The importance of preparing medical students to manage different types of uncertainty.

Price competition and other aspects of the changing health care environment are threatening many academic health centers (AHCs) and causing them to reassess their education and research missions. In order to design effective AHCs for the next century, medical leaders must define the unique competencies needed by tomorrow's physicians and describe the educational enterprises required to produce physicians with these competencies. Two of the most important of these competencies are the ability to manage the uncertainty associated with creating clinical paradigms and the ability to manage the uncertainty associated with managing care delivery. Creating clinical paradigms involves (1) developing knowledge about disease categories and (2) developing knowledge about the most appropriate therapy for a disease in a particular category. Both these tasks involve uncertainty. The second type of uncertainty is associated with managing care delivery and is largely a matter of optimizing current clinical paradigms. The challenges are (1) to correctly assign patients' diseases to existing disease categories, and (2) to correctly choose and manage the delivery of the most appropriate therapies to these patients. Currently, AHCs are more competent in managing--and educating students to manage--the uncertainty involved in creating clinical paradigms. But there is an increasing demand for physicians who manage the second type of uncertainty associated with care delivery. The authors conclude that in order to remain viable, AHCs, and particularly their medical schools, must broaden their educational goals so that students can learn to manage both forms of uncertainty.

Translating public health research into public health practice: outcomes and characteristics of successful collaborations.

For over five years we have been involved in a series of collaborations between academic public health and state and local public health organizations. This article briefly describes the outcomes produced and under development by these collaborations and delineates and discusses some characteristics we now hypothesize will predict successful academic/practice collaboration. These collaborative projects with public health organizations in Alabama, Indiana, and New Mexico have produced outcomes that influenced the organization of the agencies and the allocation of resources within the agencies. The collaborations also have contributed to the body of literature concerning management processes in public health agencies and influenced the teaching of strategic management to students of health services. Our experiences and interactions led to the identification of 10 characteristics we believe predict successful academic and practice collaborations, discussed in three groups as (1) characteristics of successful academic collaborators, (2) characteristics of successful collaborating public health organizations, and (3) characteristics of successful collaborative projects.

A way to approach the strategic decisions facing academic health centers.

Rapid changes taking place in the various markets served by academic health centers (AHCs) are forcing these institutions to make difficult strategic decisions that may change AHCs' historic priorities. The authors present an approach that can help AHCs visualize possible new configurations of their traditional services of research, education, and clinical care. This approach is based on successful strategic management methods from the private sector and involves a three-dimensional "topography of services" encompassing all possible configurations of AHCs' services. From among the many possible configurations, the authors discuss three in detail. The historic one, which they call the traditional model, is characteristic of AHCs that give high priority to biomedical and clinical research, have broad medical education activities, and deliver comprehensive, high-quality clinical care. In the future, this configuration will be rare, and two others are likely to predominate. First is the "revised" traditional model, which would offer "boutique" clinical services, biomedical research, and medical education for MD-PhD students, residents, and fellows seeking tertiary care or academic careers. The patient care required for undergraduate medical education and clinical research would be provided by partnerships with community-based providers. Second is the academic services model, which would focus on competitive primary and secondary clinical services, health services and operations research, and primary care medical education. The authors discuss the implications of these models for AHCs' organizational structures and faculty incentives. They conclude that the clarity with which AHCs' strategic decisions are made and communicated to faculties and the incentive systems that are selected to motivate faculty and to provide the selected services may ultimately determine which institutions survive.

General and functional level health care managers: neither 'manage' very much.

This paper reports the results of a study of 40 (20 paired general and functional level managers) in 20 health care organizations. The managers were personally interviewed and were asked to supply additional self-coded data from calendar entries, telephone logs, and in/out baskets. The results of this study indicated that health care managers, like their business counterparts, spend most of their time performing tasks other than traditionally defined management functions. In fact, major portions of the typical day of general and functional managers are spent exchanging routine information, processing paperwork, and interacting with others. As the studies have confirmed with regard to business managers, the health care general managers in this study focused much of their attention on issues and events external to the organization. The information sources they valued most were primarily external to the organization. The functional managers, by comparison, were more oriented to internal issues and information sources. In general, this study indicated that the patterns of managerial work in health care organizations are similar to those in business organizations and that managers in both settings spend half their time doing things that are not 'managerial' in nature.

Keeping strategic thinking in strategic planning: macro-environmental analysis in a state department of public health.

This paper examined the tendency of strategic decision makers in public health to allow their strategic planning process to degenerate into short-term, operational management. The temptation is great in light of pressing current problems. However, the danger of not thinking strategically about the future and of failing to attempt to position the organization in such a way as to take advantage of its strengths and minimize the adverse consequences of its weaknesses can be catastrophic. An attempt is made to illustrate how one state department of public health attempted to ensure that strategic thinking remained a part of its strategic planning process. The process was built around the energizing of the expertise present in the department and the mobilization of resources under the direction of the State Health Officer. The process is ongoing and is constantly fine tuned. However, the procedure utilized can be adapted easily to the unique circumstances facing most public health organizations.

Strategic planning for public health practice using macroenvironmental analysis.

Macroenvironmental analysis is the initial stage in comprehensive strategic planning. The authors examine the benefits of this type of analysis when applied to public health organizations and present a series of questions that should be answered prior to committing resources to scanning, monitoring, forecasting, and assessing components of the macroenvironment. Using illustrations from the public and private sectors, each question is examined with reference to specific challenges facing public health. Benefits are derived both from the process and the outcome of macroenvironmental analysis. Not only are data acquired that assist public health professionals to make decisions, but the analytical process required assures a better understanding of potential external threats and opportunities as well as an organization's strengths and weaknesses. Although differences exist among private and public as well as profit and not-for-profit organizations, macroenvironmental analysis is seen as more essential to the public and not-for-profit sectors than the private and profit sectors. This conclusion results from the extreme dependency of those areas on external environmental forces that cannot be significantly influenced or controlled by public health decision makers.

Rapid insulin initiation in non-insulin-dependent diabetes mellitus.

Three insulin-initiation regimens were compared in 43 severely hyperglycemic non-insulin-dependent diabetic patients: a "standard" regimen (Lente insulin once daily), a "rapid" regimen (a mixture of regular and Lente insulins twice daily), and a "rapid/intravenous" regimen (the "rapid" regimen preceded by overnight intravenous infusion of regular insulin). The mean serum glucose level fell more rapidly in both groups receiving "rapid" regimens, reaching less than 200 mg/dl in 3.0 days with the "rapid" regimen compared with 5.9 days with the "standard" regimen (p less than 0.005). Duration of hospitalization was similarly reduced (6.4 versus 9.9 days, p less than 0.0001) as was the cost of hospitalization. In contrast to the "rapid" regimens, symptomatic hypoglycemia was common and adequate glycemic control was rare with the "standard" regimen. Thus, rapid initiation of insulin therapy with 0.5 to 0.6 units/kg per day of a mixture of regular and intermediate-acting insulins given twice daily is effective, safe, and reduces the cost of hospitalization in patients with non-insulin-dependent diabetes mellitus who require insulin treatment.