Institutional challenges for mining and sustainability in Peru.

Global consumption continues to generate growth in mining. In lesser developed economies, this growth offers the potential to generate new resources for development, but also creates challenges to sustainability in the regions in which extraction occurs. This context leads to debate on the institutional arrangements most likely to build synergies between mining, livelihoods, and development, and on the socio-political conditions under which such institutions can emerge. Building from a multiyear, three-country program of research projects, Peru, a global center of mining expansion, serves as an exemplar for analyzing the effects of extractive industry on livelihoods and the conditions under which arrangements favoring local sustainability might emerge. This program is guided by three emergent hypotheses in human-environmental sciences regarding the relationships among institutions, knowledge, learning, and sustainability. The research combines in-depth and comparative case study analysis, and uses mapping and spatial analysis, surveys, in-depth interviews, participant observation, and our own direct participation in public debates on the regulation of mining for development. The findings demonstrate the pressures that mining expansion has placed on water resources, livelihood assets, and social relationships. These pressures are a result of institutional conditions that separate the governance of mineral expansion, water resources, and local development, and of relationships of power that prioritize large scale investment over livelihood and environment. A further problem is the poor communication between mining sector knowledge systems and those of local populations. These results are consistent with themes recently elaborated in sustainability science.

[Biological procedures, civil and military health facilities, and recommendations of good practice and hospital reform: the example of diabetes management]. / Actes de biologie, établissements de santé civils et militaires, recommandations de bonnes pratiques et réformes hospitalières: exemple de la prise en charge du diabète.

In the context of implementing hospital reforms, the objective of this work was to compare practice in relation to evidence-based guidelines and recommendations for good practice in diabetes screening and management. Laboratory test consumption was determined for patients hospitalized for diabetes in 2005 in three public hospitals (one civilian, two military) taking care of diabetic patients and performing related biological tests. For the 395 admissions in these three hospitals during 2005 [Diagnosis-related group (DRG) 10M02V "Diabetes, age 36 to 69 years without co-morbidity"], the average length of stay and the number of biological acts ["B"] performed were lower than those given by the French national health cost study scale and by the Montpellier University Hospital database. In terms of qualitative coherence between the guidelines for treatment and the recommendations, the total number of biological acts ["B"] is higher than if one were to strictly apply the good practice suggested by the French Health Authority. These three hospitals have and apply different guidelines for practice in the area of diabetes management. The implementation of reforms such as DRG-based payment scales may be an additional leverage to ensure that the recommendations of best practices are effective. Improved methods and tools for data collection and monitoring are essential, especially for estimating revenue and expenditure.

Medical director contracting.

Those nephrologists who are entering into new, or re-negotiating old, medical director contracts should take into consideration the large number of changes in the environment that have a bearing on the structure and wording of proposed contracts. This contribution offers specific guidance to assist with those efforts.

Dynamics of hospital-based plastic surgery.

BACKGROUND: Legislative regulations, decreasing reimbursements for office procedures, and malpractice premiums have transformed plastic surgery from an office-based specialty into a hospital-based one. Simultaneously, hospital economics has altered, wherein the "business model" has all but subsumed the old "medical care" model. Integration between plastic surgeons and the new hospital structure has been difficult for both. Limited understanding of the financial dynamics of hospital-based practices, unfamiliarity with the administrative processes, and resistance to accept and assimilate changes by both sides pose hurdles, in some situations even forcing plastic surgeons out of hospital settings. METHODS: Using well-defined financial terminology, changing national development in health care policy, and hospital-based administrative strategies as a backdrop, this study finds common ground for the plastic surgery specialty to coapt with the hospital. RESULTS: Key missing elements in the interaction between plastic surgeons and hospital administrations and ways of integrating these components are identified. To do so effectively, plastic surgeons must first understand the basic tenets of management that drive hospital administrators, participate at every level they can in guiding these processes, and assume leadership roles that will ultimately dictate the way they work and conduct their professional lives. CONCLUSIONS: It is critical that plastic surgeons engage in important processes that govern the economics of hospital-based health care delivery. This commitment will also ensure that all three groups (the patients, physicians, and hospital administrators) achieve a degree of satisfaction. The message to plastic surgeons is clear: be proactive and lead a campaign of change.

Physician employment: this time around, give finance a leading role.

Finance managers can play a leading role in determining the success of physician employment by addressing physicians' financial concerns. Physicians can benefit from financial managers' help in clarifying how practice decisions affect financial outcomes, and making the entire process transparent. Communication should include validation of data integrity, development of targeted reports, education, and frequent opportunities for dialogue.

How are health professionals earning their living in Malawi?

BACKGROUND: The migration of health professionals from southern Africa to developed nations is negatively affecting the delivery of health care services in the source countries. Oftentimes however, it is the reasons for the out-migration that have been described in the literature. The work and domestic situations of those health professionals continuing to serve in their posts have not been adequately studied. METHODS: The present study utilized a qualitative data collection and analysis method. This was achieved through focus group discussions and in-depth interviews with health professionals and administrators to determine the challenges they face and the coping systems they resort to and the perceptions towards those coping methods. RESULTS: Health professionals identified the following as some of the challenges there faced: inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a stimulating work environment, inadequate supervision, poor access to continued professionals training, limited career progression, lack of transparent recruitment and discriminatory remuneration. When asked what kept them still working in Malawi when the pressures to emigrate were there, the following were some of the ways the health professionals mentioned as useful for earning extra income to support their families: working in rural areas where life was perceived to be cheaper, working closer to home village so as to run farms, stealing drugs from health facilities, having more than one job, running small to medium scale businesses. Health professionals would also minimize expenditure by missing meals and walking to work. CONCLUSION: Many health professionals in Malawi experience overly challenging environments. In order to survive some are involved in ethically and legally questionable activities such as receiving "gifts" from patients and pilfering drugs. The efforts by the Malawi government and the international community to retain health workers in Malawi are recognized. There is however need to evaluate of these human resources-retaining measures are having the desired effects.

From bedside to boardroom - nursing shared governance.

A brand-new nursing shortage is revitalizing shared governance. This innovative organizational model gives staff nurses control over their practice and can extend their influence into administrative areas previously controlled only by managers. But nursing shared governance is hard to define. Its structures and processes are different in every organization; and its implementation is like pinning Jell-O to a wall. Is it appropriate for every situation? Is it worth the price? And can it really measure up to its glowing reputation? This article presents an overview of nursing shared governance, looking at themes and experiences from its rich 25-year tradition. The author identifies its essential elements, provides guidance for professionals who wish to embark on the journey, and describes the current status of shared governance as of 2004.

The manpower crisis in academic radiology: don't kill the milk cow for meat.

There is a manpower crisis in academic radiology departments. These departments cannot sustain their academic missions from clinical revenues alone. Salaries can' t be competitive with private practice, and the recruitment and retention of faculty members are compromised. The education of medical students, residents, and fellows and the clinical and basic research that sustains the specialty suffers. There is no simple remedy; academic departments need philanthropy from industry and private practice, more support from the government and the schools of medicine, and more efficient clinical practices. The future of our specialty is truly at stake. Academic departments are responsible for the great majority of training and technical innovation in the specialty. If academic departments cannot sustain their academic missions, the specialty of diagnostic radiology will certainly suffer.

Medical student indebtedness and the propensity to enter academic medicine.

This paper considers the potential impact of medical school indebtedness and other variables on the propensity of US doctors to enter academic medicine. Probit models provide some evidence that indebtedness reduces the likelihood that physicians will choose academic medicine as their primary activity. Nevertheless, the magnitude of this effect is not large. As indebtedness may be endogenous, the probits are rerun using an instrumental variables approach. These estimates imply that over time indebtedness may have an important impact on the propensity of physicians to enter academic medicine.

Medicare payment changes and physicians' incomes.

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.

Physician retirement plans: the impact of organizational structure.

A primary concern of many physicians is the accumulation of adequate funds while practicing to maintain their lifestyles after retirement. Take a look at how some business arrangements can affect retirement planning.

National Academy of Neuropsychology/Division 40 of the American Psychological Association practice survey of clinical neuropsychology in the United States, Part I: practitioner and practice characteristics, professional activities, and time requirements.

Leaders of the National Academy of Neuropsychology and Division 40 (Clinical Neuropsychology) of the American Psychological Association determined that current information on the professional practice of clinical neuropsychology within the United States (U.S.) was needed. These two organizations co-sponsored a national survey of U.S. clinical neuropsychologists that was conducted in September 2000. The primary goal of the survey was to gather information on such topics as: practitioner and practice characteristics, economic variables (e.g., experience with major third party payors, such as Medicare and managed care), practice expenses, billing methods, experiences with Current Procedural Terminology (CPT) codes, time spent on various clinical tasks, use of assistants, and income. The adjusted return rate of 33.5% (n = 1,406) reflects the number of surveys returned with sufficient data by licensed doctoral level clinicians with membership in one or both sponsoring organizations. In this first of two articles describing the survey results, characteristics of practitioners and practices, various types of professional activities, and time requirements for clinical tasks are presented and discussed. It was noted that the proportion of women in the field is increasing rapidly. Private practice is the predominant employment setting. Findings also document that members of the two sponsoring organizations are very similar with regard to employment setting, professional characteristics, and weekly activities. That is, involvement in clinical practice and research, as well as private practice versus institutional employment, was very similar between organizations. However, across organizations, work setting (private practice vs. institution) was associated with significant and meaningful differences. Private practitioners have a more diverse set of weekly clinical activities, are less likely to use assistants, and engage in more forensic activities. Across work setting, with the exception of forensic evaluations, those using assistants invest a greater number of hours per evaluation, but bill approximately the same numbers of hours per evaluation.