David Blumenthal

Over 30 years in medicine, I have observed a significant increase in the numbers of physicians, both young and not so young, curious about or intent upon careers involving health policy and public service. This undoubtedly reflects the turmoil in our health care system and the increasing role government has played in addressing its problems. Yet relatively few senior physicians with experience in public service write or speak openly about how to make such service useful and meaningful.

Patient safety has emerged as an important challenge to the leadership of academic medical centers (i.e., teaching hospitals with significant research activity). This article describes the evidence regarding patient safety at academic medical centers (AMCs) and the special circumstances of AMCs that create challenges and opportunities for making improvements. While the research on the relative safety of patients in AMCs compared to other types of hospitals is sparse, it seems clear that AMCs in general do not stand out as models of patient safety. AMCs are unique as health care providers because of the multiple consequences of their three missions: patient care, research, and teaching. Aspects of these missions can serve to both enhance an AMC’s ability to address safety issues and at the same time create unique and challenging barriers. For example, the research enterprise may distract managers’ focus on safety issues but at the same time provide a wealth of highly trained talent for investigating and reducing safety problems. By addressing these challenges, AMCs have the opportunity, even the obligation, to be both the source of new knowledge on health care safety as well as the transmitter of new skills in safe patient care for the health care providers of the future.

Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.

A productive and ethical relationship between the pharmaceutical industry and physicians is critical to improving drug discovery and public health. In response to concerns about inappropriate financial relationships between the pharmaceutical industry and physicians, national organizations representing physicians or industry have made recommendations designed to reduce conflicts of interest, legal exposure, and dissemination of biased information. Despite these initiatives, the prescribing practices of physicians may be unduly influenced by the marketing efforts of industry and physicians may inadvertently distribute information that is biased in favor of a commercial entity. Moreover, physicians may be vulnerable to prosecution through federal anti-kickback and false claims statutes because of potentially inappropriate financial relationships with pharmaceutical companies. Since academic medical centers have a critical role in establishing professional standards, the faculty of Yale University School of Medicine developed guidelines for the relationships of faculty with the pharmaceutical industry, which were approved in May 2005. Input from clinical faculty and from representatives of the pharmaceutical industry was utilized in formulating the guidelines. In contrast to existing recommendations, the Yale guidelines, which are presented as an Appendix here, ban faculty from receiving any form of gift, meal, or free drug sample (for personal use) from industry, and set more stringent standards for the disclosure and resolution of financial conflict of interest in Yale’s educational programs. The growing opportunities for drug discovery, the need to use medications in a more evidence-based manner, and preservation of the public trust require the highest professional standards of rigor and integrity. These guidelines are offered as part of the strategy to meet this compelling challenge.

Background: Comprehensive knowledge about the level of healthcare information technology (HIT) adoption in the United States remains limited. We therefore performed a baseline assessment to address this knowledge gap. Methods: We segmented HIT into eight major stakeholder groups and identified major functionalities that should ideally exist for each, focusing on applications most likely to improve patient safety, quality of care and organizational efficiency. We then conducted a multi-site qualitative study in Boston and Denver by interviewing key informants from each stakeholder group. Interview transcripts were analyzed to assess the level of adoption and to document the major barriers to further adoption. Findings for Boston and Denver were then presented to an expert panel, which was then asked to estimate the national level of adoption using the modified Delphi approach. We measured adoption level in Boston and Denver was graded on Rogers' technology adoption curve by co-investigators. National estimates from our expert panel were expressed as percentages. Results: Adoption of functionalities with financial benefits far exceeds adoption of those with safety and quality benefits. Despite growing interest to adopt HIT to improve safety and quality, adoption remains limited, especially in the area of ambulatory electronic health records and physician-patient communication. Organizations, particularly physicians' practices, face enormous financial challenges in adopting HIT, and concerns remain about its impact on productivity. Conclusion: Adoption of HIT is limited and will likely remain slow unless significant financial resources are made available. Policy changes, such as financial incentivesto clinicians to use HIT or pay-for-performance reimbursement, may help health care providers defray upfront investment costs and initial productivity loss.

Questions about the process leading to particular medical decisions are seldom addressed in discussions of health care quality. In some cases, strict adherence to treatment protocols may overlook important elements in the clinical decision-making process, such as physicians' judgment and patients' preferences. Papers by Annette O'Connor and colleagues and Karen Sepucha and colleagues are welcome additions to this debate because they highlight the importance of the medical decision-making process; they suggest that the quality of this process should be considered when evaluating health care quality. I explore some key limitations and uncertainties that must be addressed before work in this area can become broadly applicable.

The Information Revolution Has Raised Myriad questions about how the health care system will function in the future (Gingrich and Magaziner 2000; National Research Council 2000). The consensus seems to be that new information technologies will significantly affect almost every aspect of health care, from the way that employers and individuals purchase health insurance to the way that doctors and patients provide and receive care (National Research Council 2000).Although peer‐reviewed evidence to support these predictions is scarce, the available data suggest that the major health care actors are actively experimenting with the new capabilities to exchange information. A February 2002 survey by Harris Interactive (www.Harrisinteractive.com) found that 137 million Americans were users of the Internet and the World Wide Web and 110 million reported going on‐line at least three times a month to look for health care information (Landro 2002). An earlier survey by the Pew Charitable Trusts reported that of those Americans who used the Internet for health care purposes, 92 percent found the information useful.The information revolution has the potential to reduce the asymmetry of information between patients and doctors and thereby to undermine a central pillar of physicians' claim to professional status: the possession of distinctive competence based on technical know‐how selflessly applied and collectively monitored. A close analysis of the information revolution's likely effects suggests that for some patients with some conditions, their access to more and better information will indeed reduce the magic, mystery, and power of the medical profession. However, the information revolution also offers opportunities for physicians to bolster the cognitive and moral bases of professionalism. To seize those opportunities, physicians must master new roles and skills and avoid unacceptable conflicts of interest.

The last comprehensive study measuring the preparedness of physicians early in their practicing careers, the 1991 Robert Wood Johnson Foundation's survey of young physicians, found that 80% of respondents thought their formal medical education did a "good" or "excellent" job of training them for clinical practice. However, many respondents felt unprepared for a variety of conditions they would encounter in their professional life, such as identifying depression, treating patients with severe disabilities, and treating elderly patients.¹ Subsequent specialty-specific studies have underlined these apparent gaps in physician readiness for practice. Physicians in pediatrics,² general preventive medicine,³ rural practice,⁴ and neurosurgery⁵ have been found to be underprepared for conditions and tasks for which residency ideally should have prepared them.