Medical associations: guilds or leaders?BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7094.1564 (Published 31 May 1997) Cite this as: BMJ 1997;314:1564
Either play the role of victim or actively work to improve healthcare systems
- Donald M Berwick, Presidenta
- a Institute for Healthcare Improvement, 135 Francis Street, Boston MA 02215, USA
In many Western nations traditional medical associations are encountering an opportunity in threat's clothing. If they see through the disguise, and act accordingly, they can lead health care. If they do not, they may find themselves bewildered by their sense of helplessness.
The opportunity comes from the social need for better health care. Any honest review of the literature in clinical science and health services research must conclude that there is a large gap between how health care could perform and how it does perform. In medical care error rates are too high, waste is too pervasive, technically correct clinical services are too often withheld, and technically incorrect procedures are too often used.1 Service characteristics of health care–such as waiting times, consistency of response, and attention to dignity–are well below those of many other industries.2 The patients whom we serve are neither insatiable nor ungrateful when they demand that we do better, although that demand is becoming more strident, inducing new forms of surveillance, regulation, market pressure, and media attention.
Therein lies the opportunity for new leadership from medical associations: not to explain why we cannot do better but to set about the task of leading improvements. Unfortunately (because it makes the job harder), leading improvement requires most medical associations to change both their attitude and agenda. The change in attitude is necessary because the associations' traditional aim–to perfect and protect the profession–will not suffice to meet the social need for improved care. To improve health care we require not better professions but better systems of work.
A “system” in this sense is a set of elements interacting to achieve a shared aim. Here is the trick: to improve the performance of a system, …