Governing Health

Die (vergleichende) Wohlfahrtsstaatforschung neigt zum Gebrauch absoluter Kategorien wie „Staat“, „Markt“, „Klasse“ oder „Soziale Gerechtigkeit“, um die Entstehung und Entwicklung von Wohlfahrtsstaaten zu erklären, zu messen oder zu kategorisieren. Insbesondere auf der Grundlage der Arbeiten Michel Foucault‘s zum Thema Gouvernementalität versucht diese Masterarbeitarbeit, alternative Perspektiven auf die Trans-formation von Wohlfahrtsstaaten zu bieten und die Entwicklungen in ihrer historischen Gebundenheit und der Komplexität der sich in ihnen widerspiegelnden sozialen Beziehungen zu verstehen. Dafür werden Episoden türkischer Gesundheitspolitik seit dem späten Osmanischen Reich interpretiert. Die Kernthemen sind die sich ändernde politischen Vorstellungen von Gesundheit einerseits und andererseits Techniken und Strategien, die politische Akteure anwenden, um das Politikfeld Gesundheit zu strukturieren und das Verhalten relevan-ter Akteure zu steuern. Die Arbeit greift insbesondere auf Primärquellen, wie offizielle Regierungspapiere, Reden, oder Leitfadeninterviews mit Experten zurück. Die Analyse zeichnet den politischen Diskurs über Ge-sundheit(spolitik) nach, der von „Barmherzigkeit und Gnade“ über die „Sicherung der Stärke der Nation“ bis hin zu der Idee eines „Rechtes auf Gesundheit“ reicht, welche seit den 1980er Jahren durch neoliberales Vo-kabular wie „(minimaler) Universalismus“, „Eigenverantwortung“ oder „Effizienz und Wettbewerb“ ergänzt wird. Derweil blieben trotz der Entstehung und Ausdehnung des Politikfeldes mit zugeordnetem bürokrati-schen Apparat, viele Programme und Projekte aufgrund der gesellschaftlichen und wirtschaftlichen Struktur sowie fortlaufender Konflikte zwischen unterschiedlichen Regierungsmentalitäten inkonsistent und unvollen-det. Erst mit dem sogenannten Health Transformation Program, das seit 2003 unter der Partei für Gerechtig-keit und Fortschritt (AKP) implementiert wird, scheint ein Gesundheitssystem entstanden zu sein, welches sich durchgängig auf eine neoliberale Regierungslogik bezieht und die formalen Prinzipien einer Marktwirt-schaft als Regierungsprinzip auf die Erstellung von Programmen, Projekten und Regulierungen im Gesund-heitssektor projeziert.Scholars of the welfare state tend to use absolute categories such as “class”, “state”, “market” or “social jus-tice” to measure, classify and compare welfare states. Drawing predominantly on Michel Foucault’s lectures on governmentality, this master’s thesis attempts to offer alternative perspectives on the transformation of welfare states by analyzing developments in the Turkish health system in consideration of their historicity and of the complexity of social relations reflected in them. Interpreting different historical episodes of Turk-ish health policies since the late Ottoman Empire, special attention is paid not only to changing political con-ceptions of health, but also to the techniques and strategies that governments have relied on to influence the conduct of providers and receivers of health services. The study draws predominantly on primary sources such as official government papers, speeches and expert interviews. Dominant political discourses on health have reached from “charity and favor” under the Sultans over “securing the strength of the nation” in the early Republic to the idea of everybody’s “right to health”, that is eventually mixed and complemented with neoliberal vocabulary such as “(minimal) universalism”, “individual responsibility”, or “efficiency and compe-tition”. In spite of the emergence of healthcare as a policy area being attached to an expanding bureaucratic apparatus, most programs and projects have remained inconsistent and fragmentary due to the composition of Turkish society and economy and the persistent struggles between different forms of governments. The findings suggest that only with the so-called Health Transformation Program (HTP) that is implemented since 2003 under the government of the Justice and Development Party (JDP), a health system has emerged that is consistently based on a distinguished mode of government. Neoliberalism, understood as the attempt to take the formal principles of a market economy and projecting them onto a general art of government, con-stitutes the underlying tenet of the HTP’s wide net of programs, projects and regulations by which the gov-ernment attempts to create, rather actively but from a distance, a health system in which all players act ra-tional, economically and self-responsible

Supervising the Supervisors—Procedural Training and Supervision in Internal Medicine Residency

At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents’ perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown. To examine the experience and practice patterns of residents performing bedside procedures. Cross-sectional e-mail survey of 653 internal medicine (IM) residents at seven California teaching hospitals. Surveys asked questions in three areas: (1) resident experience performing procedures: numbers of procedures performed and whether they received other (e.g., simulator) training; (2) resident comfort performing and supervising procedures; (3) resident reports of their current level of supervision doing procedures, experience with complications as well as perceptions of factors that may have contributed to complications. Three hundred sixty-seven (56%) of the residents responded. Most PGY1 residents had performed fewer than five of any of the procedures, but most PGY-3 residents had performed at least ten by the end of their training. Resident comfort for each procedure increased with the number of procedures performed (p < 0.001). Although residents reported that peer supervision happened often, they also reported high rates of supervising a procedure before feeling comfortable with proper technique. The majority of residents (64%) reported at least one complication and did not feel supervision would have prevented complications, even though many reported complications represented technique- or preparation-related problems. Residents report low levels of comfort and experience with procedures, and frequently report supervising prior to feeling comfortable. Our findings suggest a need to examine best practices for procedural supervision of trainees

Efficacy and Safety of Tunneled Pleural Catheters in Adults with Malignant Pleural Effusions: A Systematic Review

BackgroundMalignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE.ObjectiveTo systematically review published data on the efficacy and safety of the TIPC for treatment of MPE.DesignWe searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies.Main measuresSymptomatic improvement and complications associated with use of the TIPC.Key resultsNineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%).ConclusionsBased on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE

Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors

BACKGROUND: A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION: Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY: The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards

Factors Associated with a Career in Primary Care Medicine: Continuity Clinic Experience Matters

BackgroundDue to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice.MethodsWe conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000-2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher's exact tests for categorical variables and t tests for continuous variables.ResultsOf the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups.ConclusionsStrong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians