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book reviews

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medicine; they occur in abundance in other pro-fessions and industries. During the past two dec-ades, an approach dubbed the “theory of con-straints” has grown in popularity and success inindustry. This approach began with EliyahuGoldratt’s particularly readable “business novel”

entitled The Goal, which is currently in its thirdedition (North River Press, 2004). Several relatedbooks have been published since then. The new-est book in that array, We All Fall Down, extendsthe principles and analytic approaches of thetheory of constraints to health care systems. Thestory is set in a mid-sized academic hospital inthe United Kingdom, and the characters and theirfoibles are so familiar as to be both comfortingand frightening.

Coauthor Julie Wright, an adherent of Goldratt’sapproach, directed a hospital admissions depart-ment and then managed an after-hours service

that provided primary care to half a million peo-ple in Britain’s National Health Service. CoauthorRuss King is a freelance writer who tries tosmuggle humor into science. Together they iden-tify the core problem in the hospital; that is, theinability of the system and its managers to solicitand integrate the knowledge and experience offront-line workers (physicians, nurses, and sup-port staff) and to shape and establish adequate“buy-in” for quality improvement plans. They alsoconsider the inefficiencies created when patientsare located on many different floors throughoutthe hospital; this arrangement makes it impos-sible for physicians to see all their patients in atimely fashion. Although the authors consider theinefficiencies (e.g., extra admissions) produced

when less experienced physicians compose thestaff of the emergency department, they do notconsider the effect of tighter supervision on theeducation of young physicians. The authors de-scribe the limitations of manual administrationsystems that track the flow of patients through-out the hospital, and they hypothesize that post-ing information about patient flow on an elec-tronic “bed board,” akin to a hotel reservationsystem, will improve throughput. The familiar-ity — or perhaps the universality — of theseproblems (or undesirable effects) to academicphysicians in the United States leads me to believethat the authors’ analysis (or at the very least,their approach) is probably widely applicable.

Aside from important insights about the hos-pital setting, the book briefly introduces many

of the tools associated with the theory of con-straints. It provides a useful review for physiciansand managers who may have seen these toolsbefore, but the descriptions are quite telegraphicand not sufficiently detailed to allow a novice toapply them. However, the book might motivate

practitioners and managers to approach Goldratt’sprevious business novels such as The Goal and It’sNot Luck (North River Press, 1994), or even LisaScheinkopf’s Thinking for a Change: Putting the TOCThinking Processes to Use (Boca Raton, Fla.: CRCPress, 1999) and H. William Dettmer’s Breakingthe Constraints to World Class Performance (New York:McGraw-Hill, 1998). Wright and King’s book pro-

vides useful approaches to managing changeand overcoming resistance to change. It alsooffers a guide to the identification and manage-ment of bottlenecks or constraints to patient flow.In medicine, as in other environments, one core

problem is variation. Advocates of “total qualityimprovement” and the “six sigma” approach tryto stamp out variation, whereas advocates of thetheory of constraints recognize that variationcannot always be eliminated. Rather, good phy-sicians and administrators should be able to man-age variation. Advocates of the theory of con-straints argue for establishing and communicatinga common goal within a system and developingmeasurements that support progress toward thatgoal in all parts of the system.

We All Fall Down should be a respected additionto the libraries of clinicians who practice in ahealth care system and of managers of clinicalenterprises.Stephen G. Pauker, M.D.Tufts–New England Medical CenterBoston, MA [email protected]

Measuring Medical

Professionalism

Edited by David Thomas Stern. 311 pp. New York, OxfordUniversity Press, 2006. $49.50. ISBN 0-19-517226-4.

This book on the multifaceted problem of measuring medical professionalism is in-teresting and valuable. It has something for anyreader seeking to understand whether, why, or howprofessionalism in medicine might be evaluated.

The editor, David Thomas Stern, asks whether

The New England Journal of MedicineDownloaded from nejm.org on March 25, 2012. For personal use only. No other uses without permission.

Copyright © 2006 Massachusetts Medical Society. All rights reserved.

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the concept of “professionalism” is like the con-cept of “obscenity” — something hard to definebut recognizable when observed. Stern, along

with Louise Arnold, rejects this glib definitionin a very thoughtful essay the two contributed tothis book identifying the central qualities of pro-

fessionalism as excellence, humanism, account-ability, and altruism . Predictably, the many othercontributors to the book perceive professional-ism and its assessment or measurement in manydifferent ways.

Jon Veloski and Mohammadreza Hojat, in theirchapter entitled “Measuring Specific Elements ofProfessionalism: Empathy, Teamwork, and Life-long Learning,” apply systems theory to the as-sessment of professionalism. On the basis of theassumption that empathy, teamwork, and a com-mitment to lifelong learning are important com-ponents of professionalism, they have developed

questionnaires to assess each of these qualities.These assessments may be thought of as global,quantitative assessments of specific propertiesthat define professionalism. The authors suggestthat the evaluations are important tools for test-ing hypotheses concerning the admission of stu-dents to medical school, studying changes in theattitudes of students as they progress from pre-clinical to clinical studies, predicting performancein the training of house staff, and evaluatingchanges in medical school curricula.

Maxine Papadakis and Helen Loeser, in theirchapter entitled “Using Critical Incident Reportsand Longitudinal Observations to Assess Profes-sionalism,” address the measurement of profes-sionalism not as a continuous quantitative func-tion but as a binary function — pass or fail — akinto a driving test. Critical incident reports, whichare faculty reports of students’ behavior that isdeemed to be unprofessional, are the init ial stepin identifying outliers — students or physiciansin training who may have special needs, are re-sponding poorly to the stresses of the programor other parts of their lives, and may requirecounseling or remediation. Papadakis and Loeserdescribe their experience of assessing profes-sionalism through a physician evaluation systemat the University of California, San Francisco(UCSF), and they point to the need for faculty tounderstand and actively participate in the on-siteevaluation of student and house staff behaviors.They acknowledge that “single events do not nec-essarily define professionalism.” They also pro-

vide data on the number and types of unprofes-sional behaviors identified since the inception ofthe system at UCSF in 1995, describe the distri-bution of critical incidents among the clinicalservices, and outline the process and legal issuesassociated with remediation. Shiphra Ginsberg

and Lorelei Lingard, in their chapter entitled “Us-ing Reflection and Rhetoric to Understand Pro-fessional Behaviors,” suggest that critical incidents,serving as topics for reflective essays or smallgroup discussions, have the potential for st imu-lating students to examine their own reasoningand behavior.

Debra Klamen and Reed Williams, in a chap-ter entitled “Using Standardized Clinical Encoun-ters to Assess Physician Communication,” addressthe important issue of standardization in evalu-ation and the increasing dependence on “stan-dardized patients,” who they define succinctly as

“nonphysicians carefully trained to perform inmultiple roles of patient, teacher, and evaluator while realistically replicating a patient encoun-ter.” They present data on the reliability and va-lidity of standardized patient examinations, wheth-er evaluated by the “standardized” patient or athird-party observer.

Although this mode of evaluation has the advantages of standardization and the generation ofreproducible data, many medical educators andclinical teachers (this reviewer among them) ques-tion the technique. When students know they areexamining a standardized patient, is their behav-ior representative of their usual behavior? Studentshave a remarkable ability to show the side of them-selves that they perceive as desirable; why else

would virtually every applicant for internship ap-pear in a trim, ultraconservative dark suit? Mostof clinical medicine is taught by careful historytaking, examination of real patients, and discus-sions of differential diagnosis, pathophysiology,or disease management. Students’ behavior andtheir ability to elicit relevant information and dem-onstrate critical assessment of data are easilyobserved during such clinical teaching sessions.In my view, the advantages of assessment duringcontact with real patients — a situation that isnot a one-time experience, is not perceived as a“test,” and fits the medical model — outweighthe lack of “standardization.”

Even though readers may quarrel with someof the views expressed in this book, the editorshould be praised for bringing together this tal-



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ented group of medical educators. In his acknowl-edgments, Stern writes, “These authors are morethan expert researchers or physicians, theydemonstrate the highest degree of collegiality,intellectual integrity, compassion, and teamwork— they practice what they preach.” This book

suggests that they also preach what they practice. Jerome Lowenstein, M.D.New York University School of MedicineNew York, NY 10016Book Reviews Copyright © 2006 Massachusetts Medical Society.

correction

Cardiovascular Events Associated with Rofecoxib in a Colorec-tal Adenom a Chemoprevent ion Trial (March 17, 2005;352:1092-102). In the reported results, the test for proportionality ofhazards used linear time rather than the logarithm of timethat was specified in the Met hods section. Analysis using thelogarithm of time leads to t he following changes:

The first complete paragraph on page 1097 should have read,“In a post hoc assessment, visual inspection of Figure 2 suggestedthat the Kaplan–Meier curves separated 18 months after ran-domization. However, the results of an overal l test of the propor-tional-hazards assumption for the entire 36-month observationperiod did not reach statistical signif icance (P = 0.07).”

Therefore, statements regarding an increase in risk after18 months should be removed from the Abstract (the sentence“The increased relative risk became apparent after 18 monthsof treatment; during the f irst 18 months, the event rates weresimilar in the two groups” should be deleted, as should thesentence beginning “There was earlier separation . . .”) andfrom the Discussion section (the sentence “In post hoc ana ly-ses, the increased relative risk of adjudicated thrombotic events

was fi rst observed afte r approxim ately 18 months of treat-ment” should be deleted).

In addition, the first full paragraph on page 1100 shouldhave read, “In our randomized, placebo-controlled trial, wefound an increased risk of confirmed thrombotic events asso-ciated with the use of rofecoxib. Visual inspection of the Kap-lan–Meier curves suggested that there was an increased fre-quency of thrombotic events associated with rofecoxib therapyafter 18 months. Other investigators reported . . . .”

This Correction was published at www.nejm.org on June 26, 2006.

notices

Notices submitted for publication should contain a mailingaddress and telephone number of a contact person or depart-

ment. We regret that we are unable to publish all noticesreceived. Notices also appear on the Journal’s Web site(www.nejm.org/meetings). The listings can be viewed intheir entirety or searched by location, month, or key word.

INTERNATIONAL SOCIETY OF HEMATOLOGY

The “31st World Congress” will be held in San Juan, PuertoRico, Aug. 9–12.

Contact Imedex, 4325 Alexander Dr., Alpharetta, GA 30022-3740; or see http://www.ish2006.org.

NORTH CAROLINA OCCUPATIONAL SAFETY

AND HEALTH EDUCATION & RESEARCH CENTER

The following courses wil l be offered in Chapel Hill, N.C.,unless otherwise indicated: “Occupational Health NursingCertification Review” (Marco Island, Fla., Aug. 7–9); “29th An-nual Occupational Safety and Health Summer Institute” (Mar-co Island, Fla., Aug. 7–11); “Supervising Lead Abatement Pro-grams” (refresher course, Aug. 21); “Asbestos Operations andMaintenance” (Sept. 11 and 12); “Comprehensive IndustrialHygiene (CIH) Review Course” (Sept. 18–22); “Building In-spection and Management Planning for Asbestos” (Oct. 2–6;refresher course, Sept. 7); “Supervising Asbestos AbatementProjects” (Oct. 23–27; refresher course, Sept. 6); and “CertifiedSafety Professional (CSP) Review Course” (Nov. 13–17).

Contact Occupational Safety and Health Education & Re-search Center, University of North Carolina, 3300 Hwy. 54 W.,Chapel Hill, NC 27516-8264; or call (888) 235-3320 (national)or (919) 962-2101 (North Carolina); or fax (919) 966-7579; orsee http://www.sph.unc.edu/osherc/; or e-mail [email protected].

12TH WORLD CONGRESS ON PAIN

The congress wi ll be held in Glasgow, Scotland, Aug. 17–22.It is sponsored by the International Association for the Studyof Pain.

Contact Elizabeth Twiss, 909 NE 43rd St., Suite 306, Seattle,WA 98105-6020; or call (206) 547-6409; or fax (206) 547-1703;or e-mail [email protected]; or see http://www.iasp-pain.orgor http://www.painbooks.org.

SINGAPORE GENERAL HOSPITAL POSTGRADUATE

MEDICAL INSTITUTE

The following conferences will be held in Singapore: “Pro-fessionalism in Medicine” (Aug. 22–25) and “Regional Confer-ence on Cost-Effective Healthcare” (Oct. 28–31).

Contact Singapore General Hospital Postgraduate MedicalInstitute, Blk 6 Level 1, Outram Rd., Singapore 169608; or call(65) 6321 4078; or fax (65) 6226 0356.

4TH ANNUAL INTERNATIONAL NEURO-ONCOLOGY

UPDATE

The meeting will be held in Memphis, Tenn., Aug. 24 and

25. It is sponsored by Methodist University Hospital–Neurosci-ence Institute, Johns Hopkins University, and the Carlo BestaInternational Neurological Institute.

Contact Katie Rapp, Methodist Healthcare, 1211 UnionAve., Suite 900, Memphis, TN 38104; or cal l (901) 516-0609;or see http://neuro.methodisthealth.org; or e-mail [email protected].

CYTOKINES 2006

The “6th Joint Meeting” of the International Cytokine Soci-ety, the International Society for Interferon and Cytokine Re-search, and the European Cytokine Society will be held in Vi-enna, Aug. 27–31.

Contact Ärztezentrale Med.Info, Helferstorferstrasse 4,1014 Vienna, Aust ria; or call (43) 1-531 16-39; or fax (43) 1-53116-61; or e-mail azmedin [email protected].

MONTEFIORE MEDICAL CENTER–ALBERT EINSTEINCOLLEGE OF MEDICINE

The following courses will be offered: “Clinical Neurologyfor Psychiatrists” (Los Angeles, Sept. 8–10; New York, Oct. 6–8)and “Psychiatry for Psychiatrists: The Pre-Test” (Los Angeles,Sept. 11 and 12; New York, Oct. 9 and 10).

Contact Montefiore Medical Center, The University Hospitalfor the Albert Einstein College of Medicine, Jerome L. andDawn Greene Medical Arts Pavilion, 3400 Bainbridge Ave., 5thFl., Bronx, NY 10467-2490; or see http://www.cnfp.org.

Notices



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