How do professionals respond to the commodification of health care? Using an interactionist perspective, we answer this question by referring to the findings of five qualitative studies of hospital surgeons, mental health-care professionals, emergency and ambulance personnel, and youth workers in the Netherlands. We find that differential levels of professional autonomy, dominance and discretion spawn different combinations of the logics of the market, bureaucracy and professionalism. We discern five new ways of enacting professionalism: (1) entrepreneurialism: embracing commodification as integral part of professionalism; (2) activism: rallying against encroachment on the profession; (3) bureaucratization: seeking reassurance in procedures; (4) pretending: faking compliance to protect autonomy; and (5) performing: upholding the profession through conscious and skillful management of appearance in the eyes of patients and the public. Hidden strategies of opposition, however, support commodification since most professionals outwardly play by the rules and mix the logic of care with those of the market and bureaucracy, rendering alternative courses of action and solidarity more difficult. Uncertainty is increasing for all professionals, leading to feelings of insecurity and reflexivity but also to creativity. Professionalism is increasingly 'disembedded', called into question, and de-routinized.
BackgroundIn several countries, the number of hours worked by general practitioners (GPs) has decreased, raising concern about current and impending workforce shortages. This shorter working week has been ascribed both to the feminisation of the workforce and to a younger generation of GPs who prefer more flexible working arrangements. There is, however, limited insight into how the impact of these determinants interact. We investigated the relative importance of differences in GPs’ working hours in relation to gender, age, and employment position.MethodsAn analysis was performed on real-time monitoring data collected by sending SMS text messages to 1051 Dutch GPs, who participated during a 1-week time use study. We used descriptive statistics, independent sample t-tests, and one-way ANOVA analysis to compare the working time of different GP groups. A path analysis was conducted to examine the difference in working time by gender, age, employment position, and their combinations.ResultsFemale GPs worked significantly fewer hours than their male peers. GPs in their 50s worked the highest number of hours, followed by GPs age 60 and older. GPs younger than 40 worked the lowest number of hours. This relationship between working hours and age was not significantly different for women and men. As shown by path analysis, female GPs consistently worked fewer hours than their male counterparts, regardless of their age and employment position. The relationship between age and working hours was largely influenced by gender and employment position.ConclusionsThe variation in working hours among GPs can be explained by the combination of gender, age, and employment position. Gender appears to be the most important predictor as the largest part of the variation in working hours is explained by a direct effect of this variable. It has previously been reported that the difference in working hours between male and female GPs had decreased over time. However, our findings suggest that gender remains a critical factor for variation in time use and for policy instruments such as health workforce planning.
Background In mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of recruitability at the bedside. We developed a protocol for individualization of positive end-expiratory pressure (PEEP) and tidal volume (VT) utilizing EIT-derived information on recruitability, overdistension and alveolar cycling. The aim of this study was to assess whether the EIT-based protocol allows individualization of ventilator settings without causing lung overdistension, and to evaluate its effects on respiratory system compliance, oxygenation and alveolar cycling. Methods 20 patients with ARDS were included. Initially, patients were ventilated according to the recommendations of the ARDS Network with a VT of 6 ml per kg predicted body weight and PEEP adjusted according to the lower PEEP/FiO2 table. Subsequently, ventilator settings were adjusted according to the EIT-based protocol once every 30 min for a duration of 4 h. To assess global overdistension, we determined whether lung stress and strain remained below 27 mbar and 2.0, respectively. Results Prospective optimization of mechanical ventilation with EIT led to higher PEEP levels (16.5 [14–18] mbar vs. 10 [8–10] mbar before optimization; p = 0.0001) and similar VT (5.7 ± 0.92 ml/kg vs. 5.8 ± 0.47 ml/kg before optimization; p = 0.96). Global lung stress remained below 27 mbar in all patients and global strain below 2.0 in 19 out of 20 patients. Compliance remained similar, while oxygenation was significantly improved and alveolar cycling was reduced after EIT-based optimization. Conclusions Adjustment of PEEP and VT using the EIT-based protocol led to individualization of ventilator settings with improved oxygenation and reduced alveolar cycling without promoting global overdistension. Trial registrationThis study was registered at clinicaltrials.gov (NCT02703012) on March 9, 2016 before including the first patient.
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