The social negotiation of fitness for work: tensions in doctor-patient relationships over medical certification of chronic pain

The UK government is promoting the health benefits of work, in order to change doctors' and patients' behaviour and reduce sickness absence. The rationale is that many people 'off sick' would have better outcomes by staying at work; but reducing the costs of health care and benefits is also an imperative. Replacement of the 'sick note' with the 'fit note' and a national educational programme are intended to reduce sickness-certification rates, but how will these initiatives impact on doctor-patient relationships and the existing tension between the doctor as patient advocate and gate-keeper to services and benefits? This tension is particularly acute for problems like chronic pain where diagnosis, prognosis and work capacity can be unclear. We interviewed 13 doctors and 30 chronic pain patients about their experiences of negotiating medical certification for work absence and their views of the new policies. Our findings highlight the limitations of naïve rationalist approaches to judgements of work absence and fitness for work for people with chronic pain. Moral, socio-cultural and practical factors are invoked by doctors and patients to contest decisions, and although both groups support the fit note's focus on capacity, they doubt it will overcome tensions in the consultation. Doctors value tacit skills of persuasion and negotiation that can change how patients conceptualise their illness and respond to it. Policy-makers increasingly recognise the role of this tacit knowledge and we conclude that sick-listing can be improved by further developing these skills and acknowledging the structural context within which protagonists negotiate sick-listin

Adapting structuration theory to understand the role of reflexivity: Problematization, clinical audit and information systems

This paper is an exploratory account of the further development and application of a hybrid framework, StructurANTion, that is based on Structuration Theory and Actor Network Theory (ANT). The use of social theories in general and their use in information systems (IS) research in particular is explored leading to the use of the framework to examine the concept of what are termed humanchine networks in the context of clinical audit, within a healthcare Primary Care Trust (PCT). A particular focus is on the manner in which information systems-based reflexivity contributes to both entrenching a networks’ structurated order as well as contributing to its emancipatory change. The case study compares clinic-centric and patientcentric audit and seeks to further extend the understanding of the role of information and information systems within structurated humanchine activity systems. Conclusions indicate that the use of more socially informed IS methods and approaches can incorporate more emancipatory ideals and lead to greater adoption and usage of more relevant and useful clinical information systems and practices

Exhaust jet wake and thrust characteristics of several nozzles designed for VTOL DOWNWASH suppression. Tests in and out of ground effect with 70 deg F and 1200 deg F nozzle discharge temperatures

Jet wake degradation and thrust characteristics of exhaust nozzles designed for VTOL downwash suppression and fuselage and ground effect

Asymptotic silence-breaking singularities

We discuss three complementary aspects of scalar curvature singularities: asymptotic causal properties, asymptotic Ricci and Weyl curvature, and asymptotic spatial properties. We divide scalar curvature singularities into two classes: so-called asymptotically silent singularities and non-generic singularities that break asymptotic silence. The emphasis in this paper is on the latter class which have not been previously discussed. We illustrate the above aspects and concepts by describing the singularities of a number of representative explicit perfect fluid solutions.Comment: 25 pages, 6 figure

Bianchi VIII Empty Futures

Using a qualitative analysis based on the Hamiltonian formalism and the orthonormal frame representation we investigate whether the chaotic behaviour which occurs close to the initial singularity is still present in the far future of Bianchi VIII models. We describe some features of the vacuum Bianchi VIII models at late times which might be relevant for studying the nature of the future asymptote of the general vacuum inhomogeneous solution to the Einstein field equations.Comment: 22 pages, no figures, Latex fil

Dynamics of spatially homogeneous solutions of the Einstein-Vlasov equations which are locally rotationally symmetric

The dynamics of a class of cosmological models with collisionless matter and four Killing vectors is studied in detail and compared with that of corresponding perfect fluid models. In many cases it is possible to identify asymptotic states of the spacetimes near the singularity or in a phase of unlimited expansion. Bianchi type II models show oscillatory behaviour near the initial singularity which is, however, simpler than that of the mixmaster model.Comment: 27 pages, 3 figures, LaTe

An almost isotropic cosmic microwave temperature does not imply an almost isotropic universe

In this letter we will show that, contrary to what is widely believed, an almost isotropic cosmic microwave background (CMB) temperature does not imply that the universe is ``close to a Friedmann-Lemaitre universe''. There are two important manifestations of anisotropy in the geometry of the universe, (i) the anisotropy in the overall expansion, and (ii) the intrinsic anisotropy of the gravitational field, described by the Weyl curvature tensor, although the former usually receives more attention than the latter in the astrophysical literature. Here we consider a class of spatially homogeneous models for which the anisotropy of the CMB temperature is within the current observational limits but whose Weyl curvature is not negligible, i.e. these models are not close to isotropy even though the CMB temperature is almost isotropic.Comment: 5 pages (AASTeX, aaspp4.sty), submitted to Astrophysical Journal Letter

Global dynamics of the mixmaster model

The asymptotic behaviour of vacuum Bianchi models of class A near the initial singularity is studied, in an effort to confirm the standard picture arising from heuristic and numerical approaches by mathematical proofs. It is shown that for solutions of types other than VIII and IX the singularity is velocity dominated and that the Kretschmann scalar is unbounded there, except in the explicitly known cases where the spacetime can be smoothly extended through a Cauchy horizon. For types VIII and IX it is shown that there are at most two possibilities for the evolution. When the first possibility is realized, and if the spacetime is not one of the explicitly known solutions which can be smoothly extended through a Cauchy horizon, then there are infinitely many oscillations near the singularity and the Kretschmann scalar is unbounded there. The second possibility remains mysterious and it is left open whether it ever occurs. It is also shown that any finite sequence of distinct points generated by iterating the Belinskii-Khalatnikov-Lifschitz mapping can be realized approximately by a solution of the vacuum Einstein equations of Bianchi type IX.Comment: 16 page

The Asymptotic Behaviour of Tilted Bianchi type VI0_0 Universes

We study the asymptotic behaviour of the Bianchi type VI$_0$ universes with a tilted $\gamma$-law perfect fluid. The late-time attractors are found for the full 7-dimensional state space and for several interesting invariant subspaces. In particular, it is found that for the particular value of the equation of state parameter, $\gamma=6/5$, there exists a bifurcation line which signals a transition of stability between a non-tilted equilibrium point to an extremely tilted equilibrium point. The initial singular regime is also discussed and we argue that the initial behaviour is chaotic for $\gamma<2$.Comment: 22 pages, 4 figures, to appear in CQ

Spherically symmetric relativistic stellar structures

We investigate relativistic spherically symmetric static perfect fluid models in the framework of the theory of dynamical systems. The field equations are recast into a regular dynamical system on a 3-dimensional compact state space, thereby avoiding the non-regularity problems associated with the Tolman-Oppenheimer-Volkoff equation. The global picture of the solution space thus obtained is used to derive qualitative features and to prove theorems about mass-radius properties. The perfect fluids we discuss are described by barotropic equations of state that are asymptotically polytropic at low pressures and, for certain applications, asymptotically linear at high pressures. We employ dimensionless variables that are asymptotically homology invariant in the low pressure regime, and thus we generalize standard work on Newtonian polytropes to a relativistic setting and to a much larger class of equations of state. Our dynamical systems framework is particularly suited for numerical computations, as illustrated by several numerical examples, e.g., the ideal neutron gas and examples that involve phase transitions.Comment: 23 pages, 25 figures (compressed), LaTe