- Email: [email protected]
Managing resistance to change
F
Mary Kiernan-Stern, MSW, LCSW
rom time to time in my responsibilities as a medical social worker, I become involved with a “complicated” case. Translation: a case was referred to the social worker to intervene and “fix” the problem because no one else knew what to do with the client or the issues surrounding the client. Necessity is the mother of invention, so when all else failed, that was my cue to be creative.
Hmm, creative case management…. You may not think there is a guideline or a protocol for this, but there is in our own professional standards of social work case management.1 The social worker has these primary responsibilities in addressing social problems: 1. Engage the identified client or client system in the problem-solving process 2. Assess the needs of the client from the client’s perspective 3. Develop a service plan that focuses on the client’s strengths and capitalizes on them for the client to succeed in meeting his or her goals TCM 48
September/October 2005
4. 5. 6.
7.
Link the client with appropriate services and resources Coordinate interventions with other helping professionals Monitor the progress of the client to ensure that services, in fact, are delivered and that the service plan is effectively implemented Evaluate the outcomes of the interventions outlined in the service plan through appropriate and timely follow-up and documentation
In carrying out these tasks, social workers are key service providers in the areas of prevention, needs assessment, harm
reduction, and the provision of hope. I really like the “provision of hope” part; this focus defines social work case management as a tool for generating options to achieve better outcomes. The most critical variable in the process of outcomes management is the client and the provider relationship. Arthurs2 said, “It is at this level that outcomes are initially negotiated and then adjusted to meet changing patient/family relationships.”2 In this case scenario, I received a physician referral for an intake assessment on Mr. Kassel (the client’s name and identifying details
have been changed to maintain confidentiality), who at the time of my visit was beginning radiation treatment for a head and neck cancer. The doctor was very concerned that Kassel would have early and difficult medical side effects from the radiation treatment because the client was adamant that he would not stop drinking alcohol on a daily basis. With the prospect of such painful consequences, it would be unlikely that Kassel would complete the outpatient treatment necessary to optimize a remission of this rather aggressive cancer. Without compliance, it seemed more probable that he would require inpatient care sooner than really needed. My colleague’s parting words were “good luck.” With that caveat, I met with Kassel in my office. I learned that he was 57 years old and “used to work in construction” but had an accident a few years ago that left him unable to work. He lived alone, received disability benefits and health insurance through his union, and told me he liked to go fishing when he could. He stopped smoking 6 months ago because, he reported, “My throat hurt too much.” At his side was an expensive-looking attache case. Kassel came dressed in denim pants and a work shirt, so I asked why he had the case with him today. He replied, “I carry my case everywhere I go because it has my beer in there.” “Mr. Kassel, how much beer does your attache case hold?” “Oh, I have 24 cans of beer in there now.” Through more conversation he told me that he drank 24 cans of beer a week and that was the only alcohol he consumed. “I just like the taste of beer.” I explained the doctor ’s concern about consuming alcohol during the 7 weeks of radiation treatment. I asked if he thought he would be able to cut down on his beer intake because less alcohol would mean fewer side effects. He agreed. We made a contract that this week he would drink only 20 cans of beer.
The process of engagement is the point at which we need to be more immune to the pressure-cooker of time. An investment of time at this stage of the process will save time, money, and energy all along the continuum of care and will give us better outcomes as well. I visited with Kassel the following week and asked him how he was feeling. He was doing well. “Since you are doing so well this week, do you think you would be able to drink 16 cans of beer next week?” He assured me he could, and so it continued until he came to see me during week 6 of his treatment. “Mrs. Stern, this week I have four cans of beer in my briefcase. What am I going to do if I have no cans of beer for the week?” I asked if he had ever tried a nonalcoholic beer. He said he never did, and I suggested that he replace his regular supply with the nonalcoholic variety so he could still enjoy the taste of beer. Kassel completed all of his radiation treatment with just the expected routine side effects and no inpatient hospital stays. When he returned 2 weeks later for his follow-up medical appointment, I visited with him and noticed that he came without his case.
At his 3-month follow-up appointment, Kassel asked to see me. His cancer appeared to be in remission, and he told me that he had decided to “stick with the nonalcoholic beer.” Since becoming disabled he had felt “useless” and did not know how to spend his days. He asked me for information on how to become a volunteer driver with the American Cancer Society so that he could help other cancer patients. Several months later when I saw him again, he was escorting a new patient to the cancer center. This past semester, I presented Kassel’s case to my social work students with only the basic intake information. Their task was to do an assessment and to develop an intervention plan. Many of the students could not move beyond the apparent “hopelessness” of the client’s situation (i.e., he was depressed, had a problem with alcohol, did not want to change, and probably would not live very long). This also appeared to be the doctor’s impression of Kassel during his initial medical examination. While his medical situation was serious, the perception of Kassel’s beer drinking as pathologic and hopeless made this case “complicated” and the client “difficult.” The obvious but conventional approach to take would have been to try and convince the client to totally abstain from alcohol, go to Alcoholics Anonymous or some other rehabilitation program, and scare him into compliance with the protocol for treatment. This type of confrontation in problem-solving is what I refer to as a “go in the front door” approach. Many times this approach can backfire and actually may support a client’s resistance to change. I chose to focus on what seemed feasible for this client to control—the amount of beer he was consuming. Whatever his need for carrying his weekly ration of alcohol, I could see that he was capable of setting limits. He organized his drinking as if it were a job. Eventually, Kassel himself was able to find more positive activities to substitute for his beer drinking. I used a “back door” approach to change, one that is a more indirect or passive method of intervention. Perhaps because I did not intervene in the way that the September/October 2005
TCM 49
client might have expected, he was open to suggestions for problem solving. By focusing on the first three principles of social work case management— engagement with the client, assessment of the problem from the client’s perspective, and the client’s strengths—I was able to provide Kassel with realistic options for coping with his medical condition and treatment. This made managing the rest of the outcome process fairly uncomplicated.
Creative case management may be defined as the ability to positively reframe adversity into an opportunity for the client, rather than the perspective of having the client choose between the lesser of two evils.
Generating options is the creative side of social work and the initial task in providing hope that a future change will have a positive benefit. Creative case management may be defined as the ability to positively reframe adversity into an opportunity for the client, rather than the perspective of having the client choose between the lesser of two evils. Often in the case management process, we are held hostage to the variable of time. We are required to facilitate a multidimensional process of change in circumstances where it is only natural for human nature to resist change. We may not make the time to accurately assess where the client is, and then we proceed with an intervention plan that is too difficult for the client to comply with in that circumstance. One of the basic rules in social-work intervention is to give the client a small task to achieve as the first objective in reaching a longer-term goal. The client will be more likely to succeed in the completion of and the compliance with a smaller task and will feel more positive about his or her own ability to cope. By building on accomplishments, the client becomes more engaged and invested in continuing with the change process and better prepared to complete more complicated tasks. This is the foundation of hope. As you can see from the intervention with Kassel, he was compliant from the very beginning of our relationship. Starting with a small and simple task can facilitate the change process in a more timely and efficient way. It seems counterintuitive to the case management process, but we can waste a lot of TCM 50
September/October 2005
energy trying to move a resistant client when we use the “front door” approach in the beginning of building a relationship. The process of engagement is the point at which we need to be more immune to the pressure-cooker of time. An investment of time at this stage of the process will save time, money, and energy all along the continuum of care and will give us better outcomes as well. In another case illustration, I received a referral from a physician who wanted me to meet with a newly diagnosed breast cancer patient and “convince” her that she needed chemotherapy. Case management by coercion was not something I was familiar with, but I did agree to meet with the patient for an assessment. Client self-determination was clearly not a high priority for the clinician. This 38-year-old woman was in for an initial consultation for radiation therapy
after lumpectomy. Even though the pathology report indicated that the tumor was not aggressive and the excision showed clean margins and no lymphnode involvement, the physician believed that having the additional “insurance” of chemotherapy would greatly reduce a recurrence of cancer, given the patient’s age. The patient reported to the doctor that if he continued to insist on chemotherapy, she would not agree to return for the radiation treatment. Without recounting too much medical information, a standard protocol for this client’s type of cancer was either a lumpectomy and a course of radiation treatment or a lumpectomy followed by a chemotherapy regimen. Cancers that are invasive and/or have metastasized usually are treated with chemotherapy and radiation therapy. I met Ms. Thomas on the day of her initial consultation with the doctor. After
reassuring her that my job was not to convince her of anything, I learned she was employed as an executive secretary with a legal firm in Washington, DC, and that she lived with a teenage nephew. In addition to caring for her nephew, she was also the primary caregiver to a younger sister who had been diagnosed years before with multiple sclerosis (MS). Her sister received disability benefits and lived alone in an apartment in Maryland. Thomas lived in northern Virginia and commuted daily, either before or after work, to check on her sister. She appeared very tired and extremely anxious as she provided this information to me. I asked her to tell me about her concerns regarding chemotherapy in general. She replied, “Chemotherapy is a poison, and one of the side effects of this treatment is that it could damage your kidneys. Many of my family members have died from hypertension and kidney disease. I do not want to take anything that will risk damage to my kidneys…. I have to take care of other people in my life…they depend on me.” Thomas told me that she used to play the flute and had studied to become a musician until life took a different turn for her. “I have not played the flute in a number of years.” In reviewing her situation and consulting with the medical staff, I suggested to Thomas that she have a medical workup to obtain a baseline status of her kidney function. If there was any medical or renal issue, she would be in a better position to receive proactive treatment for that condition. Should her cancer recur at some point, she could feel reasonably certain about making a rational decision regarding chemotherapy. Thomas stated she now felt more comfortable about beginning radiation therapy. We worked on making the daily 6week period for her treatment as convenient as we could in order for her to continue working. With her permission, I obtained resource information for her to help in the care of her sister, including a telephone support group for people with MS. Her renal workup would be done before beginning her radiation treatment.
I visited Thomas after she completed her first week of radiation. Her renal study results showed no evidence of any underlying disease or hypertension. She agreed to meet with our dietitian, who would be able to guide her with a food plan for maintaining her energy throughout the course of treatment and promote long-term health benefits. The client reported that she was managing well overall, but since being diagnosed with cancer she barely slept 3 hours a night because she had difficulty falling asleep. I gave her a homework assignment—play the flute for a few minutes every night before she went to bed. She laughed and said, “That kind of an assignment I think I can handle.” A few days later, Thomas came to see me. She reported having less trouble falling asleep at night and did feel more rested. With a home health aide coming to care for her sister 3 days a week, the client was able to forgo her daily commutes to Maryland, though she spoke with her sister every day. She completed all of her radiation treatment and was compliant with all the recommended follow-up visits.
had not been requested, this client might have left after her medical consultation, never returning for appropriate medical care; as health care providers, we would never have known why. When I look back on this case scenario, I may not have convinced the patient she needed chemotherapy, but I did help to convince her that by taking care of herself first, she would be able to continue taking care of her family. In helping to address her fears in a nonjudgmental manner, the client was able to make room in her life for the music she loved as a gift of healing rather than a symbol of loss. This is hope, and it is a great motivator. Conclusion A lot of research is being done today on the value of hope in achieving positive physical health and mental health outcomes. Returning to our basic skills in the case management process will help us stay in tune with effective interventions, and, with our own abilities to see the value in the unexpected ways, we contribute to the building of hope for our clients and communities and ourselves. ❏ References
Several months later, I was shopping in a local bookstore when I was approached by a rather elegant woman.
1.
“Mrs. Stern, do you remember me?”
2.
“Ms. Thomas, how nice it is to see you again.” “I want to tell you that I am now playing the flute again with a small group. When my plan for a career in music was stopped dead in its tracks, I never imagined that I would be able to have a life as a musician.” Initially, Thomas was more afraid of renal disease than cancer. She had so many life stressors to manage, combined with high anxiety, that she was at risk of not completing her radiation treatment, the most important first-line defense in keeping her cancer in remission. Her fear was not accurately diagnosed by the medical staff. This is how a person becomes, in an instant, “a noncompliant patient.” If a referral for a social worker
National Association of Social Workers. Standards for social work case management. 1992. Available at: www.socialworkers.org/practice/standards/sw_case_ mgmt.asp. Accessed 28 Jul 2005. Arthurs D. Case managers and the outcomes management process: a case study. Semin Nurse Manag 1996;4:178-81.
Mary Kiernan-Stern, MSW, LCSW is the director of the MSW field education program and a faculty member for George Mason University’s Department of Social Work in Arlington, Va. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 1-888-834-7287; reprint no. YMCM 315 doi:10.1016/j.casemgr.2005.07.007
September/October 2005
TCM 51
Mary Kiernan-Stern, MSW, LCSW
rom time to time in my responsibilities as a medical social worker, I become involved with a “complicated” case. Translation: a case was referred to the social worker to intervene and “fix” the problem because no one else knew what to do with the client or the issues surrounding the client. Necessity is the mother of invention, so when all else failed, that was my cue to be creative.
Hmm, creative case management…. You may not think there is a guideline or a protocol for this, but there is in our own professional standards of social work case management.1 The social worker has these primary responsibilities in addressing social problems: 1. Engage the identified client or client system in the problem-solving process 2. Assess the needs of the client from the client’s perspective 3. Develop a service plan that focuses on the client’s strengths and capitalizes on them for the client to succeed in meeting his or her goals TCM 48
September/October 2005
4. 5. 6.
7.
Link the client with appropriate services and resources Coordinate interventions with other helping professionals Monitor the progress of the client to ensure that services, in fact, are delivered and that the service plan is effectively implemented Evaluate the outcomes of the interventions outlined in the service plan through appropriate and timely follow-up and documentation
In carrying out these tasks, social workers are key service providers in the areas of prevention, needs assessment, harm
reduction, and the provision of hope. I really like the “provision of hope” part; this focus defines social work case management as a tool for generating options to achieve better outcomes. The most critical variable in the process of outcomes management is the client and the provider relationship. Arthurs2 said, “It is at this level that outcomes are initially negotiated and then adjusted to meet changing patient/family relationships.”2 In this case scenario, I received a physician referral for an intake assessment on Mr. Kassel (the client’s name and identifying details
have been changed to maintain confidentiality), who at the time of my visit was beginning radiation treatment for a head and neck cancer. The doctor was very concerned that Kassel would have early and difficult medical side effects from the radiation treatment because the client was adamant that he would not stop drinking alcohol on a daily basis. With the prospect of such painful consequences, it would be unlikely that Kassel would complete the outpatient treatment necessary to optimize a remission of this rather aggressive cancer. Without compliance, it seemed more probable that he would require inpatient care sooner than really needed. My colleague’s parting words were “good luck.” With that caveat, I met with Kassel in my office. I learned that he was 57 years old and “used to work in construction” but had an accident a few years ago that left him unable to work. He lived alone, received disability benefits and health insurance through his union, and told me he liked to go fishing when he could. He stopped smoking 6 months ago because, he reported, “My throat hurt too much.” At his side was an expensive-looking attache case. Kassel came dressed in denim pants and a work shirt, so I asked why he had the case with him today. He replied, “I carry my case everywhere I go because it has my beer in there.” “Mr. Kassel, how much beer does your attache case hold?” “Oh, I have 24 cans of beer in there now.” Through more conversation he told me that he drank 24 cans of beer a week and that was the only alcohol he consumed. “I just like the taste of beer.” I explained the doctor ’s concern about consuming alcohol during the 7 weeks of radiation treatment. I asked if he thought he would be able to cut down on his beer intake because less alcohol would mean fewer side effects. He agreed. We made a contract that this week he would drink only 20 cans of beer.
The process of engagement is the point at which we need to be more immune to the pressure-cooker of time. An investment of time at this stage of the process will save time, money, and energy all along the continuum of care and will give us better outcomes as well. I visited with Kassel the following week and asked him how he was feeling. He was doing well. “Since you are doing so well this week, do you think you would be able to drink 16 cans of beer next week?” He assured me he could, and so it continued until he came to see me during week 6 of his treatment. “Mrs. Stern, this week I have four cans of beer in my briefcase. What am I going to do if I have no cans of beer for the week?” I asked if he had ever tried a nonalcoholic beer. He said he never did, and I suggested that he replace his regular supply with the nonalcoholic variety so he could still enjoy the taste of beer. Kassel completed all of his radiation treatment with just the expected routine side effects and no inpatient hospital stays. When he returned 2 weeks later for his follow-up medical appointment, I visited with him and noticed that he came without his case.
At his 3-month follow-up appointment, Kassel asked to see me. His cancer appeared to be in remission, and he told me that he had decided to “stick with the nonalcoholic beer.” Since becoming disabled he had felt “useless” and did not know how to spend his days. He asked me for information on how to become a volunteer driver with the American Cancer Society so that he could help other cancer patients. Several months later when I saw him again, he was escorting a new patient to the cancer center. This past semester, I presented Kassel’s case to my social work students with only the basic intake information. Their task was to do an assessment and to develop an intervention plan. Many of the students could not move beyond the apparent “hopelessness” of the client’s situation (i.e., he was depressed, had a problem with alcohol, did not want to change, and probably would not live very long). This also appeared to be the doctor’s impression of Kassel during his initial medical examination. While his medical situation was serious, the perception of Kassel’s beer drinking as pathologic and hopeless made this case “complicated” and the client “difficult.” The obvious but conventional approach to take would have been to try and convince the client to totally abstain from alcohol, go to Alcoholics Anonymous or some other rehabilitation program, and scare him into compliance with the protocol for treatment. This type of confrontation in problem-solving is what I refer to as a “go in the front door” approach. Many times this approach can backfire and actually may support a client’s resistance to change. I chose to focus on what seemed feasible for this client to control—the amount of beer he was consuming. Whatever his need for carrying his weekly ration of alcohol, I could see that he was capable of setting limits. He organized his drinking as if it were a job. Eventually, Kassel himself was able to find more positive activities to substitute for his beer drinking. I used a “back door” approach to change, one that is a more indirect or passive method of intervention. Perhaps because I did not intervene in the way that the September/October 2005
TCM 49
client might have expected, he was open to suggestions for problem solving. By focusing on the first three principles of social work case management— engagement with the client, assessment of the problem from the client’s perspective, and the client’s strengths—I was able to provide Kassel with realistic options for coping with his medical condition and treatment. This made managing the rest of the outcome process fairly uncomplicated.
Creative case management may be defined as the ability to positively reframe adversity into an opportunity for the client, rather than the perspective of having the client choose between the lesser of two evils.
Generating options is the creative side of social work and the initial task in providing hope that a future change will have a positive benefit. Creative case management may be defined as the ability to positively reframe adversity into an opportunity for the client, rather than the perspective of having the client choose between the lesser of two evils. Often in the case management process, we are held hostage to the variable of time. We are required to facilitate a multidimensional process of change in circumstances where it is only natural for human nature to resist change. We may not make the time to accurately assess where the client is, and then we proceed with an intervention plan that is too difficult for the client to comply with in that circumstance. One of the basic rules in social-work intervention is to give the client a small task to achieve as the first objective in reaching a longer-term goal. The client will be more likely to succeed in the completion of and the compliance with a smaller task and will feel more positive about his or her own ability to cope. By building on accomplishments, the client becomes more engaged and invested in continuing with the change process and better prepared to complete more complicated tasks. This is the foundation of hope. As you can see from the intervention with Kassel, he was compliant from the very beginning of our relationship. Starting with a small and simple task can facilitate the change process in a more timely and efficient way. It seems counterintuitive to the case management process, but we can waste a lot of TCM 50
September/October 2005
energy trying to move a resistant client when we use the “front door” approach in the beginning of building a relationship. The process of engagement is the point at which we need to be more immune to the pressure-cooker of time. An investment of time at this stage of the process will save time, money, and energy all along the continuum of care and will give us better outcomes as well. In another case illustration, I received a referral from a physician who wanted me to meet with a newly diagnosed breast cancer patient and “convince” her that she needed chemotherapy. Case management by coercion was not something I was familiar with, but I did agree to meet with the patient for an assessment. Client self-determination was clearly not a high priority for the clinician. This 38-year-old woman was in for an initial consultation for radiation therapy
after lumpectomy. Even though the pathology report indicated that the tumor was not aggressive and the excision showed clean margins and no lymphnode involvement, the physician believed that having the additional “insurance” of chemotherapy would greatly reduce a recurrence of cancer, given the patient’s age. The patient reported to the doctor that if he continued to insist on chemotherapy, she would not agree to return for the radiation treatment. Without recounting too much medical information, a standard protocol for this client’s type of cancer was either a lumpectomy and a course of radiation treatment or a lumpectomy followed by a chemotherapy regimen. Cancers that are invasive and/or have metastasized usually are treated with chemotherapy and radiation therapy. I met Ms. Thomas on the day of her initial consultation with the doctor. After
reassuring her that my job was not to convince her of anything, I learned she was employed as an executive secretary with a legal firm in Washington, DC, and that she lived with a teenage nephew. In addition to caring for her nephew, she was also the primary caregiver to a younger sister who had been diagnosed years before with multiple sclerosis (MS). Her sister received disability benefits and lived alone in an apartment in Maryland. Thomas lived in northern Virginia and commuted daily, either before or after work, to check on her sister. She appeared very tired and extremely anxious as she provided this information to me. I asked her to tell me about her concerns regarding chemotherapy in general. She replied, “Chemotherapy is a poison, and one of the side effects of this treatment is that it could damage your kidneys. Many of my family members have died from hypertension and kidney disease. I do not want to take anything that will risk damage to my kidneys…. I have to take care of other people in my life…they depend on me.” Thomas told me that she used to play the flute and had studied to become a musician until life took a different turn for her. “I have not played the flute in a number of years.” In reviewing her situation and consulting with the medical staff, I suggested to Thomas that she have a medical workup to obtain a baseline status of her kidney function. If there was any medical or renal issue, she would be in a better position to receive proactive treatment for that condition. Should her cancer recur at some point, she could feel reasonably certain about making a rational decision regarding chemotherapy. Thomas stated she now felt more comfortable about beginning radiation therapy. We worked on making the daily 6week period for her treatment as convenient as we could in order for her to continue working. With her permission, I obtained resource information for her to help in the care of her sister, including a telephone support group for people with MS. Her renal workup would be done before beginning her radiation treatment.
I visited Thomas after she completed her first week of radiation. Her renal study results showed no evidence of any underlying disease or hypertension. She agreed to meet with our dietitian, who would be able to guide her with a food plan for maintaining her energy throughout the course of treatment and promote long-term health benefits. The client reported that she was managing well overall, but since being diagnosed with cancer she barely slept 3 hours a night because she had difficulty falling asleep. I gave her a homework assignment—play the flute for a few minutes every night before she went to bed. She laughed and said, “That kind of an assignment I think I can handle.” A few days later, Thomas came to see me. She reported having less trouble falling asleep at night and did feel more rested. With a home health aide coming to care for her sister 3 days a week, the client was able to forgo her daily commutes to Maryland, though she spoke with her sister every day. She completed all of her radiation treatment and was compliant with all the recommended follow-up visits.
had not been requested, this client might have left after her medical consultation, never returning for appropriate medical care; as health care providers, we would never have known why. When I look back on this case scenario, I may not have convinced the patient she needed chemotherapy, but I did help to convince her that by taking care of herself first, she would be able to continue taking care of her family. In helping to address her fears in a nonjudgmental manner, the client was able to make room in her life for the music she loved as a gift of healing rather than a symbol of loss. This is hope, and it is a great motivator. Conclusion A lot of research is being done today on the value of hope in achieving positive physical health and mental health outcomes. Returning to our basic skills in the case management process will help us stay in tune with effective interventions, and, with our own abilities to see the value in the unexpected ways, we contribute to the building of hope for our clients and communities and ourselves. ❏ References
Several months later, I was shopping in a local bookstore when I was approached by a rather elegant woman.
1.
“Mrs. Stern, do you remember me?”
2.
“Ms. Thomas, how nice it is to see you again.” “I want to tell you that I am now playing the flute again with a small group. When my plan for a career in music was stopped dead in its tracks, I never imagined that I would be able to have a life as a musician.” Initially, Thomas was more afraid of renal disease than cancer. She had so many life stressors to manage, combined with high anxiety, that she was at risk of not completing her radiation treatment, the most important first-line defense in keeping her cancer in remission. Her fear was not accurately diagnosed by the medical staff. This is how a person becomes, in an instant, “a noncompliant patient.” If a referral for a social worker
National Association of Social Workers. Standards for social work case management. 1992. Available at: www.socialworkers.org/practice/standards/sw_case_ mgmt.asp. Accessed 28 Jul 2005. Arthurs D. Case managers and the outcomes management process: a case study. Semin Nurse Manag 1996;4:178-81.
Mary Kiernan-Stern, MSW, LCSW is the director of the MSW field education program and a faculty member for George Mason University’s Department of Social Work in Arlington, Va. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 1-888-834-7287; reprint no. YMCM 315 doi:10.1016/j.casemgr.2005.07.007
September/October 2005
TCM 51