Biomedical subjects
Publications and source records attributed to D Mechanic.
Despite growing consumerism and skepticism about authority in the culture as a whole, most patients continue to be pliant. If there is a serious threat to physician autonomy, it is more likely to come from third-party payers and new forms of medical practice, particularly the rise of for-profit hospital chains, than from patients. Though physicians are restless, they will learn to adapt to the new conditions of practice.
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Data from a variety of research areas are reviewed consistent with the hypothesis that attention to inner feelings and bodily changes increases awareness of an potency of distress and the prevalence of reported symptoms. The paper focuses on adolescence, a life-stage characterized by increased self-awareness and dramatic physical maturation. Increased introspectiveness is associated among many adolescents with more psychological pain and symptom reporting. It is hypothesized that discontinuities in family life and school and peer experiences, a major subclass of stressors, exacerbate self-awareness while stability and successful coping protect against painful self-perceptions.
Persons who terminated membership in a prepaid group practice when compared with continuing members have less health problems as measured by bed disability and psychologic well-being, report access difficult and inconvenient, and are less likely to have established a stable relationship with a physician in the plan. Access is perceived as a problem by continuing members, as well as by a large proportion of disenrollees. Enrollees who join the plan on the basis of more direct knowledge of its actual operation are more likely to continue in the plan, but this is not accounted for by satisfaction levels. They are also more successful in establishing stable physician relationships.
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This article examines the use of general medical services in a representative sample from a defined geographic area and in a sample of persons seeking psychiatric care from the same area. Psychiatric patients made 100 per cent more general medical care visits in the retrospective period and 83 per cent more in the prospective period than persons who did not seek mental health care. The analysis focuses on the determinants in general medical care use between those who sought mental health care and those who did not. The first hypothesis is that physical symptoms and dysfunction concomitant with psychologic disorder explain the difference. The second argues that the association is a product of help-seeking orientations and illness behavior. The third focuses on variations due to differences in access. The first two types of factors are the most important. Using sex, physical symptoms and illness behavior measures, we explain 50 per cent of the differences in retrospective utilization and 40 per cent of the differences in prospective data.
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Neither patients nor physicians are doing a great deal about growing costs, improving the rationality of medical services, or asking hard questions about the value of existing patterns. They have little incentive to do so, and when they do, it is with the clear awareness of their own economic interest. If budgetary cuts have to be made, they inevitably occur at the points of least political resistance-the poor, the old, and the chronically ill. The "middle course" of government intervention-between the harsh realities of a private medical marketplace and the bureaucratic consequences of a rationally planned system of care-has been a costly and inefficient regulatory muddle. Constructive compromises in future policy will be complicated and fiercely political.
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A significant proportion of patients are motivated in seeking care, in part, because of psychological distress or the physical problems compounded by such distress. The appropriate diagnosis and management of these problems constitute formidable clinical problems. The potential role of social work practice within ambulatory medical care is examined in relation to improving the responsiveness of care for such patients, and attention is given to strategies of management. Factors inhibiting the introduction of such services include the traditional orientations of social work and the discontinuity between public conceptions of medical care and social work practice.
Comparisons of prepaid, Medicaid and fee-for-service patients using the Marshfield Clinic and affiliated non-Clinic physicians indicate that a well-organized multispecialty group can successfully provide accessible and responsive care to rural populations and integrate varying types of payment systems. Most patients were highly satisfied, but differences in satisfaction among varying subgroups were substantially attributable to access barriers. Patients in the Greater Marshfield Community Health Plan (prepaied patients) were most generally satisfied, but patients using non-Clinic affiliates were higher on socioemotional satisfaction, reflecting certain barriers to personal care in complex organizational settings.
One hundred thirty-eight persons in varying outpatient settings in the People's Republic of China were interviewed briefly. Hospital outpatient utilization appeared to reflect not only severity of illness, but also patients' attitudes and beliefs, illness behavior patterns, and convenience, modifying the formal system of care to some extent. Traditional clinics in commune and county hospitals were typically used to treat psychiatric disorders (defined as physical conditions), chronic illness, and other conditions for which Western medicine offers only symptomatic treatment.