Cornell University Press

The culture and politics of health care work

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The culture and politics of health care work

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The Complexities of Care

Nursing Reconsidered

edited by Sioban Nelson and Suzanne Gordon

"Nursing, everyone believes, is the caring profession. Texts on caring line the walls of nursing schools and student shelves. Indeed, the discipline of nursing is often known as the ‛caring science.’ Because of their caring reputation, nurses top the polls as the most-trustworthy professionals. Yet, in spite of what seems to be an endless outpouring of public support, in almost every country in the world nursing is under threat, in the practice setting and in the academic sector. Indeed, its standing as a regulated profession is constantly challenged. In our view, this paradox is neither accidental nor natural but, in great part, the logical consequence of the fact that nurses and their organizations place such a heavy emphasis on nursing's and nurses' virtues rather than on their knowledge and concrete contributions."-from the Introduction

In a series of provocative essays, The Complexities of Care rejects the assumption that nursing work is primarily emotional and relational. The contributors-international experts on nursing- all argue that caring discourse in nursing is a dangerous oversimplification that has in fact created many dilemmas within the profession and in the health care system. This book offers a long-overdue exploration of care at a pivotal moment in the history of health care. The ideas presented here will foster a critical debate that will assist nurses to better understand the nature and meaning of the nurse-patient relationship, confront challenges to their work and their profession, and deliver the services patients need now and into the future.

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Differential Diagnoses

A Comparative History of Health Care Problems and Solutions in the United States and France

by Paul V. Dutton

Although the United States spends 16 percent of its gross domestic product on health care, more than 46 million people have no insurance coverage, while one in four Americans report difficulty paying for medical care. Indeed, the U.S. health care system, despite being the most expensive health care system in the world, ranked thirty-seventh in a comprehensive World Health Organization report. With health care spending only expected to increase, Americans are again debating new ideas for expanding coverage and cutting costs. According to the historian Paul V. Dutton, Americans should look to France, whose health care system captured the World Health Organization's number-one spot.

In Differential Diagnoses, Dutton debunks a common misconception among Americans that European health care systems are essentially similar to each other and vastly different from U.S. health care. In fact, the Americans and the French both distrust "socialized medicine." Both peoples cherish patient choice, independent physicians, medical practice freedoms, and private insurers in a qualitatively different way than the Canadians, the British, and many others. The United States and France have struggled with the same ideals of liberty and equality, but one country followed a path that led to universal health insurance; the other embraced private insurers and has only guaranteed coverage for the elderly and the very poor.

How has France reconciled the competing ideals of individual liberty and social equality to assure universal coverage while protecting patient and practitioner freedoms? What can Americans learn from the French experience, and what can the French learn from the U.S. example? Differential Diagnoses answers these questions by comparing how employers, labor unions, insurers, political groups, the state, and medical professionals have shaped their nations' health care systems from the early years of the twentieth century to the present day.

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Divining without Seeds

The Case for Strengthening Laboratory Medicine in Africa

by Iruka N. Okeke

Infectious disease is the most common cause of illness and death in Africa, yet health practitioners routinely fail to identify causative microorganisms in most patients. As a result, patients often do not receive the right medicine in time to cure them promptly even when such medicine is available, outbreaks are larger and more devastating than they should be, and the impact of control interventions is difficult to measure. Wrong prescriptions and prolonged infections amount to needless costs for patients and for health systems. In Divining without Seeds, Iruka N. Okeke forcefully argues that laboratory diagnostics are essential to the effective practice of medicine in Africa.

The diversity of endemic life-threatening infections and limited public health resources in tropical Africa make the need for basic laboratory diagnostic support even more acute than in other parts of the world. This book gathers compelling case studies of inadequate diagnoses of diseases ranging from fevers-including malaria-to respiratory infections and sexually transmitted diseases. The inherited and widely prevalent health clinic model, which excludes or diminishes the hospital laboratory, is flawed, to often devastating effect. Fortunately, there are new technologies that make it possible to inexpensively implement testing at the primary care level. Divining without Seeds makes clear that routine use of appropriate diagnostic support should be part of every drug delivery plan in Africa and that diagnostic development should be given high priority.

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Doctors at War

Life and Death in a Field Hospital

Mark de Rond

Doctors at War is a candid account of a trauma surgical team based, for a tour of duty, at a field hospital in Helmand, Afghanistan. Mark de Rond tells of the highs and lows of surgical life in hard-hitting detail, bringing to life a morally ambiguous world in which good people face impossible choices and in which routines designed to normalize experience have the unintended effect of highlighting war's absurdity. With stories that are at once comical and tragic, de Rond captures the surreal experience of being a doctor at war. He lifts the cover on a world rarely ever seen, let alone written about, and provides a poignant counterpoint to the archetypical, adrenaline-packed, macho tale of what it is like to go to war.

Here the crude and visceral coexist with the tender and affectionate. The author tells of well-meaning soldiers at hospital reception, there to deliver a pair of legs in the belief that these can be reattached to their comrade, now in mid-surgery; of midsummer Christmas parties and pancake breakfasts and late-night sauna sessions; of interpersonal rivalries and banter; of caring too little or too much; of tenderness and compassion fatigue; of hell and redemption; of heroism and of playing God. While many good firsthand accounts of war by frontline soldiers exist, this is one of the first books ever to bring to life the experience of the surgical teams tasked with mending what war destroys.

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Healing Together

The Labor-Management Partnership at Kaiser Permanente

by Thomas A. Kochan, Adrienne E. Eaton, Robert B. McKersie, and Paul S. Adler

Kaiser Permanente is the largest managed care organization in the country. It also happens to have the largest and most complex labor-management partnership ever created in the United States. This book tells the story of that partnership-how it started, how it grew, who made it happen, and the lessons to be learned from its successes and complications. With twenty-seven unions and an organization as complex as 8.6-million-member Kaiser Permanente, establishing the partnership was not a simple task and maintaining it has proven to be extraordinarily challenging.

Thomas A. Kochan, Adrienne E. Eaton, Robert B. McKersie, and Paul S. Adler are among a team of researchers who have been tracking the evolution of the partnership between Kaiser Permanente and the Coalition of Kaiser Permanente Unions ever since 2001. They review the history of health care labor relations and present a profile of Kaiser Permanente as it has developed over the years. They then delve into the partnership, discussing its achievements and struggles, including the negotiation of the most innovative collective bargaining agreements in the history of American labor relations. Healing Together concludes with an assessment of the Kaiser partnership's effect on the larger health care system and its implications for labor-management relations in other industries.

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India and the Patent Wars

Pharmaceuticals in the New Intellectual Property Regime

Murphy Halliburton

India and the Patent Wars contributes to an international debate over the costs of medicine and restrictions on access under stringent patent laws showing how activists and drug companies in low-income countries seize agency and exert influence over these processes. Murphy Halliburton contributes to analyses of globalization within the fields of anthropology, sociology, law, and public health by drawing on interviews and ethnographic work with pharmaceutical producers in India and the United States.

India has been at the center of emerging controversies around patent rights related to pharmaceutical production and local medical knowledge. Halliburton shows that Big Pharma is not all-powerful, and that local activists and practitioners of ayurveda, India’s largest indigenous medical system, have been able to undermine the aspirations of multinational companies and the WTO. Halliburton traces how key drug prices have gone down, not up, in low-income countries under the new patent regime through partnerships between US- and India-based companies, but warns us to be aware of access to essential medicines in low- and middle-income countries going forward.

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The Informed Patient

A Complete Guide to a Hospital Stay

Karen A. Friedman, M.D., and Sara L. Merwin, MPH

"In this immensely useful and readable volume, Karen A. Friedman and Sara Merwin demystify the hospital experience and provide patients and families the information they need to navigate the confusing swirl of a hospital stay. Bring this book with you to the hospital—it will make your stay more understandable, it will keep you more engaged, and it might just save your life."—Robert Wachter, MD, author of The Digital Doctor

" The Informed Patient is a must-read for anyone ever hospitalized, going to be hospitalized, or caring for a friend or family member who is, was, or will be hospitalized. The reader will be given the skills and confidence to approach a hospitalization in an informed manner, demystifying the experience."—Nick Fitterman, MD, FACP, SFHM, Northwell Health and Hoftstra Northwell School of Medicine

Even the most capable individuals are challenged when confronted with the complexity of the modern hospital experience. The Informed Patient is a guide and a workbook, divided into topical, focused sections with step-by-step instructions, insights, and tips to illustrate what patients and their families can expect during a hospital stay. Anyone who will experience a hospital stay—or friends or family who may be in charge of a patient’s care—will find all the help and advice they could need in the detailed sections that cover every aspect of what they can expect.

Karen A. Friedman, MD, and Sara Merwin, MPH, offer hands-on advice about how patients, health care providers, and medical staff can work together to achieve good outcomes. Through anecdotes, tips, sidebars, and clinical scenario vignettes, The Informed Patient presents ways to enhance and optimize a hospital stay, from practical advice on obtaining the best care to dealing with the emotional experience of being in the hospital.

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Inside Chronic Pain

An Intimate and Critical Account

by Lous Heshusius, with a foreword by David B. Morris and an afterword by Scott M. Fishman, MD

Chronic pain, which affects 70 million people in the United States alone-more than diabetes, cancer, and heart disease combined-is a major public health issue that remains poorly understood both within the health care system and by those closest to the people it afflicts. This book examines the experience of pain in ways that could significantly improve how patients and practitioners deal with pain. It is the first volume of a new collection of titles within the acclaimed Culture and Politics of Health Care Work series called How Patients Think, intended to give voice to the concerns of patients about their own medical care and the formulation of health policy.

Since surviving a near-fatal car accident, Lous Heshusius has suffered from chronic pain for more than a decade, forcing her to give up her career as a professor of education. Inside Chronic Pain, based in part on the pain journal Heshusius keeps, is a stunning memoir of a life lived in constant pain as well as an insightful and often critical account of the inadequacies of the health care system-from physicians to hospitals and health insurance companies-to understand chronic pain and treat those who suffer from it. Through her own frequently frustrating experiences, she shows how health care providers often ignore, deny, or incorrectly treat chronic pain at immense cost to both the patient and the health care system. She also offers cogent suggestions on improving the quality and outcome of chronic pain care and management, using her encounters with exceptional medical professionals as models.

Inside Chronic Pain deals with pain's dramatic and destructive effects on one's sense of self and identity. It chronicles the chaos that takes place, the paralyzing effect of severe pain, the changes in personality that ensue, and the corrosive effects of severe pain on the ability to attend to day-to-day tasks. It describes how one's social life falls apart and isolation takes over. It also relates moments of happiness and beauty and describes how rooting the self in the present is crucial in managing pain.

A unique feature of Inside Chronic Pain is the clinical commentary by Dr. Scott M. Fishman, president of the American Pain Foundation. Fishman has long tried to improve the lives of patients like Heshusius. His medical perspective on her very human narrative will help physicians and other clinicians better understand and treat patients with chronic pain.

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My Imaginary Illness

A Journey into Uncertainty and Prejudice in Medical Diagnosis

by Chloë G. K. Atkins; with a foreword by Bonnie Blair O'Connor and an afterword by Brian David Hodges, MD

At age twenty-one, Chloë Atkins began suffering from a mysterious illness, the symptoms of which rapidly worsened. Paralyzed for months at a time, she frequently required intubation and life support. She eventually became quadriplegic, dependent both on a wheelchair and on health professionals who refused to believe there was anything physically wrong with her. When test after test returned inconclusive results, Atkins's doctors pronounced her symptoms psychosomatic. Atkins was told not only that she was going to die but also that this was her own fault; they concluded she was so emotionally deranged that she was willing her own death.

My Imaginary Illness is the compelling story of Atkins's decades-long battle with a disease deemed imaginary, her frustration with a succession of doctors and diagnoses, her immersion in the world of psychotherapy, and her excruciating physical and emotional journey back to wellness. As both a political theorist and patient, Atkins provides a narrative critique of contemporary medicine and its problematic handling of uncertainty and of symptoms that are not easily diagnosed or known. She convincingly illustrates that medicine's belief in evidence-based practice does not mean that individual doctors are capable of objectivity, nor that the presence of biomedical ethics invokes ethical practices in hospitals and clinics.

A foreword by Bonnie Blair O'Connor, who teaches medical students how to listen to patients, and a clinical commentary by Dr. Brian David Hodges, a professor of psychiatry, enrich the book's narrative with practical guidance for medical practitioners and patients alike.

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Never Good Enough

Health Care Workers and the False Promise of Job Training

Frontline health care workers have always been especially vulnerable to the perpetual tides of health care 'reform,' but in the mid-1990s in New York City, they bore the brunt of change in a new way. They were obliged to take on additional work, take lessons in recalibrating their attitudes, and, when those steps failed to bring about the desired improvements, take advantage of training programs that would ostensibly lead to better jobs. Such health care workers not only became targets of pro-market and restructuring policies but also were blamed for many of the problems created by those policies, from the deteriorating conditions of patient care to the financial vulnerability of entire institutions.

In Never Good Enough, Ariel Ducey describes some of the most heavily funded training programs, arguing that both the content of many training and education programs and the sheer commitment of time they require pressure individual health care workers to compensate for the irrationalities of America's health care system, for the fact that caring labor is devalued, and for the inequities of an economy driven by the relentless creation of underpaid service jobs. In so doing, the book also analyzes the roles that unions-particularly SEIU 1199 in New York-and the city's academic institutions have played in this problematic phenomenon.

In her thoughtful and provocative critique of job training in the health care sector, Ariel Ducey explores the history and the extent of job training initiatives for health care workers and lays out the political and economic significance of these programs beyond the obvious goal of career advancement. Questioning whether job training improves either the lives of workers or the quality of health care, she explains why such training persists, focusing in particular on the wide scope of its "emotional" benefits. The book is based on Ducey's three years as an ethnographer in several hospitals and in-depth interviews with key players in health care training. It argues that training and education cannot be a panacea for restructuring-whether in the health care sector or the economy as a whole.

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