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The culture and politics of health care work

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The culture and politics of health care work

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

At age twenty-one, Chloƫ 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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Out of Practice

Fighting for Primary Care Medicine in America

by Frederick M. Barken, MD

Primary care medicine, as we know and remember it, is in crisis. While policymakers, government administrators, and the health insurance industry pay lip service to the personal relationship between physician and patient, dissatisfaction and disaffection run rampant among primary care doctors, and medical students steer clear in order to pursue more lucrative specialties. Patients feel helpless, well aware that they are losing a valued close connection as health care steadily becomes more transactional than relational. The thin-margin efficiency, rapid pace, and high volume demanded by the new health care economics do not work for primary care, an inherently slower, more personal, and uniquely tailored service.

In Out of Practice, Dr. Frederick Barken juxtaposes his personal experience with the latest research on the transformations in the medical field. He offers a cool critique of the "market model of medicine" while vividly illustrating how the seemingly inexorable trend toward specialization in the last few decades has shifted emphasis away from what was once the foundation of medical practice. Dr. Barken addresses the complexities of modern practice-overuse of diagnostic studies, fragmentation of care, increasing reliance on an array of prescription drugs, and the practice of defensive medicine. He shows how changes in medicine, the family, and society have left physicians to deal with a wide range of geriatric issues, from limited mobility to dementia, that are not addressed by health care policy and are not entirely amenable to a physician's prescription. Indeed, Dr. Barken contends, the very survival of primary care is in jeopardy at a time when its practitioners are needed more than ever.

Illustrated with case studies gleaned from more than twenty years in private practice and data from a wide range of sources, Out of Practice is more than a jeremiad about a broken system. Throughout, Dr. Barken offers cogent suggestions for policymakers and practitioners alike, making clear that as valuable as the latest drug or medical device may be, a successful health care system depends just as much on the doctor-patient relationship embodied by primary care medicine.

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Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

Health Care Fraud and What to Do about It

by Terry L. Leap

U.S. health care is a $2.5 trillion system that accounts for more than 17 percent of the nation's GDP. It is also highly susceptible to fraud. Estimates vary, but some observers believe that as much as 10 percent of all medical billing involves some type of fraud. In 2009, New York's Medicaid fraud office recovered $283 million and obtained 148 criminal convictions. In July 2010, the U.S. Justice Department charged nearly 100 patients, doctors, and health care executives in five states of bilking the Medicare system out of more than $251 million through false claims for services that were medically unnecessary or never provided. These cases only hint at the scope of the problem.

In Phantom Billing, Fake Prescriptions, and the High Cost of Medicine, Terry L. Leap takes on medical fraud and its economic, psychological, and social costs. Illustrated throughout with dozens of specific and often fascinating cases, this book covers a wide variety of crimes: kickbacks, illicit referrals, overcharging and double billing, upcoding, unbundling, rent-a-patient and pill-mill schemes, insurance scams, short-pilling, off-label marketing of pharmaceuticals, and rebate fraud, as well as criminal acts that enable this fraud (mail and wire fraud, conspiracy, and money laundering).

After assessing the effectiveness of the federal laws designed to fight health care fraud and abuse-the antikickback statute, the Stark Law, the False Claims Act, HIPAA, and the food and drug laws-Leap suggests a number of ways that health care providers, consumers, insurers, and federal and state officials can bring health care fraud and abuse under control, thereby reducing the overall cost of medical care in America.

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Safety in Numbers

Nurse-to-Patient Ratios and the Future of Health Care

by Suzanne Gordon, John Buchanan, and Tanya Bretherton

Legally mandated nurse-to-patient ratios are one of the most controversial topics in health care today. Ratio advocates believe that minimum staffing levels are essential for quality care, better working conditions, and higher rates of RN recruitment and retention that would alleviate the current global nursing shortage. Opponents claim that ratios will unfairly burden hospital budgets, while reducing management flexibility in addressing patient needs.

Safety in Numbers is the first book to examine the arguments for and against ratios. Utilizing survey data, interviews, and other original research, Suzanne Gordon, John Buchanan, and Tanya Bretherton weigh the cost, benefits, and effectiveness of ratios in California and the state of Victoria in Australia, the two places where RN staffing levels have been mandated the longest. They show how hospital cost cutting and layoffs in the 1990s created larger workloads and deteriorating conditions for both nurses and their patients-leading nursing organizations to embrace staffing level regulation. The authors provide an in-depth account of the difficult but ultimately successful campaigns waged by nurses and their allies to win mandated ratios. Safety in Numbers then reports on how nurses, hospital administrators, and health care policymakers handled ratio implementation.

With at least fourteen states in the United States and several other countries now considering staffing level regulation, this balanced assessment of the impact of ratios on patient outcomes and RN job performance and satisfaction could not be timelier. The authors' history and analysis of the nurse-to-patient ratios debate will be welcomed as an invaluable guide for patient advocates, nurses, health care managers, public officials, and anyone else concerned about the quality of patient care in the United States and the world.

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The Vanishing Physician-Scientist?

edited by Andrew I. Schafer

Throughout history, physicians have played a vital role in medical discovery. These physician-scientists devote the majority of their professional effort to seeking new knowledge about health and disease through research and represent the entire continuum of biomedical investigation. They bring a unique perspective to their work and often base their scientific questions on the experience of caring for patients. Physician-scientists also effectively communicate between researchers in the "pure sciences" and practicing health care providers. Yet there has been growing concern in recent decades that, due to complex changes, physician-scientists are vanishing from the scene.

In this book, leading physician-scientists and academic physicians examine the problem from a variety of perspectives: historical, demographic, scientific, cultural, sociological, and economic. They make valuable recommendations that-if heeded-should preserve and revitalize the community of physician-scientists as the profession continues to evolve and boundaries between doctors and researchers shift.

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With God on Our Side

The Struggle for Workers' Rights in a Catholic Hospital

by Adam D. Reich

When unions undertake labor organizing campaigns, they often do so from strong moral positions, contrasting workers' rights to decent pay or better working conditions with the more venal financial motives of management. But how does labor confront management when management itself has moral legitimacy? In With God on Our Side, Adam D. Reich tells the story of a five-year campaign to unionize Santa Rosa Memorial Hospital, a Catholic hospital in California. Based on his own work as a volunteer organizer with the Service Employees International Union (SEIU), Reich explores how both union leaders and hospital leaders sought to show they were upholding the Catholic "mission" of the hospital against a market represented by the other. Ultimately, workers and union leaders were able to reinterpret Catholic values in ways that supported their efforts to organize.

More generally, Reich argues that unions must weave together economic and cultural power in order to ensure their continued relevancy in the postindustrial world. In addition to advocating for workers' economic interests, unions must engage with workers' emotional investments in their work, must contend with the kind of moral authority that Santa Rosa Hospital leaders exerted to dissuade workers from organizing, and must connect labor's project to broader conceptions of the public good.

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