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¿No tenemos líderes como los de antes o es que simplemente tenemos demasiada información sobre ellos? ¿Es posible mantener un liderazgo político, su efecto y su acción, a lo largo de los años y de las legislaturas, como pasaba en una era previa a la de la ‘democracia mediática’? (Muñoz-Alonso y Rospir, 1999) Difícil. No se da. Los políticos, y muy especialmente los líderes, son más vulnerables a un contexto social y mediático que los hiperexpone a una ‘nueva visibilidad’ teorizada con éxito por el sociólogo John B. Thompson. Su desgaste, así, es directamente proporcional a su nivel de exposición. Y con ellos, su entorno más directo, su equipo. Porque como apunta  Seth  Godin,  referente  en  el  estudio del marketing político, cada vez más, todo en el líder nos lo describe. También su equipo de asesores. ¿Serán solución o problema? ¿Ayudan más a construir o a deconstruir al líder? En buena parte, el secreto de su éxito o de su fracaso lo será también de su asesorado. Y su invisibilidad jugará un papel clave en ello.

Master of Public Health - MPH / Providing quality health services is a concept currently given a high priority by the World Health Organization (WHO). As a member of WHO, Namibia is determined to improve health services delivery in the country. In order to achieve this, both doctors and patients must fully engage in the planning and implementation of health services. There have been long standing complaints from patients attending Tsumeb district hospital in Namibia about unsatisfactory services from doctors. The Regional Health Management Team and District Coordinating Committee have tried to make sure that all essential services required at the district hospital are in place and functional. Despite these measures, some patients continue to express dissatisfaction with the services provided by doctors. The aim of this study was to describe factors considered by patients in choosing a doctor at Tsumeb district hospital Outpatient department. The research was an observational descriptive cross-sectional study. Data was collected using a structured questionnaire administered by the researcher in interviews to a sample of 235 patients attending the Tsumeb Out Patient Department over five weeks. Data was analyzed using Epi-Info computer software. Approval to conduct the research was sought from the Namibian Ministry of Health Research Ethical Committee and Regional Health Management Team prior to commencing the study. Study participants received full information on the purpose and process of the study in their preferred language and were allowed to withdraw at any stage without consequences. All data was made anonymous and securely stored. The majority of the study sample (90 percent) did not have a tertiary level of education. Although a majority of the study sample (80 percent) said there were long waiting times at Tsumeb hospital Out Patient Department and 48 percent indicated that the environment at Tsumeb hospital was unfriendly, a significant percent of patients surveyed (38.3 percent) were present for follow-up care. This could be attributed to patients who attend Tsumeb hospital being of low socio-economic status and hence having a limited choice of health services, or it could suggest that overall patients were satisfied with the doctors they saw, as 67 percent of returning patients agreed with the statement that Out Patient Department doctors are competent. Four participants complained about the lack of confidentiality among nurses, an issue that was not part of the original questionnaire. In order to improve the quality of patient care, there is a need for the Tsumeb hospital authority to address key complaints around waiting times and staff attitudes.

Despite improvements in cancer management over the past 25 years, unrelieved symptoms continue to be reported. Little is known about how patients' problems and concerns are communicated to professionals during oncology treatment. This research investigates communication between cancer patients and clinicians in hospital outpatient clinics. Data were collected by non-participant observation and audio recording of consultations. Analyses were by qualitative content analysis and conversation analysis. An Objectives, Strategies and Tactics model was applied to organise the findings. 74 consultations between cancer patients and 15 doctors were observed and audio recorded. Pain talk is defined and identified as a substantial topic, occurring in 39/74 consultations. Doctor-initiated questions are the predominant discourse feature occupying over two-fifths of pain talk sequences. Their questions are prominent not only in initiating discussions but also in directing further talk. In other words, clinicians' questions control both the content and order of talk within pain talk sequences ( eg, over three-quarters of doctor-initiated questions are in a closed form which focus narrowly on limited physical aspects of patients' pain). It is argued that this limited information exchange alongside other communication tactics, is used to identify the 'right kind' of pain which may benefit from cancer therapy and to truncate talk of problems perceived to be outside of this specialist remit.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24793号 / 医博第4985号 / 新制||医||1066(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 阪上 優, 教授 松村 由美, 教授 佐藤 俊哉 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

De longue date, l’hôpital public a voulu faire fonctionner un service public autonome avec ses propres moyens et ses personnels.Cependant, il s’est trouvé dans l’obligation d’ouvrir ses portes à des opérateurs privés (l’intervention des médecins libéraux l’illustre) pour répondre à ses besoins de fonctionnement et d’organisation, dont les voies ont été ouvertes par la dernière loi hospitalière. Ainsi, la loi HPST a créé des dispositifs contractuels via notamment le « contrat d’exercice libéral » et le contrat de « clinicien hospitalier » pour que l’hôpital public propose des conditions statutaires plus attractives à l’attention de ces nouveaux opérateurs.Ce besoin nouveau qui s’impose, sans être véritablement souhaité, entraîne le recours à des solutions juridiques trop diversifiées.De ce fait, une cohabitation et un foisonnement de statuts s’est créé au sein de l’hôpital public. Cette situation apporte une vraie contradiction de règles statutaires, un véritable fatras qui met à mal sa cohérence.Un rapprochement des statuts des praticiens hospitaliers et des praticiens libéraux paraît inévitable pour clarifier et donner une lisibilité à l’hôpital public avec le souci unique d’apporter des soins de qualité aux usagers du service public. / The public hospital has long been willing to operate an independent public service with its own means and own staff.However, it was forced to open its doors to some private operators (the intervention of private doctors illustrates it) to satisfy its needs for operating and organization, the path of which has been opened by the last Hopsital Act. Thus, the HPST Law has created some contractual arrangements mainly with the “private practice contract”and the contract of “hospital clinical practitioner” in order that the public hospital offers more attractive statutory conditions to these new operators.This new major need, not being really desired, requires legal solutions which are too diverse.Consecuently, a coexistence and a lot of statuses have emerged within the public hospital. This situation causes a real contradiction of the statutory rules, a real hackneyed nonsense which undermines its consistency.An harmonization of the hospital and private practitioners statuses seems to be inevitable in order to clarify and make the public hospital more transparent with the sole concern to improve the quality of the health care provided to the public service users.

Compreendendo a mobilidade do trabalho como um fenômeno que promove o deslocamento espacial, setorial e profissional de trabalhadores, com o objetivo de o capital explorar força de trabalho e acumular excedente econômico e observando que os médicos no Brasil trabalham de forma particularmente diversificada, transversa e longitudinalmente, em múltiplos sub-empregos, procura-se apreender dimensões da mobilidade da força de trabalho de médicos no sistema brasileiro de serviços de saúde. Com a intenção de contribuir para a compreensão e crítica do fenômeno da disponibilidade desses profissionais, como processo sócio-histórico significante para a implementação do Sistema Único de Saúde, desenvolvem-se táticas de aproximação sucessiva ao empírico da mobilidade do trabalho de médico, em diversidade metodológica, pela integração de métodos quantitativos e qualitativos, utilizando-se de entrevista, pesquisa bibliográfica e análise de documentos e de dados secundários de pesquisas. Apreende-se, além de espacial, setorial e profissional, um deslocamento temporal na mobilidade da força de trabalho de médicos no modo como se dispõe no sistema brasileiro de serviços de saúde. Captura-se o desenvolvimento de estratégias e contra-estratégias de mobilidade, indicando-se que, constituído como um dilema, da falta ou da má distribuição de médicos, o problema culmina tratado muitas vezes de forma derivada, restrita e recalcada, apesar de aludidos os seus condicionantes e determinantes. Colhem-se representações e categorias de pensamento de atores dos sistemas de formação, de gestão de sistema de serviço de saúde e de representação da categoria profissional de médicos sobre possibilidades e limites de interiorização do trabalho médico no Brasil denotativas da fragmentação e segmentação do sistema brasileiro de serviços de saúde. Prestam-se outras contribuições para estudos de epidemiologia, de sociologia do trabalho e de psicologia do trabalho. / Understanding labor mobility as a phenomenon that promotes spatial, sectoral and professional displacement of workers, with the aim of capital exploiting their workforce and accumulating economic surplus, noting that medical doctors working in Brazil do it in a way which is particularly diverse, transverse and longitudinal, in multiple sub-jobs, seeking to grasp the dimensions of mobility of the workforce of medical doctors in the Brazilian system of health services. Aiming to contribute to the understanding and critique the phenomenon of availability of such professionals as a significant socio-historical process for the implementation of the National Universal Health System, developing tactics of successive approximation to the empirical labor mobility of medical, in methodological diversity, by the integration of quantitative and qualitative methods, using interviews, literature review and analysis of documents and secondary data research. Seizing up, beyond spatial, sectoral and professional, a temporal shift in the mobility of the workforce of medical doctors in the way it disposes the Brazilian system of health services. Capture the development of strategies and counter-strategies of mobility, indicating that, constituted as a dilemma, of lack or maldistribution of medical doctors, the problem often culminates being treated derivatively, restricted and repressed, although alluded their condition and determinants. Representations and thought thinking categories of actors of formation systems, management systems of health service and representation of the profession of medical doctors about the possibilities and limits of internalization of medical work in Brazil are gathered denoting the fragmentation and segmentation of the Brazilian health services system. It lends other contributions to epidemiology, sociology of work, psychology of work studies.

Background: Prescribing errors are the most frequent type of error in the medication use process. High risk medicines (HRMs) are a sub-class of medications that if used erroneously have potentially devastating consequences which defined by Institute for Safe Medication Practices (ISMP) as the drugs that bear a heightened risk of causing significant patient harm when they are used in error. Therefore, prescribing errors with HRMs are of concern to healthcare professionals that are responsible for ensuring mitigating patient safety. This thesis examines to what extent prescribing errors with HRMs in hospital occur, the causes of prescribing errors with HRMs and the differences to non-HRMs and the prescribing errors with HRMs during the on-call period. Method: The research adopted a mixed methods approach to explore prescribing errors with HRMs in hospitals and three studies were undertaken. The first study was a systematic review of the literature to explore the prevalence and incidence of prescribing errors with HRMs in hospitals. The second study was a secondary analysis of 59 existing interviews with foundation year doctors to explore the causes of prescribing errors with HRMs and compare them to those for non-HRMs reported in the same interviews. The third study was a qualitative study of the challenges of prescribing HRMs safely during the on-call period. This final study involved six focus groups with foundation year doctors (total participants number was 42). Results: Overall, findings demonstrated that there is paucity of studies that explored the prevalence of prescribing errors with HRMs and this literature showed inconsistency in definitions of prescribing errors, HRMs lists, severity scales and study methods (Study One). This resulted in a very wide range of prevalence of prescribing errors with HRMs. In terms of causes of prescribing errors with HRMs (Study Two), prescribing HRMs was considered a complex task for participants, especially those requiring dosage calculations, errors in the legal prescription requirements for controlled medications occurred with HRMs only and the on-call period was a particularly challenging period to prescribe safely especially with HRMs. In Study Three, the reasons found for this include the nature of the on-call period as a fast-paced environment, the methods of communication such as the bleep system, lack of accessibility to patient information and lack of plan from the primary team. Conclusions: HRMs form part of general medications, meaning they share similar traits, but the potentially devastating consequences of HRMs and the complicated task posed by prescribing them makes errors in their prescription profound. Therefore, HRMs need closer attention and more concern from healthcare professionals, researchers and policymakers. Such attention could result in a significant reduction in adverse outcomes and improved patient safety.

Compreendendo a mobilidade do trabalho como um fenômeno que promove o deslocamento espacial, setorial e profissional de trabalhadores, com o objetivo de o capital explorar força de trabalho e acumular excedente econômico e observando que os médicos no Brasil trabalham de forma particularmente diversificada, transversa e longitudinalmente, em múltiplos sub-empregos, procura-se apreender dimensões da mobilidade da força de trabalho de médicos no sistema brasileiro de serviços de saúde. Com a intenção de contribuir para a compreensão e crítica do fenômeno da disponibilidade desses profissionais, como processo sócio-histórico significante para a implementação do Sistema Único de Saúde, desenvolvem-se táticas de aproximação sucessiva ao empírico da mobilidade do trabalho de médico, em diversidade metodológica, pela integração de métodos quantitativos e qualitativos, utilizando-se de entrevista, pesquisa bibliográfica e análise de documentos e de dados secundários de pesquisas. Apreende-se, além de espacial, setorial e profissional, um deslocamento temporal na mobilidade da força de trabalho de médicos no modo como se dispõe no sistema brasileiro de serviços de saúde. Captura-se o desenvolvimento de estratégias e contra-estratégias de mobilidade, indicando-se que, constituído como um dilema, da falta ou da má distribuição de médicos, o problema culmina tratado muitas vezes de forma derivada, restrita e recalcada, apesar de aludidos os seus condicionantes e determinantes. Colhem-se representações e categorias de pensamento de atores dos sistemas de formação, de gestão de sistema de serviço de saúde e de representação da categoria profissional de médicos sobre possibilidades e limites de interiorização do trabalho médico no Brasil denotativas da fragmentação e segmentação do sistema brasileiro de serviços de saúde. Prestam-se outras contribuições para estudos de epidemiologia, de sociologia do trabalho e de psicologia do trabalho. / Understanding labor mobility as a phenomenon that promotes spatial, sectoral and professional displacement of workers, with the aim of capital exploiting their workforce and accumulating economic surplus, noting that medical doctors working in Brazil do it in a way which is particularly diverse, transverse and longitudinal, in multiple sub-jobs, seeking to grasp the dimensions of mobility of the workforce of medical doctors in the Brazilian system of health services. Aiming to contribute to the understanding and critique the phenomenon of availability of such professionals as a significant socio-historical process for the implementation of the National Universal Health System, developing tactics of successive approximation to the empirical labor mobility of medical, in methodological diversity, by the integration of quantitative and qualitative methods, using interviews, literature review and analysis of documents and secondary data research. Seizing up, beyond spatial, sectoral and professional, a temporal shift in the mobility of the workforce of medical doctors in the way it disposes the Brazilian system of health services. Capture the development of strategies and counter-strategies of mobility, indicating that, constituted as a dilemma, of lack or maldistribution of medical doctors, the problem often culminates being treated derivatively, restricted and repressed, although alluded their condition and determinants. Representations and thought thinking categories of actors of formation systems, management systems of health service and representation of the profession of medical doctors about the possibilities and limits of internalization of medical work in Brazil are gathered denoting the fragmentation and segmentation of the Brazilian health services system. It lends other contributions to epidemiology, sociology of work, psychology of work studies.

Darbo tikslas. Atskleisti gydytojų požiūrį į motyvavimą dirbti rajoninėse sveikatos priežiūros įstaigose. Uždaviniai. 1. Išskirti pagrindinius veiksnius, susijusius su gydytojo darbo rajono sveikatos priežiūros įstaigoje pasirinkimu. 2. Atskleisti problemas, su kuriomis susiduria gydytojai, neseniai pradėję dirbti rajoninėse sveikatos priežiūros įstaigose. 3. Išsiaiškinti gydytojų nuomonę apie priemones, kurios yra taikomos arba galėtų būti taikomos siekiant pritraukti ir išsaugoti gydytojus dirbti rajonuose. Tyrimo metodika. Taikant kokybinį tyrimo metodą, giluminio interviu būdu, apklausti 8 Lietuvos rajonų sveikatos įstaigose dirbantys gydytojai rezidentai ir 3 neseniai (iki 3 metų) rajonų gydymo įstaigose pradėję dirbti gydytojai. Rezultatai. Dirbti į rajonines sveikatos priežiūros įstaigas vykstama dėl mažesnės konkurencijos darbo rinkoje, didesnių atlyginimų. Gydytojai apie darbo vietas sužino skambindami patys į ligonines arba per turimus ryšius. Rajoninės įstaigos motyvuoja gydytojus atvykti dirbti į rajoną finansinėmis ir nepiniginėmis priemonėmis, siūlant didesnį atlyginimą, rezidentūros apmokėjimą, palankų darbo grafiką atvykstančiam gydytojui. Universitetų priemonės vertinamos negatyviai, nes yra netiesioginis dėstytojų ir gydytojų nuteikimas prieš darbą rajone, nėra sudaromos sąlygos studijų metų padirbti rajone. Gydytojas rajone įgauna žinių ir praktinių įgūdžių atlikdamas įvairesnių procedūrų, kartais srityse, kurios yra už jo kompetencijos ribų. Rajoninėse... [toliau žr. visą tekstą] / Aim of the study. To identify and analyze the doctors’ motivation aspects to work at hospitals in the rural areas. Objectives. 1. To identify the main factors that influence the doctors’ decision to work at hospitals in the rural areas. 2. To determine the problems that doctors are facing in their beginning at work in the rural areas. 3. To investigate the doctors’ opinion about the instruments that were used or could be adopted in practice to attract and retain doctors in rural hospitals. Methods. Qualitative study was used to get the information which contains motivating factors for doctors to work at the rural hospitals. Using in-deph semistructured questionnaires were asked 8 residency students and 3 doctors at rural hospitals. Respondents were selected using short (less than 3 years) working period in rural hospital criteria. Results. Lower competition in labor market and higher salaries are the push factors for doctors to choose the rural workplace. Most of the doctors request the hospitals directly for the vacant positions or get the information about available positions from people they know. Rural hospitals attract doctors with higher wages, refund the payment of residency studies and adjust a better working schedule. The incentives of universities should be better developed because there is lack of rural practice possibilities for the students. There is indeed strong influence made by lecturers who spread negative and inadequate approach about rural hospitals... [to full text]