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History of Health Services Research Project
Interview with Paul Cleary

Interview Index

April 28, 1998
Boston, Massachusetts
Conducted by Edward Berkowitz

Berkowitz: The first question I'd like to ask is, when you look at your vita, you see that you're Canadian, and you were a physics undergraduate. Where were you an undergraduate? In Canada?

Cleary: I started out at Georgetown in Washington and then transferred as a junior to the University of Wisconsin.

Berkowitz: Were you always oriented toward this country? Or did it just happen that way?

Cleary: My parents are American, but my dad took a position in Canada. I have dual citizenship. We've sort of been oriented toward the United States. Canada also has an unusual, relative to here, education system. They have a five-year high school system. A lot of people agree that you do better by going to a first year of college. So there was always that bias towards going back to the United States for college, both because of the family background plus you'd have to go through this grade 13 in Canada, which was seen as undesirable. So I went to Georgetown, transferred junior year to Wisconsin. I assume you're trying to figure out how I got from physics to sociology.

Berkowitz: What was the draw at Wisconsin?

Cleary: My sister was a professor there.

Berkowitz: What field was she in?

Cleary: She was in (she's passed away now) educational psychology. She was a measurement expert, a psychometrician, and there was quite a well known measurement group there. You may not know these groups, but people like Henry Kaiser and Chester Harris, people who did early work on factor analysis and scaling techniques were there. I just visited her and that was very attractive, so I transferred there. While I was there, just because of her network of colleagues and friends, I became very acquainted with a whole range of social scientists and decided I wanted to go to graduate school in sociology or psychology.

Berkowitz: Did you meet David Mechanic as an undergraduate?

Cleary: No. I applied to several places for graduate school and had pretty much decided to go to Wisconsin. My first encounter with him was actually prior to admission to graduate school. He called me up and offered me a trainee ship in medical sociology. I said, "That sounds great. What's a trainee ship and what's medical sociology?" A trainee ship sounded very attractive at the time. It still is a very attractive concept. As you might imagine, he gave a very compelling and persuasive explanation of what medical sociologists did. So I said, "Gee, that sounds really interesting so I'll do that."

Berkowitz: Let's go to 1971 or so. When was this? When did you graduate from college?

Cleary: Yes. It was 1971. You're right.

Berkowitz: You graduated in the class of '70? You thought you were going to be an academic? Had you thought this through at that point?

Cleary: You know, you're never sure, but that's what I was thinking of. My sister was an academic and I met all these academic researchers, and that seemed like a fun thing to do.

Berkowitz: And you had been doing physics. Were you just doing general physics?

Cleary: Yes. As an undergraduate I was doing physics and hadn't started to do too much specialization.

Berkowitz: Would you have said your strengths were quantitative or lab skills or?

Cleary: Clearly going into physics I started out not knowing what these concepts mean, thinking I wanted to be a scientist and obviously having quantitative skills. One of the things that was attractive about Wisconsin is-you probably don't know-they have an extremely strong quantitative group there. They were very oriented towards quantitative methods.

Berkowitz: Who was the leader of that?

Cleary: There were people like Robert Hauser who was the head of the methods program, and there was a whole range of very strong methodologists. So the idea of coming into that program with really strong math and statistics skills, or at least math background, I was very attracted to them, and the kind of work they did was very attractive to me. The other top places that I applied to were Berkeley, Chicago and North Carolina. North Carolina also had a very quantitative program, but Wisconsin was attractive. My sister was there and had all these friends there at that point.

Berkowitz: Were you caught up in any of the campus events of the period?

Cleary: Yes.

Berkowitz: In what way? You were there when all the things happened, when that Army building was blown up.

Cleary: It was actually the Army Math Research Center, which was in the physics building. I was there actually that evening when it blew up.

Berkowitz: You were in the building?

Cleary: No, no, no. I was in Madison. We had just gotten back from a trip when the building actually blew. I was part of that era.

Berkowitz: So you really did...?

Cleary: I really was involved.

Berkowitz: Did you see any link between that and sociology? Were you going to be action-oriented as a sociologist?

Cleary: Did I see any link at the time? I was in physics. I just loved physics-still do-I just found it fascinating. I read Science and Scientific American. A couple of things happened. It became apparent to me that the degree of abstraction one started to reach in doing graduate research in physics was really quite extreme. You were starting to get so far from real events that it was becoming a little less attractive to me. And that was just a very exciting period where your perception of the whole world revolved around social issues, social change. You believed in social change and being able to implement social change. And then there were a group of people doing science who were committed to that. For example, one of my first courses was with a guy named Maurice Zeitlin who had spent a lot of time in Cuba and wrote about what was happening in Cuba, thinking about political sociology. That was very, very exciting, so the fact that all of this fit together-you could actually do research, be involved in social evaluation and change-it was just a really very heady time intellectually.

Berkowitz: I see. So when you went to graduate school you were committed to medical sociology by virtue of having this trainee ship?

Cleary: I literally had never heard of medical sociology. I took just enough courses as a junior and senior to finish my degree in physics. Then I started taking some courses that were prerequisite for the graduate courses. I'd never taken a medical sociology course, didn't know what it was, hadn't thought about medicine as an area of inquiry. The trainee ships have very, very few constraints, so some people take trainee ships and totally shift. I was very oriented towards a methods program. In fact one or two years I was actually supported by a methods trainee ship. It stuck. I found it extremely interesting and satisfying.

Berkowitz: I assume that David Mechanic was your thesis advisor?

Cleary: Yes.

Berkowitz: When did that bond start?

Cleary: He was the director of the program. There was him and a fellow by the name of James Greenley, who has now passed away, so it was really between him and Jim as senior professors. I worked with someone else in psychology named Howard Leventhal. I worked very closely with him too. He's actually at Rutgers now. I published several papers with him. So I started working with David and Howard right at the beginning.

Berkowitz: What was your thesis about?

Cleary: My master's thesis was on emergency room use, and my Ph.D. thesis was on use of psychotropic drugs. It didn't really pan out too well. At the time it was a very interesting topic. Psychotropic drugs were the most frequently prescribed drugs and it wasn't clear who was most likely to receive them. At the time, we were involved in a study which I was the project director of, in central Wisconsin, an area called Marshfield, Wisconsin was fascinating because it was a very unusual health care setting in which there was a central hospital and there was an HMO. The HMO worked with satellites. It was a pre-paid plan. Back then, a very small proportion of people were enrolled. So this concept of an HMO in rural Wisconsin was kind of interesting. There were non-exclusive arrangements, so you had providers at the hospital providing both fee-for-service and prepaid health care. Dave Mechanic, Jim Greenley and a variety of people had long-standing interests in psychological distress factors that predispose people to using health care. So they came up with the idea of doing a community-based study of symptoms, response to symptoms, help seeking, and so on. So we did this study. At the time, I was a graduate student who really just tried to do a decent job. None of it was my initiative. It was, as I recall now, four counties; we did a population-based probability sample of the community and went out and did face to face interviews on the kind of symptoms they had, who sought care, didn't seek care. A lot of emphasis on psychological distress, psychiatric symptoms, illness behavior and so on. I don't know how much you know David's work, but those kinds of issues about help seeking. Within that context, we were very interested in who used psychotropic drugs.

Berkowitz: And the data from that was where you got your thesis?

Cleary: Yes. Eventually I ended up combining data from three or four studies because it turned out that no one in that area used psychotropic drugs because it was this mid western Lutheran kind of thing.

Berkowitz: What year did you get your Ph.D.? 1978 or earlier?

Cleary: No. It took a long time. My graduation date was '80.

Berkowitz: Really? So that was nine years. You must have been working on other things.

Cleary: I was a project director and I was playing music. In those days there was less, although now we really try and push to get people through graduate programs, of a push. Wisconsin was a very attractive place where you could work on research projects and write papers. I had a couple of dry holes in terms of theses. At the time-I smile about it now-it was very stressful because the clock was running out and I sort of felt I would never get a degree, never get anything done.

Berkowitz: I see. Was Rutgers your first job or was there another job in there?

Cleary: No. Rutgers was my first job. What happened was I was at Wisconsin and Dave Mechanic decided to go to Rutgers. Actually he was moving because he was getting married to Linda Aiken.

Berkowitz: A lot of academic history is explained by people getting married.

Cleary: Linda was at the Robert Wood Johnson Foundation, I believe. He just one day said, "Would you be interested in going with me?" At the time, I didn't know where he was going. I knew the main places he was looking at were maybe Penn, Princeton and Rutgers. He ended up going to Rutgers. So I went with him to that job.

Berkowitz: He not only could get the job, but he could bring people with him. That's pretty good. That doesn't happen too often in this day and age. Your appointment was in the social work school in some way, right?

Cleary: Yes. I was in the School of Social Work. I was a research assistant professor there.

Berkowitz: What was the reason for that, do you know? That wasn't your natural thing, right?

Cleary: David's primary appointment was in the School of Social Work. It had to do with internal politics and availability of slots and so on, and he just ended up with his primary appointment being in the School of Social Work.

Berkowitz: Your appointment has this word research in it. Did you also teach?

Cleary: I did a little teaching at my own initiative.

Berkowitz: Is that something you like to do?

Cleary: Yes. I love teaching.

Berkowitz: So you then become an academic and you do health services research. Mental health was definitely one of your interests and alcoholism. I'm sure there were others too. How were you oriented to do these projects? Were you looking for grants?

Cleary: I assume you're trying to get a sense of what influences people in the topics they choose.

Berkowitz: Yes. How one chooses what one does.

Cleary: At Rutgers we were really doing the Marshfield Clinic Analyses. A lot of those papers we just based on those data and those ideas and the ideas you were reading about at the time in general health and social behaviors. I was really taking a cue and stimulation from the work that David had done. He never required that; it was just that those were very exciting ideas to me at the time, just following up on ideas.

Berkowitz: So he was a real mentor to you? Both in graduate school and now as a young academic.

Cleary: Yes. Very much. There were some new projects that came up, but they were sort of in the same paradigm, because the people that would come there to visit were interested in-it's hard to explain. As I say, there was sort of a paradigm that a lot people were working on-I'll call it the stress paradigm-trying to assess how people perceive and react to stressors, coping skills, social support, how those impact on outcomes that people have, how they influence health-seeking behavior. There were a lot of studies we did in that way. At that time there was that Three Mile Island incident.

Berkowitz: That was 1980, was it?

Cleary: It must be. Somewhere around there. Before 1980, probably '78 maybe.

Berkowitz: Carter was president. That much I know.

Cleary: You're right. I'm sorry. Yes, right around there. People were funding. Peter Houts came to visit. We ended up doing a study of Three Mile Island. We actually wrote a book together on that.

Berkowitz: About how people react to this stress?

Cleary: Yes. How people reacted, what the stress reactions were, whether there was illness around the area.

Berkowitz: What did you find?

Cleary: We found, in terms of objective illness, very, very little impact. And we had some nice models of stress. We could find a gradient depending on distance and develop models of migration and movement and reactions. I guess an over-arching theme was that it was less noxious than many people would have believed, which actually is not inconsistent with the large literature on the way people react to disasters or events. They cope pretty well.

Berkowitz: That area was right near Harrisburg, right?

Cleary: That's right. Then I sort of knew that it was appropriate and I needed to get out on my own. Working with David was nothing but wonderful. I have nothing but positive things to say about it. He was always very, very supportive, but we agreed that you have to strike out on your own at some point. So I was just keeping my eye open. At the time, I'd been dating a woman who was finishing up law school at Yale and whom I eventually married. So we started looking for positions jointly. At the time, there didn't seem to be many options. I wasn't getting any offers. It was very hard. A couple of times I'd get an interview, but there wasn't a lot of that. But a job came up in Boston at Beth Israel Hospital; there was a group doing alcohol research. I actually had done some alcohol research. Way back when I was at Wisconsin I had taken a summer job in the Division of Mental Hygiene and done some work with them in their alcohol program, had done some modeling of cirrhosis rates and written some papers on that. So I had some background in that area. Then with the Wisconsin Marshfield work I had looked at substance abuse and psychiatric symptoms, so I sort of knew those areas. There was a group here doing work on recognition and management of alcohol problems in primary care. I left out one piece of my history. When I was at Marshfield, one of the things I got involved in independent of the Marshfield community study was they were doing studies of screening for psychiatric illness in primary care settings. So I actually worked on a separate contract with NIMH and wrote some papers on screening scales. In other words, you give a person a questionnaire and if they answer five questions positively, what's the probability that they have psychiatric illness. I did some pretty interesting studies in that. So when I came to Rutgers I had my background of having looked at this community-based stuff and several studies looking at the recognition and management of these kinds of problems in primary care settings. So then this group in Boston came along. I was at Rutgers and Tom Delbanco was the person who originally contacted me. They had a grant from the Robert Johnson Foundation and their contract officer was Martita Marx who knew David and Linda.

Berkowitz: Linda was working, or had been working, at the Foundation, right?

Cleary: Linda was working at the Foundation at the time and knew of me and said, "Why don't you try this guy, Paul Cleary, because he does a lot of things that are very similar," and they did. It seemed like they were doing interesting things, and I guess they thought I was close enough to be semi-useful. To make a long story bearable, my wife was able to find a position here and we moved to Boston. So for a couple of years I did alcohol research. Another thing that I forgot to mention about back in Wisconsin. One of the interests that Howard Leventhal with whom I worked, had was smoking behavior. I had written a major review paper with him. I started doing some of that work here. I'd have to look at my CV to see what I was doing when, but there was a general orientation towards recognition and management of psychiatric problems, behavioral issues, and primary care settings. A group, also associated with Beth Israel, also was doing a study where they were looking at the measurement and management of functional impairment in primary care settings. I'd never done this measurement of functional impairment stuff, or disability probably as you think of it, but I had done a lot of measurement work and had done a lot of work in primary care settings. And I had done a lot of work on this whole concept of what physicians are and are not aware of, how you can facilitate their becoming aware of other psychiatric problems or alcohol or functional status problems and started to form this coherent paradigm, at least in my mind, and then to work with them to figure out how to respond to those things. So there's a bunch of papers we've written on the functional status questionnaire, measurement of functional status. We actually did an experiment with Bob Brook and his colleague at UCLA and at Beth Israel in Boston on giving feedback to physicians. We created a little report and said who had functional impairment and so forth.

Berkowitz: I see. So now you're here.

Cleary: So now I'm here and doing alcohol work. There's a smoking institute here I started working on based on the stuff I did with Howard and then this functional impairment.

Berkowitz: What would you say your field is? Are you a health services researcher?

Cleary: That's what I used to say to my mother, that I was a health services researcher.

Berkowitz: Were you aware of this field from the beginning?

Cleary: No. I didn't know that was what I was doing. I would have said I was a behavioral scientist.

Berkowitz: Or a sociologist?

Cleary: Or a sociologist, yes. It was becoming less and less like sociology and more like looking at behavioral science.

Berkowitz: So when did you become a health services researcher? Do you remember going to the meetings of the association?

Cleary: I remember going to the first couple of meetings. You can probably remind me of what that history is. When were those?

Berkowitz: I should know more about it than I do. I just don't know.

Cleary: I remember going to one meeting in Boston. It was the kind of meeting where you could meet with half the people there and just hang out in the lobby.

Berkowitz: Was that when you were still a graduate student?

Cleary: No, it was when I was here.

Berkowitz: In the '80s sometime.

Cleary: Yes. In the '80s. And I'm sure it had been going on for several years. It seemed like a very young organization. For a variety of reasons, Beth Israel wasn't an optimal setting. I was in the Department of Social Medicine. A fellow named Jack Rowe, who's now president of Mt. Sinai in New York, said, "Would you be interested in coming over and working on the Division on Aging?" And I said, "Well, I don't know anything about aging." He said, "That's OK. We need competent people who do interesting stuff to come over and work with us." Actually, the work I had been doing on functional status assessment did fit into the work they were doing. I started doing some of that work. The next step was Barbara McNeil, with whom I'd been working on a project here, founded the Department of Health Care Policy, which is where I am now.

Berkowitz: Which is where we are now?

Cleary: Yes. And she asked me to come over there and that became my full-time life.

Berkowitz: I see. In terms of this work you do, do you feel that you're limited by not being a physician?

Cleary: No.

Berkowitz: You just look; you don't touch.

Cleary: Most of the physicians I work with do exactly what I do. I used to feel extremely constrained in a couple ways. One is there was a lack of receptivity to basic concepts like, "Can you improve my ability to detect things? Should you be assessing the accuracy of my diagnoses?" I remember when we started graduate school, a lot of these were very revolutionary concepts. I remember that any time you'd try to do a clinical study-and I don't know if it was an age effect or period effect or personality effect-it seemed like it was always a very, very, very skeptical audience. I don't know where the transition occurred, but I feel now like physicians are eager to have my input and involvement in studies and we're at least equal partners. The physicians I work with, I think, would say that. There are certain areas where their expertise is critical, but increasingly-again, I work mostly with generalists, general internists-if there's a clinical issue that we need addressed, often we'll jointly call upon or involve a specialist. If we've working in HIV care, we will defer to the person who's an HIV expert, or if we're doing a cardiac study, we bring in the cardiologist. So it's even the distinction in terms of doing what we do-there's a huge overlap. I don't ever really feel constrained. Now, if I'm doing a study of heart attacks, which I do, I feel constrained that I really need to know state-of-the-art research in cardiovascular disease, but I also know I would feel the same way, Barbara McNeil feels the same way, the colleagues with me here who have MDs, feel the same way, so I don't feel at all constrained.

Berkowitz: I see. What is the study of heart attacks that you're doing now?

Cleary: We're doing one of these PORTs Are you familiar with that terminology?

Berkowitz: Tell me about it.

Cleary: The PORTs are a set of studies funded by the AHCPR [ Agency for Health Care Policy and Research]. PORT stands for Patient Outcome Research Team. These are studies initiated 7 or 8 years ago. The basic concept, the genesis of a lot of this work was some of the things Jack Wennberg had been doing, that there are treatments for which there is a lot of variability and about which there is either controversy or ambiguity about the best way to do things, and that it would be useful to approach those in a comprehensive, systematic way to figure out how to do that. Jack Wennberg's work on prostatectomy would be an example. We study treatment of heart attacks. The original paradigm was to use Medicare claims data because you could get a population base and use a variety of techniques. There's quite a bit of heterogeneity in what the PORTs do. There are about 16 PORTs. We have studied variations in the way heart attacks are treated, variations in the likelihood of getting surgical treatment, examined the relationship between type of treatment and outcomes, etc. That's a big, multi-disciplinary team effort.

Berkowitz: You mentioned the funding source for that. What other funding sources have you utilized over the years?

Cleary: Over the years, when I was doing my mental health work, NIMH [National Institute of Mental Health] was a source of funding and a constant source of support in varying degrees from various foundations, private foundations. The main foundations I've worked with include the Hartford Foundation, Robert Wood Johnson Foundation, Commonwealth Fund and the MacArthur Foundation.

Berkowitz: You've been pretty successful. Of course you've been in teams that have gotten support.

Cleary: Teams, yes. And then I've gotten support from the National Institute on Aging and, over the past number of years, the Agency for Health Care Policy and Research has been a major federal supporter, although recently we've gotten more support from the Health Care Finance Administration [HCFA].

Berkowitz: Did you have trouble working with Robert Wood Johnson?

Cleary: No. They have the most rigorous financial accounting of any foundation or institute in the country. They are pretty tight about those kinds of things.

Berkowitz: Let's talk for a minute about the Milbank. That's obviously a very long tradition of this Milbank research. You've been the editor of the journal for, what, five years?

Cleary: Five or six years.

Berkowitz: How did that come about? That's a very prestigious thing, I would think, being editor of the Milbank Quarterly.

Cleary: Dan Fox, whom I didn't know at the time, called me up one day and asked if I would be interested in being considered as a candidate for editor of the Milbank Quarterly. I said yes and wrote him some letters with ideas of what I would do if I were editor. And it worked out that I became editor. I think the origin of that was that Arthur Kleinman is on his board. I think-no one has really told me this explicitly, I've just pieced together various comments-Arthur recommended me.

Berkowitz: I think David probably was on the board too, on the board of editors. I'm sure he was; I don't know when.

Cleary: No, I meant the board of the Milbank itself. Anyway, that's my impression. They had a search committee, which is a subset of the publication committee, which is a subset of the board. They were interviewing people. Or maybe I was just the only person who would do it, I don't know.

Berkowitz: You had quite a tough act to follow too. The other fellow, whose name I can't remember, was a large character.

Cleary: Yes, David-David Willis-was a wonderful guy, a consummate editor and quite an impressive individual. He was a very, very tough act to follow.

Berkowitz: How big an operation is that? Is there someone that does editorial assistance?

Cleary: Yes, I have an editorial assistant here in Boston-basically everything's here now-and a copy editor who does copy editing for the Quarterly and for other Fund publications. And we just hired an Internet manager. So I have a person who works full-time on electronic publishing, which we're exploring aggressively now.

Berkowitz: Where do you want to take the journal? Do you have a vision for it? What's its role in this field? This is a health services research journal if any one is, right?

Cleary: Yes. If you can bear with me, I'll backtrack to when I took over the journal. As you know, the journal has a long, long history. What I determined at the time was that it was appropriate to think about changing the role of the journal. The journal had an illustrious history publishing work on disability, as you know, and aging and in a variety of fields. I remember, as a first year graduate student, reading the Milbank and that being a wonderful, illustrious source of knowledge.

Berkowitz: Edgar Sydenstricker who was on the Committee on Economic Security in 1935 worked for the Milbank, as did Falk, I. S. Falk.

Cleary: Yes. It's really quite impressive. It used to be one of the few games in town. If you go back 15 years in journals publishing health services/health policy, it published everything. It was really a major force. In the interim-this is just sort of my impressions of what was happening-a lot had changed. Five years ago there were many journals doing this. Whereas the concept of the New England Journal of Medicine publishing an article on policy or health services research 15 years ago would have been laughable, now they regularly do it.

Berkowitz: Right. Arnold Relman was a big force in that, I believe.

Cleary: Yes. I publish articles in the New England Journal and don't even think twice about it, but it's a clear outlet for my work. Certainly JAMA, The Journal of the American Medical Association is a major outlet for our services work. I publish a couple of articles there a year, and they're often conceptual articles or theory articles. We published a conceptual model of how to think about health-related quality of life, the relationship between health-related quality of life and clinical measures. And there are journals of aging. I think David Willis was really path-breaking in publishing work on aging. There are numerous journals on demography, another area where the Milbank was really quite innovative. So, there's Health Services Research, there's Inquiry, there's 15 journals that publish general issues like this, and around the specialty areas like aging or demography or disability-or X, Y, and Z-they're just all over the place. So I decided that the niche is not health services research per se, but rather health policy, and I obviously publish a fair amount of health services research, but I always try to select articles that have implications for policy. Or, as Dan always harps on, the phrase decision makers, in other words people that are deciding policy or making programmatic decisions. There's still a chasm between what we do in academe and the people making day-to-day decisions. When I first met with Dan, I said, "What I would really like to do is try to bridge that gap a little." That's how I see the Milbank Quarterly. I really rarely even consider a methodological piece, for example, even though my own interests are quite methodological in nature. And I often will just send, to a review of pure health services research, an article that doesn't have some policy relevance or implications. I'm really trying to focus more on the policy end of things.

Berkowitz: Do you think you've been successful in that?

Cleary: It might be better to ask other people. I think the quality of articles we have published has been extremely high, and I think we're doing OK.

Berkowitz: As a consumer or a practitioner, the impression that people got, certainly that I got in my experience was that there was overly elaborate copy editing and, that the process in general, was very slow, which caused a lot of people to say, "To hell with it. I'm not going to send it there to have it peer-reviewed by five different people." David Willis was a meticulous stylist. Will it be England or Great Britain, the Netherlands or Holland? Presumably you've heard stories like that. You've changed that a little bit?

Cleary: I hope I have. I laid out a business plan and one of the things I said was almost identical to what you said, so the review cycle is much, much shorter than it used to be. Sometimes I've gotten four reviewers, but I often go with one or two, predominantly three. I've tried to cut down the review process as much possible, make it more timely and responsive.

Berkowitz: What's Dan's input to this? Presumably you have your own autonomy as editor.

Cleary: Yes. Dan is very involved. I have total autonomy as editor. He has never asked me to reconsider an editorial decision, even when I know he had a very strong personal interest in a particular article, for example, that I turned down. I keep him totally apprised of what I'm doing.

Berkowitz: Do you still have four issues a year?

Cleary: Four issues a year. For example, prior to any issue going to press I write up something called "In this issue," which is a summary of what's in each issue, and I send that to him for comments and to apprise him of what's going to appear in each issue. He is very helpful. He provides editorial suggestions. But without exception he's been positive about the direction the journal is going, what I've decided to include. The farthest he's gone was when there was a particular piece he was extremely interested in, thought it was a home run. I made the decision that it was not.

Berkowitz: For the journal.

Cleary: Yes. And I knew that would be a sensitive decision, so before doing that decision I said, "Here's what my decision is going to be. Here's the reason I'm making the decision, the external reviewers. And here's what I'm going to say about that." The most he's ever said is, "Could you give this person an opportunity then to do X, or something?" He's been very hands off, which is quite interesting, because he does tend toward micro management and control. So my strategy has just been to apprise him of everything, and he has never, ever interfered with anything.

Berkowitz: One last question about the journal. What's the role of the journal with regard to book reviews? I see there are some book reviews. I don't see review essays.

Cleary: It used to do all kinds of things. Ron Bayer was the interim editor after David left and I took over. He was actually editor for maybe a year. Anyway, he was very interested in book reviews and set up a book review section and commissioned a number of books reviews. I decided I didn't want to do that and have not published any book reviews since I've been editor that were not initiated by Ron.

Berkowitz: Is that because you don't see books as the central thing for the field or just not for the journal?

Cleary: They are just something I didn't think would be of great interest to the readers of that particular journal. It's a quarterly, so they're not quite as timely. Part of it was selfish. Managing book reviews is a very time consuming process. It's probably myopia. I've never been that impressed by their value. It wasn't part of the agenda that I set for the journal, or where I wanted to spend my time.

Berkowitz: How much of your time do you spend on the journal? An eighth?

Cleary: It's hard to say. Of a forty-hour week, which no one spends, I'd say closer to a third.

Berkowitz: Oh, my goodness, that's really a commitment. And that really is a way for you to shape the field, isn't it?

Cleary: That was the concept. Having been there and done that, I don't know if editors really shape the field or they reflect the field. I suppose you move it one degree to the left or one degree to the right, but I don't know. One thing I've come to understand is that there are several thousand journals out there, and there's almost an unlimited number of outlets for health services research and health policy. There's a new one appearing every four months, and not all of them have the influence as does an article in JAMA. On the other hand, if I turn down an article, someone else is going to publish it. That's the main criteria of my success: whether you convey important information, you influence the field. You had asked where I'm trying to head. What we're doing now is trying to use electronic media to maximize the impact of what we're doing. One way to maximize impact is to do some electronic things. For example we have a web site, which everyone has now. Last year we commissioned an article that was designed for the web. Don Detmer and Reed Cushman, we commissioned a paper on information policy, the issue of privacy. It was very, very timely. The idea was, "Can we use this medium-we've been around the block about what people have done and what's failed-to make things more accessible to the kinds of people we would like to influence, the decision makers?" For example, one of the things you can't get when you pick up the Milbank Quarterly is that someone will reference a government document. Electronically you can make a link, so you can click on that even if it's not in your library or published. The idea is to try to create a resource that uses the flexibility of the web to connect you to things that were cited or related resources.

Berkowitz: Sort of ambitious. The things I cite, they're not on the web, I'm sure.

Cleary: Yes. It's ambitious. So that's what we're plugging away at now. We're having some meetings with the Institute of Medicine. We're thinking of co-sponsoring some kind of core health policy electronic resource.

Berkowitz: That would be quite a departure for them. That's interesting too. They're very interested in this information question, privacy, all that. Don Detmer, I know, is a very big player.

Cleary: The Institute has recognized that-and I consider them actually very effective in disseminating evidence in panels, I've been very impressed with how well they disseminate these studies-they don't do as good a job as they would like, so they're very, very interested in this whole concept. We're going to have some meetings next month, I think.

Berkowitz: Well, good. Thank you very much. That's very helpful.


Agency for Health Care Policy and Research. See AHCRP. See AHCRP AHCPR   9
Arnold Relman   10
Arthur Kleinman   9
Barbara McNeil   8
Bob Brook   7
Chester Harris   2
Dan Fox   9
Dave Mechanic   4
David Mechanic   2    3
David Willis   10    11
Don Detmer   12
Health Care Finance Administration. See HCFA Health Services Research   10
Henry Kaiser   2
Howard Leventhal   4    7
Jack Rowe   8
Jack Wennberg   9
Jack Wennberg's   9
JAMA. See Journal of American Medicine Association
James Greenley   4
Jim Greenley   4
Linda Aiken   4
Martita Marx   6
Maurice Zeitlin   3
National Institute on Aging   9
NIMH   6    9
Peter Houts   6
Reed Cushman   12
Robert Hauser   2
Ron Bayer   12
Journal of the American Medical Association   10
Tom Delbanco   6
University of Wisconsin   1

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