Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care. Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

Cette thèse se positionne dans la lignée d'une série de travaux menés depuis une vingtaine d'années en France sur l’évolution des métiers et des professions de la production urbaine, architecturale et paysagère, au prisme de l'émergence de nouvelles attentes sociétales. Elle analyse plus précisément les attitudes et les modalités d'interventions des concepteurs, dans des projets urbains marqués depuis le milieu des années 2000 par de fortes ambitions en matière de participation citoyenne associées à des enjeux de développement durable. Dans quelle mesure l'émergence de telles commandes en France, particulièrement perceptible dans les premières opérations d'écoquartiers, modifient-elles les représentations des concepteurs vis-à-vis de la participation citoyenne, leurs modes d'exercice, leurs compétences, voire leur manière de considérer leur métier ? / This thesis is written within the context of a series of works undertaken over the last twenty years in France on the subject of the trades and professions of urban, architectural and landscape production, as considered through the prism of new social expectations. The thesis analyses the attitudes and forms of intervention adopted by designers of urban projects that,since the mid 2000s, have featured strong citizen participation ambitions associated with sustainable development issues. To what extent has the emergence of these demands in France, particularly noticeable in the case of the first sustainable neighborhoods, modified designers’ representation of citizen participation, as well as their own practice, skills andgeneral vision of their profession?

Cette thèse interroge les effets de l’intégration de l’impératif participatif dans les organismes HLM à partir de trois terrains de recherche complémentaires : les discours des dirigeants du « Mouvement HLM », les dispositifs de « concertation locative » et les actions de « développement social ». Nous mettons tout d’abord en évidence la manière dont les dispositifs participatifs viennent accompagner le tournant néolibéral de l’action publique à partir de la fin des années 1970 et montrons ce faisant l’ancienneté de la coexistence entre deux formes de participation - la première mettant l’accent sur l’évaluation du service rendu et la seconde sur l’accompagnement social des locataires. Le regard est ensuite porté sur les pratiques actuelles des organismes HLM, étudiées à partir d’une enquête menée au sein d’un organisme HLM dans le cadre d’une convention industrielle de formation par la recherche (CIFRE). En caractérisant les attendus attachés aux dispositifs, les conditions de leur mise en en œuvre et leurs effets sur le système d’acteurs, la démonstration met en lumière le sens donné à la participation dans le milieu HLM, caractérisé par la coexistence de logiques patrimoniale, entrepreneuriale et sociale. Ce faisant, elle enrichit la compréhension des logiques qui président à la formalisation et à la diffusion de dispositifs participatifs dans les sociétés contemporaines d’une part, de leurs effets sur les pratiques professionnelles et les relations entre institutions et individus d’autre part. Cette thèse entend ainsi contribuer à l’analyse des transformations systémiques produites par l’intégration de la participation dans les structures sociales. / This thesis examines the effects of the integration of the participatory imperative in social housing organizations. It is grounded in three complementary fieldworks: "Mouvement HLM"’s speeches, the "rental consultation" settings and "social development"’s actions. This work first demonstrates how participatory mechanisms support the neoliberal turn in public action that started in the late 1970s. In so doing, it shows the historical coexistence between two forms of participation. The first form emphasizes on the evaluation of service delivery. The second insists on social assistance for tenants. The analysis then focuses on social housing organizations’ contemporary practices and is based on a survey conducted in a social housing organization under an Industrial Research Training Convention (CIFRE). Looking at the participatory settings’ expected outcomes, their implementation’s prerequisites and their effects on the system of actors, the demonstration highlights the meaning of "participation" in social housing organizations which are characterized by the coexistence of patrimonial, entrepreneurial and social logics. On the one hand, this thesis broadens the understanding of the logics that govern the formalization and the propagation of participatory settings in contemporary society. On the other hand, it deepens the comprehension of participatory setting’s effects on professional practices and relationships between individuals and institutions. Therefore, this thesis aims to contribute to the analysis of systemic transformations produced by the integration of participation in social structures.