Corresponding author: William C. Roberts, MD, Baylor Cardiovascular Institutee, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246.

Dr. Ballard was a resident in internal medicine at the Mayo Clinic from 1983 to 1986. Following completion of his residency, he stayed at the Mayo Clinic and soon became head of the Section of Health Services Evaluation and associate professor of epidemiology at the Mayo Medical School. He then went to the University of Virginia School of Medicine in Charlottesville, Virginia, as associate professor of medicine at that medical school. In 1994, he went to Emory University as professor of epidemiology, professor of medicine, and director of the Center for Clinical Evaluation Sciences in the school of medicine.

Dr. Ballard is well known for his health care research; in 1995 he was selected by the Association for Health Services Research as the outstanding investigator <40 years of age. He has published >100 articles in peer-reviewed medical journals, 25 chapters in various books, and 20 editorials. We are fortunate to have attracted him to Baylor. His role is to improve health care across the entire Baylor Health Care System through health care research and innovation. He is also a terrific guy.

William Clifford Roberts, MD (hereafter, WCR): I am in my home today (November 3, 1999) with Dr. David Ballard, who has kindly agreed to speak with me and, therefore, to the readers of the BUMC Proceedings. David, I would like to discuss your early background. Where you were born?

David Joseph Ballard, MD (hereafter, DJB): I was born March 2, 1956, in St. Joseph's Hospital in Lexington, Kentucky, and grew up there with 7 siblings (Figure 2). When I entered the first grade at Christ the King Elementary School in Lexington, I had siblings in the eighth, seventh, sixth, fourth, and third grades. The first week of school I was referred to my oldest sister's eighth-grade class for remediation of untoward behavior.

My father was the first board-certified otolaryngologist in central Kentucky. He met my mother at the end of World War II at Chanute Air Force Base Hospital at Chanute Field in Rantoul, Illinois, where my father was a surgeon in the US Army Air Force and my mother was stationed after serving as a flight nurse in the US Army Air Force in Europe. After the war my father completed his otolaryngology training at St. Louis University and returned with my mother and the first of their 8 children to his native Kentucky, where he established a solo clinical practice in Lexington.

I spent my first 14 years in Lexington and was fortunate after finishing the eighth grade to have the opportunity to go to the Lawrenceville School in Lawrenceville, New Jersey, for my secondary school education. While at the Lawrenceville School, I was able to pursue a variety of interests and became particularly interested in issues related to history, economics, and policy (Figure 3).

By the time I finished secondary school I had been fairly well immersed in the world of clinical medicine. I had spent numerous hours in my father's office as an office assistant, attended hospital rounds with my father, and observed a variety of surgical procedures in the operating room with my father and other surgeons who were on the staff of St. Joseph's Hospital. As I was beginning to think about postsecondary school educational opportunities, I realized that I had an interest in health care from a health systems perspective as well as from a clinical practice perspective.

WCR: Where did you come in the birth order?

DJB: I was the sixth of 8 (Figure 4).

WCR: How many were boys vs girls?

DJB: The eighth was a boy, who made the family even at 4 sons and 4 daughters. Therefore, my parents named him Steven.

WCR: I gather in high school you not only did well in your studies but were a pretty good athlete.

DJB: I enjoyed athletics. At the Lawrenceville School I played at the varsity level in baseball, basketball (Figure 5), and football. I was captain of the baseball team my senior year, and I was all-state in New Jersey in baseball and football. During my senior year I was also selected by the National Football Foundation and Hall of Fame as the outstanding scholar-athlete among secondary schools in New Jersey and Pennsylvania.

WCR: What did you play in football?

DJB: Our coach, Dr. Kenneth Keuffel, had been the captain of the Andover team, where he was a classmate of George Bush, and an end on the Princeton team with Hal Urschel, MD. He continues to coach in his mid 70s and is probably the foremost authority on the single wing. Over the past 40 years, he has deployed an unbalanced-line single-wing formation. In this formation, I was the starting 5-tackle during my junior and senior years. I also started as a defensive tackle and occasionally as an end in a 5-down men defensive formation.

WCR: In baseball?

DJB: I was the starting catcher from the end of my sophomore year through my senior year.

WCR: I see that you went to the University of North Carolina (UNC) to college. How did that come about?

DJB: I was planning to attend either Harvard or Amherst, where I had received early notifications of acceptance, but in February of my senior year, Lawrenceville asked me to consider interviewing for the Morehead scholarship at UNC. The Morehead scholarship, which was initiated in the mid 1950s, is patterned along the lines of the Rhodes scholarship. John Motley Morehead, who invented the process of synthesizing acetylene and developed a company that today is known as Union Carbide, founded the Morehead program based on his belief “that the most important investment that can be made in a people is that which is made in the education and training, as leaders, of those who have been endowed by their creator with the capacity for leadership.” Along with nominees from other secondary schools across the USA and Canada that now include St. Mark's School of Texas and The Hockaday School in Dallas as well as English public schools such as Charterhouse, Eton College, and Rugby School, I spent my 18th birthday at UNC interviewing for the scholarship.

I was very impressed with the intellectual resources of the Chapel Hill campus but was also entranced with UNC after attending a magical basketball game in which North Carolina scored 8 points in the final 17 seconds of regulation time against Duke. The game went into overtime and was won by UNC. Among UNC basketball history aficionados, the game is regarded as the most remarkable victory among >1000 Tar Heel victories. When I was offered the Morehead scholarship the following week, I decided to forego my plans to attend college in Massachusetts and, instead, go to UNC. While I was immersed in the academic environment of the nation's first state university, I also attended some amazing basketball games during the 1974 to 1983 period in which I lived in Chapel Hill. That time span encompassed the “Jordan years,” including an in-bounds pass steal followed by a dunk by Michael Jordan over the 7'4" Ralph Sampson to win by 1 point the last game that Samson's University of Virginia team played in Chapel Hill.

WCR: Did you enjoy college?

DJB: Yes. I enjoyed UNC a great deal (Figure 6). It is a tremendous university with exceptional resources in the health sciences. It was a particularly good choice for me in terms of pursuing my professional interests. As a freshman undergraduate, in addition to playing baseball, I was able to take a course on health care organization taught by faculty from the school of medicine and school of public health. I worked with one of the nation's leading health economists for my undergraduate thesis work in economics. As an undergraduate I also met Ed Wagner, MD, MPH, the mentor for my doctoral programs in medicine and epidemiology who at that time was a professor of medicine and head of the Robert Wood Johnson Clinical Scholars Program at UNC. After we worked together at UNC, Ed became in 1983 the director for the Center of Health Studies at Group Health Cooperative, Puget Sound, in Seattle. More recently, as director of the McCool Institute for Health Care Innovation, Dr. Wagner has been leading a $25-million initiative funded by the Robert Wood Johnson Foundation to test strategies to improve chronic illness care in collaboration with Don Berwick, MD, MPP, CEO of the Institute for Healthcare Improvement.

WCR: You were pretty clear by the time you went to college that you wanted to go to medical school?

DJB: Yes. I knew at that time I was interested in clinical issues related to the delivery of medical care and studying broader policy issues related to health care delivery.

WCR: In retrospect, how do you think you got interested in that aspect of it? You mentioned you went to your father's office a good bit and you made rounds with him, scrubbed with him in the operating room. By the time you went to college you were pretty well versed with day-to-day medicine, and yet early on you decided you wanted to look at the delivery of health care in the big picture, not with a single patient?

DJB: Yes. I was very fortunate to have exposure at an early age to clinical practice through my father (Figure 7). These experiences led to thinking about the evidence base for clinical practice and to questions such as, “Why did this patient have a tonsillectomy?” My father was also very instrumental in having his children think about the overarching issues of health policy as related to decisions made by individual physicians. I remember having discussions with him about the initial implementation of Medicare policies and what impact that had on his practice in the mid to late 1960s.

WCR: What do your other 7 siblings do? Are any of them physicians?

DJB: Two of my sisters are physicians. One whose training is in internal medicine, nutrition, and preventive medicine is the associate director of the Applied Research Program of the National Cancer Institute in Bethesda. Her work examines the individual, societal, and health systems factors that may explain cancer occurrence and outcomes across the USA. Another sister is board certified in physical medicine and rehabilitation and has a master's degree in public health and occupational medicine. She works in rehabilitation medicine in a large group practice in Louisville, Kentucky, and also has a major commitment to occupational medicine with some of the larger corporate employers in Kentucky. One of my 3 brothers is a physician. He is an otolaryngologist in central Kentucky.

WCR: He followed your father?

DJB: My brother is in clinical practice in Danville, Kentucky. In the mid 1970s, my father developed Parkinson's disease and in his early 50s was unable to continue his practice in Lexington, Kentucky. Many physicians in my father's circumstances might have profited by selling their practice, essentially directing their patients to other otolaryngologists for a lump-sum payment. My father did not believe that this approach was appropriate ethically, so he simply asked his patients to select one of the other otolaryngologists in Lexington and transferred his office records along with a summary letter to the physician the patient selected. My brother today still sees patients in Danville who were patients of my father's 30 years ago, but my father stopped practicing several years before my brother completed his training.

WCR: Danville, Kentucky, is where the first abdominal operation was performed, an oophorectomy.

DJB: My brother operates at Ephraim McDowell Regional Medical Center, which is named for the surgeon who performed the first successful ovariotomy on Christmas day 1801. The patient was a 47-year-old woman who had a preoperative diagnosis of twin pregnancy but was found during surgery to have a cystic ovarian tumor that weighed more than 20 pounds. Dr. McDowell was also one of the founders of Centre College, which is located in Danville.

WCR: So, 4 of your parents' 8 children became physicians. What do the other 4 do?

DJB: My oldest sister is a reading specialist. Her doctoral training is in education, and she works with the public school system in Frankfort, Kentucky. One of my brothers is a dentist in Lexington, Kentucky. My younger sister is a lawyer who is the director of the Post-Trial Division of the public defender program for the Commonwealth of Kentucky. I have a younger brother whose work has been in hotel and restaurant management and other business management roles.

WCR: Is your father still alive?

DJB: He had increasing disability from Parkinson's disease and succumbed to aspiration pneumonia 3 years ago.

WCR: How old was he when he died?

DJB: He was 76.

WCR: Is your mother alive?

DJB: Yes. She is 80 this year and is very healthy and engaging with her 8 children and 16 grandchildren. She lives in central Kentucky near 6 of her children and 11 of her grandchildren.

WCR: What were the secrets of your home life that gave each of the 8 of you the spur to excel?

DJB: My parents were very focused on the role of education. My father was the only child in a family of 11 children to graduate from college. He completed college and medical school in 6 years and was board certified in otolaryngology by the age of 27. My parents provided us with the opportunity to attend secondary school anywhere in the USA, which led to my decision to go to New Jersey to the Lawrenceville School in 1970. While my mother spent her time nurturing the 8 children she had over a 12-year period and did not work for compensation outside of the home, she made a profound impression on my 4 sisters regarding their opportunity to excel academically and to contribute professionally. Several of my sisters were high school valedictorians, including my younger sister, who graduated with highest honors from Amherst College and now leads the public defender program in Kentucky.

WCR: Do you all get together much now?

DJB: Yes. My mother spends time with us in Dallas. She is a highly effective supervisor of homework for our 7-year-old son and our 11-year-old daughter. All of my mother's children and grandchildren met this past summer for a surprise 80th birthday party for her in Louisville, Kentucky.

WCR: How did you select UNC for medical school?

DJB: As an undergraduate I met people in the UNC schools of medicine and public health with interest in health care research and health care policy and, in particular, I developed a relationship with Ed Wagner, who was the head of the Robert Wood Johnson Clinical Scholars Program. I applied in the fall of 1977 via the early admission program to UNC School of Medicine and was fortunate to be accepted there, so I decided to pursue graduate studies at UNC in medicine and public health.

WCR: You majored in both economics and chemistry in college, a double major. That is a pretty unusual major combination, but actually it fits exactly into what you later wanted to do.

DJB: The Lawrenceville School offered a lot of advanced placement courses, and I was essentially a second-semester sophomore when I started as an undergraduate at UNC. This allowed me to complete in 4 years the more advanced courses to fulfill the degree requirements in both economics and in chemistry while spending one semester in Great Britain doing the fieldwork for my economics honors thesis.

WCR: To get your master's degree in public health as well as your MD degree, it took 1 additional year, making medical school 5 years rather than 4 years. How did your PhD degree come about?

DJB: At UNC with the guidance of Ed Wagner, I was able to chart out an academic program leading to an MD, master's of science in public health, and PhD in epidemiology. At that time there were no formal combined MD/master's or MD/PhD programs in public health, so we simply designed one that enabled me to complete over 5 years the MD program and the course work for the MSPH and PhD. Prior to starting my internal medicine training in 1983 at Mayo Clinic, I completed all of the course work and all of the other requirements for the doctoral degree in epidemiology at UNC. I wrote several research proposals while I was a Mayo medicine resident to obtain funds to support my doctoral dissertation and was able to attract the funding to implement those projects and finish them after I completed my clinical training at Mayo.

WCR: So that is why your PhD degree was actually awarded after your 3-year training in internal medicine?

DJB: Yes.

WCR: Why did you decide to do that training in internal medicine?

DJB: I have always thought it is important to have an in-depth understanding of health care delivery to be able to address some of the important problems in improving it in this country. While I envisioned that my career would primarily be in health care research and in education, I wanted to be able to draw upon the clinical experience and perspectives of training in internal medicine. My career training plans were also shaped through working with my mentor at UNC, who was an internist and a member of the school of public health faculty in the Department of Epidemiology.

WCR: Even though you are a very athletic fellow and surgery seems to attract athletic types, surgery never really appealed to you?

DJB: As an undergraduate my thesis was focused on issues related to home visiting and primary care in the British National Health Service. Through that experience, I became very interested in primary care and in the population-level health care systems perspectives linked to engaging the challenges of primary care. This led me to think about training in family medicine or internal medicine, and ultimately I decided I would do my clinical training in internal medicine.

WCR: Why did you choose the Mayo Clinic to do your internal medicine training?

DJB: My undergraduate economics thesis research in the British National Health Service and my epidemiology master's thesis work on a National Heart, Lung, and Blood Institute–funded hypertension-control project in eastern North Carolina led me to believe that organizations with a primary focus on health care delivery were going to be the best environments in which to test strategies to improve health care (1, 2). As I thought about places where I might do that and organizations with a rich tradition of clinical training and health care research, Mayo seemed to be the best place to continue to pursue those interests while furthering my understanding of clinical medicine.

WCR: During that training, did you participate in research projects that you subsequently continued?

DJB: I used some of my free time as a medicine resident to begin to work with colleagues in the Section of Clinical Epidemiology at Mayo and wrote research proposals that provided some of the resources for my early research once I joined the staff at the Mayo Clinic.

WCR: Did you enjoy practicing medicine?

DJB: I very much enjoyed the 3 years of clinical training at Mayo in internal medicine. When I finished in 1986, I was faced with my first professional career decision. I was offered the opportunity to join the Mayo staff in a 50% internist–50% health care research role or to commit all of my time to health services research. I decided that my professional efforts could have the greatest impact across the Mayo Health System through a focused commitment to health care research.

WCR: Your support with that decision came virtually entirely from the grants you were able to get?

DJB: I was fortunate to have a great deal of external funding at that time, but it is also important to underscore Mayo's commitment to health care research. Although I do not keep up with the exact figures, Mayo has an annual research budget of somewhere on the order of $120 million, and about $60 to $70 million a year of Mayo funds is used to support research efforts. While most of my work at Mayo was externally supported, I was able to attract these external resources due to the substantial infrastructure resources; exceptional colleagues in biostatistics, epidemiology, and informatics; and unwavering institutional commitment to the value of health care research. My success at Mayo was built upon institutional investments by Mayo dating back to a unified medical record and common patient registration system in the early 1900s and the recruitment in 1930 of a physician/biostatistician to begin what is now known as the Department of Health Sciences Research, which has >30 doctorally trained researchers in biostatistics, economics, epidemiology, informatics, medical anthropology, and psychology.

WCR: After you finished your medical residency, you stayed at the Mayo Clinic from 1986 to 1991. Did you enjoy that 5-year period?

DJB: I very much enjoyed my professional opportunities at Mayo Clinic and, more importantly, I also met my wife, Michela Caruso, in 1985 at Mayo. Michela is an Italian citizen who was an endocrinologist in Rome when she came to Mayo to train in medicine and endocrinology. Shortly after we were married in 1986 (Figure 8) and I joined the Mayo staff, she decided to continue her clinical training in radiation oncology. Upon the completion of her training, Michela and I left Rochester so she could pursue a fellowship opportunity at the University of Virginia.

WCR: What did you accomplish at the Mayo Clinic in the 5 years you were faculty or staff there? What projects did you complete and are you most proud of?

DJB: An area of work that was particularly productive was collaborating with a colleague in vascular surgery, John W. (Jeb) Hallett, Jr., MD, who is now the dean of Mayo Medical School. Jeb and I were quite interested in generating information about the effectiveness of infrarenal aortic aneurysm management strategies. On a personal level Jeb had been the surgeon who had operated on my father-in-law from Rome, who had a rapidly expanding infrarenal aortic aneurysm. Jeb and I recognized that in the mid 1980s there were significant opportunities to improve the scientific foundations for decision making by surgeons and patients in this area.

One of the first things we did was to conduct the first population-based study of risk of rupture for infrarenal abdominal aortic aneurysms, which was subsequently published in 1989 in The New England Journal of Medicine (3). That manuscript identified that the risk of rupture for smaller aneurysms (<6 cm) was lower than the estimates that had been published in surgical and medical textbooks. Jeb and I also did a community-based study of the outcomes of elective surgery for infrarenal aneurysms, which was published in the Journal of the American College of Cardiology (4).

Putting those 2 pieces together identified the substantial uncertainty about the effectiveness of elective aortic aneurysm surgery for the majority of people who were undergoing this procedure in the USA. This led us to work with the RAND Corporation and 11 other academic medical centers, through which a panel of 9 physicians from a range of specialties reviewed the literature concerning the effectiveness of aortic aneurysm management and then rated a broad range of indications for performing the procedure (5). We applied these ratings of indications to the medical record information for 1200 patients who underwent aneurysm surgery at these 12 academic medical centers. In that study we found that approximately 60% of all the patients undergoing elective aneurysm surgery in those institutions had indications for the procedure that fell in the range rated by the RAND panel as being clinically uncertain in terms of appropriateness (6).

That work and other research motivated the British National Health Service and the US Veterans Affairs system to develop and fund randomized trials of immediate surgery vs watchful waiting for the spectrum of patients rated by the RAND panel as being in the clinically uncertain range. The British National Health Service trial was published in the fall of 1998 in The Lancet and showed that immediate surgery conferred no survival benefit relative to watchful waiting for individuals with aneurysms 4.0 to 5.5 cm and proved to be a much more costly strategy for the British National Health Service (7–9). We expect to conclude the US Veterans Affairs study in 2000 and have the first randomized trial data from the USA regarding the relative effectiveness of the immediate surgery vs watchful waiting management strategies (9).

WCR: What do you mean a more costly strategy?

DJB: If one summed up the total health care cost for the patients randomized to the immediate surgery arm and contrasted that with the total cost for those patients randomized to the watchful waiting arm, over a 5-year period those patients who were in the immediate surgery arm did not experience a survival benefit, and their medical care was ?1064 (about $1700) per patient more expensive than was the care for patients randomized to the watchful waiting arm (8). The bottom line for the British National Health Service was no health benefit for patients but a much greater cost for immediate surgery. Within the Veterans Affairs study we hope to have an answer to this question in the next 6 months or so. We randomized approximately 1200 patients to these 2 different strategies and have now followed up on those patients for about 5 years (9).

WCR: That was your major area of research during the period at the Mayo Clinic?

DJB: That was an area of particular focus and represented the richness of the research opportunities of the Mayo environment, in which individuals with backgrounds such as mine in health care analysis and clinical medicine have worked with Mayo clinicians since 1930. In terms of health care quality issues at an institutional level, I was concerned, as were many other health services researchers, when the Health Care Financing Administration (HCFA) released in the public domain information related to observed vs predicted mortality for hospitals across the USA. Many observers used this information as a hospital quality-of-care report card. I was concerned about the inadequate clinical content of the claims information used by HCFA. While at Mayo I conducted analyses with Denis Cortese, who was chair of the Mayo Rochester Clinical Practice Committee and is now CEO of Mayo Jacksonville, that identified some of the biases in HCFA's approach. Our research, along with papers written by other researchers, underscored the limitations of mortality results drawn from claims data as a measure of hospital quality of care (10).

WCR: I gather you enjoyed your experiences at the Mayo Clinic very much.

DJB: Yes. Mayo is a remarkable organization that is superbly effective in aligning health care research with improving clinical care.

WCR: Do you consider that the finest clinical care institution in the country?

DJB: I think that one can have a subjective sense of quality of care as well as an objective sense. From a subjective qualitative perspective, I can share with you my experiences as an internal medicine resident taking care of very severely ill patients in the middle of the night. I was extremely impressed with the commitment of Mayo staff, from the ward clerk to the radiology technician to the blood bank person to the attending physician who would come in at 3:00 am to help sort out a difficult problem. I was particularly impressed with the effective functioning of systems of care at Mayo.

WCR: “Systems of care” meaning what?

DJB: The coordinated care of patients, whether in a coronary care unit setting or patients with complicated diabetes mellitus. This evolves from the commitment of staff across a broad range of areas in the Mayo environment to providing patient-focused high quality of care. Whether one is a medicine resident or a surgeon or a ward clerk or nurse, at Mayo one is very impressed with the sense of team approach to addressing patients' needs.

WCR: How did you enjoy your experience in Charlottesville?

DJB: The University of Virginia (UVA) provided me with an excellent opportunity to explore my interests related to national issues concerning quality of care. A large part of my work at UVA was focused on working with peer-review organizations to develop new models for improving quality of care for Medicare beneficiaries (11, 12). Don Detmer, MD, who at that time was UVA's vice president for health sciences, and I shared an interest in reshaping the efforts of HCFA to improve the quality of care in the USA. With Don's support and guidance, I developed a research network that supported collaboration between UVA and several peer-review organizations that focused on improving the quality of care for Medicare beneficiaries. This work ultimately led to developing the first pilot effort for transitioning from trying to improve health care quality through case review or “picking up bad apples” to improving quality through analyzing patterns of care in populations and implementing evidence-based practice guidelines in populations.

In a paper published in the 1995 Annals of Internal Medicine, we described the first efforts in this regard by the peer-review organization community through the national demonstration project that was conducted in collaboration with the Connecticut peer-review organization (11). That research identified opportunities to improve acute myocardial infarction care in the state of Connecticut. In subsequent work by the Connecticut peer-review organization, feeding back information to physicians and hospital personnel and working with those personnel to improve care processes was shown to lead to improved care of Medicare beneficiaries with acute myocardial infarction in Connecticut.

WCR: How long did you stay at UVA?

DJB: I was at UVA from 1991 until 1994. In 1994 my wife and I decided that we wanted to live in a larger metropolitan community and decided to relocate to Atlanta.

WCR: What was your most fulfilling professional accomplishment in Atlanta?

DJB: I was most pleased with our continued success in working with partners from the peer-review organization community to provide leadership for the evolving Health Care Quality Improvement Program of HCFA. In 1998 HCFA awarded 6 national leadership contracts for peer-review organizations to advance health care improvement in 6 specific clinical areas (acute myocardial infarction, adult immunizations/pneumonias, breast cancer, congestive heart failure, cerebrovascular disease, and diabetes) (13). There are >30 peer-review organizations across the USA, and 4 of the 6 national contracts were won by 4 of the 5 members of our peer-review organization network. The contract award batting average of 4 for 5 (80%) for our member organizations relative to the 2 for 30 or so (7%) for the other peer-review organizations across the USA indicated that the network that we had established in 1991 had by 1999 achieved its goal of leading the nation in developing and implementing methods to improve the quality of care for Medicare beneficiaries. The quality-of-care measures that we evaluated through this network will serve as the basis for much of the efforts over the next 3 years on the part of peer-review organizations as well as other organizations across the USA such as the Joint Commission on Accreditation of Health Care Organizations.

WCR: How did Baylor get you out here?

DJB: I had been drawn initially to the Mayo Clinic because of my belief that the best environment in which to conduct health services research and quality of care research would be within community-based regional health care delivery systems. During the national search for my position through several discussions with John Anderson, MD, senior vice president for clinical integration of the Baylor Health Care System, Boone Powell, Jr., and others, I became increasingly convinced that Baylor was poised to be an innovative laboratory for health care research and improvement. This thinking was coupled with the realization that academic health systems were going to find it increasingly difficult to invest in and sustain quality improvement and evaluation resources. I became convinced that regionally based health systems such as the Baylor Health Care System and the Mayo Health System, which are much more focused on health care delivery than are most academic health systems, are increasingly going to be the preferred laboratories in the USA for this type of work.

It is interesting to observe, subsequent to my decision to relocate to Baylor, the ongoing changes within the academic health systems. For example, the University of Pennsylvania Health System, which has had a quality improvement program that has been emulated across the country, has been unable to sustain that activity in the midst of very large negative operating margins. My colleague who led this effort at Penn, David Shulkin, MD, MBA, recently left the University of Pennsylvania to pursue these interests in a venture outside the university. Physicians who are interested in health care quality improvement and have worked within academic health systems have felt that they could have more impact by working more directly with integrated community-based health care delivery systems. Many of us in the health care research community believe that places like Baylor, the Mayo Health System, Intermountain Healthcare, and Cedars-Sinai are the types of environments where our work can have the greatest impact.

WCR: What are your plans here at Baylor as senior vice president for health care research and improvement? What specific projects are you going to initiate here, at least at first?

DJB: My approaches at Baylor are twofold. The first efforts are to survey and engage the health care quality improvement efforts that are of great interest to Baylor physicians. Second, I am working with John Anderson; Joel Allison, senior executive vice president and chief operating officer of the Baylor Health Care System; and others to develop strategies to engage the patient care and research components of the Baylor Health Care System mission in order to achieve the Baylor Health Care System vision “to be one of the preeminent health care systems in the world.” John and I and many others believe that health care research will be one of the important areas for development that will allow Baylor to realize that vision. In the words of Don Berwick, one of our national colleagues in the area of health care improvement, “Teaching and research contribute to curing illness, alleviating suffering and disability, and promoting health, and they must be supported within the health care system” (14). The challenge is to align the Baylor Health Care System strategies in patient care and research in order to achieve the type of synergy between patient care and research to which Berwick refers.

In terms of the initial projects that are under way, with David Winter, MD, the chair of the Quality Committee for HealthTexas Provider Network, and Carl Couch, MD, president of HealthTexas, we are beginning to measure clinical preventive service delivery by HealthTexas primary care physicians. I have been extremely impressed with the commitment of the HealthTexas primary care physicians to improving the care they deliver. We are currently in the initial measurement phase of that effort. Our initial work is focused on measuring for women 66 to 75 years of age (1) use of pneumococcal vaccine, (2) flu immunizations, (3) mammography use, and (4) for those women who are smokers, smoking cessation counseling.

I continue to be very interested in issues related to surgical care effectiveness and outcomes. I am working with Wynne Snoots, MD, and other orthopedic surgeons to develop an information system to better capture information related to the indications, processes of care, and outcomes for total hip arthroplasty and total knee arthroplasty. This will enable us to describe the performance of these procedures at Baylor with respect to national criteria concerning the appropriateness of total hip arthroplasty and total knee arthroplasty. We will also use these data to evaluate the outcomes achieved for these patients relative to the resources that were invested in their care.

WCR: At your 4 previous medical institutions—UNC, the Mayo Clinic, UVA, and Emory University—the physicians were mainly on salary, and now you are at an institution where very few faculty or staff are on salary. Will that be a barrier for you in collecting the data you need to analyze what care is best?

DJB: I think that the tradition of research excellence, for example, at the Mayo Health System may relate in some part to the salaried nature of the compensation for physicians there. Mayo's success in health care research relates also to very wise investment decisions over 50 years ago in development of information systems and clinical records to support clinical research and health services research. To answer your question regarding data more directly, a key element for our success in health care research and improvement will be the deployment of effective information technology strategies. Pete Dysert, MD, the chief medical information officer for the Baylor Health Care System, and Bob Pickton, the chief information officer, are very committed to working with me and John Anderson and others in putting in place the information systems that will support health care research and improvement.

Another component of the answer to your question relates to the challenge for hospital-based health care delivery systems in partnering with the physician community. Similar to the Mayo Health System model of physicians as health systems employees, one significant resource of the Baylor Health Care System is the relationship that Baylor has with the HealthTexas physicians. There are also other relationships that will provide outstanding opportunities for collaboration, such as those in cancer care with Texas Oncology Physicians Association (TOPA) and the nationally distributed research network that TOPA and US Oncology bring to the Baylor Health Care System. I think the key ingredient for our success will be highly motivated physicians who want to improve the care they offer their patients and who work in an environment that provides incentives for research and innovation to improve the health of their patients.

In this regard, I worked recently with 2 very busy Baylor physicians in the area of asthma to submit to the National Institutes of Health a randomized trial of strategies to improve asthma care for inner-city children from indigent areas of Dallas. That proposal, like many that I put together at Mayo, Emory University, and UVA, was crafted through meetings over weekends, at night, and in the early morning. The salaried nature of the Mayo Health System compensation for physicians and the relationship of physicians as employees within the system may make these health care research and improvement collaborations somewhat easier to realize. Nevertheless, I have been very impressed with the commitment of the physicians affiliated with the Baylor Health Care System to developing and implementing health care research and improvement initiatives.

WCR: So you are happy in Dallas?

DJB: Dallas has been a wonderful community for my family and me.

WCR: When did you come to Baylor?

DJB: I started working here in June of 1999.

WCR: You have children?

DJB: My wife and I have a 7-year-old son and an 11-year-old daughter (Figure 9).

WCR: Are they well adjusted now to Dallas?

DJB: Yes. In June I asked my children to rate on a 1 out of 10 scale their quality of life in Dallas. My son (who had just left his 2 closest friends in Atlanta) rated it a 1, with 1 being the worst and 10 being the best. My daughter gave it a 5. The last time I asked them, my son reported that his rating is now 8 and my daughter's is 9.

WCR: What about your wife?

DJB: Michela has just begun her clinical work here due to the large clinical practice and administrative responsibility she had with Georgia Cancer Specialists in Atlanta and the time required for her practice to recruit a qualified radiation oncologist to serve as her successor. She continued her clinical practice in Atlanta until the middle of October. She began working in early November with TOPA, is very impressed with the medical community in Dallas, and is looking forward to the evolution of her clinical practice here.

WCR: David, is there any topic we have not touched on that you think could be important to mention?

DJB: In planning for the second hundred years for the Baylor Health Care System, I bring perspectives from my experience at the Mayo Health System and other institutions. Baylor has wonderful traditions of clinical care and medical education upon which to build world-class programs in health care research. I think that the early success of the Baylor Research Institute will be a foundation upon which broader-based research programs can be developed that are aligned with the mission of the Baylor Health Care System.

As I envision the particular opportunities that I have to contribute in the Baylor Health Care System environment, Baylor is in its early stages in terms of establishing a health care research capability—about where Mayo was at the end of the first quarter of this century. An analogy that comes to my mind is the arrival in 1930 of Joseph Berkson, MD, DSc, a statistician-physician from Johns Hopkins who was recruited to Mayo. At that time, Berkson was perhaps the only doctorally trained statistician-physician in the world. To more critically evaluate the quality of their clinical practice and to enhance the scientific foundations for clinical practice at Mayo and elsewhere, the Mayo brothers and Henry Plummer, MD, recruited Berkson to develop a system-wide health care research and improvement resource. Seventy years later the Mayo Health System, in addition to continuing to be internationally recognized for its high quality of care, is also recognized as a world-class health care research organization. The department that Berkson founded in 1930 currently has a group of distinguished doctorally trained scientists in biostatistics, epidemiology, economics, and informatics.

Along these lines, I am focused on achieving the Baylor Health Care System vision of becoming one of the preeminent health care systems in the world. The lessons that I have learned at Mayo and elsewhere will help me to work with John Anderson and others to craft and implement effective strategies to realize this vision.

WCR: You have been at 4 fine institutions, UNC, Mayo Clinic, UVA, and Emory, and you have been here at Baylor about 5 months. What is your sense of how Baylor's clinical care compares with these other 4 institutions at this point in your observations?

DJB: My sense is that Baylor is an outstanding health care organization. I am very impressed with the commitment of Baylor to clinical excellence and to the team approach in this environment, which reminds me quite a bit of the Mayo Health System. Baylor does have the benefit of a medical education program like Mayo and, unlike many academic health systems, Baylor and Mayo share a primary focus on excellence in patient care. That core focus allows the type of work that I do in health care research and improvement to be closely connected with the patient care mission of the Baylor Health Care System.

WCR: David, I am glad you are here at Baylor and I am proud of the institution for having attracted you here. I wish you all the best, and I appreciate your openness not only to me but also of course to the readers of the Baylor Proceedings.

DJB: Bill, it has been a great pleasure to visit with you today, and I am very pleased to have the opportunity to work with you and other new colleagues across the Baylor Health Care System.

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