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Biomedical subjects

H Waitzkin

Publications and source records attributed to H Waitzkin.

At least 37 records · Page 2Linked to original sources
PubMed1995

Women's narratives in primary care medical encounters.

OBJECTIVE: This study asked how women's narratives of social and emotional problems are dealt with in primary care encounters. Our conceptual work extended perspectives from narrative analysis to focus on elements of ideology, social control, underlying structure, and features of discourse that appear marginal to medicine's technical tasks. METHOD: Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with criteria to guide sampling, transcription, interpretation, and presentation of findings. We applied the method to encounters which were selected randomly from a data base derived from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. FINDINGS: As shown by illustrative encounters, women's narratives in primary care often express emotional troubles related to gender roles. Medical discourse in these encounters tends to marginalize contextual issues that contribute to women's distress. Such discourse conveys acceptance of reproductive commitments, medical management of psychic distress, and lack of criticism regarding social problems that affect women. CONCLUSIONS: Narrative analysis clarifies the medical processing of women's emotional problems that derive in large part from the social context of medicine. Women patients and medical practitioners often deal with these issues in primary care encounters rather than in psychiatric settings. These findings suggest directions for improving the discourse of primary care encounters.

Antidepressive Agents↗
PubMed1994

The strange career of managed competition: from military failure to medical success?

Managed competition remains untested as the basis of a national health program. However, key principles of managed competition first emerged in the military. For this study, published works on systems analysis and the planning-programming-budgeting system (PPBS), developed by Alain Enthoven and colleagues at the US Department of Defense during the 1960s, were compared with published presentations of managed competition. The influence of PPBS waned after it generated controversy and opposition. PPBS and managed competition represent similar managerial strategies of policy reform. Although the origin of managed competition in failed military policy does not ensure failure in the medical arena, this history also does not augur success.

Cost-Benefit Analysis↗
PubMed1994

Narratives of aging and social problems in medical encounters with older persons.

This study asks: How do older patients and their doctors deal with social problems in the discourse of routine medical encounters? Our research has been influenced by a growing recognition of narratives as an important analytic focus in the study of patient-doctor communication. We attempted to advance theoretical knowledge by emphasizing elements of sociocultural context, ideology, social control, underlying structure, and features of discourse that appear marginal to medicine's technical tasks. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we tried to move methodologically beyond prior work by developing a new interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by illustrative encounters, a characteristic narrative structure and sequencing emerge, which tend to marginalize contextual problems, to leave them incompletely expressed, and to reinforce ideologies of stoicism and individualism.

Aged↗
PubMed1993

Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.

This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.

Adult↗
PubMed1993

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.

California↗
PubMed1992

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.

California↗
PubMed1991

Access to medical care for documented and undocumented Latinos in a southern California county.

To determine local access to medical care among Latinos, we conducted telephone interviews with residents of Orange County, California. The survey replicated on a local level the national access surveys sponsored by the Robert Wood Johnson Foundation. We compared access among Latino citizens of the United States (including permanent legal residents), undocumented Latinos, and Anglos, and analyzed predictors of access. Among the sample of 958 respondents were 137 Latino citizens, 54 undocumented Latinos, and 680 Anglos. Compared with Anglos, Latino citizens and undocumented immigrants had less access to medical care by all measures used in the survey. Although undocumented Latinos were less likely than Latino citizens to have health insurance, by most other measures their access did not differ significantly. By multivariate analysis, health insurance status and not ethnicity was the most important predictor of access. Because access to medical care is limited for both Latino citizens and undocumented immigrants, policy proposals to improve access for Latinos should consider current barriers faced by these groups and local differences in access to medical care.

Adult↗
PubMed1990

Local advocacy for the medically indigent. Strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program ensures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. We report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence state and national policies that affect local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system that guarantees access, they can substantially improve the availability of local services.

California↗
PubMed1990

On studying the discourse of medical encounters. A critique of quantitative and qualitative methods and a proposal for reasonable compromise.

Studies of doctor-patient communication, although leading to diverse findings, have not lent themselves to replication and also have not captured important features of medical discourse. Quantitative methods alone do not deal with the complexities of medical encounters, usually are not helpful in analyzing the social context of discourse, do not clarify underlying themes and structures, and are costly and tedious to use. With qualitative methods, the selection of discourse for analysis is not straightforward, quality of interpretation is difficult to evaluate, and textual presentation is not clear-cut. Several criteria of an appropriate method offer reasonable compromises in dealing with medical discourse: 1) discourse should be selected through a sampling procedure, preferably a randomized technique; 2) recordings of sampled discourse should be available for review by other observers; 3) standardized rules of transcription should be used; 4) the reliability of transcription should be assessed by multiple observers; 5) procedures of interpretation should be decided in advance, should be validated in relation to theory, and should address both content and structure of texts; 6) the reliability of applying interpretive procedures should be assessed by multiple observers; 7) a summary and excerpts from transcripts should accompany the interpretation, but full transcripts should also be available for review; and 8) texts and interpretations should convey the variability of content and structure across sampled texts. An ongoing study applies these criteria to research on ideology and social control in medical encounters.

Communication↗
PubMed1990

Functional status and financial barriers to medical care among the poor.

We compared the functional status of 94 poor patients with financial barriers to recommended medical care with that of 94 poor control patients without such barriers in a university-affiliated community clinic. Financial barriers existed when an insured patient's health insurance failed to cover recommended care or when an uninsured patient could not afford recommended care. Patients with financial barriers scored significantly lower than control subjects on the psychologic function/mental health component of the functional status questionnaire and tended to score lower on all other functional status measures. The results suggest that poor patients with financial barriers to recommended medical care may be sicker than other poor patients.

Adult↗
PubMed1989

Evaluating health-care needs of the poor: a community-oriented approach.

PURPOSE: Concern has arisen over the provision of health care for the poor. In a project sponsored by a local community hospital, we conducted a telephone survey to determine unmet health-care needs of low-income families living in Orange County, California, and made recommendations to address those needs. METHODS: The survey assessed demographic characteristics and access to medical care of 652 adults and their families. RESULTS: In general, we found that the poor (incomes below 125% of the poverty level), the uninsured, and the Latino respondents had lower access measures than the nearly poor (incomes between 125% and 200% of the poverty level), insured, and Anglo subjects. However, insurance status was the strongest predictor of access in this low-income population. Important unmet health-care needs included prenatal care and preventive care. In response to our findings, the sponsoring hospital has instituted new health-care programs to help meet these needs. CONCLUSION: This community-oriented approach for improving problems of access to medical care for the poor may be appropriate for other localities.

California↗