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

Managers\u27 beliefs related to employee involvement.

American companies have experimented with employee involvement (EI), also referred to as workplace democracy, quality of worklife, and participatory decision making since the late 1960\u27s. Results are mixed but interest remains high because organizations that have adapted to this new form are industry leaders. Research of the literature suggested (and this research agrees) that EI will be a long term success when management: (1) shares information and power at all levels of the organizational unit, (2) emphasizes cooperative problem solving to meet organizational goals, and (3) engenders a sense of dignity, meaning and community in every employee in the organizational unit. This study at four manufacturing sites investigates the link between the process of change to EI management and managers\u27 beliefs. In-depth interviews of 25 managers and 8 hourly employees (plus printed matter) provide data for this qualitative research. Grounded theory from the data generated five Management Characteristics and seven Antecedents for Change which provide a framework for further analysis of managers\u27 beliefs related to EI. Research sites had different types of manufacturing, different organizational histories, and EI programs were at different stages of development, but 13 themes emerged which were highly consistent (and two themes that were dissimilar were still clearly significant to the change process). The study establishes that both the organizational change process and Antecedents affect a manager\u27s response to EI. Some experiences and beliefs make it easier for a manager to adapt to EI management and some make it more difficult. Antecedents that were shown to have both positive and negative affects on the process include self confidence, family, education, and work experiences, mentors, organizational culture, and personal characteristics, beliefs and values

Cognitive load selectively influences the interruptive effect of pain on attention.

Pain is known to interrupt attentional performance. Such interference effects seem to occur preferentially for tasks that are complex and/or difficult. However, few studies have directly manipulated memory load in the context of pain interference to test this view. Therefore, the present study examines the effect of experimental manipulations of both memory load and pain on three tasks previously found to be sensitive to pain interference. Three experiments were conducted. A different task was examined in each experiment, each comprising of a high and low cognitive load versions of the task. Experiment 1 comprised of an attention span (n-back) task, Experiment 2 an attention switching task, and Experiment 3 a divided attention task. Each task was conducted under painful and non-painful conditions. Within the pain condition, an experimental thermal pain induction protocol was administered at the same time participants completed the task. The load manipulations were successful in all experiments. Pain-related interference occurred under the high load condition, but only for the attention span task. No effect of pain was found on either the attentional switching or divided attention task. These results suggest that while cognitive load may influence the interruptive effect of pain on attention, this effect may be selective. Since pain affected the high load version of the n-back task, but did not interrupt performance on attentional switching or dual task paradigms, this means our findings did not completely support our hypotheses. Future research should explore further the parameters and conditions under which pain-related interference occurs

Robust designs for Poisson regression models

We consider the problem of how to construct robust designs for Poisson regression models. An analytical expression is derived for robust designs for first-order Poisson regression models where uncertainty exists in the prior parameter estimates. Given certain constraints in the methodology, it may be necessary to extend the robust designs for implementation in practical experiments. With these extensions, our methodology constructs designs which perform similarly, in terms of estimation, to current techniques, and offers the solution in a more timely manner. We further apply this analytic result to cases where uncertainty exists in the linear predictor. The application of this methodology to practical design problems such as screening experiments is explored. Given the minimal prior knowledge that is usually available when conducting such experiments, it is recommended to derive designs robust across a variety of systems. However, incorporating such uncertainty into the design process can be a computationally intense exercise. Hence, our analytic approach is explored as an alternative

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND: Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012. OBJECTIVES: To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU). SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials. SELECTION CRITERIA: RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end. DATA COLLECTION AND ANALYSIS: Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment. MAIN RESULTS: We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned. AUTHORS' CONCLUSIONS: We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT

Magnetization of undoped 2-leg S = 1/2 spin ladders in La4Sr10Cu24O41

Magnetization data of single crystalline La4Sr10Cu24O41 are presented. In this compound, doped spin chains and undoped spin ladders are realized. The magnetization, at low temperatures, is governed by the chain subsystem with a finite interchain coupling which leads to short range antiferromagnetic spin correlations. At higher temperatures, the response of the chains can be estimated in terms of a Curie-Weiss law. For the ladders, we apply the low-temperature approximation for a S=1/2 2-leg spin ladder by Troyer et al.Comment: 2 pages, 2 figure

Re-engineering the Federal planning process: A total Federal planning strategy, integrating NEPA with modern management tools

The National Environmental Policy Act (NEPA) of 1969 was established by Congress more than a quarter of a century ago, yet there is a surprising lack of specific tools, techniques, and methodologies for effectively implementing these regulatory requirements. Lack of professionally accepted techniques is a principal factor responsible for many inefficiencies. Often, decision makers do not fully appreciate or capitalize on the true potential which NEPA provides as a platform for planning future actions. New approaches and modem management tools must be adopted to fully achieve NEPA`s mandate. A new strategy, referred to as Total Federal Planning, is proposed for unifying large-scale federal planning efforts under a single, systematic, structured, and holistic process. Under this approach, the NEPA planning process provides a unifying framework for integrating all early environmental and nonenvironmental decision-making factors into a single comprehensive planning process. To promote effectiveness and efficiency, modem tools and principles from the disciplines of Value Engineering, Systems Engineering, and Total Quality Management are incorporated. Properly integrated and implemented, these planning tools provide the rigorous, structured, and disciplined framework essential in achieving effective planning. Ultimately, the goal of a Total Federal Planning strategy is to construct a unified and interdisciplinary framework that substantially improves decision-making, while reducing the time, cost, redundancy, and effort necessary to comply with environmental and other planning requirements. At a time when Congress is striving to re-engineer the governmental framework, apparatus, and process, a Total Federal Planning philosophy offers a systematic approach for uniting the disjointed and often convoluted planning process currently used by most federal agencies. Potentially this approach has widespread implications in the way federal planning is approached