The manager role in relation to the medical profession

Background: Managers and physicians have two important roles in healthcare organisations. However, several studies have identified problems in the manager–physician relationship and more knowledge is needed to improve the situation. Using theories on organisation, professions, and role taking to inform thinking, this thesis addresses one aspect of the manager-physician relationship, namely how managers handle their role in relation to the medical profession. This was studied in the context of sickness certification, a frequent and problematic task for many physicians in Sweden. Aim: The aim of this thesis was to increase the knowledge about how managers in Swedish healthcare organisations handle their manager role in relation to the medical profession. Methods: The empirical studies (I-IV) build on one another. Focus group discussions with 26 physicians (I), two questionnaires to all board-certified specialists in Stockholm county (n=2497, resp. n=2208) (II), individual interviews with 18 county council chief executive officers (CEOs) (III), and interviews with 38 healthcare managers (20 clinical department managers (CDMs) and the same18 CEOs as in study III) (IV) constitute the database for the thesis. Qualitative methods were used to analyse data in three of the studies: content analysis (I), grounded theory (III), and linguistic discourse analysis (IV). Descriptive statistics were used in study II. Results: The problems physicians described in their work with sickness certification could be classified into four categories: the design of the social insurance system, the organisation of healthcare, the performance of other stakeholders, and the physicians’ own work situation. Although all of these concern policy issues and managerial responsibility on different structural levels in healthcare, the role of managers was absent in the physicians’ discussions (I). When specifically asked about management of sickness certification issues, the majority reported lack of both substantial management support and a well-established workplace policy (II). With these findings as a point of departure, studies III and IV addressed managers’ role taking. In many ways managers themselves contributed to making the manager role weak and absent in relation to the medical profession (III, IV). The CEOs had a strong focus on physicians and physicians’ behaviour rather than on their own managerial behaviour or that of their subordinate managers. When strategies for managing physicians were addressed, many described physician-specific strategies that led to a paradox of control in relation to the medical profession - the pragmatic strategies helped managers to manage physicians in daily work, but seemed to weaken the manager role in the organisation (III). Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse was predominant, where managers frequently used the attributes “physician” or “non-physician” to categorise themselves and other managers in their manager roles. Some managers also combined the two discourses in a “yes, but...” approach to management in the organisation. Expressions of a mutually shared manager community were almost totally missing in the managers’ statements (IV). Conclusions: The results show that managers have a weak, partially absent, and rather ambiguous manager role in relation to the medical profession. How the manager role is handled and regarded within healthcare organisations constitutes part of the organisational conditions for the role taking of managers, physicians, and other healthcare professionals. The findings indicate that there is a need to support healthcare managers in their role taking in the organisation - both those managers who also are physicians, and managers with other underlying professions. Management aspects regarding sickness certification tasks also need to be strengthened. A weak and ambiguous manager role may have negative consequences not only for the work of managers, but also for that of physicians and other healthcare professionals, and for the quality of care

Oekologische Leistungshonorierung anhand eines Oekopunkte-Systems mit Bieterverfahren

The necessity, the points of departure, and the methodology for the remuneration of ecological goods and services are subjects in the current environmental policy. In particular, recent discussion has focused on ecological incentives as an addition to conventional instruments of nature protection. Among such incentives, eco-credits (in German: "Oekopunkte") have been gaining increasing attention. In some cases they already have reached the test stage. Due to restricted governmental funds, however, it remains questionable whether eco-credits will effectively improve the economic efficiency and ecological effectiveness of proposed incentives. In this paper, it will be argued that a bid auction, similar to a variable-rate tender procedure, would improve the efficiency and effectiveness of eco-credits. Considering eco-credits in terms of efficiency indicators, it is proposed that eco-credits be acquired according to a voluntary payment, rather than being offered at a fixed price. It is expected that buyers base their voluntary payments on their production-costs which would therefore lead to an improvement of efficiency. This paper analyzes the mechanisms of such a design and applies the concept rudimentarily to the farming industry.Oekopunkte, Leistungshonorierung, Bieterverfahren, Effizienz, Effektivitaet

Inter-organizational collaboration for energy efficiency in the maritime sector: the case of a database project

This article explores the complexities of establishing knowledge-sharing practices between organizations through a case study of the creation of a database for energy efficiency measures relevant to the shipping sector. As researchers and policy-makers tend to point towards knowledge sharing and collaboration as means towards a more energy-efficient society, there is a need to better understand the knowledge sharing practices in such initiatives. The study is based upon extensive fieldwork where the first author was recruited to a collaborative network on energy efficiency in the shipping sector, to aid in the development of the collaboration while carrying out participatory-observational research in an ethnographic tradition. The study highlights the need to maintain realistic expectations for new knowledge-sharing collaborations, and the necessity to allow such arrangements to develop over time

On the mineralogy of the O Casteliño spodumene pegmatite near Lalín, Galicia, Spain

[Abstract] The mineralogy of a spodumene-bearing pegmatite from northwestern Spain is briefly described. Analyses of spodumene, tantalite and wodginite are give

Predictors of Time to Relapse/Recurrence after Electroconvulsive Therapy in Patients with Major Depressive Disorder: A Population-Based Cohort Study

Objective. The aim of the study is to define predictors of relapse/recurrence after electroconvulsive therapy, ECT, for patients with major depressive disorder. Methods. A study of all patients (n = 486) treated by means of ECT for major depressive disorder was performed. The data were derived from a regional quality register in Sweden. Psychiatric hospitalisation or suicide was used as a marker for relapse/recurrence. Results. The relapse/recurrence rate within one year after ECT was 34%. Factors associated with increased risk of relapse/recurrence included comorbid substance dependence and treatment with benzodiazepines or antipsychotics during the follow-up period. Conclusions. Within the first years after ECT, relapses/recurrences leading to hospitalisation or suicide are common. Treatment with lithium might be beneficial, while benzodiazepines, antipsychotics, or continuation ECT does not seem to significantly reduce the risk of relapse/recurrence

Managers' perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare

<p>Abstract</p> <p>Background</p> <p>This study focused on the manager role in the manager-physician relationship, considered from the manager perspective. The aim was to understand how top executives in Swedish healthcare regard management of physicians in their organisations, and what this implies for the manager role in relation to the medical profession. Abbott's theory of professional jurisdiction was used to inform thinking about managerial control and legitimacy in relation to physicians.</p> <p>Methods</p> <p>Data from semi-structured individual interviews with 18 of the 20 county council chief executive officers (CEOs) in Sweden were subjected to qualitative analysis.</p> <p>Results</p> <p>The results show that, when asked about their views on <it>management </it>of physicians, the CEOs talked about "how physicians are" rather than describing their own or their subordinate managers' managerial behaviour or strategies. Three types of descriptions of physicians were identified: 1) they have high status and expertise; 2) they lack knowledge of the system; 3) they do what they want in the organisation. The CEOs seldom reported that general management strategies were used to manage physicians. Instead, they described four types of physician-specific management strategies that were used in their organisations: organisational separation of physicians; "nagging and arguing"; compensations; relying on the physician role. These strategies seemed to reflect pragmatic behaviour on behalf of the managers that helped them to maintain control over physicians in daily work. However, in a longer perspective, they seemed to decrease the legitimacy of the manager role and also contribute to weakening of that role in the organisation.</p> <p>Conclusions</p> <p>Many CEOs seemed to regard the manager role in their organisations as weak and described difficulties in both taking and defining that role (for themselves or others) in relation to the physician role. Further research is needed to elucidate how managers in healthcare organisations assume the manager role in relation to the medical profession. Studies indicate that lack of clarity concerning manager role authority and responsibility may have negative consequences not only for the working conditions of managers, physicians, and other healthcare professionals, but also for the quality of care.</p

Left Atrial Appendage Printing Process

The left atrial appendage senior design team aims to assist in closing off the left atrial appendage that is susceptible to coagulation due to non-valvular atrial fibrillation. Coagulation in the left atrial appendage (LAA) can be life threatening as it can lead to a stroke. Dr. Chris Porterfield performs a procedure that uses the Boston Scientific Watchman to close the appendage. He finds that sizing the Watchman properly is difficult with limited visuals from live CT scans. He proposed converting the CT scans into a 3D printed model of the left atrial appendage and left atrium so he can visually measure the opening and predict the trajectory angle of the Watchman device into the left atrial appendage. He currently has a base algorithm and procedure to convert and modify the CT scan into a .stl file, which can then be printed with standard PLA material using a 3D printer on Cal Poly’s campus. The project is limited to the printers and their material capabilities on Cal Poly’s campus. There are currently many programs that convert CT scans to printable files and this project aims to evaluate each to conclude which produces the most accurate 3D model. The procedure to create the model must also be quick to perform, repeatable and reproducible as well as easy to follow. After researching the various programs, we concluded that 3D Slicer allows us to print anatomically accurate models of the left atrium and LAA. Using this software, the user uploads CT scans obtained from the radiologist as a DICOM file. Once uploaded, the user will proceed to setting the threshold parameter to the designated values. The user will then scroll through the CT scan to identify the left atrium and LAA in one of the views. After locating the anatomies, the user will use the scissors tool to extrude out any unnecessary anatomy. Once isolated, the model will need to be hollowed out and set to the defined parameters. After a final cut is made to open the model for internal viewing, is it saved as a .stl file and sent to a 3D printing software such as Cura. From this point on, the user will refer to the printer’s manual for the printing procedure while using the parameters we listed as a guide. After the print is concluded, the user will be able to measure the opening of the LAA and determine which entry angle is most optimal. The key customer requirements we aimed to achieve were ease of use, time, production cost, shape/accuracy, repeatability and reproducibility. For ease of use, we had users go through our MPI, Training Guide and Operations Manual and had them rate between 1-10 on how clear and concise our directions were. We scaled the range so that 1 meant that our procedure was clear and concise enough to replicate while 10 meant it was near impossible to follow. We aimed to achieve an average score of less than 3. For time, we were given a timeframe of 24 hour to fully slice and print the model. Since this procedure is not officially ICD-9 billable yet, the cost of production must remain below $50 per print. Based on the sizing chart provided by Boston Scientific for the various sizes of the Watchman device, we decided that the shape/accuracy must be less than 10% variation from the CT scan, while the repeatability and reproducibility must have no statistical difference in variation from the ANOVA. After running ANOVA on the data obtained from measuring the 9 testing prints, the results showed that our slicing/printing procedure and the measurements taken for testing were adequate enough to prove the functionality of all our protocols. The results of ANOVA showed that there were no significant differences in our data except for depth reproducibility which means that our customer requirements of reproducibility and repeatability were almost met. For the ease of use requirement, Dr. Porterfield and his clinical specialist, Sarah Griess, went through our Manufacturing Process Instructions, 2 Training Guide, and Operations Manual and performed the feedback survey we provided. Based on those results, we concluded that our protocols are functional and easy to follow which is essential to producing an accurate model. To prove model accuracy, we had Dr. Porterfield size the Watchman device as he currently does and confirmed that our printed models were accurate

Undersökning av karstvittring inom Kristianstadsslättens NV randområde och bedömning av dess betydelse för grundvattnets sårbarhet

Under våren 2002 undersöktes ett område vid Vanneberga ängar vid Kristianstadsslättens randområde med målet att ge svar på kalkstenens beskaffenhet och dess betydelse för grundvattnets sårbarhet. I området utfördes resistivitets-, självpotential- och VLF-mätningar i syfte att hitta vattenförande zoner i kalkstenen. Kartering av skärningar och slukhål med avseende på karstfenomen gjordes för en diskussion kring eventuella underjordiska gångar. Resultaten utifrån resistivitetsmätningarna kan tolkas som att det kan finnas koncentrerade vattenförande zoner vid dolinen i Vanneberga. Det går också att tolka resultaten som att det råder risk för att utsläpp transporteras snabbt vidare ut på Kristianstadsslätten. Området runt dolinen är dessutom utsatt för rasrisk. Vidare undersökningar i området är föreslagna.In the spring of 2002, a region at Vanneberga meadows at Kristianstad Plain peripheral region was examined with respect to provide answers of the limestone nature and its significance for groundwater vulnerability. The area was examined with resistivity-, SP- and VLF measurements in order to find water-bearing structures in the limestone. Mapping of karst phenomena were made for the discussion of underground cavities. The results showed that hydraulic conductive anomalies can be interpreted from resistivity analysis and that there may be conductive cavities at the dolin in Vanneberga. It is also possible to interpret the results as a risk that emissions may be transported quickly out to the Kristianstad Plain. The area around the dolin is additionally exposed to risk of collapse. Further investigations are proposed.Geofysik kan skydda grundvattnet Det råder risk för att eventuella utsläpp vid väg 21 kan transporteras snabbt vidare ut på Kristianstadsslätten. Undersökningar vid Nävlingeåsens randzon konstaterar detta. Stora vattenflöden har observerats vid Vanneberga ängar i den kalkrika berggrundens så kallade karstfenomen. Porositeten i kalkstenen vid undersökningsområdet är mätbart högre än i kalksten vid andra undersökta närområden. Under våren 2002 undersöktes ett område vid Vanneberga ängar som ligger vid Kris-tianstadsslättens randområde. Målet var att ge svar på kalkstenens beskaffenhet och dess betydelse för grundvattnets sårbarhet. I området utfördes olika typer av geofysiska undersökningar i syfte att hitta vattenförande zoner i kalkstenen. Efter avbildningar av skärningar och slukhål kunde en diskussion kring eventuella underjordiska gångar hållas. Geologin är unik Området ligger vid en förkastningszon i urberget som består av ögonförande skiffrig gneisgranit. Då Nävlingeåsen, som är det sydvästra urbergsblocket, höjdes relativt till det nordöstra Vinslövsblocket under kritatiden avlagrades sediment som glaukonitsand, sandsten och kalksten med fossil som belemniter och foraminiferer. Ovanför dessa avlagringar finner vi idag jordarter bildade vid den senaste istiden. Karstfenomen De karstfenomen som hittats i området är så kallade avsänkningstrattar, alluvialdoliner, med aktiva slukhål och slukhål som fyllts med sediment. De senare icke aktiva formerna brukar kallas för paleokarst. Det är upplösning av kalkstenen som bildat karstfenomenen i sprickor och bankgränser. Kalkstenens lösta joner har följt med regnvattnet vidare ner i grundvattensystemet. Vid Vanneberga ängar har dessutom jorden ovanför kalkstenen spolats ner i gångarna. Geofysiken visar riskerna Resultaten utifrån de geofysiska mätningarna vid Vanneberga ängar har tolkats som att det kan finnas koncentrerade vattenförande zoner vid dolinen i Vanneberga. Det går också att tolka resultaten som att det råder risk för att utsläpp transporteras snabbt vidare ut på Kristianstadsslätten. Området runt dolinen är dessutom utsatt för rasrisk. Vidare under-sökningar i området är föreslagna

Fertilitet, mänskligt kapital och ekonomisk tillväxt

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.I denna avhandling granskas tre modeller i vilka den gemensamma nämnaren är fertilitet. Syftet med avhandlingen är att granska fertilitet både ur ett mikro- och ett makroperspektiv. Hur påverkar ekonomiska faktorer fertiliteten och hur ter sig den ekonomiska tillväxten då mänskligt kapital orsakar tillväxten och fertiliteten är endogen. Fertilitet och befolkningstillväxtens inverkan på ekonomin har intresserat nationalekonomer redan länge. Den fortfarande kanske mest kända teorin om hur befolkningsökning och ekonomi hänger samman är antagligen Thomas Malthus mycket berömda teori från 1700-talet. I sin teori argumenterar Malthus för att inkomsterna per person alltid kommer att bibehållas på subsistensnivå. På 1960-talet började man granska många fenomen som tidigare ansetts som icke-ekonomiska ur ett mikroekonomiskt perspektiv. Denna utvidgning av nationalekonomins traditionella område omfattade bland annat den produktionen som sker i hemmen i form av t.ex. måltider och barn. Gary S. Becker var den första som utvecklade en mikroekonomisk modell om fertilitet. I kapitel två av detta arbete behandlas Beckers och Barros mikroekonomiska modell om fertilitet (1988). Till skillnad från tidigare mikroekonomiska modeller om fertilitet införs i denna modell altruism i föräldrarnas efterfrågan på barn. Föräldrarna maximerar som en följd av altruismen en dynastisk nyttofunktion och resultatet är att fertiliteten beror positivt av graden av altruism, barns överlevnadsmöjligheter och den reella räntan. Oberoende av om föräldrarnas motiv för att ha barn är rent altruistiska eller inte så är barnens kvalitet eller mängden mänskligt kapital som barnen besitter en faktor som påverkar föräldrarnas beslut om antalet barn de vill ha. Föräldrarnas beslut angående kvantitet och kvalitet på barn kan ej granskas skilt för sig. De endogena tillväxtmodellerna som började utvecklas på 1980-talet undersöker de interna faktorerna i ekonomin som påverkar tillväxten bl.a. fertiliteten. Dessa tillväxtmodeller betonar det mänskliga kapitalets viktiga roll för den ekonomiska tillväxten i motsats till de nyklassiska modellerna som såg den exogent givna teknologiska utvecklingen som den viktigaste orsaken till tillväxt. De två andra modellerna som granskas i min avhandling är endogena tillväxtmodeller vilka båda använder sig av Beckers och Barros modell om fertilitet och i vilka det mänskliga kapitalet är avgörande för den ekonomiska tillväxten. I Beckers, Murphys och Tamuras modell (1990) utgår man från att avkastningen på investeringar i det mänskliga kapitalet ökar då mängden mänskligt kapital ökar. Modellen implicerar två olika samhällen, ett i vilket det finns lite mänskligt kapital och fertiliteten är hög och ett annat i vilket det finns få barn och mycket mänskligt kapital. Till sist diskuteras Nis och Wangs modell (1994) i vilken staten uppbär inkomstskatt för att finansiera det offentliga skolsystemet