We begin this editorial with a sincere welcome to the distinguished new board members who have joined the journal since last year. Their presence is an assurance of the publication's continued high quality, and we look forward to a close collaboration with the entire board. This issue contains the complete list of the new board. At the same time we want to express our appreciation once again to the individuals who have left the board since last year: David Berry, John Blair, Laurel Files, Maria Friedman, and Wallace Lonergan. We thank them for their faithful and notable service to the journal. The journal's board, together with other members of the academic community, provide a most important service to researchers through the thoughtful and thorough assessments manuscripts receive. We are most grateful to our colleagues for their willingness to serve on the board or assess papers as ad-hoc reviewers.

This issue begins with four articles that address topics in the areas of patient care, human resources management, and strategy.

Turner et al. studied the acceptance of telemedicine by patients and report several interesting and important results. For example, they found that patients were comfortable with telemedicine in situations that are routine or constitute an emergency. When situations were more equivocal, as in the case of treatment changes, patients preferred personal visits with the physician. The authors raise an interesting question from the findings when they wonder who defines a situation as routine or equivocal because that assessment may differ between physician and patient. This question points to the social construction of disease and the medical importance of the social interactions between providers and patients.

Telemedicine will no doubt play an increasing role in clinician-to-patient contacts. It is becoming the latest "technological imperative" and is strongly advocated, for example, for home health care. In that setting it is advocated as a tool to reduce significantly staff time and cost through the avoidance of travel time. Research into these claims is only in its beginning, and one can only hope that significant efforts will be made to study the relational aspects of care as well as the cost. Home health care is often delivered to individuals for whom the direct personal contact with a caregiver is an important aspect of their lives, and it is not well understood how patients' or caregivers' behavior or experience might be affected by a significant reduction in opportunity to interact in each other's physical presence. The recent evidence report by the Agency for Healthcare Research and Quality shows that much more research is needed in evaluating the effect of telemedicine on cost and quality of care. The article by Turner et al. in this issue makes an important contribution in this area.

The Williams and Skinner article looks at the effect of job satisfaction for physicians. Their extensive literature review reveals that job dissatisfaction is associated with turnover and that it has a negative impact on physicians' well being. A more disconcerting finding is that it also has a potential negative impact on patients through the treatment and prescribing decisions. We are witnessing profound changes in the medical profession. Physicians have less autonomy now than members of the profession were used to in the past. Other research has shown that fewer physicians function as independent private practitioners; that more and more are employed by large organizations; and that in any setting physicians are under pressure to increase their productivity as measured in volume of patient contact and lower use of resources. At the same time the cost of practicing medicine is going up and physicians' income is going down. Significant change in occupations is sometimes associated with change in their gender composition. For example, cotton spinning and hospital administration turned into male occupations as technology and practices changed. Conversely, secretarial work, typesetting, and insurance adjusting opened up to women as fewer men became available for those jobs. Over the recent past medical schools have admitted larger numbers of women, and one cannot but wonder whether this change in enrollment is associated with the changes occurring in the medical profession and signals the beginning of the feminization of medicine.

Two of the articles in this issue deal with hospitals that changed ownership. The article by Anderson et al. compared coordination and decision-making patterns in hospitals that had undergone conversion with those in hospitals that had not changed ownership. The results show that converted hospitals had greater participation in decision making by clinicians. The authors point out that this result could be seen as counter-intuitive if one were to assume that during times of uncertainty management might be less inclined to solicit many different points of view. But, as the authors argue, if seen through the lens of complexity theory these findings take on a different meaning: A discontinuous change creates new relationships and interactions between people as they make sense of the new situation.

The study by Sloan, Conover, and Ostermann looked at conversion from a financial point of view. Their investigation of hospitals that went from not-for-profit to for-profit ownership found that profit margins were higher in the years after conversion and that rates of return exceeded the cost of capital. The authors interpret this as suggesting that for-profit organizations were able to purchase facilities from communities at attractive prices.

There can be no doubt that conversion in ownership status would be a significant change for an organization and the people associated with it. A new mission will have to be internalized, new strategic directions will be implemented, and emphasis may shift away from or towards particular clinical services. The hospital's relationship with the community may change as well. Prominent members of the community may no longer be invited to serve on the board; traditional patterns of philanthropic giving may be interrupted; and concern may arise about closing of services or reductions in charity care. No matter how often it is said that hospitals are like other businesses, communities often have a special relationship to "their" hospital, and trustees often shy away from looking at the institution as just another mercantile enterprise. As commendable as that may be in certain respects, Sloan and his coauthors' interpretation of their study identifies a possible downside as well: communities do not bargain hard enough to get the best price for their hospital.

This issue closes with a FORUM on Rural Health Care. It contains three articles that offer interesting and valuable insights into the topic. John Kralewski was guest editor for this FORUM, and we thank him for the dedication he brought to this work and for his insightful introduction to the FORUM.

-Margarete Arndt, D.B.A.

Co-editor

-Barbara Bigelow, Ph.D.

Co-editor