The futures of physicians: Agency and autonomy reconsidered

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and ‘not-for-profit’ sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the traditional autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.     

Social Anxiety and Attention away from Emotional Faces

A substantial literature indicates that anxiety is often associated with selective attention to threat cues. Socially anxious individuals are excessively concerned about negative evaluation by others. One might therefore predict that high social anxiety would be associated with selective attention to negative facial expressions. On the other hand, some recent models have suggested that social anxiety may be associated with reduced processing of external social cues. A modified dot-probe task was used to investigate face attention. High and low socially anxious individuals were presented with pairs of pictures, consisting of a face (positive, neutral, or negative) and a household object, under conditions of social-evaluative threat or no threat. The results indicated that, compared to low socially anxious individuals, high socially anxious individuals show an attentional bias away from emotional (positive and negative) faces but this effect is only observed under conditions of social-evaluative threat. Theoretical and clinical implications of the results are discussed.     

FIRST‐ORDER LOGICAL VALIDITY AND THE HILBERT‐BERNAYS THEOREM

What we call the Hilbert‐Bernays (HB) Theorem establishes that for any satisfiable first‐order quantificational schema S, there are expressions of elementary arithmetic that yield a true sentence of arithmetic when they are substituted for the predicate letters in S. Our goals here are, first, to explain and defend W. V. Quine's claim that the HB theorem licenses us to define the first‐order logical validity of a schema in terms of predicate substitution; second, to clarify the theorem by sketching an accessible and illuminating new proof of it; and, third, to explain how Quine's substitutional definition of logical notions can be modified and extended in ways that make it more attractive to contemporary logicians.     

Primary and Secondary Caregiver Reports of Quality of Life in Pediatric Asthma: Are they Comparable?

This study aimed to compare primary and secondary caregiver QOL within families of children with asthma and determine the potential importance of including secondary caregiver QOL in clinical and research settings. Participants included 118 families of children with asthma that had primary and secondary caregivers. Families completed measures in a single research session. Caregivers reported on QOL, psychological functioning, and family burden; children completed a measure of QOL. Child lung function was determined from objective spirometry. Adherence to prescribed controller medication was measured for 6 weeks following the research visit. Primary caregiver QOL was significantly lower than secondary caregiver QOL (Mean overall QOL of 5.85 versus 6.17, p < .05). Better medication adherence was associated with higher primary caregiver QOL (ρ = .22, p = .02); secondary caregiver QOL, not primary caregiver QOL, was positively associated with child QOL (ρ = .20, p = .03). Families with discrepant QOL scores between caregivers (difference in scores of at least .50) were characterized by more family burden and primary caregiver psychological symptoms. Differences in QOL scores between caregivers may be a reflection of primary caregivers’ greater investment in daily asthma management. In families reporting low burden and few psychological difficulties in the primary caregiver, QOL assessments from either caregiver may may be informative and representative of how parents are adapting to child asthma. In families experiencing high levels of burden or more primary caregiver psychological difficulties, QOL reports from secondary caregivers may not be as clinically meaningful.     

Assessing adolescent mindfulness: validation of an adapted Mindful Attention Awareness Scale in adolescent normative and psychiatric populations

Interest in mindfulness-based interventions for children and adolescents is burgeoning, bringing with it the need for validated instruments to assess mindfulness in youths. The present studies were designed to validate among adolescents a measure of mindfulness previously validated for adults (e.g., Brown & Ryan, 2003), which we herein call the Mindful Attention Awareness Scale-Adolescent (MAAS-A). In 2 large samples of healthy 14- to 18-year-olds (N = 595), Study 1 supported a single-factor MAAS-A structure, along with acceptably high internal consistency, test-retest reliability, and both concurrent and incremental validity. In Study 2, with a sample of 102 psychiatric outpatient adolescents age 14-18 years, participants randomized to a mindfulness-based stress reduction intervention showed significant increases in MAAS-A scores from baseline to 3-month follow-up, relative to nonsignificant score changes among treatment-as-usual participants. Increases in MAAS-A scores among mindfulness-based stress reduction participants were significantly related to beneficial changes in numerous mental health indicators. The findings support the reliability and validity of the MAAS-A in normative and mixed psychiatric adolescent populations and suggest that the MAAS-A has utility in mindfulness intervention research.