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Special Theme: Medical Errors: SPECIAL THEME ARTICLES

Physicians' Professional Responsibility to Improve the Quality of Care

Brennan, Troyen A. MD

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Author Information

Dr. Brennan is professor of medicine at Harvard Medical School and also is a physician at Brigham and Women's Hospital; all in Boston, Massachusetts.

Correspondence and requests for reprints should be addressed to Dr. Brennan, Brigham and Women's Hospital, 75 Francis Street, Clinics 3, Boston, MA 02115; telephone: (617) 732-8961; fax: (617) 732-6656; e-mail: 〈tabrennan@partners.org〉.

This is a slightly edited version of a paper the author presented at a conference entitled “The Role and Responsibility of Physicians to Improve Patient Safety,” in Alexandria, Virginia, September 4 and 5, 2001, sponsored by the American Board of Internal Medicine Foundation and the Agency for Healthcare Research and Quality. For more information about that conference, please see this month's “From the Editor.”

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Abstract

Physicians have long recognized a professional responsibility to improve the quality of care. However, that responsibility should be evolving in light of developments in both the science of quality improvement and the ethical base of professionalism. Over the last 30 years, quality science has moved from static/structural measures to a much more sophisticated set of outcome and process issues. It has also self-consciously integrated notions of continuous improvement. The ethical base of professionalism is also more dynamic, today emphasizing the policy activist attributes of so-called civic professionalism.

The combination of modern quality measurement/improvement and activist professionalism is a virtual call to arms for the profession to advocate care that is systematically better. Recent developments in the domain of quality dealing with medical errors can be used to illustrate this synergy, and provide a set of mandates for the new professional commitment to quality.

Medical ethics has traditionally held that physicians owe patients the best care possible. The most profound commitment for the physician is to the patient's good. This commitment is translated into nearly every medical professional code that has been promulgated.

Yet the commitment to patients has also traditionally been an isolated one. The metaphor that informs the medical conscience is that of selfless attending on a single patient, no matter what the hour or other calls on the physician's time. This singular battle with disease reverberates throughout the medical profession, and is supported by the traditional medical ethics focus on the individual doctor—patient relationship.

Today, however, medical ethics, and the professional codes it gives rise to, are changing under slow but steady pressure. Increasingly we are being called upon to consider what is good, not just for the individual patient, but also what is good for the class of all patients. As part of this we must ask, How does the profession promote quality in the health care system, not just the quality of care for an individual patient?

This shift in medical professionalism brings tension with old metaphors. For example, how, some would ask, can I consider the good of the class of patients when I am committed to the individual patient I now face? As well, some might argue, how can I be concerned with systems of better quality when my time is limited and I have individuals to treat?

These are important questions, but in the end resolvable, I believe. The shift in thinking about medical professionalism is intellectually sound and brings with it new and compelling mandates that are ultimately cohesive with our traditional norms. In particular, a new civic professionalism calls for systematic quality measurement and improvement that is necessary to effectuate our commitment to patient care. In this regard our shift in thinking about ethics and quality is not a revolution but an evolution based on our understanding of health care.

In this essay, I review some of the development of the quality assurance field, pointing out that the dramatic progress in the science of both measurement and improvement in health care is based in structural, systematic improvement of care for the population, not just selfless commitment of an individual doctor to an individual patient. I then define the impact of the theory of civic professionalism on our views about ethics and quality, and suggest that civic professionalism can take advantage of modern views of quality improvement more readily than traditional ethics can. Finally, I suggest how physicians' responsibilities would change, using the recent debate about medical errors as a prism. Part of this material is taken from other essays I have written on similar subjects, as indicated in the appropriate endnotes.

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QUALITY MEASUREMENT AND IMPROVEMENT: A BRIEF HISTORY

Before going into detail on the role that civic professionalism can play in quality improvement, we must first review the evolution of the discipline of quality assurance in medical care. There were many significant early contributions by people such as Codman and Lembcke, but for our purposes it is sufficient to begin with the early 1960s.*1

At that point, of all the centers of intellectual activity on quality assurance, none equaled Johns Hopkins University in range and importance. At Johns Hopkins, an outstanding group of investigators had assembled, foremost among them John Williamson and Kerr White. As chairman of medicine at Johns Hopkins, White had become enamored of the scientific approaches to epidemiology and clinical investigation that were taking shape in England through the middle part of the century.2 Influenced especially by the work of J. N. Morris,3,4 White began to realize that the formal methods of epidemiology that Morris and others had been using to study risk factors for illness could be applied with equal power to modern problems of health systems assessment and public health management.5 Whether or not he actually coined the phrase, White provided leadership in the early 1960s for the formation of a field soon to be called health services research. He suggested to Williamson and others that these modern quantitative methods could be applied with profit to the study of quality of care, and Williamson took on the task with a vengeance. White thus provided a stimulus for the melding of two fields—the study of quality and the study of epidemiology—that together would become the central methods for academics concerned about the quality of care.

In his own right, Williamson represented another melding of interests.6 Strongly influenced by George Miller and other scholars of adult learning, Williamson's initial interest in health care research had been in the study of continuing medical education and adult learning among physicians. As White contributed the perspectives of epidemiology to the field, so Williamson contributed the perspectives of modern social and cognitive psychology. He wanted to know the processes and social systems through which knowledge grows in individual human beings. “Tools not rules” was among the aphorisms Williamson coined in an effort to emphasize that the key issues in the assessment and improvement of quality of care had to do with the ways physicians think rather than with the ways they are controlled or judged. This viewpoint on quality is entirely consistent with the theories and approaches of Walter Shewhart, W. Edwards Deming, Joseph Juran, and others associated with the modern quality management movement, and perhaps no other investigator in the entire academic terrain of quality assurance in health care anticipated more thoroughly than Williamson the understandings of quality improvement sciences as they were developing in other industries.

Perhaps the key element in Williamson's view of the problem of quality in health care is what he called the “cybernetic” model, linking measurement and feedback to the processes of learning—his own version of what people in other industries were coming to call the “Shewhart Cycle” of improvement, or the plan—do—check—act Cycle.7

In the mid-1960s, Williamson took on the task of supervising the work of a young Johns Hopkins medical resident named Robert Brook, who was soon to emerge as the leader of his own generation of quality researchers in health care. Like his mentor, Brook was as undaunted by warnings that the field of quality assurance would become an intellectual backwater as he was fascinated by evidence of extraordinary variation both in approaches to care and in the quality of outcomes.

Among Williamson's first assignments to Brook was to analyze systematically more than 15,000 medical records in order to classify and study patterns of problems in the quality of care. Brook was captivated, and in the quantitatively sophisticated environment of research at Johns Hopkins, he was able to bring to bear the full force of modern epidemiologic methods on his analysis of the assessment of health care outcomes. To this day, Brook claims (and he may well be right) that the methods he compared in his dissertation compose the full range of approaches feasible in the assessment of quality of care. In this single piece of work, Brook leaped to the forefront among methodologists equipped to study the quality of health care.

The infant sciences of quality in health care began to grow quickly in the 1970s, largely owing to three interrelated factors. First, federal grant dollars began flowing through the National Center for Health Services Research into the hands of health service investigators, some of whom were interested in the assessment and improvement of quality. Second, both private foundations and government sponsors of research were becoming more and more concerned about slowing the rate of increase in medical care costs. Their initiatives to increase the energy of research on cost-effective medical practices inevitably steered researchers toward judgments about quality of care. Third, focused training programs, such as the Robert Wood Johnson Clinical Scholars Program (which produced Robert Brook), began spawning generalist clinical investigators who combined the skills of quantitative assessment with strong backgrounds in clinical care. This new generation of scholars was thus well equipped to address issues of clinical quality.

What helped more than anything else to bind the academic field together in the 1970s and 1980s was the emergence of a new leading center for the investigation of quality in American health care, at the Rand Corporation in Santa Monica, California. Rand's preeminence in this field developed in the context of the Health Insurance Experiment (HIE), one of the largest social experiments ever undertaken in the United States. Headed by Newhouse, who was an economist, the HIE intended to offer policymakers and others information about the relationships between various approaches to financing health care insurance—especially variations in the levels of co-payments and deductibles in insurance policies—and the health status and utilization profiles of the covered populations.8,9

The remarkable research team assembled by Newhouse for the experiment (it included Ware, Brook, Mark Chassin, Allyson Ross Davies, and Sheldon Greenfield) poured out, through the 1970s and early 1980s, evidence and instruments supporting plausible methods of assessing the quality of both outcomes and processes of care. The Rand team proved that dimensions of quality as subtle as patient satisfaction, functional health status, emotional health, and appropriateness of care could be measured in ways that were, by the most stringent standards, reliable, apparently valid, and eminently practical, at least in a research environment.

Within five years of its inception, the HIE had become the standard against which to judge all other academic efforts to measure, define, and assess quality in health care systems. It produced a rich array of measurement instruments, albeit initially cumbersome ones; and even more important, it defined stable and significant dimensions of quality and translated them into operational terms. The HIE investigators showed how patients themselves could be sources of valued and reliable information about their own functional status, and they explored relationships between these patient-centered measurements and more classical medically oriented measurements of physiologic status and function. In addition, in their definition of quality, they included measurements of patient satisfaction and ease of accessibility of health care services.10

While the Rand Health Insurance Experiment was reshaping the measurement of the results of health care, equally important research, with Dartmouth professor Jack Wennberg at the forefront, was reshaping our knowledge about the activities of health care professionals—the content of care itself. Wennberg showed that the uses of health care resources varied greatly, and that this variation could not be accounted for by differences in medical needs among populations. Although it was not possible to conclude from Wennberg's research designs exactly where the quality of care was high and where it was low, his accumulating corpus of evidence made it untenable to believe that the quality of care could be consistently high across the entire range of variation that he observed. Hospitals and obstetricians within 60 miles of each other in Maine varied in their rates of hysterectomy on a population basis by 250%. It was impossible to claim that both the highest rates and the lowest ones equally represented the best available quality of care. Numerous researchers followed on Wennberg's heels, documenting variations as large or greater, and raising equally profound questions about the implications for overall quality.11

Whereas Wennberg's work was focusing on variation in rates of utilization in health care, other scholars at the Rand Corporation and elsewhere were becoming interested in variation in the appropriateness of care, building on their experience from the HIE.12 Brook, Chassin, and others developed group-process techniques through which they could assess the probabilities that particular health care procedures would help particular patients. They defined an appropriate procedure as one of likely or possible benefit to patients, whereas an inappropriate procedure was one that, on scientific grounds, stood little or no chance of helping the patient. This group of investigators discovered variations in rates of appropriateness that were every bit as large as Wennberg was documenting for utilization. For some procedures, such as carotid endarterectomy, rates of inappropriateness in some geographic areas exceeded 50%.

As quality management matured in the late 1980s, another impetus began to take shape, that is, the creation of a theory of quality improvement. Modern quality improvement techniques derivative from work by Shewhart, Deming, and Juran had become quite influential in American industry. While some of Williamson's work had anticipated a melding of these theories with quality assurance, they were singlehandedly imported into medical care by Don Berwick.

In 1987, Berwick, while serving as vice president of the Harvard Community Health Plan in eastern Massachusetts, met A. Blanton Godfrey, who was then head of the quality systems and theory division at AT&T Bell Laboratories. The two of them approached The John A. Hartford Foundation, a medical philanthropy, with a proposal for a trial of applications of modern quality improvement methods in health care settings. With the foundation's support, Berwick and Godfrey organized what came to be known as the National Demonstration Project on Quality Improvement in Health Care (NDP). Godfrey identified 20 experts from industrial quality management circles (industrial and academic settings), and Berwick enlisted 21 health care organizations interested in this experimental venture. An eight-month project, in which quality professionals worked on a volunteer basis with health care organizations on chronic performance problems, culminated in a national meeting in June 1988 at which initial reports were made on progress in this attempted transplantation of industrially developed methods into health care settings. The results gave rise to the influential book, Curing Health Care.13

Meanwhile, the application methods themselves had progressed quickly under the leadership of Paul Batalden, who in 1986 become vice president for medical care at the Hospital Corporation of America. There he developed the Quality Resource Group, which rapidly became the leading source of writing and experience in the application of quality management methods in health care settings.

By the 1990s, quality improvement in health care had become virtually a national movement, with its rhetoric and activities appearing in the work of almost every major health care organization and association in America. Hundreds, if not thousands, of American hospitals and health maintenance organizations were setting up quality management functions internally, and industrial consultants skilled in teaching various components of quality management saw rapid growth in the number of health care clients seeking their services.

However, fundamental differences persist between health care and other industries in the depth and strategic centering of their quality improvement methods. Whereas the mastery and application of such methods was a mandatory strategic thrust in globally active manufacturing companies by the mid-1980s, the health care industry, even in the 21st century, has kept its work on quality improvement, as opposed to the inspection of quality, at a relatively low, non-strategic, and programmatic level. To this day, we have not enjoyed the full promise of industrial methods of improvement of care. Indeed, part of the problem may be our traditional professional emphasis on singular devotion to the patient, a devotion that has not easily accommodated systematic population-based structural methods of improving care.

The result today is that we have a good deal of documentation of how poor the quality of care is, and yet insufficient momentum to address it using industrial-style improvement strategies. Elizabeth McGlynn and Robert Brook have recently catalogued the various ways in which quality falls short.14 As they point out, obstacles such as diffuse responsibility for quality improvement, patient cognitive dissonance (my physician is excellent, even if the health system is not), outdated system designs, and insufficient public information stymied our progress.

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CIVIC PROFESSIONALISM

An observer of the past 20 years of our health system might remark that professionalism has been eclipsed somewhat as a source of reform for health care institutions. Today we tend to look to the market, or to regulatory approaches sponsored by the government. The mandates of professional obligations are rarely used to justify reform.

This was not the case traditionally. Professions were (and are) defined as occupations controlling a certain knowledge, and hence a set of activities in commerce, that were held to higher social expectations. Physicians individually were expected to act altruistically on behalf of patients; the collective responsibility of the profession was to oversee a system that held patient care as primary. In addition, like other professions, medicine was expected to be responsible for education and training of future members of the profession. As with the relations of all professions to society, there was an implicit quid pro quo: higher expectations in return for control.

Medicine, like other professions, has not always exercised this control carefully. In fact, any profession has the temptation to become a monopoly, using the its control over specific areas of knowledge to further the economic interests of the profession.15,16 This has been a common criticism of the medical profession and has led to suspicion about the true motives of those arguing from the viewpoint of professionalism.

Some reformers have therefore welcomed the introduction of the market into health care as a way to counteract the overwhelming power of the medical profession.17 They believe that professions are synonymous with the inefficiency that results from inappropriate power in market relationships. The integration of the market into health care can be treated as an antidote to professional monopoly.18 One way to understand these arguments is that the professions' attraction to monopoly has engendered a reaction from society, that is, the de-professionalization of medicine through market incentives.

Recently, other authors have attempted to revise professionalism as a platform for reform, suggesting that professionalism should be understood as an ideology of social reform. As an alternative to market incentives, professions can “infuse social responsibility into the industrial division of labor.”19 In this sense of professionalism as social reform, professionals must be seen again as advocates for their clients; in the case of medicine, advocates on behalf of their patients and patient care. The profession as a collectivity must act on behalf of the community of patients, just as the individual physician works on behalf of individual patient interest.

So-called “civic professionalism” posits that the profession must re-identify its core principles and apply those in appropriate situations. This notion of civic professionalism is powerful today. In the context of the problems that now beset medicine, there will be few answers without development of bold new ways of thinking about the relationships between physicians and patients, and between the profession and the industry of medicine.

The principles underlying civic medical professionalism derive from traditional professional values, but they extend the accountability of the profession from dutiful action on behalf of individual patients to the social contract with the public. The European Federation of Internal Medicine (EFIM), the American Board of Internal Medicine (ABIM), and the American College of Physicians/American Society of Internal Medicine (ACP/ASIM) have recently outlined the tenets of an activist professionalism in a draft Physician Charter, consisting of three major principles and ten professional responsibilities.

Several of the professional responsibilities or “commitments” identified in this charter include quality-of-care issues. The first commitment is to professional competence. Physicians as professionals are committed to lifelong learning and must maintain their medical knowledge. As well, the profession must ensure that its members all remain competent. Its commitment to lifelong learning must be encapsulated in continuous professional development and recertification. Not only must the individual physician demonstrate commitment to the patient, but also the profession must be committed to society, demonstrated by assuring continuous education.

The second major responsibility involves a commitment to honesty with patients. A critical portion of this has to do with informing patients about when errors occur in health care. Civic professional norms require that patients be informed promptly so as to maintain a trusting relationship between doctor and patient, and also to promote continuous quality improvement. I discuss this move in the next section.

The third responsibility enunciated by the charter concerns a commitment for improving the quality of care. This entails not only maintaining clinical competence, but also working with other professionals to ensure that health care institutions produce the best possible outcomes. In particular, the charter holds that “the profession must lead systemic analyses of quality care and design better care methods and assessments.” This proposition essentially incorporates into professionalism the synthesis of the management and improvement themes in quality of care noted above. The profession is responsible for structural measurement and continuous improvement.

Concomitantly, the charter calls for a uniform standard of care, appropriately financed. Clearly, quality of care suffers for patients who do not have appropriate access, especially when those access limitations are the result of financing barriers. The Physician Charter requires that the medical profession move to eliminate barriers to access, including deficits in education, inadequate finances, and geographic and other factors based on discrimination. The charter also envisions the promotion of public health and preventive medicine as being a critical part of the public efficacy by the profession.

These aspects of the charter indicate the evolution of the way in which we think about physicians' responsibilities for quality. No longer is quality a matter of the singular physician fighting disease suffered by an individual patient. Instead, we must systematically and structurally improve the quality of care. The application of such renewed principles of patient care will involve coordination with regulators and the government, a collaboration that at least some government officials have welcomed.20 This represents nothing less than transforming the key tenets of the medical—ethical relationship between doctor and patient into civic obligations, and then translating those obligations into action. It also synchronizes with a quality improvement agenda that is based on careful research and data, and that is mediated by continuous quality improvement methods.

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SYNTHESIZING QUALITY IMPROVEMENT AND PROFESSIONAL COMMITMENT TO THE PATIENT

At this juncture, I have suggested that three key trends are coming together. First, quality measurement continues to develop as we gain more precise methods for analyzing patients' perceptions of care, patients' health status, and compliance with guidelines for appropriate care. We also have now a mature method for quality improvement, using industrial methods and synthesizing the analysis of health care as a system. Finally, we have an evolving understanding of professional commitment to the patient and to society.

Unfortunately, we have not quite reaped the benefits of a synthesis of these three trends. As noted, a critical principle of medical ethics is that individual physicians will provide the highest possible quality of care for individual patients. Translated into professional obligations, this meant that the physician must place the patient's welfare as his or her highest value. This certainly entailed a commitment to provide the highest possible quality of care. Individual physicians have done a relatively good job, even over the past two decades, of working on behalf of individual patients and retaining their trust.

But this individual commitment to patients has not translated into strong support for structural measurement and quality improvement by the industry. The failure of the quality measurement/improvement movement to reach its full potential may reflect the relative failure of the profession to undertake, as a civic activity, the effort to ensure the quality of care defined broadly. The profession has not clearly endorsed and participated in the measurement of quality, whether it be patient satisfaction, compliance with cost-effective guidelines, or outcome measures, in a way that shows our professional commitment. If anything, we have continued to raise methodologic concerns and question the validity of quality measures, a mistake from the point of view of observing civic professional obligations. Meanwhile, the field has been forfeited to some extent to insurance companies, government, and regulatory bodies—e.g., the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Civic professionalism suggests that the professional should be leading the way, not being brought along by regulations.

An excellent example comes from the most recent development in quality improvement, that is the focus on medical errors and the injuries they produce. While a number of path-breakers, most notably Don Harper Mills, had done research in this area in the 1970s, the first comprehensive analysis of medical injuries was the Harvard Medical Practice Study (MPS) led by Howard Hiatt and Paul Weiler. The MPS estimated the number of adverse events suffered by patients in New York in 1984, and the subset of these caused by negligent care. The results in New York were later confirmed by Eric Thomas and David Studdert in Colorado and Utah for 1992. Both studies outlined a tremendous problem in terms of the morbidity and mortality suffered by patients in situations in which care failed to reach a reasonable professional standard.

In the meantime, Lucian Leape, one of the original MPS investigators, had begun to import engineering notions of error prevention into the medical-injury field. He and David Bates demonstrated how drug-related adverse events could be reduced by the use of algorithms incorporated with computerized physician order entry. Laura Petersen did the same for errors based on physician-to-physician communication, using the computer to enhance “hand-offs.” Like Berwick, Leape, Bates and Petersen were importing from industry approaches that emphasized structural, systematic quality improvement and did not rely solely on individual physicians' efforts.

The MPS and Colorado/Utah studies were key portions of an influential 1999 Institution of Medicine (IOM) report, To Err is Human, that gained great publicity. Perhaps more important than the eye-opening extrapolations from the epidemiologic studies was the prescription for change in the report. Heavily influenced by Berwick and Leape, the IOM recommended systematic efforts to reduce medical injuries, eschewing individual blame. As the title suggests, the IOM agreed that we must treat errors as events that can be prevented through structural efforts. The IOM's president, Kenneth Shine, has worked tirelessly to introduce the IOM report to the American medical leadership.

In many ways, the recognition of the scope of errors and the appropriate methods for preventing them provides an opportunity for a civically oriented profession. The commitment to social goals that is at the center of civic professionalism is powerfully synergistic with a structured approach to error reduction. Several key steps seem warranted.

First, the profession retains tight control over training and education of physicians. We certify practitioners as ready to provide high-quality care. Yet we have not done much in those training programs to systematically review the causes of error; nor have we yet really developed methods for carefully identifying the factors that lead to error. Today there is little education about medical injury prevention in medical schools or training programs, and few signs of new efforts to do so. We need to change this by restructuring medical education to allow time for instruction in and discussion of quality issues and methods for improvement. Addressing medical errors is a compelling subject for such instruction.

Second, the error movement benefits from a comparison with the airline industry, in which retraining and recertification of pilots is carried out on an annual basis. Yet we as a profession have moved only very slowly toward thorough-going continuous professional development through recertification. Many practitioners are never reexamined after finishing their medical training, a situation that should not be tolerated in an industry that prides itself on quality improvement, or in a profession that has as one of its central obligations promotion of quality in patient care. Recertification must be done in a continuous public fashion. We need to become much more creative in the ways in which we persistently learn and demonstrate our continued competence to our patients and society.

Third, we must change the orientation of physicians to their work. Our education system emphasizes individualistic responsibility for competence and performance, an emphasis that is inappropriate given that medical care is essentially a complicated system that depends on processes and systems as much as on individual clinicians. Until we begin to provide knowledge of system interactions and cohesion, we will not provide the highest quality of care. Civic professionalism's movement from individual obligation to social obligation can help provide the intellectual base for treating health care as a system.

Fourth, as was suggested by the Physician Charter, we must be honest with our patients, informing them when an injury has been caused by a mistake. This will require more than mere exhortation, as it will mean that we will have to restructure the social methods for compensation of medical injury. The existing method, tort law, with its heavy emphasis on corrective justice, retraces traditional medical professionalism with its focus on the solitary individual. If we are to progress, we must endorse a blame-free environment that clearly recognizes that system change is critical. A nofault system seems to accomplish this best.21 Thus physicians have a professional responsibility to consider not only systems of prevention, but systems of compensation that harmonize with continuing quality improvement.

The error movement reminds us that quality activism must be an essential component of civic professionalism. We are missing opportunities daily to provide leadership in quality improvement, especially with regard to errors. We cannot again allow ourselves to be led by regulators, insurance companies, and employers if we are to retain the social trust critical to the profession. We face a professional mandate to broaden our agenda on quality.

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WHAT SHOULD PHYSICIANS DO?

In light of the foregoing, I would submit that there are several important steps we must take if we are to reach the promise of an activist professional agenda for quality of care.

First, we must emphasize that professionalism represents a contract between highly trained physicians and the public. That contract creates special responsibilities and prerogatives for physicians, the most critical of which is promoting quality of care. Physicians are the stewards for quality, and they must aggressively develop an agenda for improvement. This recognition of a meta-contractual responsibility for quality is a critical foundation for any other efforts to proceed.

The responsibility for instilling this responsibility lies with the leadership of medicine. The IOM has certainly taken up the challenge, unrelentingly pushing the need for a quality agenda. One sees important signs of similar activity on the part of the specialty colleges and other organizations such as the ABIM and the AAMC. Many opinion leaders seem to be reaching a similar conclusion: we are at a critical cusp of time in which we have a last chance to retain our professional role, and to do so we must become protectors of quality. Activism must persist and grow if we are to promote the professional/quality link at the level of patient care. This responsibility reaches to every physician.

Second, we must recognize that we can work on behalf of quality only if we aggregate organizationally and work on systems systematically. Individual physicians' commitment to excellence is a sine qua non, but it is not sufficient. Modern quality improvement requires team effort working on aggregated data. Students of quality improvement recognize a number of levels of change for improving quality, ranging from the individual to the environment, but critical is the group/team and organization-wide effort.22 Physicians must be prepared to work with their co-practitioners, their medical group, their hospital, and their integrated medical system to employ continuous quality improvement (CQI) approaches and demonstrate changes in process and outcome measures.

Aggregation in the practice setting requires champions, just as champions are needed at the national level. A variety of resources are available for training such champions, but again, national leadership is necessary to instigate leadership development for systems, hospitals, and group practices.

The third step is education, and again the synergy between national and local leadership is critical. We must establish the quality—professional link, and, I think, must also reiterate the various aspects of a physician charter of professionalism. Medical schools have an important role to play in this, as Jordan Cohen has pointed out.23 But just as important is training, perhaps through recertification, of practicing physicians.

For this step, we must likely turn to the various specialty societies. The American Medical Association with its extended network through the medical societies, has sadly (perhaps temporarily) lost the mantle of an altruistic profession. Instead, if we are to be serious about educating practicing physicians about professionalism and quality, we must rely on a strong confederation of specialty societies and groups. That prospect is not unrealistic if we can stimulate national leadership in quality improvement.

Fourth, we must look for partnership with the other major entities in the health care value chain. Not to take the hospital industry for granted, but I believe that if physicians become empowered by recognizing that their professional character depends on promotion of quality, then they will bring the hospitals along. The hospital is generally imbued with the same set of ethical imperatives that motivate physicians. Financial reality can dampen quality measurement and improvement efforts, but in that dynamic tension, the professional ideal is crucial and more often than not wins the day.

Much more difficult is dealing with insurers, employers, and government. Often the relationships are hostile, based on misunderstood or misdirected regulation.1 We must overcome these old antagonisms and partner with payers on quality initiatives. Their first impulse may be to use quality as an oversight/enforcement tool, to demonstrate their commitment to the public. But I doubt they will be able to resist any efforts to reach out and together develop meaningful data for measurement. This requires participation by the practicing physician when opportunities for collaboration occur.

Fifth, and related, we must eschew fear of measurement. Too often individual measures are seen as external and punitive. Instead we must ensure that measurement is integrated into quality improvement, that the measures are provided in a nonjudgmental manner, and that the presumption is that we will use them to design improvement. This must be the outcome of our partnerships, but it is also a key part of aggregating practitioners.

Sixth, we as individual physicians must act as role models. We must participate on teams, use data, and endorse evidence-based medicine. We must report when poor quality of care occurs. We must advocate the use of appropriate systems in our sites of care. And we must actively promote the fact that all of this effort is part of our alliance with patients. The prescription for professional commitment to quality is encapsulated in List 1.

List 1
List 1
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This is an aggressive and ambitious agenda. However, there is little choice that we should embrace it. Our professional responsibility to patients demands nothing less. If we do not take up the quality challenge, we are likely to find ourselves, as providers, on the periphery of decision making in the future.

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REFERENCES

1. Brennan TA, Berwick DM. New Rules: Regulation, Markets and the Quality of American Health Care. San Francisco, CA: Jossey—Bass, 1996.

2. Revans RE. Standards for Morale: Cause and Effect in Hospitals. Oxford, England: Oxford University Press, 1964.

3. Morris JN. Uses of Epidemiology. Edinburgh, Scotland: E & S Livingstone, 1957.

4. Lipworth L, Lee JAH, Morris JN. Case-fatality in teaching and non-teaching hospitals, 1956–59. Med Care. 1963;1:71–6.

5. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885–92.

6. Williamson W. Evaluating quality of patient care: a strategy relating outcome and process assessment. JAMA. 1971;218:564–9.

7. Williamson A, Williamson M. Future Policy Directions for Quality Assurance.

8. Newhouse JP, Archibald RW, Bailit HL. Free for All? Lessons from the Rand Health Insurance Experiment. Cambridge, MA: Harvard University Press, 1993.

9. Keeler EB, Rolph JE. How cost sharing reduced medical spending of participants in the health insurance experiment. JAMA. 1983;249:2220–2.

10. Ware JE, Snyder MK. Dimensions of patient attitudes regarding doctors and medical care services. Med Care. 1975;13:669–82.

11. Palmer RH, Strain R, Maurer JVW, Rothrock JK, Thompson MS. Quality assurance in eight adult medicine group practices. Med Care. 1984;22:632–43.

12. Brook RH, Park RE, Chassin MR, Solomon DH, Keesey J, Kosecoff J. Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Engl J Med. 1990;323:1173–7.

13. Berwick DM, Godfrey AB, Roessner J. Curing Health Care: New Strategies for Quality Improvement. San Francisco, CA: Jossey—Bass, 1990.

14. McGlynn EA, Brook RH. Keeping quality on the policy agenda. Health Aff. 2001;20(3):82–90.

15. Freidson E. Professional Powers: A Study of the Institutionalization of Formal Knowledge. Chicago, IL: University of Chicago Press, 1986.

16. Haskell TL (ed). The Authority of Experts: Studies in History and Theory. Bloomington, IN: Indiana University Press, 1984.

17. Clark R. Does the non-profit form fit the hospital industry? Harvard Law Review. 1982;93:1416–91.

18. Krouse EA. Death of Guilds: Professions, Estates and the Advance of Capitalism. New Haven, CT: Yale University Press, 1996.

19. Sullivan WM. What is left of professionalism after managed care? Hastings Center Rep. 1999;29:7–13.

20. Eisenberg J. Remarks at ABIM Foundation Summer Meeting, Mt. Tremblant, Quebec, August 1, 2000.

21. Studdert DM, Brennan TA. Medical injury prevention and no fault medical injury insurance. JAMA 2001 (in press).

22. Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q. 2001;79:281–315.

23. Cohen JJ. Leadership for medicine's promising future. Acad Med. 1998;73:132–7.

*Much of the following section is taken from Brennan and Berwick. Cited Here...

†Much of this section is based on work done on behalf of the ABIM/ACP-ASIM/EFIM Charter on Professionalism. Cited Here...

© 2002 Association of American Medical Colleges

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