American College of Physicians: Internal Medicine — Doctors for Adults ®

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Defining a core ideology for the specialty and College

From the October ACP Observer, copyright 2004 by the American College of Physicians.

Many patients, physicians and policy experts now believe that the American health care system is in crisis. Every day seems to bring new reports of documented deficiencies in patient safety and of unacceptable levels of medical errors. American health care, many say, consistently fails to deliver the level of quality care that biomedical science and technology have made possible.

Our own specialty is particularly threatened. Internal medicine is increasingly fragmented into narrower subspecialization, while fewer medical school graduates are drawn to internal medicine careers. Practicing internists complain of mounting administrative burdens, endangered reimbursements and a sharp decline in professional satisfaction. These threats are being played out against a backdrop of a growing demand for internists' services fueled by an aging population and rising chronic disease rates.

The internal medicine community is rallying to meet these threats. Last November, the College convened a summit of internal medicine leaders to design an action plan for revitalizing the specialty. Those attending agreed to work together to pursue four key strategies: reforming the dysfunctional payment system; redesigning medical practice to minimize administrative burdens; modernizing internal medicine education and training; and promoting the core values of the specialty and the profession.

Since November, the executive directors of key internal medicine organizations—including the Alliance for Academic Internal Medicine, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Board of Internal Medicine and a number of subspecialty societies, as well as ACP—have been meeting to further refine revitalization initiatives.

Last month, those executive directors approved this statement for our specialty: "Internal medicine is committed to meeting the health needs of adults by providing well-coordinated, evidence-based, culturally competent, patient-centered care." That statement contains many of the values of our profession—and has led me to consider the role vision can play in revitalization efforts.

The value of a core ideology

"Vision" is one of the most important concepts for developing and motivating any type of enterprise. Vision can, however, be easily confused with strategy, mission, purpose or values.

In 1994, two Stanford University School of Business professors, James C. Collins and Jerry I. Porras, published a widely acclaimed and pertinent business study entitled "Built to Last: Successful Habits of Visionary Companies." The authors' insights into the role that vision plays in innovative companies can be applied not only to corporations, but also to internal medicine.

According to the authors, a first-rate vision has two components. The first is a "core ideology," consisting of a company's core values and purpose. The second component is "envisioned future." That future centers on what the authors dubbed a "big hairy audacious goal" (BHAG), certainly one of the more whimsical business terms introduced in the 1990s. But BHAGs, the authors wrote, serve a very serious purpose: to unify an enterprise and provide an easily understood, compelling focus. Audacious goals allow organizations and individuals committed to them to visualize what it will be like to realize bold organizational aspirations.

Great companies, the authors added, become great because they simultaneously keep two dynamic forces in play: preserving their core ideology, while at the same time "stimulating progress and change."

"The most enduring and successful corporations," they wrote, "distinguish their timeless core values and enduring core purpose (which should never change) from their operating practices and business strategies (which should be changing constantly in response to a changing world)."

An 'enduring core purpose'

How does our specialty fit into this conceptual framework? On its surface, internal medicine seems too diffuse to fit that kind of corporate mold.

Take academic medicine, for instance. Unlike a company striving to produce a product line at the most attractive price, academic medicine has at least three distinguishable missions: education, research and patient care. While corporations can align their operations and business strategies with a core ideology, academic medicine struggles to achieve multiple missions that, because of financial exigencies, often compete with one another.

By the same token, ACP has many roles to fill. The College is committed not only to furthering members' lifelong education, but also to improving clinical practice, advocating for needed policies and laws, and advancing both the evidence base and the technological tools available to physicians.

College leaders have identified seven overarching goals for ACP, which are online, include one to "unify the many voices of internal medicine and its subspecialties." But what is the College's—and internal medicine's—core ideology?

If we analyze ACP's stated goals, as well as the vision statement approved last month by the specialty's leaders, we find one single, pervasive and unifying concept: "ensuring quality health care." That phrase expresses both the purpose of our profession and the driving force behind all of our endeavors.

Altered strategies

Why is "ensuring quality health care" a core ideology we need for the specialty and the College? For one, it succinctly conveys our core values and purpose to patients and policy-makers.

Even more importantly, it addresses the public's mounting concerns about the quality of American health care. Several recent reports from the Institute of Medicine have highlighted those concerns.

And changes in the practice environment and in health care financing have altered traditional strategies for ensuring health care quality. As the authors of "Quality improvement—from policy to action" published in the July 23, 2004, New Zealand Medical Journal made clear, health care quality for much of the modern era was presumably maintained through the careful selection of dedicated medical students, residents and other health care professionals. We once assumed that the apprenticeship model would instill the traditional values of professionalism throughout the health care workforce.

But that may no longer be the case. Analysts claim that changes in the health care system, as well as incentives linked to managed care, have threatened medical professionalism. That threat has in turn undermined quality improvement efforts. As a result, the quality that we and our patients once presumed was built into American health care now needs to be objectively measured. Values we once assumed were the foundation of our relationship with patients now have to be publicly demonstrated.

Ensuring quality health care is fraught with challenges. We need to define and measure quality; establish standards of performance; judge our own performance; and apply quality data to improve clinical practice.

But by adhering to our core ideology of ensuring quality health care, we will be better equipped to maneuver through constantly changing health care policies and payment systems. We will be able to unify our different factions and specialties. And we will have our best chance of reaching the audacious goal of delivering optimal health care to all.

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