With its 1999 report, To Err is Human, the Institute of Medicine created a national frenzy, estimating that between 44,000 and 98,000 patients die in hospitals per year due to preventable medical errors. Approximately 15 months later, the Institute published its follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century, calling for changes that would foster innovation and improvement in the delivery of health care. The resulting emphasis on quality care improvement in the United States has been astonishing. From physician report cards to limits on resident duty hours, legislatures, physicians, educators, and many others are all striving to make changes to an existing health care system in the name of patient safety and quality care.
These endeavors have created new challenges for physicians—ethically, morally, legally, and economically. Two of our clinical cases this month concern physicians faced with difficult decisions when their recommended treatment plan, consistent with medical judgment and quality care measures, differs from their patient's wishes. In one scenario, a physician tries to conserve valuable health care resources by encouraging a patient to accept a prescription for a higher dosage (ie, more mg per pill) and then splitting the pills. Another physician explains quality care to a concerned patient who requests medically unnecessary studies.
Quality improvement presents challenges in the areas of medical education and resident training. What should a resident do, for example, when forced to decide between a violation of her duty hours and caring for a patient who trusts and depends on her alone. In the realm of undergraduate medical education, an educator at the University of Connecticut School of Medicine describes the problems faced when that institution introduced quality improvement course work into the undergraduate curriculum.
Our commentaries in health law and health policy raise other timely concerns that affect quality of care. One is the growing controversy surrounding expanding the scope of practice of nonphysicians. Increasing numbers of state legislatures are asked to consider this issue, often without benefit of all the information needed to make their decisions. The health law case analyzes a situation in which an entire anesthesiology department was closed and all its staff terminated in an effort to improve quality of care. Our op-ed forum examines, through an interview, the value of physician report cards and their effect on quality improvement. One of the policy forum articles points out the irreconcilable demands made by 2 of the goals of quality improvement: covering the uninsured and systemic changes to improve patient safety. Finally, we look at the evolving role for patients, as consumers of health care, in quality improvement, recognizing the need for an effective partnership between physicians and informed, engaged patients.
The learning objectives for this issue of Virtual Mentor are:
1. Recognize the challenges of balancing quality of care improvement and controlling costs in the physician practice.
2. Understand the challenges to delivering quality care in an academic medical center.
3. Understand the difficulties state legislatures face when asked to expand the scope of practice of nonphysician health care professionals.
4. Identify the patient's role and contribution to quality health care.
The theme of this issue is clear—it will take patients, medical students, educators, and physicians to address the many aspects of quality care improvement. Achieving improvement will demand vision, cooperation, and a willingness to change some time-honored traditions. We hope this issue will inspire practicing physicians and physicians-in-training to take the initiative to do so.