The Hippocratic Oath, V2.0: using focus groups in health care policy.

Abstract: Objective: Re-examination of traditional concepts in medicine would help to allow meaningful health care reform. Methods: We studied 6 different pre-defined 10-person focus groups of healthcare workers and patients. The two-hour focus groups were taped and summarized using a perceptual map. Results: We found a pervasive atmosphere of fear and anxiety regarding three realms: 1) insurance coverage, 2) information technology, and 3) health justice. Respondents desired a realistic, actionable document to guide policymaking, which we discuss in the accompanying commentary. Conclusions: Our document reflects use of the tool of focus groups, which may help in providing an understanding of a population's thought processes.

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The pages of American medical journals frequently articulate the problems faced by the U.S. health care system, and less frequently, proposed solutions to those problems (Lamm, 1998; Washburn, 1999; Bonner, 1999; Mello, Studdert, & Brennan, 2003; Sage, 2003). Legislative remedies appear endlessly mired in partisan politics. In April 2005 a physician's march on Washington, D.C. attracted 80 buses from the Northeast with doctors complaining about the need for malpractice reform. The response from the political leadership acknowledged the existence of a real problem, but concluded that no meaningful political or legal action will be possible as long as proposed solutions appear to serve doctors, hospitals, and insurers without offering generally accepted benefits to society as a whole (M.C. Oz, personal communication, 2005). Our large representative organizations are often perceived as serving the prurient self-interest of our nation's physicians without a clear vision for improving the lot of our patients (Rodwin, Chang & Clausen, 2006; Boehm, 2005). In this manuscript we seek to frame the offering more broadly in order to break the stalemate, allowing meaningful health care reform to occur.

This reform will necessarily be a two-step process. The first step assesses the current sentiments of health care providers and society towards each other and our health care system. The second step uses this information to identify opportunities for meaningful change. We ultimately selected the focus group as the tool best suited to our objectives. The gathered data is expressed as a perceptual map that creates a visual assessment of the interplay of sentiments surrounding each major issue. We next used the gathered information to refine a modernized version of the physician's relationship to society: the Hippocratic Oath version 2.0, as detailed below.

METHOD

BACKGROUND

Using tools frequently entertained in political research organizations, we sought a common understanding by all stakeholders of the main maladies of medicine today. For the reasons discussed below, the focus group was selected as the final investigational tool. Together with the Washington, D.C. based Center for Health Transformation and Columbia University's Institute for Medicine as a Profession, we elicited discussion from numerous physicians, nurses, health business leaders, and laypeople using focus groups. Before the focus groups were conducted, the topics to be covered were chosen by analyzing interviews of 36 workers and leaders in health care selected and interviewed individually on various topics relating to health care policy, as detailed in Table 3. Responses from the initial survey data had showed a mistrust of government intervention in healthcare, a perception that distorted economics are at the heart of most of the problems, and a feeling that doctors have an inadequate voice in national healthcare discussions. These themes played a key role in selecting the topics for the focus groups and in formulating the final version of the covenant document detailed in Table 1.

A focus group is a research technique that gives qualitative insight into a certain population's thinking and decision-making on a given topic. Focus groups have an unbiased moderator armed with a list of questions on the selected topic. The group is selected using specifically defined criteria, and the moderator guides the discussion by loosely adhering to the question list. The discussion is recorded, and researchers later identify salient themes and content by analyzing the discussion.

Focus groups have been widely and successfully used for decades in the social sciences, urban planning, marketing, and politics. In medicine, focus groups have recently been increasingly used for research purposes in academic nursing (Mansell, Bennett, Northway, Mead & Moseley, 2004) in some areas of psychiatry (Lim, Nathan, O'Brien-Malone, & Williams, 2004; Davis & O'Neill, 2005) pediatrics (Peterson-Sweeney, 2005) and occasionally in other areas of medicine dealing with behavior changes, such as smoking cessation (Schmitt, Tsoh, Dowling, & Hall, 2005). Yet on the whole, the focus group method is in the infancy of its use in medicine.

Marshall and Rossman summarize the work of Morgan, Krueger, and others in identifying several advantages of focus groups over interviews and polling: (1) they are a more natural setting than a oneto-one interview, which encourages a fuller reflection and development of ideas in some participants; (2) they are comparatively low-cost; (3) results can be obtained quickly; and (4) they allow the facilitator the flexibility to explore unanticipated issues that may arise (Marshall & Rossman, 1999). This last advantage was particularly important in focusing the scope and emphasis of the covenant document described below. Finally, Marshall and Rossman point out that in focus groups: "The results have high face validity: Because the method is readily understood, the findings appear believable." (Marshall et al. p.114). In other words, while focus group research does require a specialized expertise, it also shares obvious similarities with the common experience of probing, developing, and refining ideas through group conversation. In contrast, the crafting and analysis of polling and interviews relies more heavily on a specialized expertise with which those outside the fields of marketing, psychology, and the social sciences are unfamiliar. As a result, those laymen relying on the findings of qualitative research can more easily grasp, and perhaps therefore more easily trust, the findings of focus groups.

An obvious disadvantage of focus groups and individual interviews is that being a qualitative research and not quantitative, these research methods cannot generate statistically significant data sets, as polling can. This makes polling a good choice for evaluating certain questions, particularly where the response is by its nature succinct and statistical significance is of primary importance. However, while a given investment of resources in polling can reach a much larger number of respondents than could focus groups, Strauss and Corbin point out that a serious disadvantage of polling is that the question-writer, the responder, and the analyst may all perceive differently a given word or phrase in the question or in the answer, and the analyst will be unable to clarify the respondent's meaning (Strauss & Corbin, 1998). In many kinds of inquiry, this will be only a minor drawback. Furthermore, the individual interview can address this concern somewhat. Yet the interview may still be a more artificial setting and tone, as noted above. In brief, polling, individual interviews, and focus groups all have their respective strengths and weaknesses.

Although we initially used polling results and individual interviews to direct our inquiry, for the reasons discussed above, the focus group was ultimately selected as the best way to approach perceptions of the deep and complex issues between the profession and business of health care delivery on one hand, and American society on the other. Several aspects of our inquiry guided our choice. First, we wanted to elicit any opinions that respondents might be unlikely to articulate in a one-on-one setting, particularly those opinions shared by others but not previously publicly expressed. Second, we wanted to discover any unexpected or surprising themes, which by their nature we would not have been able to include in any polling. Third, we wanted the respondents to have the ability to address issues raised by others and to modify or re-evaluate their own responses thereby. Finally, we wanted to encourage a more relaxed flow of ideas, concerns, and intuitions. As discussed below, unexpected themes did emerge from the focus group research.

FOCUS GROUPS TECHNIQUE

We conducted focus groups with six different pre-defined ten-person groups of various healthcare professionals, female patients, or seniors, in Atlanta, New York City, and Cincinnati. The topics addressed in each group were: 1) the general healthcare environment in America today, 2) health insurance, 3) electronic medical record keeping, 4) patient learning and compliance, 5) health justice, 6) patients' rights to access their health information, 7) participants' reactions to a list of certain healthcare facts, and 8) a healthcare covenant. For a more detailed explanation of the questions used to stimulate discussion on each of these subjects, see Table 2.

The two-hour focus groups were conducted by The Winston Group, a professional communications research group with extensive experience with this technique. Each focus group, except for the women-only group, contained a mix of genders. Each group had a mix of races with a minimum of five to eight Caucasians to roughly approximate the American populace. The six groups of ten individuals each were as follows: nurses (other than Licensed Practical Nurses or Nurse Assistants) working in a family practice office, a specialist's office, or a hospital, with careers of durations spread over less than five to more than twenty years (New York); physician academic medical professors and physician hospital administrators with careers of durations spread over less than five to more than twenty years (New York); primary care physicians with careers of durations spread over less than five to more than twenty years (Atlanta); specialist physicians with careers of durations spread over less than five to more than twenty years (Cincinnati); persons aged 60 years or older not employed in the medical profession (Atlanta); and women aged 18-50 years not employed in the medical profession (Cincinnati).

RESULTS

Transcripts of the discussions were analyzed by The Winston Group, and the key findings are summarized in a fifteen page report, "Doctor's Covenant with America Focus Group Analysis," available at http://www.healthtransformation.net. Below we identify several key themes which emerged from the analysis. These themes are opinions or statements that were repeated in substantially similar form by numerous respondents in a variety of settings. Where these themes were repeated with variations from different groups or locations, only the parts which were consistent throughout are reported here as noteworthy. For example, primary care physicians in Atlanta noted a decrease in morale due to the uncertain future of their specialty; physician academicians and administrators in New York noted a decrease in morale due to paperwork and bureaucracy; specialist physicians in Cincinnati noted a decrease in morale due to low reimbursement and high malpractice; and nurses in New York noted fair morale for themselves but also noted lower morale for the doctors they work with because of reimbursement issues. The only common element to all these responses is a decrease in the morale of physicians, which contributed to our identification of it as a major theme emerging from the research. Issues about reimbursement or bureaucracy, while consistent throughout one group or location, were not consistent across enough groups to be considered a major theme. Other issues, however, such as a lack of trust between doctors and patients, were consistent enough to be identified as one of the causes of decreased physician morale.

The interplay of sentiments elicited from the focus groups are visually summarized in the accompanying perceptual map (Figure 1), which is an abbreviated version--worded from the physicians' point of view--of The Winston Group's comprehensive perceptual map of the analysis of the themes that emerged from the transcripts. The complete map is available at http://www.healthtransformation.net. Perceptual mapping is a graphic technique used to create a visual representation of one or more focus groups' thought processes on a given topic. The balloons contain statements of themes that emerged and are arranged to show the interactions of those concepts as described in the key.

Overall, the members of the groups studied felt an increase in negative feelings toward the processes and the environment of healthcare today. Doctors' perceptions are reflected in the central proposition of the resulting perceptual map that "My morale as a doctor has decreased notably in recent years." The perceptual map balloons emanating from this central tenet cover the major categories of root issues underlying the falling morale. The secondary balloons highlight the importance of several issues that deserve amplification. Around these secondary balloons are tertiary comments quoted or paraphrased directly from one participant but representative of a consistent theme elicited throughout all groups. These are makred with one asterisk to reflect positive comments and two asterisks to show negative sentiments.

The key findings from our focus groups included the following:

* In general, doctors, patients, and nurses all noted a downward trend in morale, especially in physicians, and in positive personal interaction between all groups studied.

* The economic aspects of healthcare largely filter into the medical aspects, causing negative consequences such as an impersonal doctor-patient relationship, an increased and occasionally exclusive focus on insurance reimbursement, a constant turnover of healthcare providers, and an increase in fear and litigiousness that makes defensive medicine the norm today.

* Overall, an increase in fear on all fronts is a major factor in the downward slide in outlook noted by respondents. From doctors' fears of litigation or lack of reimbursement, to patients' fears of medical errors or lack of privacy, a culture of anxiety has contaminated every realm of medical care.

* Notably, the economic and legal factors surrounding modern American healthcare have eroded the personal relationships that once characterized medicine, by creating an atmosphere of mistrust and a lack of continuity of care. As all parties become more uneasy with the whole process, patients have worse experiences while healthcare professionals become disillusioned with their vocation.

* Generally, all parties are apprehensive about both government intervention into healthcare and about technological advances that pose threats to patient privacy and physician autonomy.

* A general feeling of helplessness was manifested on all fronts, as problems were identified but no satisfactory solutions or actionable items seemed to be in sight. Even fundamental assumptions, like the potential for improved information technology to reduce medical errors, were disputed.

It is noteworthy that several of the themes that emerged from the focus groups had shown up earlier throughout the individual interviews. Indeed, several topics had been selected for the focus groups in order to verify that their consistent themes were not confined to the setting of the individual interview. Table 3 lists the questions asked in each interview. Interviewees had been selected by the authors in consultation with the Center for Health Transformation and Columbia University's Institute for Medicine as a Profession, as well as by recommendations from other interviewees. Among these themes seen in both the focus groups and the earlier individual interviews, as illustrated by quotes from the individual interviews, were:

* a mistrust of government intervention in health care, for example HIPAA ("a complete disaster"; "a regulator's delight"; "the obsession with not sharing information prevents learning")

* a feeling that the fear of malpractice interferes with improving care ("we need to fix the faults, but currently people work against this to bury problems"; "the real question is whether malpractice is tied to honesty"; "malpractice rules today cause a code of silence"; "transparency always works eventually")

* a sharp drop in physician morale coupled with a perceived loss of voice, especially regarding professional organizations: ("I know many who feel disconnected from organized medicine"; "young doctors get ground down over time in a merciless system"; "less than 30% of doctors are in the AMA and it doesn't have the patient's interests in mind"; "we're not talking about our value systems enough")

Regarding advances in information technology, doctors' attitudes in the focus groups differed by age, with younger doctors being significantly more receptive to using electronic medical records than older ones. Many physicians expressed doubt that better information systems would meaningfully impact medical errors. The major fears cited were the difficulty in entering data and the fear that increased transparency--in complex systems would increase the risk of malpractice lawsuits. Nurses generally felt comfortable with and supportive of electronic medical records, especially regarding the ability to help prevent accidental medication interactions. Patients seemed to respond somewhat positively to the concept of electronic records, expressing an optimism that was nonetheless tempered by privacy concerns.

In the world of modern internet technology and improved communications, doctors in the focus groups noted that patients now have a great wealth of medical "knowledge" at their fingertips, and that they tap into that resource with increasing frequency. Doctors noted fearfully, however, that much of the information is faulty and it can be easily misapplied. Additionally, when patients perceive an ability to diagnose their own illnesses, mistrust arises between patient and doctor when their conclusions differ. Nurses seemed to feel slightly more positive about the ability of patients to be informed about their own health, noting that as long as patients are not trying to be their own doctors, information tends to be helpful.

On the issue of health justice and litigation, all of the focus groups were somewhat split on whether increased litigiousness had helped or hindered the safe practice of medicine. Doctors expressed concern over placing health justice in the hands of public juries and they voiced some support for a peer-review system of 'health court,' or non-binding arbitration. In discussing the role of insurance from the healthcare professional's point of view, doctors in the focus groups were emphatic that the government's role in medicine should be as limited as possible. Additionally, they expressed a belief that patients without insurance do not affect their practice much, since all patients who are seen get the same quality of care. The increased expense of inefficiently treating the uninsured was also appreciated, as was the reality that the insured ultimately pay for the uninsured anyway. Nurses were most critical of the constantly fluid nature of insurance coverage and of insurance companies' failure to support and cover preventive medicine.

DISCUSSION

Three broad, interacting areas of concern among healthcare professionals and patients emerged from the findings of the focus groups and interviews. These are 1) insurance coverage, 2) information technology, and 3) health justice, all of which were seen to interact in distorting the economics of medicine and in creating a pervasive atmosphere of fear and anxiety. The focus group respondents recognized that these three realms are closely interrelated, and that in unison positive changes in these realms could effect a substantive change in health care as a whole. Using these three themes, we finalized a document to serve as a starting point for a national discussion of how to renew the relationship between healthcare providers and society at large, detailed in Table 1.

Our research supports the belief that the professionalism of health care providers should result in a movement providing our society with clear, specific advice on improving the health of our nation. The resulting document includes the major themes identified in our research, and it would provide our nation's leaders with a clearer view of how the healing profession hopes to better deliver care. Respondents in our focus groups offered hope mixed with skepticism for such a document, in part due to a generalized feeling of helplessness to influence action items. The most common concern was that the document was too abstract. Doctors noted that they do not feel as though a statement of ideals could actually give a roadmap for improving healthcare. Nevertheless, physicians believed that they could use a realistic, actionable document dealing with the key issues we face, several of which are mentioned in the document.

Our aim in creating this draft was not to offer a detailed plan but to begin formulating a shared vision. Our goal was to stimulate discussion regarding the ideals for which to strive, not to engage in debate about details of implementation. In addition, we framed the challenge in an understandable context so a comprehensive solution could be envisioned and acted upon. Finally, key words that evoked a strong initial negative reaction among stakeholders (e.g., "government controlled," "socialized medicine," "tort reform") were avoided. While not strictly an "oath" in the ancient sense of that word, this is a nonetheless a statement of principles by which to guide the renewal of health care delivery. As such it should occupy a similar place to the Hippocratic Oath, as one foundation of the modern relationship between those providing and those receiving health care. We encourage a robust discussion of our document and we call upon others to propose improvements as the medical profession regains its voice and articulates its vision of a conviction that we can fix health care in America.

While this covenant does not answer all the challenges of health care in America today, it does provide a promising place to start, because its creation made effective use of the focus group, an investigational tool which gives a deep and complex understanding of a population's likely thought processes. Physicians young and old can use this framework for discussion as they cope with the coming changes in health policy in the United States.

ACKNOWLEDGEMENTS

David J. Rothman, PhD, Columbia University College of Physicians and Surgeons, Director, Center for the Study of Society and Medicine, and Christopher S. Sales, Tufts University School of Medicine. Dr. Rothman offered invaluable advice and guidance in this project and Mr. Sales assisted in the conduct of the study itself.

REFERENCES

Bonner, T. N. (1999). Crushing the commercial spirit in academic medicine: A crusade that failed. Academic Medicine, 74, 1067-1071.

Boehm, G. (2005). Debunking medical malpractice myths: unraveling the false premises behind "Tort Reform." Yale Journal of Health Policy Law Ethics, 5, 357-369.

Davis, K. E. & O'Neill, S. J. (2005). A focus group analysis of relapse prevention strategies for persons with substance use and mental disorders. Psychiatric Services, 56, 1288-1291.

Lamm, R. (1998). Marginal medicine. Journal of the American Medical Association, 10, 931-933.

Lim, L,. Nathan, P., O'Brien-Malone, A., & Williams, S. (2004). A qualitative approach to identifying psychosocial issues faced by bipolar patients. Journal of Nervous & Mental Disease, 192, 810-817.

Mansell, I., Bennett, G., Northway, R., Mead, D. & Moseley, L. (2004). The learning curve: advantages and disadvantages in the use of focus groups as a method of data collection. Nurse Researcher, 11, 79-88.

Marshall, C. & Rossman, G. B. (1999). Designing qualitative research (pp. 114-115). Thousand Oaks, CA: Sage Publications.

Mello, M. M., Studdert, D. M., & Brennan, T. A. (2003). The new medical malpractice crisis. New England Journal of Medicine, 348, 2281-2884.

Peterson-Sweeney, K. (2005). The use of focus groups in pediatric and adolescent research. Journal of Pediatric Health Care, 19, 104-110.

Rodwin, M. A.., Chang, H. J., & Clausen, J. (2006). Malpractice premiums and physicians' income: Perceptions of a crisis conflict with empirical evidence. Health Affairs, 25, 750-758.

Sage, W. M. (2003). Medical liability and patient safety. Health Affairs, 22, 26-36.

Schmitt, E. M., Tsoh, J. Y., Dowling, G. A., & Hall, S. M. (2005). Older adults' and case managers' perceptions of smoking and smoking cessation. Journal of Aging & Health, 17, 717-733.

Strauss, A. & Corbin, J. (1998). Basics of qualitative research (pp. 92-93). Thousand Oaks, CA: Sage Publications.

Washburn, E. R. (1999). The coming medical apocalypse. Physician Executive, 25, 34-39.

RESPONSIBILITIES AND COMPETENCIES OF HEALTH EDUCATION

Responsibility VII--Communicating Health Needs, Concerns and Resources

Competency B: Predict the impact of societal value systems on health education programs Sub-competencies:

1. Investigate the social forces causing opposing viewpoints regarding health education needs and concerns

2. Employ a wide range of strategies for dealing with controversial health issues

3. Analyze social, cultural, demographic, and political factors that influence decision-makers Competency C: Select a variety of communication methods and techniques in providing health information

Sub-competency 1: Utilize a wide range of techniques for communicating health and health education information

Competency D: Foster communication between health care providers and consumers.

Sub-competency 1: Interpret the significance and implications of health care providers' messages to consumers

Responsibility X--Advancing the Profession of Health Education

Competency C: Apply ethical principles as they relate to the practice of health education

Sub-competencies:

1. Analyze the interrelationships among ethics, values, and behavior

2. Relate the importance of a code of ethics to professional practice

Mehmet C. Oz, MD, is affiliated with the Department of Surgery at Columbia University College of Physicians and Surgeons. Nancy Desmond, MS, is affiliated with The Center for Health Transformation, Georg N. Herlitz, MD, JD, is affiliated with the Department of Surgery at Columbia University College of Physicians and Surgeons, David H. Winston, MA, and Gray Harden Raniella, BA, are affiliated with The Winston Group, and the Honorable Newton L. Gingrich, PhD, is affiliated with The Center for Health Transformation. Please address all correspondence to Mehmet C. Oz, MD, FACS, Columbia University College of Physicians & Surgeons, Department of Surgery Vice-Chairman, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, MHB 7GN-435, New York, NY 10032; PHONE: [phone]; FAX:[phone]; EMAIL: [e-mail].

Table 1. The Text of "The Hippocratic Oath, Version 2.0"

The voice of health professionals must be heard if we are to improve
our nation's health care system. This change requires restoration of
trust between communities and the health professionals who serve
them, and it can be accelerated through re-affirmation of a covenant
that healers make with those who depend on us to provide sound
medical care. Physicians and nurses work within a rich heritage of
professionals who put the patient's interest first, who continually
improve our proficiency, and who regulate themselves through
responsible organizations. But as a part of our covenant with
patients and society, we also need to advocate the following
principles to create a 21st century intelligent health system.

1. Affordable health insurance for all. All citizens should be
compelled to purchase a minimum plan (as is the case with car
insurance). Subsidies of insurance premiums must be provided for the
poor.

2. Interacting health information systems. We can promote safer,
cost-effective medical care by creating electronic patient records that
can be exchanged among health care providers and can be brought
together to produce meaningful outcomes data that will support future
decision-making. Under such a system, doctors and patients would be
better informed, and both could help advance medical practice. To
reduce wasteful paperwork we need a health information infrastructure
that includes standards for collecting and sharing data.

3. Progressive health justice programs. Patients benefit more from
programs that reduce errors in care than from compensation systems
resembling a malpractice lottery. We can only improve health care
if we learn from our mistakes. Accordingly, we need incentives such as
legal protection for doctors who quickly share, with both patients and
colleagues, the truth about poor outcomes. Medicine must also regulate
itself better by identifying problematic physicians and nurses and by
providing them with remedial services. These self-policing efforts
should be coupled with whistleblower protection. In addition, reforms
must be aimed at improving both doctors' and the public's faith in the
way legal outcomes are judged, perhaps through mandatory
court-appointed impartial experts to assist the jury during
deliberations by clarifying the medical realities of complex cases.

None of these ideas are new or radical, but the power of our agreeing
to push for change can be transformational. Specific solutions can be
debated, but we should agree on the scope of our recommendations. If
you believe we can build trust in our health care system, please share
this covenant with colleagues and patients and send a copy with your
name to your political representatives and professional societies, so
our voice will be heard. America cares about our opinion and we owe
our country an honest response.

Table 2. Explanations of the Questions or Issues Used in the Focus
Groups to Stimulate Discussion Under Each Topic.

The General Healthcare Environment in America Today

Participants were asked 1) whether morale had decreased for doctors,
nurses, and patients, 2) how they see the relationship between patients
and doctors, 3) whether the level of trust between patients and doctors
has changed, 4) whether patients are more knowledgeable about their own
medical records today, 5) whether patients are more knowledgeable about
their doctors today, and 6) in what direction they thought healthcare
in America was going. The physician and nurse groups were also asked
whether they felt any organization advocated for their interests at a
national level.

Health Insurance

All participants were asked 1) whether there was a role for government
in health insurance, 2) whether unified insurance rules was a good idea,
and 3) their overall opinion on the state of health insurance in
America today. Additionally, 1) physicians were asked how often they
see patients without insurance, and 2) physicians, nurses, and hospital
administrators were asked whether they discuss the concept of
affordable health insurance with their colleagues.

Electronic Medical Records

Participants were asked 1) whether EMRs prevent errors and save lives
(see also "Healthcare Facts" below), 2) whether they supported the idea
of patients keeping a portable digital file of their medical records to
bring with them when they see a doctor, 3) how might physicians be
encouraged to fill out electronic medical records, and 4) what they
thought were the positive and negative aspects of EMRs.

Patient Learning and Compliance

Participants were asked 1) whether patients are getting better at
managing their own health care, and 2) their opinion on direct consumer
advertising to patients.

Health Justice

Participants were asked their opinions on the ideas of 1) specialized
health courts to handle malpractice cases, 2) non-binding arbitration
for resolution of legal conflicts in medicine, 3) a system for
reporting errors and "near misses," similar to the one used by airline
pilots, in return for limited liability, 4) whether physicians provide
better care as a result of the litigious nature of our society, and 5)
ways in which the current legal system might be improved.

Patients' Rights to Access Their Health Information

Patient participants were asked 1) what sort of information should be
made available to them, 2) what rights they have as patients, and 3)
their opinion on the idea of uniform ratings of hospitals and doctors.

Healthcare Facts

Patient participants were presented with a list of four statements
about various issues and asked a) whether they believed the statement
and b) their opinion on the subject. The statements were 1) "The
Institute of Medicine reported that as many as 98,000 people die each
year due to medical errors. One out of every 1000 people who enter a
hospital die [sic] due to a medical error. You are 2000 times more
likely to die in a hospital due to medical error than you are to die in
an airplane crash." 2) "Cancer can be eliminated as a cause of death by
the year 2015." 3) "Electronic healthcare systems have been shown to
prevent errors and save lives." 4) "It takes 17 years for best
practices to be learned in medicine."

Healthcare Covenant

Respondents were presented with an early broad draft of a healthcare
covenant similar to the one in Table 1, and were asked 1) whether they
supported the idea of such a covenant, and 2) their reactions to that
draft.

Table 3. Individual Interview Questions

The following questions were selected for the preliminary individual
interviews, based on findings from prior survey data obtained by The
Winston Group and Columbia University's Center for the Study of Society
and Medicine. Participants for the individual interviews were selected
by the authors in consultation with those two organizations, and by
recommendations from other interviewees.

1) Regarding progressive health justice, which do you feel is the
better approach: reform of American tort law or improved physician
self-policing, and why?

2) Professionalism requires both activism and self-policing. How much
additional time and effort would you be willing to devote to these?

3) Regarding electronic medical records, do you feel the benefits of
the improved information flow outweigh the challenges to implementing
such a system, and why?

4) Do you think an optimal public health system for dealing with
biological warfare attacks can be practicably implemented?

5) Has the overall impact of HIPAA been worthwhile?

6) Do you think the benefits of creating outcomes databases to track
safety in healthcare would outweigh the danger of disseminating such
data to consumers in raw form, and why?

7) What are your thoughts on the constraints of evidence-based-medicine
protocols, mandatory use of generic rather than brand name drugs,
mandatory physician education and other efforts that ultimately reduce
physician autonomy?

8) Would you support mandatory affordable insurance coverage for all if
it increased the leverage of payers in reducing physicians' fees? What
do you think is the role of the Nurse Practitioner in cutting costs?

9) Do you favor single payer or privately administered, community-based
health plans? How well do you feel you understand Health Savings
Accounts (HSAs) as enacted in the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003?

10) Do you think the benefits of reduced paperwork with unified
insurance rules outweigh an increased transparency that would allow the
private sector to "own" medicine and drive down reimbursement?

11) In general, do you think the advantages of quickly implementing new
health technologies outweigh the expense and hassle of quickly
implementing them?

12) Describe your concrete vision for what the ideal health care system
would look like.

13) What is best way to reduce the costs of prescription drugs, chronic
illness treatments, and other expensive areas of healthcare?

14) What are your thoughts on the state of professionalism in American
medicine today?

15) If extensive health care reform were to occur, would it be better
to do it in one comprehensive legislative act or in coordinated
incremental steps? How would this compare to the Clinton program?

16) Who do you trust at the national level to represent your interests,
for example, the AMA, a state professional society, or the government?

17) How do you think you can best help patients, legislators, and
others involved in the process of health care reform?

18) What other questions do you think should be asked of similar
interviewees?

19) Who else do you think should be interviewed on this subject?

Figure 1.

                                               We could use a
                                           realistic, actionable
                                              document dealing
                                             with the key issues
                        More trust is        we face, several of
                     needed everywhere       which are mentioned
                       in the system           in the covenant

  ** This       ** Self-                                    * Decreased
 "creates"      diagnosis                                   medication
  disease       and self-                                     errors
                treatment
                are risky

  Much of       Patients       My morale                     Electonic
   this           have        as a doctor                     medical
   comes        increased         has                         records
   from          access        decreased                     have both
advertising    information    notably in                     pros and
               on disease       recent                         cons
                                 years         ** Too
                                             much focus
                                               on HMOs

                                                            ** Expense
  * This       * Patients      The focus       ** The       and effort
 increases     are getting     out to be      economies         of
conscious-      better at         on             are          imple-
 ness on        managing       patients'      distorted       menting
  health          their        access to
  issues        own care       care and
  such as                     the quality
cholesterol                    of their
                                 care
                                                            ** The fear
                              ** The fear                   of litiga-
                              of litiga-                    tion would
                              tion breeds                    increase
                               defensive
                               medicine

                                * Some
                                reforms
                                 hold
                                promise

FIGURE LEGEND

*: Positive Comments Underlying a Root Issue

**: Negative Comments Underlying a Root Issue

Double-Headed Arrows: Overlapping/Interacting Concepts