Two themes common to the five articles in this issue are the relevance of history for providing perspective on matters of current concern and the need for a critical perspective on both the theoretical models and the research evidence that we use to understand important problems that face health care researchers and policymakers.
This issue begins with an article by Rosemary Stevens, the distinguished historian of 20th-century health care. Stevens has written the definitive book on the development of medical specialization (Stevens 1971 and 1998) and is currently studying the specialty certifiying boards. She is knowledgeable about both the historiography and historical sociology of the medical profession and a close observer of its contemporary role. Her article, "Public Roles for the Medical Profession in the United States: Beyond Theories of Decline and Fall," assesses the potential for medical professional organizations to assume a positive role in the health care system. Stevens reflects on why these organizations lost credibility, how sociologists and historians have analyzed the changing role of the medical profession, and how the "public mission" of the profession might be reinvented.
A second historical article in this issue is "Do Not Delay: Breast Cancer and Time, 1900–1970," by Robert A. Aronowitz. Until fairly recently, medical and public health practice for breast cancer, as well as for many other diseases, had at best a weak and often an erroneous evidentiary basis (Lerner 2001). Aronowitz describes how a strong and stable public health message about the importance of avoiding delay in seeking care was promulgated by cancer surgeons and by the American Cancer Society and organizations associated with it through much of the 20th century. He draws on epidemiology, clinical science, and medical practice to demonstrate linkages between the "do not delay" message and contemporary assumptions about the natural history of cancer, the efficacy of surgery, and individual responsibility for disease. Aronowitz concludes that behavioral changes that the campaign stimulated or reinforced among both women and medical professionals led to perceptions of its effectiveness.
In "The Utility of Social Capital in Research on Health Determinants," James Macinko and Barbara Starfield examine one of the most attractive concepts in recent social epidemiology. It is well known that social factors are related to health status, within and across populations. However, understanding why various social factors are associated with differences in health status has been more challenging. The idea of social capital offers suggestions about some pathways by which social variables could affect health. Macinko and Starfield examine the several ways that "social capital" has been conceptualized, and describe its use in different research literatures—sociology, political science, economics, and community development, as well as health. They conclude by suggesting how the concept might be refined for use in explaining differences in health status and health outcomes.
Kieran Walshe and Thomas Rundall examine the relationship between evidence and practice in the management of health care organizations in "Evidence-based Management: From Theory to Practice in Health Care." Walshe and Rundall, who bring British and American perspectives to the task, observe that it is increasingly accepted that the care that patients receive should have a solid basis in research evidence. Clinicians and policymakers pay homage to this idea, as do managers of health care organizations. Managers, however, have been slow to embrace the view that the managerial function itself should have a solid basis in research, and within academic health administration programs one can find skeptics as well as advocates of evidence-based management. Walshe and Rundall contrast the cultures of clinical and managerial practice, describe an ongoing successful example of a collaboration involving researchers and managers, and analyze the barriers to health management becoming more strongly based in research.
The final article in this issue is of a more personal nature: David Mechanic's reflections on some lessons he draws from his research experience over almost 40 years. Mechanic is a prolific researcher and an elected member of the Institute of Medicine and the National Academy of Sciences. These reflections were stimulated by his being asked to give the first Sam Shapiro Lecture at Johns Hopkins University. His title reveals his themes: "Lessons from the Unexpected: The Importance of Data Infrastructure, Conceptual Models, and Serendipity in Health Services Research." He praises the pioneers who had the vision to make the arguments that secured the resources needed to put in place the systems of data collection on which so much health services research has subsequently rested. He makes the case for approaching data with sophisticated conceptual models that can focus the analysis in productive ways. Using examples from his own experience, he urges researchers to be open to unexpected findings, for these can be the source of insights that can change the way that problems are understood.
The inclusion of the reflections of a senior figure in the field represents a departure from the Quarterly's usual content. I am happy to receive such essays for review.
Although this issue includes no reports of quantitative studies, that is a matter of happenstance, not of a change in editorial policy. Quantitative research is an important part of the tradition of the Milbank Quarterly, and will continue to be prominently featured. If you have thoughts or suggestions about any matters regarding what we publish (or might publish), I would be happy to hear from you (email@example.com).
Bradford H. Gray
Editor, The Milbank Quarterly
Lerner, B.H. 2001. Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America. New York: Oxford University Press.
Stevens, R. 1971. American Medicine and the Public Interest. New Haven: Yale University Press. Updated edition, with new introduction, 1998 (Berkeley: University of California Press).
Author(s): Bradford H. Gray
Volume 79, Issue 3
Published in 2001