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sarily—that such research results are usually based on those carefully designed studies of relatively homogeneous populations in one or two settings. The question of generalizability, validity, reliability, and applicability to the real world of 5,000 or 6,000 hospitals, 400,000 physicians, and several million nurses and other health care practitioners has not been tested. It is a little bit scary to think about implementing a proposal based upon such a "thin" body of research.

In fact, if someone gave me a magic wand and offered me a choice—take your chances with the Congress and a 10-year agenda and maybe have the strategy go through (or maybe not), or wave the magic wand and have the whole program implemented tomorrow—I would take my chances with the Congress because I am not sure it would work as we outlined it. The committee was not sure it would work; that is why we identified a 10-year agenda with substantial vagueness and many unanswered open questions. In essence we were saying that we do not know the specifics, and it is going to take at least 10 years to get from here to a point where we might have something ready for "prime time."


To get ready for prime time we need to look at tasks that might be usefully categorized under the headings of basic research, applied research, and dissemination. Then we can move to capacity building. The conference discussions often turned to variations—everybody knows that there is wide variability in how certain kinds of procedures and techniques are applied; what we do not yet know is what accounts for that variability.

Do the variations reflect uncertainty, in other words, a lack of science? Put another way, God has not told us that one of these two techniques really works better. Do the variations reflect unmeasured clinical factors? Even when you include only 6 percent of a population in a randomized trial, unmeasured clinical variables account for differences in outcomes. That is, is one technique truly better than the other when appropriately applied for the right criteria and conditions, but we do not yet know what those conditions are? That would appear to be random noise, looking as though it is sometimes better, sometimes worse. Do variations reflect patient preferences, or do they reflect variable competencies of providers? Finally, some patients really like one approach rather than another, as Albert Mulley (1991) pointed out.

Most of the things we are looking at are not single shots of penicillin produced under a very tightly controlled manufacturing process. Instead, they are interventions applied by people in organizations with varying levels of quality. Most of them would be considered reasonably good, but some

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