The Wal-Marting of american psychiatry: An ethnography of psychiatric practice in the late 20th century
The Wal-Marting of american psychiatry: An ethnography of psychiatric practice in the late 20th century
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DOI：
10.1023/a:1013063216716
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发表时间：
2001-12-01
影响因子：
1.7
通讯作者：
Donald, A
中科院分区：
文献类型：
--
作者：
Donald, A
目的：美国精神病学已经从根本上重组了精神病院，收容所的资助方式的变化。成本控制措施的实施和内部化是这一改组的主要内容。本文追溯了与管理式医疗相关的成本控制方法产生的组织和模式临床工作和临床知识的新方法。方法：采用定性社会学研究的参与性观察，在三种情况下进行：公立医院、具有精神病院历史的私立医院和营利性连锁医院。本研究通过对临床医生和辅助工作人员（如利用审查员）的访谈，了解他们对工作经验的建构和理解。此外，安排了对一些管理式护理公司的人员的采访，尽管由于拒绝许可，这些公司没有进行实际的人种学经验。访谈包括临床医生谁的经验桥梁前和后管理护理时代。结果：质量保证与利用管理程序的广泛采用创造了新的评价和处理标准。这些标准产生于从以人为中心到以人口为基础的数据库的过渡。管理式医疗的支持者相信，良好的临床治疗等同于有效的成本控制。这种认识论的变化导致临床知识的发展模式沿着算法的途径，而不是主观的理解。结果，精神病学的理性化程度越来越高，速度也越来越快。这种合理化的过程产生了道德困境的执业临床医生，因为他们努力重新定义自己的职业目的和身份在一个新的秩序。结论：“质量运动”的兴起导致了临床知识的重建，这是受资本主义文化后果影响的社会实践强加的结果。结果形成了一种独特的美国精神病学。
Object: U.S. psychiatry has been radically reorganized by changes in the way the psychiatric hospital, the asylum, is funded. The imposition and internalization of cost control measures are major elements of this reorganization. This paper traces the ways in which cost control methods associated with managed care have produced new ways of organizing and patterning clinical work and clinical knowledge.Methods: Participant observation, used in qualitative sociological research, was undertaken in three settings: a public hospital, a private hospital with roots in the history of the asylum, and a for-profit hospital chain. The research consisted of observation of usual clinic practices and interviews with clinicians and ancillary staff, such as utilization reviewers, concerning their construction of and understandings about their work experience. In addition, interviews with personnel at a number of managed care companies was arranged although actual ethnographic experience was not performed in these companies due to declined permission. Interviews included clinicians whose experiences bridged the pre- and post-managed care eras.Result: This paper argues that the widespread adoption of Quality Assurance and Utilization Management procedures has created new standards of evaluation and treatment. These standards grow out of a transition from a person-centered to a population-based data base. They are justified by a conviction on the part of managed care proponents that good clinical treatment is equivalent to efficient cost control. This epistemological change results in the development of a clinical knowledge patterned along algorithmic pathways rather than subjective understanding. An increased and more rapid rationalization of psychiatry is the result. This rationalization process has produced moral dilemmas for practicing clinicians as they struggle to redefine their professional purposes and identities within a new order.Conclusion: The rise of the `Quality Movement' has led to the reconstruction of clinical knowledge as a result of the imposition of social practices influenced by the cultural consequences of capitalism. A peculiarly American psychiatry is the result.