IHI is pleased to offer 19th National Forum keynote address by Donald M. Berwick, MD, MPP, Eating Soup with a Fork, as an On Demand presentation at no charge. In this December 2007 keynote speech, typically one of the most anticipated and energizing events at the National Forum, Don Berwick examines the role of evidence and the importance of context in promoting improvement. The way ahead, he says, requires both.

Evidence-based care is the gold standard in medicine today. And the best evidence is gained through randomized clinical trials, in which all variation is removed. This is important when the question is about the efficacy of methotrexate for leukemia or beta-blockers for heart failure. But what about assessing the value of more complex interventions, such as Rapid Response Teams, chronic disease management programs, or improvement collaboratives?

Removing variation also means ignoring context, and when ideas and interventions rest on complex, non-linear relationships in social systems, context is important. Says Dr. Berwick: “We need evidence... We can’t allow subjective hopes, wishes, and dreams to pretend to be truth when unforgiving nature is at work, or we will... do harm. But the harm is equal if we treat a very complex world as if it were simple, if we treat each other as less than whole people and complex systems as simple and separate from us, and thereby reduce our capacity to learn, to converse, to explore, and to grow.”

Dr. Berwick warns against the temptation to pit science against passion and belief against proof. Listen as he suggests four ideas for change, ideas designed to lead health care beyond the debate about “evidence on the one hand, and improvement, on the other,” to a place where learning itself is improved, and progress against suffering is accelerated.