Adult orthodontics: internet information and a national survey

Aims: 1. To investigate the reliability and readability of information on the Internet on adult orthodontics. 2. To evaluate the profile and treatment of adults by specialist orthodontists in the Republic of Ireland (ROI). Materials and methods: 1. An Internet search was conducted in May 2015 using three search engines (Google, Yahoo and Bing), with two search terms (“adult orthodontics” and “adult braces”). The first 50 websites from each engine were screened and exclusion criteria applied. Included websites were then assessed for reliability using the JAMA benchmarks, the DISCERN and LIDA tools and the presence of the HON seal. Readability was assessed using the FRES. 2. A pilot-tested questionnaire about adult orthodontics was distributed to 122 eligible specialist orthodontists in the ROI. Questions addressed general and treatment information about adult orthodontic patients, methods of information provision and respondent demographics. Results: 1. Thirteen websites met the inclusion criteria. Three websites contained all JAMA benchmarks and one displayed the HON Seal. The mean overall score for DISCERN was 3.9/5 and the mean total LIDA score was 115/120. The average FRES score was 63.1. 2. The questionnaire yielded a response rate of 83%. The typical demographic profile of adult orthodontic patients was professional females between 25-35 years. The most common incisor relationship and skeletal base was Class II, division 1 (51%) and Class II (61%) respectively. Aesthetic upper brackets and metal lower brackets were the most frequently used appliances. Only 30% of orthodontists advise their adult patients to find extra information on the Internet. Conclusions: 1. The reliability and readability of information on the Internet on adult orthodontics is of moderate quality. 2. The provision of adult orthodontic treatment is common among specialist orthodontists in the Republic of Ireland.

Three-dimensional outcomes of twin-block appliance treatment and the influence of the postured wax bite

Aims 1 To identify the 3D soft tissue volumetric and linear landmark changes following treatment with the Twin-Block Appliance TBA. 2 To estimate the TBA treatment outcome on the soft tissue facial profile volumetric and linear landmark changes from the Postured Wax Bite (PWB). 3 To identify if there is any association between certain soft tissue landmark variables and successful treatment outcome of the TBA as measured by the reduction in overjet. 4 To assess the effects of TBA treatment on facial expressions. Materials and Methods Forty-seven Caucasian subjects with Class II division 1 were recruited. 3D images captured of each subject, pre-treatment (T1), with the PWB (T2) and at the end of treatment (T3). Soft tissue volumetric and linear changes as well as the correlation between facial parameters and successful treatment were calculated. Results The mean soft tissue volumetric change from T1 to T3 was 22.24 ± 16.73 cm³. Soft tissue profile linear changes from T1-T3 for lower facial landmarks were 4-5 mm. From T1-T3, the mean soft tissue volumetric change of the total sample was 60% of the change produced by the PWB (T1 to T2). Correlations were weak for all 3D facial parameters and successful overjet reduction. Facial expression changes were only significant for the lower landmarks. Conclusions 1 TBA treatment, in growing subjects, increased the lower facial soft tissue volume and caused forward movement of the lower soft tissue facial profile landmarks.2 The PWB can be used to estimate the treatment outcome of the TBA on soft tissue profile changes.3 No association was found between soft tissue landmark variables and successful overjet reduction.4 TBA treatment had no effect on the upper facial landmarks for each facial expression but it changed the lower facial expressions significantly except for maximal smile in males.

Weathering the crisis? Managing democracy at a national broadcaster

With post-2008 political and economic crises as its backdrop, this inquiry into the political roles and functions of public service broadcasting (PSB) in Ireland is principally concerned with examining the capacities for and actuality of critical and counter-hegemonic professional journalistic and institutional mediations of crisis. Recognising the diversity of influences on the normative identity of Irish PSB, the dissertation adopts a sociological approach that acknowledges the systemic embedding of media institutions in the broader field of power. An initial tracing of the formative impacts of endogenous and exogenous forces on the democratic horizons of PSB suggests that the present crisis conjuncture does not represent promising terrain for engendering critical crisis and recovery imaginaries. A methodologically diverse intra-institutional empirical research agenda aims to explore at close hand Irish PSB’s contingent navigation of crisis, encompassing ethnographic observation in the newsroom, practitioner interviews and textual analysis of broadcast output. These methods afford close analysis of practices of journalistic production and reflexivity, self-conceptions of the journalistic habitus, and ideological affinities of crisis framings in broadcast output. These analyses are supplemented by a participant observation study of the possibilities for public agenda-building in a key institutional venue of public participation in broadcasting governance. The findings offer an evidential basis for the arguments that the crisis has prompted only minimal changes to professional norms and practices of representation and inclusion; that journalistic crisis framings tend toward effecting hegemonic repair by lending support to neoliberal crisis and recovery imaginaries; and that the institutional openings for the building of public counterpower are highly constrained. The overall conclusion is made that the normative democratic orientation embedded in the professional and institutional projects of public service broadcasting help render it ill-equipped to act as a re-democratising countervailing power against the democratic regressions engendered by the present crisis of democratic capitalism.

The impact of user charges on patient choice of healthcare services in Ireland

This research assesses the impact of user charges in the context of consumer choice to ascertain how user charges in healthcare impact on patient behaviour in Ireland. Quantitative data is collected from a subset of the population in walk-in Urgent Care Clinics and General Practitioner surgeries to assess their responses to user charges and whether user charges are a viable source of part-funding healthcare in Ireland. Examining the economic theories of Becker (1965) and Grossman (1972), the research has assessed the impact of user charges on patient choice in terms of affordability and accessibility in healthcare. The research examined a number of private, public and part-publicly funded healthcare services in Ireland for which varying levels of user charges exist depending on patients’ healthcare cover. Firstly, the study identifies the factors affecting patient choice of privately funded walk-in Urgent Care Clinics in Ireland given user charges. Secondly, the study assesses patient response to user charges for a mainly public or part-publicly provided service; prescription drugs. Finally, the study examines patients’ attitudes towards the potential application of user charges for both public and private healthcare services when patient choice is part of a time-money trade-off, convenience choice or preference choice. These services are valued in the context of user charges becoming more prevalent in healthcare systems over time. The results indicate that the impact of user charges on healthcare services vary according to socio-economic status. The study shows that user charges can disproportionately affect lower income groups and consequently lead to affordability and accessibility issues. However, when valuing the potential application of user charges for three healthcare services (MRI scans, blood tests and a branded over a generic prescription drug), this research indicates that lower income individuals are willing to pay for healthcare services, albeit at a lower user charge than higher income earners. Consequently, this study suggests that user charges may be a feasible source of part-financing Irish healthcare, once the user charge is determined from the patients’ perspective, taking into account their ability to pay.

Graded Exercise Therapy Guided Self-Help Trial for Patients with Chronic Fatigue Syndrome (GETSET): Protocol for a Randomized Controlled Trial and Interview Study

Background: Chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME), is characterized by chronic disabling fatigue and other symptoms, which are not explained by an alternative diagnosis. Previous trials have suggested that graded exercise therapy (GET) is an effective and safe treatment. GET itself is therapist-intensive with limited availability. Objective: While guided self-help based on cognitive behavior therapy appears helpful to patients, Guided graded Exercise Self-help (GES) is yet to be tested. Methods: This pragmatic randomized controlled trial is set within 2 specialist CFS/ME services in the South of England. Adults attending secondary care clinics with National Institute for Health and Clinical Excellence (NICE)-defined CFS/ME (N=218) will be randomly allocated to specialist medical care (SMC) or SMC plus GES while on a waiting list for therapist-delivered rehabilitation. GES will consist of a structured booklet describing a 6-step graded exercise program, supported by up to 4 face-to-face/telephone/Skype™ consultations with a GES-trained physiotherapist (no more than 90 minutes in total) over 8 weeks. The primary outcomes at 12-weeks after randomization will be physical function (SF-36 physical functioning subscale) and fatigue (Chalder Fatigue Questionnaire). Secondary outcomes will include healthcare costs, adverse outcomes, and self-rated global impression change scores. We will follow up all participants until 1 year after randomization. We will also undertake qualitative interviews of a sample of participants who received GES, looking at perceptions and experiences of those who improved and worsened. Results: The project was funded in 2011 and enrolment was completed in December 2014, with follow-up completed in March 2016. Data analysis is currently underway and the first results are expected to be submitted soon. Conclusions: This study will indicate whether adding GES to SMC will benefit patients who often spend many months waiting for rehabilitative therapy with little or no improvement being made during that time. The study will indicate whether this type of guided self-management is cost-effective and safe. If this trial shows GES to be acceptable, safe, and comparatively effective, the GES booklet could be made available on the Internet as a practitioner and therapist resource for clinics to recommend, with the caveat that patients also be supported with guidance from a trained physiotherapist. The pragmatic approach in this trial means that GES findings will be generalizable to usual National Health Service (NHS) practice.

The design studio as liminal space

The context of this research focuses on the efficacy of design studio as a form of teaching and learning. The established model of project-based teaching makes simple parallels between studio and professional practice. However, through comparison of the discourses it is clear that they are of different character. The protocols of the tutorial tradition can act to position the tutor as a defender of the knowledge community rather than a discourse guide for the student. The question arises as to what constitutes the core knowledge that would enable better self-directed study. Rather than focus on key knowledge, there has been an attempt in other fields to agree and share ‘threshold concepts’ within disciplinary knowledge. Meyer and Land describe threshold concepts as representing “a transformed way of understanding, or interpreting or viewing something without which the learner cannot progress [1]. The tutor’s role should be to assist in transforming student’s understanding through the mastery of the ‘troublesome knowledge’ that threshold concepts may embody. Teaching and learning environments under such approaches have been described as ‘liminal’: holding the learner in an ‘in-between’ state new understanding may be difficult and involve identity shifts. Research on the consequence of pressures on facilities and studio space concur, and indicate that studio spaces can be much better used in assisting the path of learning [2]. Through an overview map of threshold concepts, the opportunities for blended learning in supporting student learning in the liminal space of the design studio become much clearer [3] Design studio needs to be recontextualised within the discourse of higher education scholarship, based on a clarified curriculum built from an understanding of what constitutes its threshold concepts. The studio needs to be reconsidered as a space quite unlike that of the practitioner, a liminal space. 1. Meyer, J.H.F. and R. Land, Threshold concepts and troublesome knowledge. Overcoming Barriers to Student Learning: Threshold concepts and troublesome knowledge., 2006: p. 19. 2. Cai, H. and S. Khan, The Common First Year Studio in a Hot-desking Age: An Explorative Study on the Studio Environment and Learning. Journal for Education in the Built Environment 2010. 5(2): p. 39-64. 3. Pektas, S.T., The Blended Design Studio: An Appraisal of New Delivery Modes in Design Education. Procedia - Social and Behavioral Sciences, 2012. 51(0): p. 692-697.

“Considering there’s supposedly nothing wrong with me, it’s not a life”: Women’s Narratives of Distress, Visiting Herbalists, and Being Well in the 21st Century

Distress can have a profoundly negative impact on the well-being of women (who are the main receivers of treatment for distress). Distress also poses a huge financial problem for the United Kingdom, the cost of which is predicted to reach over £26bn by 2026. A growing body of research has shown that various medicinal plants have potential to treat different aspects of distress. However, there is little research investigating the patient experience of western herbal practice (WHP), and none investigating women’s experiences of WHP for distress. In response, this longitudinal study utilised interviews with twenty-six women who were visiting herbalists for distress across the south-east of The United Kingdom to elicit their stories of distress, as well as their experiences of WHP. The narratives were analysed from a constructionist standpoint, using inductive thematic analysis. The participants’ narratives highlighted the profound impact of everyday distress, whilst feelings associated with distress (anxiety, low mood, isolation, shame and guilt) were frequently communicated via the use of metaphors. These negative feelings, often combined with unsuccessful biomedical encounters, frequently led to the women feeling desperate when first visiting a herbalist. The participants’ experiences of WHP showed that an accessible practitioner and good therapeutic relationship combined with flexible herbal treatment, allowed women with diverse stories of distress to overcome feelings of desperation. Ongoing support allowed the women to feel like they had a safety net as they journeyed from a place of distress, back into the wider world. These findings were supported by more unusual negative accounts, which showed how the herbal therapeutic process could be unsuccessful if elements were missing. This research is of significance as it helps to deepen our understanding of women’s experiences of distress – particularly perceptions of stigma which surround feelings of shame (linked to an inability to cope) and guilt (linked to the perceived impact of distress on others). The research also has relevance for WHP, as it highlights which positive aspects of WHP are of particular importance to women patients who are living with distress.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Potencial de cambio en las capacidades humanas de los docentes de educación básica en la región socioeducactiva de Tuxtla Gutiérrez, Chiapas, México

La investigación que se presenta fue desarrollada dentro del campo de los estudios regionales y con visión transdisciplinar. Tuvo como objetivo deconstruir conjuntamente con los participantes, las capacidades humanas regionales de nosotros los docentes de educación básica, en nuestros procesos de reflexión entre teoría y práctica, en los que se consideraron las condicionantes estructurales, en niveles macro y micro regionales, con el alcance de haber identificado el potencial de cambio en nuestra praxis de docente como acción ante nuestros alumnos, quienes configuran el tejido social de Tuxtla Gutiérrez. Desde una perspectiva sociocrítica, se tomó como punto de fuga o núcleo la teoría crítica con fundamento filosófico en la escuela de Fráncfort y con una postura epistemológica basada en el construccionismo por la estrecha relación sujeto-objeto en el estudio; por ende se empleó la metodología investigaciónacción a través de diversas técnicas e instrumentos. Los resultados fueron concentrados en categorías que facilitaron su discusión: primeramente con el potencial de cambio, que adquirió significado mediante el desarrollo de las capacidades de reflexión y conciencia del docente; luego se presentaron las capacidades humanas, de nosotros los docentes, en las que destacaron como base de otras, las capacidades de amor, autoestima y compromiso. Posteriormente, se describió la reflexión docente sobre la concepción del beneficio personal hacia el beneficio colectivo. Finalmente, se discutió sobre la proyección de la acción docente dentro de la relación alumno y región. Se concluyó que las capacidades humanas y el potencial de cambio, deconstruidos conjuntamente con los docentes participantes, fueron la respuesta del proceso investigativo en un determinado tiempo y espacio, como posibilidades de acción docente hacia la tan deseada transformación socioeducativa regional.

Pig producer perspectives on the use of meat inspection as an animal health and welfare diagnostic tool in the Republic of Ireland and Northern Ireland

Background
Currently, there is growing interest in developing ante and post mortem meat inspection (MI) to incorporate measures of pig health and welfare for use as a diagnostic tool on pig farms. However, the success of the development of the MI process requires stakeholder engagement with the process. Knowledge gaps and issues of trust can undermine the effective exchange and utilisation of information across the supply chain. A social science research methodology was employed to establish stakeholder perspectives towards the development of MI to include measures of pig health and welfare. In this paper the findings of semi-structured telephone interviews with 18 pig producers from the Republic of Ireland and Northern Ireland are presented.

Results
Producers recognised the benefit of the utilisation of MI data as a health and welfare diagnostic tool. This acknowledgment, however, was undermined for some by dissatisfaction with the current system of MI information feedback, by trust and fairness concerns, and by concerns regarding the extent to which data would be used in the producers’ interests. Tolerance of certain animal welfare issues may also have a negative impact on how producers viewed the potential of MI data. The private veterinary practitioner was viewed as playing a vital role in assisting them with the interpretation of MI data for herd health planning.

Conclusions
The development of positive relationships based on trust, commitment and satisfaction across the supply chain may help build a positive environment for the effective utilisation of MI data in improving pig health and welfare. The utilisation of MI as a diagnostic tool would benefit from the development of a communication strategy aimed at building positive relationships between stakeholders in the pig industry.

Self-perceptions of the role of the planner

The role of the planning practitioner has received considerable attention in a diverse range of theoretical and empirical debates within the broad spectrum of planning scholarship from normative debates surrounding the planner's role in society, to more empirical investigations into the skills, attributes, and evolving nature of planning practitioners. Fundamental questions surrounding the role and purpose of planners have also entered into more mainstream discussions as the democratic nature of the planning system has been consistently undermined by allegations of misconduct, corruption, and incompetence. Despite the broad range of literature and debate which centres on the role of the planner, relatively few studies have explored the views of planning practitioners themselves, making it difficult to judge whether the ideas of planning academics are actually shared by those in the field. In this paper we seek to address this particular gap and argue that such insights are critical in determining the extent to which planning practitioners serve to challenge, maintain, or reinforce existing power imbalances in the planning system. The methodology consists of a series of qualitative interviews with twenty local authority planners working throughout the Greater Dublin Area, Ireland. The results suggest that planners' self-perceptions of their role tend to reflect traditional pluralist and managerialist perspectives. More broadly, the results suggest that the role orientations of contemporary planners are being shaped by dominant discourses in current planning ideology — namely, collaborative and participatory approaches

Perceptions of the common good in planning

There has been plenty of debate in the academic literature about the nature of the common good or public interest in planning. There is a recognition that the idea is one that is extremely difficult to isolate in practical terms; nevertheless, scholars insist that the idea ‘…remains the pivot around which debates about the nature of planning and its purposes turn’ (Campbell & Marshall, 2002, 163–64). At the point of first principles, these debates have broached political theories of the state and even philosophies of science that inform critiques of rationality, social justice and power. In the planning arena specifically, much of the scholarship has tended to focus on theorising the move from a rational comprehensive planning system in the 1960s and 1970s, to one that is now dominated by deliberative democracy in the form of collaborative planning. In theoretical terms, this debate has been framed by a movement from what are perceived as objective and elitist notions of planning practice and decision-making to ones that are considered (by some) to be ‘inter-subjective’ and non-elitist. Yet despite significant conceptual debate, only a small number of empirical studies have tackled the issue by investigating notions of the common good from the perspective of planning practitioners. What do practitioners understand by the idea of the common good in planning? Do they actively consider it when making planning decisions? Do governance/institutional barriers exist to pursuing the common good in planning? In this paper, these sorts of questions are addressed using the case of Ireland. The methodology consists of a series of semi-structured qualitative interviews with 20 urban planners working across four planning authorities within the Greater Dublin Area, Ireland. The findings show that the most frequently cited definition of the common good is balancing different competing interests and avoiding/minimising the negative effects of development. The results show that practitioner views of the common good are far removed from the lofty ideals of planning theory and reflect the ideological shift of planners within an institution that has been heavily neoliberalised since the 1970s.

Informal caregiving and mental ill health – differential relationships by workload, gender, age and area-remoteness in a UK region

Informal caregiving can be a demanding role which has been shown to impact on physical, psychological and social wellbeing. Methodological weaknesses including small sample sizes and subjective measures of mental health have led to inconclusive evidence about the relationship between informal caregiving and mental health. This paper reports on a study carried out in a UK region which investigated the relationship between informal caregiving and mental ill health. The analysis was conducted by linking three datasets, the Northern Ireland Longitudinal Study, the Northern Ireland Enhanced Prescribing Database and the Proximity to Service Index from the Northern Ireland Statistics and Research Agency. Our analysis used both a subjective measure of mental ill health, i.e. a question asked in the 2011 Census, and an objective measure, whether the respondents had been prescribed antidepressants by a General Practitioner between 2010 and 2012. We applied binary logistic multilevel modelling to these two responses to test whether, and for what sub-groups of the population, informal caregiving was related to mental ill health. The results showed that informal caregiving per se was not related to mental ill health although there was a strong relationship between the intensity of the caregiving role and mental ill health. Females under 50, who provided over 19 hours of care, were not employed or worked part-time and who provided care in both 2001 and 2011 were at a statistically significantly elevated risk of mental ill health. Caregivers in remote areas with limited access to shops and services were also at a significantly increased risk as evidenced by prescription rates for antidepressants. With community care policies aimed at supporting people to remain at home, the paper highlights the need for further research in order to target resources appropriately.

Exploring Service Innovation Practices Through a Longitudinal Ethnographic Case Study

Case study research has the advantage of investigating issues that are embedded within the context of the case. A novel approach to investigation of the implementation of service innovation process has been adopted through a longitudinal ethnographic case study. This approach was found useful, as the outcome of the study was intended to be an in-depth understanding of firm’s current innovation practices and its consequences with the implementation of a novel business process. In this applied research, an array of longitudinal data was generated chiefly through the technique of participant-observation. Participant-observation as a qualitative or naturalistic method has its roots in ethnographic research. Participant-observation involves “participating in the social world, in whatever role, and reflecting on the products of that participation” (Hammersley & Atkinson, 1983, p.16). This method offers a degree of understanding of the context under study that can come only from personal experience. In this presentation, I discuss the role of the researcher-practitioner as participant-observer and the usefulness of ethnographic case study methodology and participant-observation technique to investigating service innovation practices that are embedded within the context-specific setting of the case.

Modelling and estimating models of physician labour supply and productivity

Ma thèse s’intéresse aux politiques de santé conçues pour encourager l’offre de services de santé. L’accessibilité aux services de santé est un problème majeur qui mine le système de santé de la plupart des pays industrialisés. Au Québec, le temps médian d’attente entre une recommandation du médecin généraliste et un rendez-vous avec un médecin spécialiste était de 7,3 semaines en 2012, contre 2,9 semaines en 1993, et ceci malgré l’augmentation du nombre de médecins sur cette même période. Pour les décideurs politiques observant l’augmentation du temps d’attente pour des soins de santé, il est important de comprendre la structure de l’offre de travail des médecins et comment celle-ci affecte l’offre des services de santé. Dans ce contexte, je considère deux principales politiques. En premier lieu, j’estime comment les médecins réagissent aux incitatifs monétaires et j’utilise les paramètres estimés pour examiner comment les politiques de compensation peuvent être utilisées pour déterminer l’offre de services de santé de court terme. En second lieu, j’examine comment la productivité des médecins est affectée par leur expérience, à travers le mécanisme du "learning-by-doing", et j’utilise les paramètres estimés pour trouver le nombre de médecins inexpérimentés que l’on doit recruter pour remplacer un médecin expérimenté qui va à la retraite afin de garder l’offre des services de santé constant. Ma thèse développe et applique des méthodes économique et statistique afin de mesurer la réaction des médecins face aux incitatifs monétaires et estimer leur profil de productivité (en mesurant la variation de la productivité des médecins tout le long de leur carrière) en utilisant à la fois des données de panel sur les médecins québécois, provenant d’enquêtes et de l’administration. Les données contiennent des informations sur l’offre de travail de chaque médecin, les différents types de services offerts ainsi que leurs prix. Ces données couvrent une période pendant laquelle le gouvernement du Québec a changé les prix relatifs des services de santé. J’ai utilisé une approche basée sur la modélisation pour développer et estimer un modèle structurel d’offre de travail en permettant au médecin d’être multitâche. Dans mon modèle les médecins choisissent le nombre d’heures travaillées ainsi que l’allocation de ces heures à travers les différents services offerts, de plus les prix des services leurs sont imposés par le gouvernement. Le modèle génère une équation de revenu qui dépend des heures travaillées et d’un indice de prix représentant le rendement marginal des heures travaillées lorsque celles-ci sont allouées de façon optimale à travers les différents services. L’indice de prix dépend des prix des services offerts et des paramètres de la technologie de production des services qui déterminent comment les médecins réagissent aux changements des prix relatifs. J’ai appliqué le modèle aux données de panel sur la rémunération des médecins au Québec fusionnées à celles sur l’utilisation du temps de ces mêmes médecins. J’utilise le modèle pour examiner deux dimensions de l’offre des services de santé. En premierlieu, j’analyse l’utilisation des incitatifs monétaires pour amener les médecins à modifier leur production des différents services. Bien que les études antérieures ont souvent cherché à comparer le comportement des médecins à travers les différents systèmes de compensation,il y a relativement peu d’informations sur comment les médecins réagissent aux changementsdes prix des services de santé. Des débats actuels dans les milieux de politiques de santé au Canada se sont intéressés à l’importance des effets de revenu dans la détermination de la réponse des médecins face à l’augmentation des prix des services de santé. Mon travail contribue à alimenter ce débat en identifiant et en estimant les effets de substitution et de revenu résultant des changements des prix relatifs des services de santé. En second lieu, j’analyse comment l’expérience affecte la productivité des médecins. Cela a une importante implication sur le recrutement des médecins afin de satisfaire la demande croissante due à une population vieillissante, en particulier lorsque les médecins les plus expérimentés (les plus productifs) vont à la retraite. Dans le premier essai, j’ai estimé la fonction de revenu conditionnellement aux heures travaillées, en utilisant la méthode des variables instrumentales afin de contrôler pour une éventuelle endogeneité des heures travaillées. Comme instruments j’ai utilisé les variables indicatrices des âges des médecins, le taux marginal de taxation, le rendement sur le marché boursier, le carré et le cube de ce rendement. Je montre que cela donne la borne inférieure de l’élasticité-prix direct, permettant ainsi de tester si les médecins réagissent aux incitatifs monétaires. Les résultats montrent que les bornes inférieures des élasticités-prix de l’offre de services sont significativement positives, suggérant que les médecins répondent aux incitatifs. Un changement des prix relatifs conduit les médecins à allouer plus d’heures de travail au service dont le prix a augmenté. Dans le deuxième essai, j’estime le modèle en entier, de façon inconditionnelle aux heures travaillées, en analysant les variations des heures travaillées par les médecins, le volume des services offerts et le revenu des médecins. Pour ce faire, j’ai utilisé l’estimateur de la méthode des moments simulés. Les résultats montrent que les élasticités-prix direct de substitution sont élevées et significativement positives, représentant une tendance des médecins à accroitre le volume du service dont le prix a connu la plus forte augmentation. Les élasticitésprix croisées de substitution sont également élevées mais négatives. Par ailleurs, il existe un effet de revenu associé à l’augmentation des tarifs. J’ai utilisé les paramètres estimés du modèle structurel pour simuler une hausse générale de prix des services de 32%. Les résultats montrent que les médecins devraient réduire le nombre total d’heures travaillées (élasticité moyenne de -0,02) ainsi que les heures cliniques travaillées (élasticité moyenne de -0.07). Ils devraient aussi réduire le volume de services offerts (élasticité moyenne de -0.05). Troisièmement, j’ai exploité le lien naturel existant entre le revenu d’un médecin payé à l’acte et sa productivité afin d’établir le profil de productivité des médecins. Pour ce faire, j’ai modifié la spécification du modèle pour prendre en compte la relation entre la productivité d’un médecin et son expérience. J’estime l’équation de revenu en utilisant des données de panel asymétrique et en corrigeant le caractère non-aléatoire des observations manquantes à l’aide d’un modèle de sélection. Les résultats suggèrent que le profil de productivité est une fonction croissante et concave de l’expérience. Par ailleurs, ce profil est robuste à l’utilisation de l’expérience effective (la quantité de service produit) comme variable de contrôle et aussi à la suppression d’hypothèse paramétrique. De plus, si l’expérience du médecin augmente d’une année, il augmente la production de services de 1003 dollar CAN. J’ai utilisé les paramètres estimés du modèle pour calculer le ratio de remplacement : le nombre de médecins inexpérimentés qu’il faut pour remplacer un médecin expérimenté. Ce ratio de remplacement est de 1,2.