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my office because [we've] prevented the illness in the first place." Dr. Pearl also puts accountability on patients because physicians can't achieve good outcomes alone. "My patient's health is based a little bit on what I do and a lot on what she does," he says. "Some people eat better than others. Some exercise while others don't. I have to use the doctor-patient relationship to help her take better care of herself." Dr. Pearl adds government to the equation because he says physician and patient efforts alone won't maximize health care. "If the government pushes the delivery of care and the patient in the right direction, not running health care but helping to move it in the right direction, it, too, has accountability," he says. Finding Answers to Accountability Dr. Gabica says physicians have to work within their patients' capacities to change behaviors. He cites the stages of behavioral change model advanced in the 1970s by James Prochaska, PhD. "In the transtheoretical model of interchange developed by Prochaska, for people who are living in a precontemplative stage where they are "The ethical thing is to do the right thing the first time. The ethical thing to do is maximize prevention, and in doing that, we will lower costs in the most ethical way." — Robert Pearl, MD, Executive Director and Chief Executive Officer of The Permanente Medical Group and Chair of the Council of Accountable Physician Practices thinking about making a change but they don't have information about how to go about it, providing them with information is the best technique for getting them to move to the next stage," Dr. Gabica says. "That's the contemplative stage, where they actually know what to do and how to do it, but they have to make the move." Dr. Pearl says organizations that have collaborative, multispecialty, physician-led health care are best able to provide effective service to patients. "Think about the elements that need to be in place for you as a patient to get what you need," Dr. Pearl says. "The first thing you want to know is that your doctors work together. If doctors don't get together to talk, if they don't exchange information, how do we improve quality? The challenge is, it's hard to do. It's hard to bring together physicians who have historically worked independently and may see themselves as competitors rather than collaborators on behalf of their patients." By coming together, Dr. Pearl says, physicians can diagnose earlier, treat more rapidly, avoid medical errors, offer better preventive care, provide more cost-effective ser v ices a nd ultimately increase the quality of care. Taking Charge of Change Physicians face many changes, including controlling the costs of health care, adapting to pay-forperformance methods, engaging in prevention and overseeing implementation of technology that enables physicians to have information at every point of contact. "External forces are such that health care will change," Dr. Pearl concludes. " There's no question about that. Physicians either have to decide we're going to lead that change, which I believe is best, or someone else will do it for us. By the time we say, 'Oh, I wish we had done it,' it's going to be too late. So my message for physicians is, the time to make the change is now." I MDNEWS.COM I MD NEWS Greater Boston | 11