clinics. A foreword by Bonnie Blair O'Connor, who teaches medical students how to listen to patients, and a clinical commentary by Dr. Brian David Hodges, a professor of psychiatry, enrich the book's narrative with practical guidance for medical practitioners and patients alike.

The reassuring bromides of "chicken soup for the soul" provide little solace for nurses—and the people they serve—in real-life hospitals, nursing homes, schools of nursing, and other settings. In the minefield of modern health care, there are myriad obstacles to quality patient care—including work overload, inadequate funds for nursing education and research, and poor communication between and within the professions, to name only a few. The seventy RNs whose stories are collected here by the award-winning journalist Suzanne Gordon know that effective advocacy isn't easy. It takes nurses willing to stand up for themselves, their coworkers, their patients, and the public.When Chicken Soup Isn't Enough brings together compelling personal narratives from a wide range of nurses from across the globe. The assembled profiles in professional courage provide new insight into the daily challenges that RNs face in North America and abroad—and how they overcome them with skill, ingenuity, persistence, and individual and collective advocacy at work and in the community. In this collection, we meet RNs working at the bedside, providing home care, managing hospital departments, teaching and doing research, lobbying for quality patient care, and campaigning for health care reform. Their stories are funny, sad, deeply moving, inspiring, and always revealing of the different ways that nurses make their voices heard in the service of their profession. The risks and rewards, joys and sorrows, of nursing have rarely been captured in such vivid first-person accounts. Gordon and the authors of the essays contained in this book have much to say about the strengths and shortcomings of health care today—and the role that nurses play as irreplaceable agents of change.

Florence Nightingale remains an inspiration to nurses around the world for her pioneering work treating wounded British soldiers during the Crimean War; authorship of Notes on Nursing, the foundational text for nursing practice; establishment of the world's first nursing school; and advocacy for the hygienic treatment of patients and sanitary design of hospitals. In Notes on Nightingale, nursing historians and scholars offer their valuable reflections on Nightingale and analysis of her role in the profession a century after her death on 13 August 1910 and 150 years since the Nightingale School of Nursing (now the Florence Nightingale School of Nursing and Midwifery at King's College, London) opened its doors to probationers at St Thomas' Hospital.There is a great deal of controversy about Nightingale—opinions about her life and work range from blind worship to blanket denunciation. The question of Nightingale and her place in nursing history and in contemporary nursing discourse is a topic of continuing interest for nursing students, teachers, and professional associations. This book offers new scholarship on Nightingale's work in the Crimea and the British colonies and her connection to the emerging science of statistics, as well as valuable reevaluations of her evolving legacy and the surrounding myths, symbolism, and misconceptions.

Infectious disease is the most common cause of illness and death in Africa, yet health practitioners routinely fail to identify causative microorganisms in most patients. As a result, patients often do not receive the right medicine in time to cure them promptly even when such medicine is available, outbreaks are larger and more devastating than they should be, and the impact of control interventions is difficult to measure. Wrong prescriptions and prolonged infections amount to needless costs for patients and for health systems. In Divining without Seeds, Iruka N. Okeke forcefully argues that laboratory diagnostics are essential to the effective practice of medicine in Africa.The diversity of endemic life-threatening infections and limited public health resources in tropical Africa make the need for basic laboratory diagnostic support even more acute than in other parts of the world. This book gathers compelling case studies of inadequate diagnoses of diseases ranging from fevers—including malaria—to respiratory infections and sexually transmitted diseases. The inherited and widely prevalent health clinic model, which excludes or diminishes the hospital laboratory, is flawed, to often devastating effect. Fortunately, there are new technologies that make it possible to inexpensively implement testing at the primary care level. Divining without Seeds makes clear that routine use of appropriate diagnostic support should be part of every drug delivery plan in Africa and that diagnostic development should be given high priority.

Primary care medicine, as we know and remember it, is in crisis. While policymakers, government administrators, and the health insurance industry pay lip service to the personal relationship between physician and patient, dissatisfaction and disaffection run rampant among primary care doctors, and medical students steer clear in order to pursue more lucrative specialties. Patients feel helpless, well aware that they are losing a valued close connection as health care steadily becomes more transactional than relational. The thin-margin efficiency, rapid pace, and high volume demanded by the new health care economics do not work for primary care, an inherently slower, more personal, and uniquely tailored service. In Out of Practice, Dr. Frederick Barken juxtaposes his personal experience with the latest research on the transformations in the medical field. He offers a cool critique of the "market model of medicine" while vividly illustrating how the seemingly inexorable trend toward specialization in the last few decades has shifted emphasis away from what was once the foundation of medical practice. Dr. Barken addresses the complexities of modern practice—overuse of diagnostic studies, fragmentation of care, increasing reliance on an array of prescription drugs, and the practice of defensive medicine. He shows how changes in medicine, the family, and society have left physicians to deal with a wide range of geriatric issues, from limited mobility to dementia, that are not addressed by health care policy and are not entirely amenable to a physician's prescription. Indeed, Dr. Barken contends, the very survival of primary care is in jeopardy at a time when its practitioners are needed more than ever. Illustrated with case studies gleaned from more than twenty years in private practice and data from a wide range of sources, Out of Practice is more than a jeremiad about a broken system. Throughout, Dr. Barken offers cogent suggestions for policymakers and practitioners alike, making clear that as valuable as the latest drug or medical device may be, a successful health care system depends just as much on the doctor-patient relationship embodied by primary care medicine.

U.S. health care is a $2.5 trillion system that accounts for more than 17 percent of the nation's GDP. It is also highly susceptible to fraud. Estimates vary, but some observers believe that as much as 10 percent of all medical billing involves some type of fraud. In 2009, New York's Medicaid fraud office recovered $283 million and obtained 148 criminal convictions. In July 2010, the U.S. Justice Department charged nearly 100 patients, doctors, and health care executives in five states of bilking the Medicare system out of more than $251 million through false claims for services that were medically unnecessary or never provided. These cases only hint at the scope of the problem.In Phantom Billing, Fake Prescriptions, and the High Cost of Medicine, Terry L. Leap takes on medical fraud and its economic, psychological, and social costs. Illustrated throughout with dozens of specific and often fascinating cases, this book covers a wide variety of crimes: kickbacks, illicit referrals, overcharging and double billing, upcoding, unbundling, rent-a-patient and pill-mill schemes, insurance scams, short-pilling, off-label marketing of pharmaceuticals, and rebate fraud, as well as criminal acts that enable this fraud (mail and wire fraud, conspiracy, and money laundering). After assessing the effectiveness of the federal laws designed to fight health care fraud and abuse—the antikickback statute, the Stark Law, the False Claims Act, HIPAA, and the food and drug laws—Leap suggests a number of ways that health care providers, consumers, insurers, and federal and state officials can bring health care fraud and abuse under control, thereby reducing the overall cost of medical care in America.

"If you consider Iraq—like I do, probably twenty-nine out of thirty days—to be the pinnacle of your life, then where do you go from there? And I'm sure that a lot of veterans feel that way. To them, that was it. That was everything. So now what? They have to find something meaningful and purposeful.""When I got back from Afghanistan, there was not even so much as a briefing that said, 'Let us know if you're having problems.' There wasn't so much as a phone number. There was literally nothing.""I knew it was crazy. I was thinking, the guy on the roof's either a sniper or he's going to radio ahead. And then I thought, this is San Antonio. There's not snipers on the roof, nobody's going to blow me up here.""Whenever I look at people back here at home, I know what they're going to look like dead. I know what they look like with their brains blown out or jaws blown off or eyes pulled out. When I look at somebody I see that, to this day."—Voices of veterans interviewed in Fields of CombatFor many of the 1.6 million U.S. service members who have served in Iraq and Afghanistan since 2001, the trip home is only the beginning of a longer journey. Many undergo an awkward period of readjustment to civilian life after long deployments. Some veterans may find themselves drinking too much, unable to sleep or waking from unspeakable dreams, lashing out at friends and loved ones. Over time, some will struggle so profoundly that they eventually are diagnosed with post-traumatic stress Disorder (PTSD).Both heartbreaking and hopeful, Fields of Combat tells the story of how American veterans and their families navigate the return home. Following a group of veterans and their personal stories of war, trauma, and recovery, Erin P. Finley illustrates the devastating impact PTSD can have on veterans and their families. Finley sensitively explores issues of substance abuse, failed relationships, domestic violence, and even suicide and also challenges popular ideas of PTSD as incurable and permanently debilitating. Drawing on rich, often searing ethnographic material, Finley examines the cultural, political, and historical influences that shape individual experiences of PTSD and how its sufferers are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military's response to wounded and traumatized service members, debate continues over how best to provide treatment and compensation for service-related disabilities. Meanwhile, new and highly effective treatments are revolutionizing how the Department of Veterans Affairs (VA) provides trauma care, redefining the way PTSD itself is understood in the process. Carefully and compassionately untangling each of these conflicts, Fields of Combat reveals the very real implications they have for veterans living with PTSD and offers recommendations to improve how we care for this vulnerable but resilient population.

According to the Bureau of Labor Statistics, there were approximately 1.7 million home health aides and personal and home care aides in the United States as of 2008. These home care aides are rapidly becoming the backbone of America's system of long-term care, and their numbers continue to grow. Often referred to as frontline care providers or direct care workers, home care aides—disproportionately women of color—bathe, feed, and offer companionship to the elderly and disabled in the context of the home. In The Caring Self, Clare L. Stacey draws on observations of and interviews with aides working in Ohio and California to explore the physical and emotional labor associated with the care of others. Aides experience material hardships—most work for minimum wage, and the services they provide are denigrated as unskilled labor—and find themselves negotiating social norms and affective rules associated with both family and work. This has negative implications for workers who struggle to establish clear limits on their emotional labor in the intimate space of the home. Aides often find themselves giving more, staying longer, even paying out of pocket for patient medications or incidentals; in other words, they feel emotional obligations expected more often of family members than of employees. However, there are also positive outcomes: some aides form meaningful ties to elderly and disabled patients. This sense of connection allows them to establish a sense of dignity and social worth in a socially devalued job. The case of home care allows us to see the ways in which emotional labor can simultaneously have deleterious and empowering consequences for workers.

There is constant pressure on hospitals to improve health care delivery and increase cost effectiveness. New initiatives are the order of the day in the dramatically different health care systems of the United States and Great Britain. Often, as we know all too well, these efforts are not successful. In The Challenge to Change, Rebecca Kolins Givan analyzes the successes and failures of efforts to improve hospitals and explains what factors make it likely that the implementation of reforms will rewarded by positive transformation in a particular institution's day-to-day operation. Givan's in-depth qualitative case studies of both top-down initiatives and changes first suggested by staff on the front lines of care point clearly to the importance of all hospital workers in effecting change and even influencing national policy.Givan illuminates the critical role of workers, managers, and unions in enabling or constraining changes in policies and procedures and ensuring their implementation. Givan spotlights an Anglo-American model of hospital care and work organization, even while these countries retain their differences in access and payment. Entrenched professional roles, hierarchical workplace organization, and the sometimes-detached view of policymakers all shape the prospects for change in hospitals. Givan provides important examples of how the dedication and imagination of the people who work in hospitals can make all the difference when it comes to providing quality health care even in a challenging economic environment.

Medical competence is a hot topic surrounded by much controversy about how to define competency, how to teach it, and how to measure it. While some debate the pros and cons of competence-based medical education and others explain how to achieve various competencies, the authors of the seven chapters in The Question of Competence offer something very different. They critique the very notion of competence itself and attend to how it has shaped what we pay attention to—and what we ignore—in the education and assessment of medical trainees. Two leading figures in the field of medical education, Brian D. Hodges and Lorelei Lingard, drew together colleagues from the United States, Canada, and the Netherlands to explore competency from different perspectives, in order to spark thoughtful discussion and debate on the subject. The critical analyses included in the book's chapters cover the role of emotion, the implications of teamwork, interprofessional frameworks, the construction of expertise, new directions for assessment, models of self-regulation, and the concept of mindful practice. The authors juxtapose the idea of competence with other highly valued ideas in medical education such as emotion, cognition and teamwork, drawing new insights about their intersections and implications for one another.

When unions undertake labor organizing campaigns, they often do so from strong moral positions, contrasting workers' rights to decent pay or better working conditions with the more venal financial motives of management. But how does labor confront management when management itself has moral legitimacy? In With God on Our Side, Adam D. Reich tells the story of a five-year campaign to unionize Santa Rosa Memorial Hospital, a Catholic hospital in California. Based on his own work as a volunteer organizer with the Service Employees International Union (SEIU), Reich explores how both union leaders and hospital leaders sought to show they were upholding the Catholic "mission" of the hospital against a market represented by the other. Ultimately, workers and union leaders were able to reinterpret Catholic values in ways that supported their efforts to organize.More generally, Reich argues that unions must weave together economic and cultural power in order to ensure their continued relevancy in the postindustrial world. In addition to advocating for workers' economic interests, unions must engage with workers' emotional investments in their work, must contend with the kind of moral authority that Santa Rosa Hospital leaders exerted to dissuade workers from organizing, and must connect labor's project to broader conceptions of the public good.

To cut costs and maximize profits, hospitals in the United States and many other countries are outsourcing such tasks as cleaning and food preparation to private contractors. In Cleaning Up, the first book to examine this transformation in the healthcare industry, Dan Zuberi looks at the consequences of outsourcing from two perspectives: its impact on patient safety and its role in increasing socioeconomic inequality. Drawing on years of field research in Vancouver, Canada as well as data from hospitals in the U.S. and Europe, he argues that outsourcing has been disastrous for the cleanliness of hospitals—leading to an increased risk of hospital-acquired infections, a leading cause of severe illness and death—as well as for the effective delivery of other hospital services and the workers themselves. Zuberi's interviews with the low-wage workers who keep hospitals running uncover claims of exposure to near-constant risk of injury and illness. Many report serious concerns about the quality of the work due to understaffing, high turnover, poor training and experience, inadequate cleaning supplies, and on-the-job injuries. Zuberi also presents policy recommendations for improving patient safety by reducing the risk of hospital-acquired infection and ameliorating the work conditions and quality of life of hospital support workers. He makes the case that hospital outsourcing exemplifies the trend towards "low-road" service-sector jobs that threatens to undermine society's social health, as well as the physical health and well-being of patients in health care settings globally.

Each year, hospital-acquired infections, prescribing and treatment errors, lost documents and test reports, communication failures, and other problems have caused thousands of deaths in the United States, added millions of days to patients' hospital stays, and cost Americans tens of billions of dollars. Despite (and sometimes because of) new medical information technology and numerous well-intentioned initiatives to address these problems, threats to patient safety remain and in some areas are on the rise. In First, Do Less Harm, twelve health care professionals and researchers plus two former patients look at patient safety from a variety of perspectives, finding many of the proposed solutions to be inadequate or impractical. Several contributors to this book attribute the failure to confront patient safety concerns to the influence of the "market model" on medicine and emphasize the need for hospital-wide teamwork and greater involvement from frontline workers (from janitors and aides to nurses and physicians) in planning, implementing, and evaluating effective safety initiatives. Several chapters in First, Do Less Harm focus on the critical role of interprofessional and occupational practice in patient safety. Rather than focusing on the usual suspects—physicians, safety champions, or high level management—these chapters expand the list of "stakeholders" and patient safety advocates to include nurses, patient care assistants, and other staff, as well as the health care unions that may represent them. First, Do Less Harm also highlights workplace issues that negatively affect safety: including sleeplessness, excessive workloads, outsourcing of hospital cleaning, and lack of teamwork between physicians and other health care staff. In two chapters, experts explain why the promise of health care information technology to fix safety problems remains unrealized, with examples that are at once humorous and frightening. A book that will be required reading for physicians, nurses, hospital administrators, public health officers, quality and risk managers, healthcare educators, economists, and policymakers, First, Do Less Harm concludes with a list of twenty-seven paradoxes and challenges facing everyone interested in making care safe for both patients and those who care for them.

In 2009, an influential panel of medical experts ignited a controversy when they recommended that most women should not begin routine mammograms to screen for breast cancer until the age of fifty, reversing guidelines they had issued just seven years before when they recommended forty as the optimal age to start getting mammograms. While some praised the new recommendation as sensible given the smaller benefit women under fifty derive from mammography, many women's groups, health care advocates, and individual women saw the guidelines as privileging financial considerations over women's health and a setback to decades-long efforts to reduce the mortality rate of breast cancer.In The Big Squeeze, Dr. Handel Reynolds, a practicing radiologist, notes that this episode was only the most recent controversy in the turbulent history of mammography since its introduction in the early 1970s. In a book written for the millions of women who face the decision about whether to get a mammogram, health professionals interested in cancer screening, and public health policymakers, Reynolds shows how pivotal decisions made during mammography's initial launch made it all but inevitable that the test would be contentious. He describes how, at several key points in its history, the emphasis on mammography screening as a fundamental aspect of women's preventive health care coincided with social and political developments, from the women's movement in the early 1970s to breast cancer activism in the 1980s and '90s. At the same time, aggressive promotion of mammography made the screening tool the cornerstone of a huge new industry. Taking a balanced approach to this much-disputed issue, Reynolds addresses both the benefits and risks of mammography, charting debates, for example, that have weighed the early detection of aggressively malignant tumors against unnecessary treatments resulting from the identification of slow-growing and non-life-threatening cancers. The Big Squeeze, ultimately, helps to evaluate the ongoing public health controversies surrounding mammography and provides a clear understanding of how mammography achieved its current primacy in cancer screening.

The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel.The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, Beyond the Checklist demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.The coauthors infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.

"There is no night in the ICU. There is day, lesser day, then day again. There are rhythms. Every twelve hours: shift change. Report: first all together in the big room, then at the bedside, nurse to nurse. Morning rounds. A group of doctors moves slowly through the unit like a harrow through a field. At each room, like a game, a different one rotates into the center. They leave behind a trail of new orders. Wean, extubate, titrate, start this, stop that, scan, film, scope. The steep hill the patient is asked to climb. Can you breathe on your own? Can you wake up? Can you live?"—Where Night Is DayWhere Night Is Day is a nonfiction narrative grounded in the day-by-day, hour-by-hour rhythms of an ICU in a teaching hospital in the heart of New Mexico. It takes place over a thirteen-week period, the time of the average rotation of residents through the ICU. It begins in September and ends at Christmas. It is the story of patients and families, suddenly faced with critical illness, who find themselves in the ICU. It describes how they navigate through it and find their way. James Kelly is a sensitive witness to the quiet courage and resourcefulness of ordinary people. Kelly leads the reader into a parallel world: the world of illness. This world, invisible but not hidden, not articulated by but known by the ill, does not readily offer itself to our understanding. In this context, Kelly reflects on the nature of medicine and nursing, on how doctors and nurses see themselves and how they see each other. Drawing on the words of medical historians, doctor-writers, and nursing scholars, Kelly examines the relationship of professional and lay observers to the meaning of illness, empathy, caring, and the silence of suffering. Kelly offers up an intimate portrait of the ICU and its inhabitants.