[Emigration of Quebec physicians: motivation for departure and return]

Since the 80's, outmigration of physicians from Quebec is steadily increasing. About 46 percent of outmigrating doctors explain their move by factors related to their occupational life (higher income, greater opportunity in the academic career, larger amount of resources devoted to the health care system). Nearly 40 percent relate their decision to personal factors (greater job opportunity for their wife/husband, quality of family life...). The factors linked to the context of the receiving place (political climate, linguistic regulations, income tax level...) play a minor role on the migration decision. As concerns the returning physicians, 80 percent explain their decision by personal factors. The factors linked to the occupational life have a lower role. It appears therefore that doctor outmigration from Quebec is not directly determined by manpower policies adopted by the Province during the last two decades, except the policies directly linked to the income level of professionals.

[Beyond the statistics: why are Quebec physicians emigrating?]

During the period 1986-1999, about 16% of the annual average number of active physicians in Quebec have left for the US or an other Canadian province. The absolute number was 2367. During the same period, 661 would have returned to Quebec. The majority of the outmigrating doctors were graduated from the anglophone university of the Province (although 44 percent are francophone) whereas the majority of the returning doctors were graduated from the 3 francophone universities of the Province. As a matter of fact, 78 percent of the returning doctors are francophone. The migration decision is equally linked to post-graduate training and occupational opportunities and job satisfaction. This feature should be related to an other: those who have returned to Quebec have had a geographic and occupational mobility level far lower than those who have not returned. Finally, it is noteworthy that there are significant differences between the doctors emigrating to the US and their colleagues going to an other Canadian province.

A conceptual framework for the analysis of health care organizations' performance

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

A review of organizational performance assessment in health care

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

Factors influencing the practice of vaginal birth after cesarean section

OBJECTIVES

Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians.

METHODS

A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice.

RESULTS

The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education.

CONCLUSIONS

This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.

Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous cesarean section in Quebec

Repeat cesarean section is a major factor contributing to the rising cesarean section rate. Although vaginal birth after a previous cesarean section (VBAC) is advocated in most cases, it has not yet been adopted as widespread policy. In a case-control study we compared 400 women in Quebec who underwent VBAC with 1600 women who had a repeat cesarean section from 1985 to 1987 in an attempt to identify factors that favour vaginal delivery. Using both simple and multiple logistic regression analyses we examined the effect of independent variables linked to the patients (two variables), the attending physicians (seven) and the hospitals (two) on the dependent variable (type of birth) with the use of odds ratios. We found that the physician characteristics related to type of practice and the degree of hospital specialization were significant factors in predicting the type of delivery. Women who gave birth vaginally were more likely than those who had a repeat cesarean section to be attended by a physician with a specialized practice and to give birth in a hospital providing an intermediate or high level of care. This suggests that VBAC is still perceived as a high-risk option and is managed by only a minority of specialized obstetricians.

ACTION DES ORGANOMAGNÉSIENS SUR LES COMPOSÉS β-DICARBONYLÉS: I. OBTENTION DES β-DIOLS BITERTIAIRES PAR ACTION DES ARYLMAGNÉSIENS ET DES ALKYLMAGNÉSIENS SUR LES β-DICÉTONES SYMETRIQUES

The addition of Grignard reagents to dibenzoylmethane and acetylacetone has been reinvestigated. Apart from cleavage products, it has been found that, in the case of acetylacetone, the reaction leads to the corresponding β-ditertiary diols. On the other hand, dibenzoylmethane yields only the β-hydroxyketone.