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Improving Diagnosis in Health Care (2015)

Chapter: Appendix B: Committee Member and Staff Biographies

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Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Appendix B

Committee Member and Staff Biographies

COMMITTEE MEMBER BIOGRAPHIES

John R. Ball, M.D., J.D. (Chair), is an executive vice president emeritus of the American College of Physicians and the American Society for Clinical Pathology. He is a graduate of Emory University, received a J.D. and an M.D. from Duke University, and was a Robert Wood Johnson Clinical Scholar at George Washington University. After a residency in internal medicine at Duke University, he held several health policy positions in the U.S. Public Health Service and was a senior policy analyst in the Office of Science and Technology Policy, Executive Office of the President. Dr. Ball originated the Washington office of the American College of Physicians and served as its executive vice president for 8 years. He subsequently was president and chief executive officer of Pennsylvania Hospital and an executive vice president and chief executive officer of the American Society for Clinical Pathology. In retirement, he has recently served as interim president of the Milbank Memorial Fund, on whose board he also serves. He is also a member of the board of Mission Health System in Asheville, North Carolina, where he resides. Dr. Ball was elected a member of the National Academy of Medicine in 1992.

Elisabeth Belmont, Esq., serves as the corporate counsel for MaineHealth, which is ranked among the nation’s top 100 integrated health care delivery networks and has combined annual revenues of nearly $2 billion. She has significant experience in the defense of professional liability claims and educates health care providers on using “lessons learned” from such

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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claims to inform quality improvement and patient safety initiatives to minimize medical errors. Ms. Belmont’s practice also focuses on electronic health information network strategy development and implementation to support innovations in care delivery and payment models as well as the use of “big data” to enhance care processes and clinical outcomes. She has participated in a number of national initiatives where quality improvement, patient safety, and health information technology intersect, including events sponsored by the Department of Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology, HHS Office of the Inspector General, American Health Lawyers Association, American Society of Healthcare Risk Management, and American Association for the Advancement of Science. Ms. Belmont is a member of the Board on Health Care Services of the Institute of Medicine of the National Academies. She co-chairs the National Quality Forum’s Health IT Patient Safety Measures Standing Committee. Additionally, Ms. Belmont serves as a member of the Editorial Advisory Board of Bloomberg BNA’s Health Law Reporter. Ms. Belmont is a past president of the American Health Lawyers Association, a former chair of the association’s health information and technology practice group, and a former chair of the association’s Quality in Action Task Force. She also served as principal investigator for a research study funded by the American Society of Healthcare Risk Management, Minimizing Electronic Health Record–related Serious Safety Events and Related Medical Malpractice Liability. Ms. Belmont is the recipient of numerous honors, including being named by Modern Healthcare as 1 of the 2007 Top 25 Most Powerful Women in Healthcare and being selected to receive the 2014 David J. Greenburg Service Award. She is a nationally recognized author and lecturer on a myriad of health law topics.

Robert A. Berenson, M.D., is an Institute Fellow at the Urban Institute. He is an expert in health care policy, particularly Medicare, with experience practicing medicine, serving in senior positions in two administrations, and helping organize and manage a successful preferred provider organization. His primary research and policy interests currently are in the areas of payment reform, provider and plan pricing power, quality improvement, performance measurement, and delivery system reform. Dr. Berenson recently completed a 3-year term on the Medicare Payment Advisory Commission (MedPAC), the last 2 as vice chair. From 1998–2000, he was in charge of Medicare payment policy and private health plan contracting in the Centers for Medicare & Medicaid Services. Previously, he served as an assistant director of the Carter White House Domestic Policy Staff. Dr. Berenson is a board-certified internist who practiced for 20 years, the past 12 in a Washington, DC, group practice, and while practicing

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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helped organize and manage a successful preferred provider organization serving the Washington, DC, metropolitan area. He was co-author, with Walter Zelman, of The Managed Care Blues & How to Cure Them, and, with Rick Mayes, Medicare Prospective Payment and the Shaping of U.S. Health Care. He is a graduate of the Mount Sinai School of Medicine, a Fellow of the American College of Physicians, and on the adjunct faculty of the George Washington University School of Public Health.

Pascale Carayon, Ph.D., is the Procter & Gamble Bascom Professor in Total Quality in the Department of Industrial and Systems Engineering and the director of the Center for Quality and Productivity Improvement at the University of Wisconsin–Madison. She leads the Systems Engineering Initiative for Patient Safety (SEIPS) at the University of Wisconsin–Madison (http://cqpi.engr.wisc.edu/seips_home). SEIPS is an internationally known interdisciplinary research program that brings together researchers from human factors and ergonomics with researchers from medicine, surgery, nursing, pharmacy, and health services research. Dr. Carayon received her engineer diploma from the Ecole Centrale de Paris, France, in 1984 and her Ph.D. in industrial engineering from the University of Wisconsin–Madison in 1988. Dr. Carayon’s research belongs to the discipline of human factors engineering, in particular, macroergonomics. Her scholarly contributions aimed at modeling, assessing, and improving work systems (i.e., the systems of tasks performed by individuals using various technologies in a physical and organizational environment) in order to improve system performance and worker well-being. Her research has been funded by the Agency for Healthcare Research and Quality, the National Science Foundation, the National Institutes of Health, the National Institute for Occupational Safety and Health, the Department of Defense, various foundations, and private industry. She is a fellow of the Human Factors and Ergonomics Society and a fellow of the International Ergonomics Association. She is the recipient of the International Ergonomics Association Triennial Distinguished Service Award (2012) and is the first woman to receive this prestigious award. She has published more than 100 papers and more than 220 conference papers and 30 technical reports, and she is currently the co-editor-in-chief of Applied Ergonomics. She is the editor of the Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. She is a member of the National Academies of Sciences, Engineering, and Medicine Board on Human-Systems Integration.

Christine K. Cassel, M.D., is president and chief executive officer of the National Quality Forum. Previously she served as president and chief executive officer of the American Board of Internal Medicine. Dr. Cassel

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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is a member of the President’s Council of Advisors on Science and Technology (PCAST). She is the co-chair and physician leader of PCAST working groups that have made recommendations to the President on issues relating to health information technology, scientific innovation in drug development, and systems engineering in health care delivery. She was a member of the Commonwealth Fund’s Commission on a High Performance Health System and has served on Institute of Medicine committees that wrote the influential reports To Err Is Human and Crossing the Quality Chasm. She is an adjunct professor of medicine and a senior fellow in the Department of Medical Ethics and Health Policy at the University of Pennsylvania School of Medicine, a former dean of medicine at Oregon Health and Science University, the chair of geriatrics at Mount Sinai School of Medicine in New York, and the chief of general internal medicine at the University of Chicago. Dr. Cassel is a prolific scholar, having authored and edited 14 books and more than 200 published articles.

Carolyn M. Clancy, M.D., is the chief medical officer of the Veterans Health Administration. Previously, she was appointed the assistant deputy under secretary for health (ADUSH) for quality, safety, and value (QSV) for the Department of Veterans Affairs. Prior to her appointment as ADUSH for QSV, Dr. Clancy served as the director of the Agency for Healthcare Research and Quality (AHRQ) from February 2003 to August 2013. Dr. Clancy, a general internist and health services researcher, is a graduate of Boston College and the University of Massachusetts Medical School. Following clinical training in internal medicine, she was a Henry J. Kaiser Family Foundation Fellow at the University of Pennsylvania. Before joining AHRQ in 1990, she was also an assistant professor in the Department of Internal Medicine at the Medical College of Virginia. Dr. Clancy holds an academic appointment at the George Washington University School of Medicine (clinical associate professor, Department of Medicine) and serves as a senior associate editor at Health Services Research. She serves on multiple editorial boards, including those for JAMA, Annals of Family Medicine, American Journal of Medical Quality, and Medical Care Research and Review. She is a member of the National Academy of Medicine and was elected a Master of the American College of Physicians in 2004. In 2009 she was awarded the William B. Graham Prize for Health Services Research. Her major research interests include improving health care quality and patient safety and reducing disparities in care associated with patients’ race, ethnicity, gender, income, and education. As director of AHRQ, she launched the first annual report to the Congress on health care disparities and health care quality.

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Michael B. Cohen, M.D., is a medical director in the Anatomic Pathology and Oncology Division at ARUP Laboratories, a professor and vice chair for faculty and house staff development at the University of Utah School of Medicine, and the ombudsperson for the University of Utah Health Sciences Center. Dr. Cohen received his M.D. from Albany Medical College and completed his anatomic pathology residency at the University of California, San Francisco (UCSF). Dr. Cohen has been on the faculty at Columbia, UCSF, and the University of Iowa; he was chair of the Department of Pathology at Iowa for more than a dozen years. In addition, he has served on numerous editorial boards. He has been a National Institutes of Health–funded investigator and has published extensively in the field of prostate cancer and pathology. He is the recipient of multiple honors, including the Regents Award for Faculty Excellence at the University of Iowa and the Leonard Tow Humanism in Medicine Award. Dr. Cohen has been included in Castle Connolly American’s Top Doctors since 2007 and America’s Top Doctors for Cancer since 2005; Consumers’ Research Council of America Guide to America’s Top Pathologists since 2007; and Best Doctors in America list since 2005.

Patrick Croskerry, M.D., Ph.D., FRCP (Edin), is a professor in emergency medicine and in the Division of Medical Education at Dalhousie University, Halifax, Nova Scotia, Canada. He was appointed the director of the new Critical Thinking Program at Dalhousie Medical School in 2012. In addition to his medical training, he holds a doctorate in experimental psychology and a fellowship in clinical psychology. His research is principally concerned with clinical decision making, specifically on diagnostic error. He was on the organizing committee of the first national conference on diagnostic error in 2008 and the second one in 2009; he has contributed at each international conference since. He has published more than 80 journal articles and 30 book chapters in the area of patient safety, clinical decision making, and medical education reform. He was the senior editor on a major text, Patient Safety in Emergency Medicine (2009).

Thomas H. Gallagher, M.D., FACP, is a general internist who is professor and associate chair of the Department of Medicine at the University of Washington (UW), where is also professor in the Department of Bioethics and Humanities. Dr. Gallagher received his medical degree from Harvard University, completed his residency in Internal Medicine at Barnes Hospital, Washington University, St. Louis, and completed a fellowship in the Robert Wood Johnson Clinical Scholars Program, University of California, San Francisco. Dr. Gallagher’s research addresses the interfaces between health care quality, communication, and transparency. Dr. Gallagher has published more than 95 articles and book chapters on patient safety and

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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error disclosure, which have appeared in leading journals, including JAMA, New England Journal of Medicine, Health Affairs, Surgery, Journal of Clinical Oncology, Archives of Internal Medicine, Archives of Pediatric and Adolescent Medicine, and the Joint Commission Journal. His work in error disclosure received the 2004 Best Published Research Paper of the Year award from the Society of General Internal Medicine, as well as the 2012 Medically Induced Trauma Support Services Hope Award. He also received a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. He has been principal investigator on multiple grants from the Agency for Healthcare Research and Quality, including a patient safety and medical liability demonstration project titled “Communication to Prevent and Respond to Medical Injuries: WA State Collaborative.” He also was principal investigator on grants from the National Cancer Institute, the Robert Wood Johnson Foundation, and the Greenwall Foundation. He is senior author of Talking with Patients and Families About Medical Errors: A Guide for Education and Practice, published in 2011 by the Johns Hopkins University Press. At UW, he directs both the UW Medicine Center for Scholarship in Patient Care Quality and Safety and the UW Program in Hospital Medicine. He is an appointed Commissioner on the National Commission on Physician Payment Reform. Dr. Gallagher is an active member of many professional organizations, including the American College of Physicians (Fellow), the Society for General Internal Medicine, and the American Society of Bioethics and Humanities.

Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., F.A.A.N., is a health services researcher and the assistant vice president for quality at MedStar Health, a 10-hospital, $4.6 billion health system in the mid-Atlantic, where she oversees quality for both acute and non-acute health care services. She is a Fellow of the American Academy of Nursing, a National Baldrige Examiner, and associate faculty in the Johns Hopkins Bloomberg School of Public Health, where she teaches a required course in the Master of Hospital Administration program. Formerly the director of strategic research initiatives at the Johns Hopkins Armstrong Institute, Dr. Goeschel serves on the board of the Maryland Patient Safety Center and is the author of several book chapters and more than 65 peer-reviewed articles on topics ranging from implementation of large-scale clinical improvement projects to leadership for advancing the science of health care delivery and creating a culture of accountability in health care. Previous experience includes responsibility for quality, risk management, and service excellence in a Midwest teaching hospital and serving as an advisor to the World Health Organization Patient Safety Program. She served on the National Quality Forum (NQF) National Steering Committee for Serious Reportable Events and Healthcare Associated Conditions and currently serves on an NQF

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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panel exploring linkages between cost and quality. She is increasingly interested in the study of diagnostic errors—both their etiology and understanding the relationship of diagnostic error with preventable morbidity, mortality, and costs of care.

Mark L. Graber, M.D., FACP, is a senior fellow at RTI International and professor emeritus of medicine at the State University of New York at Stony Brook. He retired as the chief of medicine at the Northport Veterans Affairs Medical Center in 2011. Dr. Graber has an extensive background in biomedical and health services research, with more than 80 peer-reviewed publications. He is a national leader in the field of patient safety and originated Patient Safety Awareness Week in 2002, an event now recognized internationally. Dr. Graber has also been a pioneer in efforts to address diagnostic errors in medicine. In 2008 he convened and chaired the Diagnostic Error in Medicine conference series, and in 2011 he founded the Society to Improve Diagnosis in Medicine (www.improvediagnosis.org). In 2014 he became the founding editor of a new journal, Diagnosis, devoted to improving the quality and safety of diagnosis, and he received the John M. Eisenberg Award for Individual Achievement in Advancing Patient Safety from the National Quality Forum and The Joint Commission.

Hedvig Hricak, M.D., Dr.Med.Sc. (Ph.D.), Dr.h.c., is the chair of the Department of Radiology at Memorial Sloan Kettering Cancer Center, a professor in the Gerstner Sloan Kettering Graduate School of Biomedical Sciences, and a professor of radiology at the Weill Medical College of Cornell University. She also holds a senior position within the Molecular Pharmacology and Chemistry Program of the Sloan Kettering Institute. Previously, she was chief of the uroradiology and abdominal imaging sections of the Department of Radiology, University of California, San Francisco. She earned her M.D. from the University of Zagreb in Croatia, and her Dr.Med.Sc. (Ph.D.) from the Karolinska Institute in Stockholm, Sweden. Her research and clinical expertise is in the use of diagnostic imaging, specifically for the detection and assessment of genitourinary and gynecological cancers. She has worked continuously to develop and promote the use of evidence-based imaging algorithms to assist in cancer management, focusing on the development and validation of biomarkers from cross-sectional (ultrasound, MRI, CT) and molecular (DCE-MRI, MR spectroscopy, PET/CT and PET/MRI) imaging. Over the last 20 years, while serving in administrative leadership positions, she has been actively engaged in continuous process improvement and quality assurance efforts. Dr. Hricak served on the National Institutes of Health Board of Scientific Counselors, the National Cancer Institute (NCI) board of

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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scientific advisors, and the Advisory Council of the National Institute of Biomedical Imaging and Bioengineering. She is a member of the National Academy of Medicine. She served on the Institute of Medicine committee that produced the report A National Cancer Clinical Trials System for the 21st Century: Reinvigorating the NCI Cooperative Group Program. Since 2008 she has been a member of the Nuclear Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine. She chaired the Academies Committee on the State of the Science of Nuclear Medicine, which wrote the oft-cited report Advancing Nuclear Medicine Through Innovation. In addition, she chaired the 2009 Beebe symposium of the Academies, which focused on radiation exposures from imaging and image-guided interventions. The many leadership posts she has held in professional organizations include president of the California Academy of Medicine and president of the Radiological Society of North America board of directors. Over the course of her career, she has received numerous honors and awards, including foreign membership in both the Croatian Academy of Arts and Sciences and the Russian Academy of Medicine, and an honorary doctorate in medicine from Ludwig Maximilian University in Munich, Germany.

Anupam B. Jena, M.D., Ph.D., is an associate professor of health care policy and medicine at Harvard Medical School and an attending physician in the Department of Medicine at Massachusetts General Hospital, where he practices general inpatient medicine and teaches medical residents. He is also a faculty research fellow at the National Bureau of Economic Research. As an economist and a physician, Dr. Jena researches several areas of health economics and policy, including medical malpractice, the economics of medical innovation and cost effectiveness, the economics of physician behavior, and the effect on physician quality of reforms to medical education. Dr. Jena graduated Phi Beta Kappa from the Massachusetts Institute of Technology with majors in biology and economics. He received his M.D. and Ph.D. in economics from the University of Chicago. He completed his residency in internal medicine at Massachusetts General Hospital. In 2007 he was awarded the Eugene Garfield Award by Research America for his work demonstrating the economic value of medical innovation in HIV/AIDS. In 2013 he received the National Institutes of Health Director’s Early Independence Award to fund research on the physician determinants of health care spending, quality, and patient outcomes.

Ashish K. Jha, M.D., M.P.H., is the K.T. Li Professor of International Health and director of the Harvard Global Health Institute at the Harvard T.H. Chan School of Public Health. He is also a practicing general internist

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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with a clinical focus on hospital care. Over the past 6 years he has served as a senior advisor for quality and safety to the Department of Veterans Affairs (VA). Dr. Jha received his M.D. from Harvard Medical School in 1997 and trained in internal medicine at the University of California, San Francisco, where he also served as the chief medical resident. He completed his general medicine fellowship from Brigham and Women’s Hospital and Harvard Medical School and received his M.P.H. in clinical effectiveness from the Harvard School of Public Health in 2004. He joined the faculty in July 2004. The major themes of his research include the impact of public policy on the health care delivery system with a focus on patient safety, clinical outcomes, and costs of care. Much of his work has focused on understanding how policy efforts such as public reporting, pay for performance, and the promotion of the use of health information technology affect clinical quality, patient safety, and health care costs. Dr. Jha’s most recent work has focused on key levers for improvement, including organizational leadership and how it affects the delivery of safe, effective, and efficient care.

Michael Laposata, M.D., Ph.D., is the chair of the Department of Pathology at the University of Texas Medical Branch at Galveston. He received his M.D. and Ph.D. from Johns Hopkins University School of Medicine and completed a postdoctoral research fellowship and residency in Laboratory Medicine (Clinical Pathology) at the Washington University School of Medicine in St. Louis. He took his first faculty position at the University of Pennsylvania School of Medicine in Philadelphia in 1985, where he was an assistant professor and director of the hospital’s coagulation laboratory. In 1989 he became the director of clinical laboratories at the Massachusetts General Hospital and was appointed to the faculty in pathology at Harvard Medical School, where he became a tenured full professor of pathology. His research program, with more than 160 peer-reviewed publications, has focused on fatty acids and their metabolites. His research group is currently focused on the study of fatty acid alterations in cystic fibrosis. Dr. Laposata’s clinical expertise is in the field of blood coagulation, with a special expertise in the diagnosis of hypercoagulable states. Dr. Laposata implemented a system whereby the clinical laboratory data in coagulation and other areas of laboratory medicine are systematically interpreted with the generation of a patient-specific narrative paragraph by a physician with expertise in the area. This service is essentially identical to the service provided by physicians in radiology and anatomic pathology except that it involves clinical laboratory test results. In 2005 Dr. Laposata was recognized by the Institute of Quality in Laboratory Medicine of the Centers for Disease Control and Prevention for this innovation. Dr. Laposata is the recipient of 14 major

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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teaching prizes at Harvard, the Massachusetts General Hospital, and the University of Pennsylvania School of Medicine. His recognitions include the 1989 Lindback award, a teaching prize with competition across the entire University of Pennsylvania system; the 1998 A. Clifford Barger mentorship award from Harvard Medical School; election to the Harvard Academy of Scholars in 2002 and to the Vanderbilt University School of Medicine Academy for Excellence in Teaching in 2009; and the highest award—by vote of the graduating class—for teaching in years 1 and 2 at Harvard Medical School in 1999, 2000, and 2005.

Kathryn McDonald, M.M., has more than 20 years of experience in health care, working in a variety of settings: industry, hospitals, and academia. She is the executive director of the Center for Health Policy and the Center for Primary Care and Outcomes Research (CHP/PCOR) at Stanford University, a senior scholar at the centers, and the associate director for the Stanford–University of California, San Francisco, Evidence-Based Practice Center (with RAND). Her research focuses on evidence-based health care quality measures and interventions, with an emphasis on organizational context and key health care stakeholders (patients/families, clinicians, systems administrators). Her research portfolio includes initial and ongoing development of the publicly released Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Quality Indicators (www.qualityindicators.ahrq.gov), reviews of patient safety practices (Making Healthcare Safer I and II), and two series of evidence reports on quality improvement strategies (Closing the Quality Gap, Quality Kaleidoscope). She continues to lead a multi-institution measure development team for support of and expansions to the AHRQ Quality Indicators. She is the lead author of the Care Coordination Measures Atlas (www.ahrq.gov/qual/careatlas). She has published more than 100 peer-reviewed articles and evidence reports, presents regularly at national meetings, and collaborates with a wide network of investigators, health care practitioners, and patients and their families. Ms. McDonald has a strong service record, currently as the chair of the Patient Engagement Committee of the Society to Improve Diagnosis in Medicine and the associate editor of the journal Diagnosis. Previously, she was the president of the Society for Medical Decision Making and a member of the Institute of Medicine committee that issued the report Child and Adolescent Health and Health Care Quality: Measuring What Matters. She holds a master of management degree (M.B.A. equivalent) from Northwestern University’s Kellogg School of Management, with an emphasis on the health care industry and organizational behavior, and a B.S. in chemical engineering from Stanford University.

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Elizabeth A. McGlynn, Ph.D., is the director of Kaiser Permanente’s Center for Effectiveness and Safety Research (CESR). She is responsible for the strategic direction and scientific oversight of CESR, a virtual center designed to improve the health and well-being of Kaiser’s 9 million members and the public by conducting comparative effectiveness and safety research and implementing findings in policy and practice. Dr. McGlynn is an internationally known expert on methods for evaluating the appropriateness, quality, and efficiency of health care delivery. She has conducted research in the United States and in other countries. Dr. McGlynn has also led major initiatives to evaluate health reform options under consideration at the federal and state levels. Dr. McGlynn is a member of the National Academy of Medicine. She serves as the secretary and treasurer of the American Board of Internal Medicine Foundation board of trustees. She is on the board of AcademyHealth, the Institute of Medicine Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine, and the Reagan–Udall Foundation for the Food and Drug Administration. She chairs the scientific advisory group for the Institute for Healthcare Improvement. She co-chairs the coordinating committee for the National Quality Forum’s Measures Application Partnership. She serves on the editorial boards for Health Services Research and The Milbank Quarterly and is a regular reviewer for many leading journals. Dr. McGlynn received her B.A. in international political economy from Colorado College, her M.P.P. from the University of Michigan’s Gerald R. Ford School of Public Policy, and her Ph.D. in public policy analysis from the Pardee RAND Graduate School.

Michelle Rogers, Ph.D., is an associate professor in the College of Computing and Informatics at Drexel University. She has more than 10 years of experience using human factors engineering methods and sociotechnical systems theory to study the impact of health information technology (health IT) on clinical workflow and the usability of technology in order to support patient safety and reduce human error. Over her career, her projects focused on understanding the impact of health IT on clinical workflow and patient safety, as is demonstrated in her work with the Computerized Patient Record System, the Bar-Code Medication Administration system, and MyHealthVet (Veterans Affairs patient portal) in use at the Veterans Health Administration where she was a faculty research scientist. Her current work involves applying human factors engineering methods to study health care practices, information and data needs related to maternal/child care, as well as the implementation and use of electronic medical records at Makerere University in Uganda.

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Urmimala Sarkar, M.D., M.P.H., is associate professor of medicine at the University of California, San Francisco (UCSF), in the Division of General Internal Medicine, a core faculty member of the UCSF Center for Vulnerable Populations, and a primary care physician at San Francisco General Hospital’s Richard H. Fine People’s Clinic. Dr. Sarkar’s research focuses on patient safety in outpatient settings, including adverse drug events, missed and delayed diagnosis, failures of treatment monitoring, health information technology and social media to improve the safety and quality of outpatient care, and implementation of evidence-based innovations in real-world, safety-net care settings. She is the principal investigator of a Patient Safety Learning Laboratory, which applies design thinking and interdisciplinary, iterative approaches to characterize and address safety gaps in outpatient settings (Agency for Healthcare Research and Quality P30HS023558), and of an implementation and dissemination network to support innovations to improve the safety and quality of care in safety-net settings across California (Agency for Healthcare Research and Quality R24HS022047). Dr. Sarkar is an associate editor for Patient Safety Net (psnet.ahrq.gov), the most comprehensive national Web-based resource for patient safety, and a member of the editorial board of the Joint Commission Journal of Quality and Patient Safety. Dr. Sarkar completed clinical training in internal medicine and health services research fellowship training at UCSF, holds an M.P.H. in epidemiology from the University of California, Berkeley, an M.D. from the University of California, San Diego, and a B.S. with honors in biological sciences from Stanford University.

George E. Thibault, M.D., became the seventh president of the Josiah Macy Jr. Foundation in January 2008. Immediately prior to that, he served as the vice president of clinical affairs at Partners Healthcare System in Boston and the director of the Academy at Harvard Medical School (HMS). He was the first Daniel D. Federman Professor of Medicine and Medical Education at HMS and is now the Federman Professor, Emeritus. Dr. Thibault previously served as the chief medical officer at Brigham and Women’s Hospital and as the chief of medicine at the Harvard-affiliated Brockton/West Roxbury Veterans Affairs Hospital. He was the associate chief of medicine and the director of the Internal Medical Residency Program at the Massachusetts General Hospital (MGH). At the MGH he also served as the director of the Medical Intensive Care Unit and the founding director of the Medical Practice Evaluation Unit. For nearly four decades at HMS, Dr. Thibault played leadership roles in many aspects of undergraduate and graduate medical education. He played a central role in the New Pathway curriculum reform and was a leader in the new integrated curriculum reform at HMS. He was the founding director of the Academy at HMS, which was created to recognize outstanding teachers

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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and to promote innovations in medical education. Throughout his career he has been recognized for his roles in teaching and mentoring medical students, residents, fellows, and junior faculty. In addition to his teaching, his research has focused on the evaluation of practices and outcomes of medical intensive care and variations in the use of cardiac technologies. Dr. Thibault is chair of the board of the MGH Institute of Health Professions, and he serves on the boards of the New York Academy of Sciences, the New York Academy of Medicine, the Institute on Medicine as a Profession, the New York Academy of Medicine, and the Lebanese American University. He serves on the President’s White House Fellows Commission, and for 12 years he chaired the Special Medical Advisory Group for the Department of Veterans Affairs. He is past president of the Harvard Medical Alumni Association and past chair of alumni relations at HMS. He is a member of the National Academy of Medicine. Dr. Thibault graduated summa cum laude from Georgetown University in 1965 and magna cum laude from HMS in 1969. He completed his internship and residency in medicine and fellowship in cardiology at MGH. He also trained in cardiology at the National Heart, Lung, and Blood Institute in Bethesda and at Guys Hospital in London, and he served as chief resident in medicine at MGH. Dr. Thibault has been the recipient of numerous awards and honors from Georgetown (Ryan Prize in Philosophy, Alumni Prize, and Cohongaroton Speaker) and Harvard (Alpha Omega Alpha, Henry Asbury Christian Award, and Society of Fellows). He has been a visiting scholar both at the Institute of Medicine and Harvard’s Kennedy School of Government and a visiting professor of medicine at numerous medical schools in the United States and abroad.

John B. Wong, M.D., FACP, is a practicing general internist, the chief of the Division of Clinical Decision Making at Tufts Medical Center, the director of Comparative Effectiveness Research at Tufts Clinical Translational Science Institute, and a distinguished professor of medicine at Tufts University School of Medicine. A graduate of Haverford College, he received his M.D. from the University of Chicago followed by internal medicine residency and medical informatics fellowship in Clinical Decision Making at Tufts Medical Center. A past president of the Society for Medical Decision Making, he has participated in consensus conferences, guideline development and appropriateness use criteria assessment for the World Health Organization, National Institutes of Health, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, American Association for the Study of Liver Diseases, American Heart Association, American College of Cardiology, European League Against Rheumatism, and OMERACT. Besides translating guidelines into quality improvement and performance measures in the American Medical Associ-

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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ation Physician Consortium for Performance Improvement Work Groups, he has developed award-winning decision aids for shared decision making with the Informed Medical Decisions Foundation. Dr. Wong’s research focuses on the application of decision analysis to help patients, physicians, and policy makers choose among alternative tests, treatments, and policies, thereby promoting rational evidence-based efficient and effective patient-centered care. A co-author of Learning Clinical Reasoning and Decision Making in Health and Medicine and more than 150 scientific publications and book chapters, including the Reference Manual on Scientific Evidence for the National Academy of Sciences, his research areas include clinical and diagnostic reasoning, decision sciences, test interpretation, Bayesian methods, quality and appropriateness of care, health economics, patient-centeredness, shared decision making, and evidence-based medicine.

STAFF BIOGRAPHIES

Erin Balogh, M.P.H., is a program officer for the Institute of Medicine’s Board on Health Care Services and the National Cancer Policy Forum (NCPF) of the National Academies of Sciences, Engineering, and Medicine. She has directed NCPF workshops on patient-centered cancer treatment planning, affordable cancer care, precompetitive collaboration, combination cancer therapies, and reducing tobacco-related cancer incidence and mortality. She staffed consensus studies focusing on the quality of cancer care, omics-based test development, the national clinical trials system, and the evaluation of biomarkers and surrogate endpoints. She completed her M.P.H. in health management and policy at the University of Michigan School of Public Health, and she graduated summa cum laude from Arizona State University with bachelor’s degrees in microbiology and psychology. Ms. Balogh interned with AcademyHealth in Washington, DC, and worked as a research site coordinator for the Urban Institute in Topeka, Kansas. Previously, Ms. Balogh was a management intern with the Arizona State University Office of University Initiatives, a strategic planning group for the university. She was the recipient of the Institute of Medicine Above and Beyond award (2014) and the staff team achievement award (2012).

Bryan Miller, Ph.D., is a research associate for the Institute of Medicine’s Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine. He earned an M.A. from the Brains and Behavior program at Georgia State University in 2007, and he completed his Ph.D. in philosophy of science at Johns Hopkins University in the summer of 2014. He has performed research at the Berlin School of Mind and Brain and Charité University Hospital in Berlin and taught courses

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
×

in the philosophy of science, the philosophy of psychology, and bioethics at several universities in the Baltimore–Washington, DC, area.

Sarah Naylor, Ph.D., completed a Ph.D. in developmental biology at Washington University in 2012 and earned a B.S. with distinction in bioengineering from the University of Illinois. She performed postdoctoral research at the National Institutes of Health and worked as an intern in the Office of Autism Research Coordination within the National Institute of Mental Health. She is currently a Science & Technology Policy Fellow with the American Association for the Advancement of Science in Evaluation and Assessment in the Office of the Assistant Director for Engineering.

Kathryn Garnham Ellett, M.P.P., is a policy analyst for the Assistant Secretary for Financial Resources at the Department of Health and Human Services (HHS), where she has been working on Centers for Medicare & Medicaid Services (CMS) policy since 2010. She was on detail as a research associate for the Institute of Medicine Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine from April through July 2015. At HHS her portfolio includes Medicare post-acute care and hospice, Medicare Quality Improvement Organizations, and CMS’s survey and certification program. She completed her M.P.P. at the University of Toronto in 2010 and her B.S. at Queen’s University in Kingston, Ontario. Prior to her time at HHS she worked in home health care. She also worked for a hospital system implementing an eldercare access strategy in emergency rooms and has researched nursing home staffing and palliative care.

Celynne Balatbat is the special assistant to the president of the National Academy of Medicine. Previously, she was a research assistant with the Institute of Medicine’s Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine. She received her B.A. in neuroscience and behavior from Vassar College in 2013. Before coming to the Academies, she interned in the advocacy department at AARP California and worked as a laboratory assistant in a medical microbiology lab at the University of California, Davis.

Patrick Ross is a research assistant with the Institute of Medicine’s Board on Health Care Services and National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine. Patrick graduated from Concordia College in Moorhead, Minnesota, in 2013 with a B.A. in psychology with minors in biology and chemistry, where his senior research project focused on bacteriocins in Neisseria meningitidis.

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Before joining the Academies, Patrick worked in various health advocacy groups, including Families USA.

Laura Rosema, Ph.D., joined the Institute of Medicine’s Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine as part of the Winter 2015 Christine Mirzayan Science and Technology Policy Fellowship class. Prior to the fellowship, she served as the scientific advisor for Bill Gates’s Global Good Fund, a private initiative chartered to commercialize inventions in developing countries. At Global Good, Dr. Rosema advised on investment strategy and technical directions for the fund. She has led evaluations on topics that include using biometric signatures for health record tracking, implantable medical devices, and diagnostic development for malaria elimination programs. She received her Ph.D. in chemistry from the University of Washington and earned her master’s and bachelor’s degrees in inorganic chemistry from Bryn Mawr College. She is currently a Science & Technology Policy Fellow with the American Association for the Advancement of Science serving in the National Institutes of Health Office of Science Policy, in the Office of Science Management and Reporting.

Beatrice Kalisch, R.N., Ph.D., FAAN, is the 2013 Distinguished Nurse Scholar in residence at the Institute of Medicine and the Titus Professor at the University of Michigan in Ann Arbor. She has conducted numerous research studies on such subjects as nursing teamwork, missed nursing care (errors of omission), the image of the nurse, and the impact of U.S. federal funds on nursing education and practice. Dr. Kalisch has published extensively, authoring 10 books and more than 150 peer-reviewed articles. She has made more than 800 presentations of her research throughout the world. She serves on the editorial boards of several national and international journals. Dr. Kalisch has also served as a visiting professor at several institutions, including Huazhong University of Science and Technology, Tongji Medical College, Wuhan, China, and the University of Sao Paulo, Brazil. She is listed in numerous bibliographies, such as Who’s Who in America and Who’s Who of American Women, Who’s Who in the World, Foremost Women of the Twentieth Century, and Community Leaders of the World. Dr. Kalisch is a Fellow in the American Academy of Nursing and a member of Phi Kappa Phi. She serves as a member as well as leader in numerous local, state, and national advisory committees addressing health policy and nursing issues. Dr. Kalisch has been the recipient of many awards, including distinguished alumna at both the University of Maryland and the University of Nebraska, the Shaw Medal from the President of Boston College, the Department of Labor research award, Joseph L. Andrews Bibliographic Award from the American Association of Law Libraries, book

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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of the year awards, nurse researcher award from the American Organization of Nurse Executives, and the Sigma Theta Tau Award for Excellence in Nursing.

Roger Herdman, M.D., was the director of the Institute of Medicine’s (IOM’s) Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine until June 2014. He received his undergraduate and medical school degrees from Yale University. Following an internship at the University of Minnesota and a stint in the U.S. Navy, he returned to Minnesota, where he completed a residency in pediatrics and a fellowship in immunology and nephrology and also served on the faculty. He was a professor of pediatrics at Albany Medical College until 1979. In 1969 Dr. Herdman was appointed director of the New York State Kidney Disease Institute in Albany, New York, and shortly thereafter was appointed deputy commissioner of the New York State Department of Health, a position he held until 1977. That year he was named New York State’s director of public health. From 1979 until joining the U.S. Congress Office of Technology Assessment (OTA), he served as a vice president of Memorial Sloan Kettering Cancer Center in New York City. In 1983 Dr. Herdman was named assistant director of OTA, where he subsequently served as director from 1993 to 1996. He later joined the IOM as a senior scholar and directed studies on graduate medical education, organ transplantation, silicone breast implants, and the Department of Veterans Affairs national formulary. Dr. Herdman was appointed director of the IOM/National Research Council National Cancer Policy Board from 2000 through 2005. From 2005 until 2009, Dr. Herdman directed the IOM National Cancer Policy Forum. In 2007 he was also appointed director of the IOM Board on Health Care Services. During his work at the IOM, Dr. Herdman worked closely with the U.S. Congress on a wide variety of health care policy issues.

Sharyl Nass, Ph.D., is director of the Board on Health Care Services and director of the National Cancer Policy Forum for the Institute of Medicine (IOM) of the National Academies of Sciences, Engineering, and Medicine. The Board addresses the organization, financing, effectiveness, workforce, and delivery of health care to ensure the best possible care for all patients. The Cancer Forum examines policy issues pertaining to the entire continuum of cancer research and care.

For more than 15 years at the IOM, Dr. Nass has worked on a broad range of topics that includes the quality of care, clinical trials, oversight of health research, development and assessment of medical technologies, and strategies for large-scale biomedical science. She has a Ph.D. in cell and tumor biology from Georgetown University and undertook postdoc-

Suggested Citation:"Appendix B: Committee Member and Staff Biographies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
×

toral training at the Johns Hopkins University School of Medicine. She also holds a B.S. in genetics from the University of Wisconsin–Madison, and she studied developmental genetics and molecular biology at the Max Planck Institute in Germany under a fellowship from the Heinrich Hertz-Stiftung Foundation. She was the 2007 recipient of the Cecil Award for Excellence in Health Policy Research, the 2010 recipient of a Distinguished Service Award from the Academies, and the 2012 recipient of the IOM staff team achievement award (as the team leader).

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Next: Appendix C: Previous Diagnostic Error Frameworks »
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Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.

Improving Diagnosis in Health Care a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001) finds that diagnosis-and, in particular, the occurrence of diagnostic errors—has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

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