Is the doctor in? The evolving role of organized medicine in health policy

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.     

Is there a Need for a European Criminology?

Readers were invited in Issue 4, 2000 to give their comments on the subject of European criminology. The Editors also invited some scholars on a personal title. The comments, ranging from 1,200 to 2,000 words are presented in alphabetical order. The comments are written by: Rosemary Barberet, Josine Junger-Tas, Martin Killias, H.-J. Schneider, Alenka élih, Henrik Tham, Bas van Stokkom and Lode Walgrave. Together they offer a view on the ideas and different views on European criminology.     

Is there a place for hair analysis in doping controls?

The actual antidoping control rules applied in sports (as established by the International Olympic Committee and the International Sport Federations) state that a positive case is chemically established by the unequivocal detection of a forbidden parent molecule and/or any of its metabolite(s) in urine, no matter the amounts which were administered and when the drug was taken. Screening is accomplished most of the time by using GC-MS procedures. These have been optimized to detect most if not all of the forbidden compounds which are put on a list. Recently, attempts have been made on scalp hair to demonstrate the value of this matrix as a possible means for differentiating between therapeutic use and doping abuse. In particular, GC-mass selective detector and GC-high resolution MS were successfully applied to treated animals and body-builders for anabolic agents (steroids and beta-2-agonists) at high sensitivity detection (low ng/g level). Naturally occurring molecules, like testosterone and its metabolites, could also be differentiated from their synthetic counterparts. Positive cases are more often challenged in courts and retrospectivity in time of the drug(s) intake is becoming an important issue for evaluating the responsibility of the person. This is can be based on hair analyses if the drugs have been taken at regular intervals. Stimulants and narcotics are often used in sports like drug of abuse in the ordinary social contexts. On the other hand, anabolic agents, when taken to improve the physical performances, follow complex regimens with the mixing of various formulas and dosages. Scalp hair references ranges for these as well as for endogenous substances still wait to be established statistically for competing, well-trained athletes. The incorporation rate into blond or gray hair is poorer than that of dark colored hair raising the question of individuals equality against the controls, a very important matter of concern for the sport's governing bodies. The frequency of hair cutting and short hair cuts necessary to gain speed in specific sports like swimming are other critical factors. On the other hands, irregular hair growth, associated with the washout effect through multiple washing and staining processes over expanded time intervals can cause concentrating or diluting effects. So far, a minority of prohibited substances could be detected in scalp hair with the sensitivity and specificity required in the context of the sport's activities. From the above, clear limitations of the usefulness of hair analysis in doping control analysis are obvious until a lot more data relevant to this particular field have been collected.     

Family caregivers: a shadow workforce in the geriatric health care system?

Based on two years of fieldwork, conducted between March 2003 and March 2005 in the health care industry of the northeastern United States, this study shows that the work of family caregivers of elders goes far beyond previously recognized care in the home to acknowledge care inside health care facilities and in conjunction with community services. It reveals that family caregivers--untrained, undersupported, and unseen--constitute a "shadow workforce," acting as geriatric case managers, medical record keepers, paramedics, and patient advocates to fill dangerous gaps in a system that is uncoordinated, fragmented, bureaucratic, and often depersonalized. Detailed examination of what family caregivers actually do in traversing multiple domains reveals the extent of their contribution to and the weaknesses in the present geriatric health care system. It suggests that the experiences of family caregivers must be central to the creation of new policies and a more coordinated system that uses the complex work of family caregivers by providing the training and support that they need.