the medical profession. These include professional autonomy and accountability, training and socialization of physicians, traditions of informal peer review, and unfamiliarity with quality assurance as a formal process.

Autonomy and Accountability

The tension between autonomy in the practice of medicine and accountability for its quality is a hallmark of this profession. In granting the medical profession primary responsibility for quality, society has recognized the special expertise required to determine what constitutes goodness in technical care and has insulated physicians from interference by outside interests that might subvert clinical judgment. At the same time, it has expected a reasonable degree of public accountability. These are principles that the medical profession has espoused and to which society has largely adhered.

The desires of the medical profession to define quality and to control the means for assuring it have been recognized by delegating the monitoring function outside hospitals to organizations controlled by or responsive to physicians (such as the Medicare PROs). Within hospitals, the organized medical staff is entrusted with that responsibility. The medical profession also controls the criteria and standards by which quality of care is to be judged.

Opinions differ as to which societal requirements constitute interference with professional prerogatives and which are legitimate demands for accountability. In this tension between accountability and professional autonomy, one finds the origin of much that troubles quality assurance efforts today.

Socialization and Peer Relations

Two related characteristics of medicine are (1) the emphasis placed on recruitment, training, and socialization and (2) the significance accorded to informal rather than formal quality assurance interventions carried out by fellow clinicians. Both mechanisms are intended to produce professionals who are both technically competent and morally equipped to be self-critical and self-correcting. In professional training and in later practice, monitoring individual performance has been informal rather than formal. Individual conduct has been regulated indirectly through inclusion in or exclusion from the network of professional referrals and by other, more or less subtle indicators of professional approval.

Medical professionals depend economically and to some extent emotionally on one another. The careers of physicians depend on the approval of colleagues who vouch for their competence by sending them patients. Colleagues also offer encouragement and support for what may be regarded as



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