No abstract

To gain a better understanding of the effects of medical schools related to transformations in medical practice, science, and public expectations, the Association of American Medical Colleges (AAMC) established the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) in 1994. Recognizing the privileges academic medicine enjoys as well as the power of and the strain on its special relationship with the American public, APMOMS formed the Working Group on Fulfilling the Social Contract. That group focused on the question: What are the roles and responsibilities involved in the social contract between medical schools and various interested communities and constituencies? This article reports the working group's findings. The group describes the historical and philosophical reasons supporting the concept of a social contract and asserts that medical schools have individual and collective social contracts with various subsets of the public, referred to as "stakeholders." Obligations derive implicitly from the generous public funding and other benefits medical school receive. Schools' primary obligation is to improve the nation's health. This obligation is carried out most directly by educating the next generation of physicians and biomedical scientists in a manner that instills appropriate professional attitudes, values, and skills. Group members identified 27 core stakeholders (e.g., government, patients, local residents, etc.) and outlined the expectations those stakeholders have of medical schools and the expectations medical schools have of those stakeholders. The group conducted a survey to test how leaders at medical schools responded to the notion of a social contract, to gather data on school leaders' perceptions of what groups they considered their schools' most important stakeholders, and to determine how likely it was that the schools' and the stakeholders expectations of each other were being met. Responses from 69 deans suggested that the survey provoked thinking about the broad issue of the social contract and stakeholders. Leaders on the same campuses disagreed about what groups were the most important stakeholders. Similarly, the responses revealed a lack of national consensus about the most important stakeholders, although certain groups were consistently included in the responses. The group concludes that medical school leaders should examine their assumptions and perspectives about their institutions' stakeholders and consider the interests of the stakeholders in activities such as strategic planning, policymaking, and program development.

In September 2001, the Agency for Healthcare Research and Quality (AHRQ) and the ABIM Foundation jointly sponsored an invitational conference entitled "The Role and Responsibility of Physicians to Improve Patient Safety." The goal of the conference was to begin a national conversation focusing on the individual clinician's role and strategies physicians might employ to advance patient safety. The authors summarize the main themes and issues that emerged at the conference. The authors draw from work by the Institute of Medicine (IOM) to support the need for greater emphasis on quality improvement. To date, most of the work in this area has involved a systems-level approach, and physicians are often viewed as obstacles to improvement programs. By contrast, physicians may view population- or systems-based approaches to health care as interfering with the delivery of care to specific patients. The authors argue that physicians, individually and collectively, have a key role in quality improvement efforts, albeit a role that is yet fully defined. After reviewing successful examples involving physicians, the authors explore the major levers to achieve change-removing barriers, creating incentives, emphasizing collaboration, increasing education, and promulgating regulation-and summarize ten recurring themes, including both current and near-term opportunities, for physicians to exercise leadership in quality improvement and patient safety. Finally, they assert that even modest change can lead to substantial improvements, particularly if medical societies and the profession's standard-setting bodies work together.

The authors analyzed existing relationships between medical schools and clinical enterprises in order to develop models of these relationships. The conceptual framework for the models uses three variables to assess the nature of the relationships: (1) high academic control-high clinical enterprise control; (2) high academic influence-low academic influence; and (3) self-contained system-open system (i.e., the extent to which the resources needed for clinical education are provided by the relationship between the clinical enterprise and the medical school). The authors present four conceptual models of the relationship between the medical school and the clinical enterprise: (1) The "single ownership; owned integrated system" is characterized by a closed clinical delivery system owned or controlled by the academic institution. (2) The "general partner" organization emphasizes an open clinical environment in which the medical school forms alliances with clinical entities, and the school is a dominant partner. (3) The "limited partner" organization operates with an open clinical delivery system that the school relates to through affiliations and contractual relationships, and the school is a less dominant partner. (4) The "wholly owned, subsidiary" organization operates in a controlled clinical environment in which the medical school is a subsidiary of the larger integrated delivery system. Each model is presented in its pure organizational form, then augmented with descriptions of the different ways that the medical school and other components may relate to each other. Also, the advantages and disadvantages of each model for the medical school are discussed. The authors emphasize that no model is superior to the others; instead, the best choice for a medical school depends on the history, local circumstances, and leadership of the school and other organizations. The authors' intent is to assist the leaders of medical schools as they design strategies for the future relationships of their institutions.