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Description
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... |
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