free sample letter of intent

Application Tips and Sample Letters of Intent Document Contents: Tips To Help You Develop a Competitive Letter of Intent Application Letter of Intent – Sample 1 Letter of Intent – Sample 2 Letter of Intent – Sample 3 Letter of Intent – Sample 4 Letter of Intent – Sample 5 Letter of Intent – Sample 6 Letter of Intent – Sample 7 Letter of Intent – Sample 8 Tips To Help You Develop a Competitive Letter of Intent Application Important Note: Please make sure that your letter of intent is a maximum of four pages, double-spaced and that you use a 10, 11, or 12-point font. Cited refe rences are not required but may be included on a separate page, if needed. 1. Get a better sense of the kinds of research projects funded through this program by visiting http://www.investigatorawards.org/invesitgators/. Keep in mind that this program does not generally fund R01-type projects that might be funded by NIH or NSF. 2. Before you begin writing your letter of intent, view the sample letters that we have included on the following pages. It can also help to read carefully the criteria that will be used to evaluate your application by visiting http://www.investigatorawards.org/applications/default.asp?p=32. 3. In framing your topic, develop your project within its larger policy context. Be sure to discuss the significance for national policy of the problems your project addresses, and its potential contribution to informing health policy in the U.S. The reviewers will look for this information when reading your application. 4. Present your project in a way that is likely to capture the reviewers’ attention and interest. Each reviewer reads many applications – try to make clear up front why your project is “special.” Keep in mind that the reviewers represent a range of disciplines and points of view, and write in a way that can communicate across fields. 5. Show how your project might provide new information, a fresh/original perspective, a creative approach, advanced methods for analyzing problems, etc. Emphasize the innovative and creative aspects of your project. Make a compelling case for why the problem you are tackling is significant or how the work you propose to do can help advance understanding, break new ground, or shape new policy options. If you are proposing to continue or synthesize past work, describe what is new about your project and the value it can add. 6. Identify the research questions and issues to be explored, describe the approach you will take, and discuss how the proposed study could illuminate the questions you seek to understand. You have only four pages so you can’t discuss details, but you must provide enough information to convince a reviewer that you have the appropriate methods and access to data sources to do what you propose. 7. Include a statement about your qualifications and track record. 8. If you have a co-investigator, mention any prior experience working together on research projects. 9. Describe the products you expect to produce, how you plan to reach your target audiences, the length of time you expect your project to take, and an estimate of the total amount of funding needed ($335,000 maximum including indirect costs calculated at a rate of up to 12%). An itemized budget is not required. Letter of Intent – Sample 1 Restarting a Stalled Policy Revolution: Patient Safety and Professional Responsibility On March 9, 2005, researchers reported in JAMA that hospital computer physician order entry systems facilitated some risks eyen as they prevented others.1 In the next issue of JAMA, another team of researchers presented results from a survey that showed that hospital CEOs/COOs thought that a mandatory non-confidential system of error reporting would discourage reporting of events to their hospitals' internal reporting system, encourage lawsuits, and provide no gains in patient safety 2. In casting a skeptical eye on measures advocated by leaders of the patient safety movement, each of these articles signals that the once considerable momentum and enthusiasm for system reform has stalled. A paradigm shift that sought to improve the quality of care by directing attention to the faulty operation of the health care delivery system while downplaying the contributions of individual professionals now finds favored proposals open to intense, critical scrutiny. This project has three goals: (1) to use a social constructionist framework for understanding how patient safety has been framed as a social problem in public arenas;3 (2) to observe, describe, and analyze the tensions, resistances, and conflicts between the systems perspective championed by reformers and the emphasis by practitioners on individual responsibility that is part of the culture of medicine. How have conflicting directives of these two perspectives on medical work played out in the interactions of various stakeholders at different levels of the delivery system? And (3) to combine the analysis of patient safety as a social problem and social movement with the observations of behavior within a network of interlinked organizations who share a commitment to patient safety to identify leverage points for policy reform that, links patient safety and quality improvement. Beginning with the press release in November of 1999 announcing the Institute of Medicine's Report on preventable adverse events, To Err is Human: Building a Safer Health Care System followed the next spring by the Institute of Medicine's companion report, Crossing the Quality Chasm, the delivery of health services appeared on the brink of an important paradigm shift 4. As 2001 ended, there appeared to be great political momentum for change, a sense of movement marked by Congressional hearings with promises of increased funding for research, legislation by many states that mandated reporting of 1 Letter of Intent – Sample 1 serious adverse events, increased concern and activity focused on issues of patient safety within the national societies of numerous medical specialties, and the formation of advocacy groups to pressure providers to adopt measures promoting patient safety. The convergence of three interlinked streams of research, combined with the maturation of information technology, fueled this social movement focused on patient safety as a pathway toward quality improvement in health care. The first of these research streams insisted on outcome measures to assess both the adequacy of different treatment regimes for clinical conditions and also the efficiency of hospital systems. The development of outcomes research moved debates about of "quality of care" from a subject of philosophical speculation to a topic of empirical research. Closely linked to research developing outcomes measurement was the development of an evidence-based medicine movement. Advocates of evidence-based medicine focused on specific treatments to define best practices and to eliminate treatments that wasted resources with interventions of dubious benefit The third and most important factor in terms of capturing attention in the public arena was the release of the Institute of Medicine's report, To Err is Human: Building A Safer Health Care System. The report dramatized the extent of a hitherto unappreciated public problem, harm to patients because of preventable adverse events. The report documented that between 44,000 to 98,000 patients died each year because of adverse events, half of which were preventable; that preventable adverse events were the eighth leading cause of death; and that the cost of these misadventures was between 17 and 29 billion dollars annually, exclusive of any litigation costs. The report sought to shift understanding of error: responsibility lay in faultily designed systems rather than hapless operators. The 10M report forwarded a set of recommendations to mitigate systems' problems: better training of personnel to improve awareness of system dangers, new technologies to prevent the inevitable mistakes of fallible human operators, and new procedures to improve the functioning of the system as a whole. These measures were central to a broader change within the culture of medicine that sought to replace responses to error that emphasize "naming, blaming and shaming" with ones that encourage full disclosure and creative responses in a blame-free environment. The promise of change was fueled not just by a convergence of research streams focused on improving quality care by reducing adverse events, but also by rapid changes in "bioinformatics" and the digital revolution. Inexpensive Personal Digital Assistants with the capacity to link remote data bases; user-friendly search engines for locating the most recent evidence; the sophisticated facsimile machines that transmit clinical images digitally; software programs that enable ordering pharmaceuticals while promising to eliminate medication errors from illegible handwriting, incorrect dosages, and unfortunate drug interactions; as well as the promise of an electronic medical record which would decrease fragmentation, increase accessibility, and make retrieval of critical data easier-all of these developments promised programmatic solutions that would 2 Letter of Intent – Sample 1 reduce adverse events with only marginal increases to costs. Now, almost five years later, it is clear that the promise of reform has fallen short of the Institute of Medicine's admittedly ambitious goal of reducing preventable error by half within five years. This project seeks to understand what stalled the promised policy revolution, what leverage points for change have not been fully exploited, and how the momentum for change can be recaptured. To accomplish this, I will use both the archival techniques associated with the analysis of how social problems are framed in public arenas and also direct observations and interviews with actors in the interlinked network of organizations working toward improving patient safety to focus on a set of related questions: (1) How well does a view of adverse events that focuses on systems properties and the measurement of outcomes fit with the professional culture and work practices of health care workers? (2) What measures that have been widely instituted to reduce error and improve quality have been adopted and which resisted by health care workers? Can the idea of personal responsibility, so deeply embedded in both the professional culture of physicians and nurses, be harmonized with a perspective that sees problems as the result of the system as a whole? Can a systems perspective that relies on information technologies be designed and deployed in ways that fits the work routines of health care workers? (3) How do other policy changes, such as the reduction of resident work hours or reductions in nursing personnel to reduce costs, conflict with the goals of the patient safety movement and the desire to improve quality? (4) How do other public concerns, such as increased attention to malpractice crisis, create resistance to some of the preferred policies for improving quality that the patient safety movement has advocated? For example, how does an increased focus on liability affect the promotion of "blame" or "guilt" free environment that encourages an open discussion of error through the development of a mix of mandatory and voluntary reporting systems for serious adverse events and near misses? I have been working on how physicians learn to recognize, understand and manage error for the last twenty-five years.5 In this project, I plan to utilize the contacts in a variety of policy circles built up during this sustained involvement to gain access to settings that will allow me to gather data on how problems are understood and solutions proposed at different levels of social organization within the health care delivery system. I plan to track the patterns of communication and feedback among different levels of the health care system. At a national level, I will track the websites and access archives of importa nt national organizations involved with the patient safety movement such as the Joint Commission for the Accreditation of Health 3 Letter of Intent – Sample 1 Care Organizations, the National Patient Safety Foundation, The Patient and Family Advocacy Council of the National Patient Safety Foundation, and the Committee on Patient Safety of The American College of Surgeons.6 I will also track media coverage of patient safety to provide an account of how patient safety has been presented in print media. At the level of the local organization, I will make observations on a number of hospital patient safety committees. My goal here is to see how the committees understand and then transform into concrete policy legislative directives that are paradoxically both concrete and vague.7 Finally, I will investigate what difference all this activity makes at the everyday level of the delivery care for the protection of safety and the prevention of harm through error. I plan both to observe surgical mortality and morbidity conferences and interview nurses and residents to see if the systems paradigm for understanding error is reflected in the way that errors are understood, explained, and managed. Specifically, I will be looking for talk that eschews as a cause "operator error" and elaborates on the complexity of systemic factors. There will be a number of products from this research. First, I will present research results to the professional audiences of clinical educators and policy makers to which I have long had access. Next, I will publish results in academic journals both medical, health-policy oriented, and sociological. Finally, I plan to produce a book that describes and analyzes the recent history of the patient safety movement, at the same time that it proposes recommendations for the future. I am seeking funding fo r thirty months of the project. 4 Letter of Intent – Sample 2 I write to announce my intention to apply for an Investigator Award in Health Policy Research. My project is a multidisciplinary study of drug approval at the U.S. Food and Drug Administration (FDA). The puzzle animating my project is the historical and contemporary variance in FDA behavior: why is the FDA characterized by organizational conservatism (e.g., delay and stringency in drug approval) with some technologies and at some times, and organizational risk-taking at others? My central hypothesis is that the FDA acts primarily to protect and enhance its reputation for consumer protection and scientific accuracy, and that this motivation has specific health policy costs and benefits. I will produce a book on the politics of FDA drug approval, a series of academic articles on the policy consequences of FDA regulation (and recent reforms), and a series of policy papers addressed to policymakers, think tanks and the media. I will address the following questions: (1) The Politics of FDA Reputation: Why does the FDA exercise the power that it does? How does the FDA build and maintain its reputation for consumer protection and scientific accuracy? (2) The Costs and Benefits of Reputation Protection: What are the policy effects of FDA reputation protection? In particular, does reputation protection lead the FDA to Ø overreact to its own mistakes and/or to criticism from the medical community? Ø privilege safety concerns relative to clinical efficacy issues in drug review? Ø induce longer clinical development times when statutes compel speedier FDA approvals? Ø ignore the economic (price-reducing) value of new technologies and thereby contribute to higher drug prices in the United States? 1 Letter of Intent – Sample 2 FDA regulation of pharmaceuticals has immense and significant consequences for health and health policy in the United States. Undue delay in the approval or development of new therapies can mean hundreds (perhaps thousands) of lives lost, research investments forfeited, prolonged monopolies and higher drug prices. Faulty approval of new medicines can compromise public safety and undermine professional and investor confidence in pharmaceutical development. By advancing an empirically grounded theory of how FDA regulators behave, and by applying that theory to health policy issues, my project will identify key areas where current FDA policymaking needs reform. The project will also address the crucial issue of incentives: how can a complex professional organization be motivated to provide a policy goal which is politically opaque (the safety and efficacy of the nation’s drug supply) while ensuring quick access to beneficial therapies? Claim 1: Reputation and the FDA. The primary goal of the FDA in pharmaceutical regulation is to protect and enhance its reputation for consumer protection and scientific accuracy. The reputation is constructed of dual beliefs and dual constituencies. The first belief, widely supported in public opinion polling and news reports, is that the FDA functions to protect the public from harmful products. The second belief is that the FDA can be trusted to make scientifically rigorous and clinically accurate decisions. The first belief is embedded in FDA’s ties to consumer organizations, women’s organizations, and public health advocates. The second belief is embedded in a different but also vital constituency: organized medical professionals and related scientific disciplines. The FDA’s reputation is perhaps its most prized organizational asset, and the source of its immense policymaking power. Precis of Research Strategy for Claim #1 I will combine quantitative and qualitative methods in examining FDA reputation protection. I will first examine historically and qualitatively the foundations of the FDA’s reputation. Beginning with the thalidomide tragedy and the 1962 Kefauver Amendments to the Food, Drug and Cosmetic Act, 8 I will study the evolution of public and academic beliefs about FDA decisions. I will conduct interviews with current and former FDA officials, particularly in the Center for Drug Evaluation and Research (CDER), and focus these interviews upon the efforts of FDA officials to maintain public and scientific credibility. I will also examine archival documents of the American Medical Association, several state medical societies, and 8 The roots of this reputation extend further back, to the efforts of Harvey Wiley and the USDA Bureau of Chemistry in the Progressive Era and the agency’s response to the sulfanilamide tragedy of 1937. 1 have already examined these acts in prior papers and book chapters. 2 Letter of Intent – Sample 2 women’s groups and consumer groups in order to assess their respective ties to the FDA, and their support for FDA authority and decisions. I will also conduct interviews with contemporary members of these organizations. Second, I will conduct quantitative analyses of FDA drug approval decisions using duration analyses and other maximum likelihood models. I will first assess whether the FDA becomes more conservative [in terms of slower drug approval times] following agency errors or controversies. Second, I will test the hypothesis that safetyrelated errors are more publicly visible than efficacy-related errors, and that the FDA therefore emphasizes safety over efficacy in drug approval. I will test this claim by (1) examining broadcast and print news stories on FDA decisions, (2) aggregating measures of uncertainty over drug safety and efficacy and correlating these with the probability and duration of approval, (3) assessing whether regulatory stringency (delay in approval, labelling requirements) rises when a drug’s marginal efficacy is low (therapeutic alternatives are available) but marginal safety is still at issue. Claim 2: Policy Consequences of Reputation Protection. If FDA decision-makers aim to maximize their reputation for consumer protection and scientific accuracy, then several testable hypotheses follow. First, economic considerations (in particular the price-reducing effect of new drugs) are unlikely to materially affect FDA decisionmaking. If the FDA shields its public reputation, it will pay attention primarily to the clinical value of drugs, ignoring their economic value. These “values” are usually correlated but may diverge if, for instance, a new antiinfective offers no new clinical improvements but its market entry would cut prices for existing anti-infectives. Second, if slow drug approval has been a mechanism by which the FDA has protected its reputation in the past (see Carpenter 2002 AJPS), then the FDA may respond to statutory pressure to acceleration by taking steps to lengthen the clinical development process (the “Investigational New Drug” or IND stage). In other words, it may induce a longer and more intensive clinical trial stage when the new drug approval stage is forcibly compressed. I have some (coarse) interview-based evidence that the FDA has done this in the past ten years. Research Strategy for Claim 2: First I will conduct archival/documentary and interview-based analyses of FDA decision making to ascertain what the dominant values are that guide drug approval decisions. Second, I will conduct quantitative tests of drug approval (duration analyses of drug approval times) to assess several hypotheses: Ø whether drugs whose entry induces greater equilibrium price declines are approved more quickly (my theory suggests no relationship) 3 Letter of Intent – Sample 2 Ø whether the FDA induces longer clinical development times for drugs when outside forces compel the agency to abbreviate NDA review. [IND times are also determined by other factors such as novelty of compound, primary indication, and speed of firm.] Ø whether the FDA reacts to “mistakes” and controversies (an increase in adverse events reporting, or highly publicized drug recalls, or criticism from esteemed medical journals) by (a) slowing or reducing all approvals, (b) slowing or reducing approvals only in the division that made the error, or (c) substituting more stringent IND and ex post regulation of therapeutic class in which the controversy occurred. Anticipated Contribution to Health Policy: By studying the ideology and incentives guiding FDA decision making, my project will bring a dose of political and sociological reality to academic and policy analyses of regulation. By examining the policy consequences of reputation protection, it will offer potential lessons to students of the pharmaceutical industry and health economics. My hope is that the project speaks to policymakers, doctors, and social scientists alike, and sheds new light on a U.S. institution in which all Americans have a stake. Objectives, Time and Budget: I anticipate three to four years of work on this project. I will produce (a) a book on the politics of FDA drug approval, (b) a series of academic papers on FDA policy, and (c) a set of “policy papers” intended for media and policy audiences on FDA regulation and the pharmaceutical market. I request funds for salary support, for research assistants, for data collection and storage, and for travel to the policymaking sites where I will conduct interviews and the archival sites where I will gather material. 4 Letter of Intent – Sample 3 This is a letter of intent to apply for an Investigator Award. My objective is to produce a book on the social costs of drinking and the potential effectiveness of alcohol-control measures in reducing those costs. The book would have as its primary intended audience scholars, advocates, and policymakers who are concerned with the proper government role in regulating alcohol availability and use. Furthermore, the normative framework will be of some interest to public -health researchers and scholars of social policy. One model for this effort is The Costs of Poor Health Habits by Willard Manning, Emmett Keeler, Joseph Newhouse, and others (Harvard University Press, 1991). I have been conducting research in this area for more than 20 years. For the last decade much of this research has been joint with another economist now a Professor of Business Administration. He will co-author the proposed book. We have made a number of conceptual and empirical contributions that will be integrated, updated, and greatly expanded in the current effort. Help in turning all this into a readable book will come from the Executive Editor for Economics at Princeton University Press, who has been discussing this possibility with us for several years. Among the topics to be covered in the proposed book are the following. 1. Social costs and policy. In recent years there has been a concerted campaign to control tobacco use by restricting access, raising prices, eliminating advertising, and banning indoor use. By some metrics (including those favored by economists) drinking imposes far greater social costs on our society than smoking, yet excise taxes and other alcohol-control measures have received short shrift in recent years. We will develop alternative conceptual frameworks for measuring the social costs (and benefits) of drinking, especially the economist’s cost-benefit framework and the cost-of-illness framework, and then trace out the implications of using each framework for setting policy priorities. It is particularly interesting to compare alcohol-related harms with those associated with smoking; they have much in common but there are interesting differences. For example, most of the direct harm from smoking is borne by the smoker, while much of the harm from alcohol abuse is suffered by others. Another contrast is that “moderate” consumption of tobacco is harmful, while moderate consumption of alcohol may be beneficial. 2. The productivity paradox. As long ago as 1926, economists have argued that reducing alcohol consumption would enhance overall productivity. Yet the evidence on the link between drinking and productivity is not so clear cut. Abstainers typically earn less than drinkers even when account is taken of differences in education, experience, health, and other characteristics. The evidence on drinking and academic achievement is also puzzling in some respects. These results, coupled 1 Letter of Intent – Sample 3 with closely parallel results from the medical literature, suggest that abstention is not an appropriate policy goal (at least of adults). But in our view that conclusion is premature and deserves closer scrutiny -- which we plan to give it. On the other hand, there is no doubt that curtailing alcohol abuse would be of great benefit: Heavy drinking is associated with underachievement and early termination of schooling, as well as increased risk for injury, criminal involvement, poor pregnancy outcomes, and neglect of social responsibilities. 3. Alcohol control as prevention. After the failed experiment of Prohibition, public leaders embraced alcohol control as an alternative approach that they believed would continue to encourage temperance without engendering corruption and crime. But in the post-War era the belief in the value of alcohol control has been undercut by a re-interpretation of the Prohibition experience (‘You can’t legislate morality’) and the rise of the alcoholism movement. Policy objectives now do not include reducing general availability, but rather are limited to reducing underage drinking and drunk driving while responding humanely to alcoholism. Yet there is clear and extensive evidence, largely lost in the public discussion, that alcohol-control measures are effective and worthwhile in reducing alcohol abuse and its consequences. In part this conclusion follows from the observation that drinking practices are closely linked in any social group, which makes it difficult to reduce the prevalence of heavy drinking in that group without also reducing the amount consumed by the typical drinker. But much of our research and that of others demonstrates a direct link between alcohol control and alcohol-related harms. Alcohol- control measures are by no means the only (or even most important) influence on drinking and abuse, but they are of particular interest because of being under the control of policymakers. 4. The unfortunate decline in alcohol excise taxation and prices. Fifty years ago alcohol excise taxes were far higher than they are today (adjusting for overall inflation). Congress and the states have allowed inflation to largely “repeal” these taxes, with the result that alcoholic-beverage prices have dropped precipitously. New developments in both economic theory and econometrics have provided a great deal of information about the consequences of this price reduction for drinking, youthful drinking, bingeing, and the myriad consequences of drinking and abuse. It is also important to take account of the fact that alcohol taxes are regressive, and are particularly burdensome to the families of heavy drinkers. In sum, what we propose to write is the scientific and normative foundation of a public- health-promoting approach to alcohol-control policy. The policy pendulum has swung away from concern with alcohol in recent years, but it seems quite likely that such an important cause of injury, birth defect, crime, and social failure will not stay off the agenda forever. If I can get release time from other responsibilities, I expect to complete this work over the course of two years. Please let me know if you need any additional information. 2 Letter of Intent – Sample 4 In contemporary America there are more people living alone and dying alone than in any point in history. Although demographers have documented these trends, social scientists have done little empirical work to understand their significance and the health or health policy challenges they pose, particularly to impoverished people, communities, and service providers. While prominent books such as Robert Putnam’s Bowling Alone have addressed the issue of declining social participation in American life, they rarely look closely at the lived experience of isolation and deprivation, or at the difficulties of serving and caring for the isolated. Putnam, for example, heralds the elderly as models of “joiners,” and says nothing about the millions of seniors who suffer the consequences of isolation. William Julius Wilson, who has also written extensively about the problem of “social isolation,” is more concerned about the isolation of communities than of individuals, and his work has not motivated research on ‘literal social isolation” in American cities. My proposed research project, Social Isolation in American Life, uses multiple methods — ethnography, interviews, mapping, and archival work — to understand this emerging issue. Drawing upon extensive fieldwork, it aims to document how individuals, families, and institutions manage isolation — defined as living alone with limited social ties — in practice. Through historical research, it will document America’s longstanding interest in isolation as a social problem. Through policy analysis, it will explore how governmental agencies, social service organizations, and health providers are beginning to address social isolation, and it will propose more effective strategies for assisting the isolated and integrating them with key contacts, resources, and services. I became interested in living and dying alone while conducting research. Drawing upon several years of fieldwork and interviews, my studies examine the solitary deaths of hundreds of Chicago residents in July 1995, and explore the reasons that so many city residents live and die alone during ordinary times. My effort to understand how different city residents experienced isolation, and how service agencies and health providers addressed the condition, led me to several of the sites and institutions where isolation is visible or relevant: single room occupancy hotel residences, neighborhoods with concentrated poverty and high crime rates, social service agencies that do case work with the isolated, nonprofit organizations that provide social contacts for people who live alone, and local government agencies (including departments of police, health, and aging) that serve the 1 Letter of Intent – Sample 4 isolated. Perhaps the most important site was the Office of the Public Administrator, where the staff investigates cases where someone dies alone and no one claims the body or the estate. My study of the case files and interviews with investigators — who, like their colleagues in San Francisco and other major cities, reported a steady and significant increase in the number of cases they manage each year9 — convinced me that social scientists and policy scholars are strangers to what one investigator called “the secret society of people who live and die alone.” The response from health officials, medical researchers, and policy scholars confirmed that advancing knowledge about this condition is an urgent social project. My research for Social Isolation in American Life will begin with a historical survey of interest in and anxiety about isolation in the United States. Surprisingly, concerns about social isolation generated much of the pioneering urban research by the early Chicago School sociologists, including Robert Park and Louis Wirth, and by later scholars such as St. Clair Drake, Horace Cayton, Herbert Gans, and William Julius Wilson. According to Gans, studies that assess and account for some form of isolation rank among the best selling American sociology books of all time, including five of the six most popular: The Lonely Crowd, Tally’s Corner, The Pursuit of Loneliness, The Fall of Public Man, and Habits of the Heart. This interest in social isolation is unmatched in any other nation’s intellectual history. Yet even the American scholarship on isolation has failed to examine the health and welfare of people who live alone and have limited social ties. I will examine why social scientists have not reached this level of analysis, and why it has been so difficult to study literal isolation in the U.S. The empirical core of the project will be based on continued fieldwork in places and institutions where social isolation is a pressing concern. Through in-depth interviews with people who live alone, I will examine the life histories of the isolated and look for meaningful patterns. I will follow-up on one of the surprising findings of my earlier work — that elderly men, who are far less likely to live alone than elderly women, were almost three times more likely to die alone in the disaster—by assessing how gender is related to social practices and network ties among people who live alone. I will also use fieldwork to understand the statistically documented relationships between depression and isolation, and between fear of crime, exposure to crime stories in the media, and social withdrawal. Through fieldwork and spatial statistics, I will consider whether there are there local social See Ian Gurley. Nancy Lum, Merle Sande, Bernard Lo, and Mitchell Katz. 1996. Persons Found in their Homes Helpless or Dead.” New England Journal of Medicine 334:1710-1716; and Nieves, Evelyn. 2000. “In San Francisco, More Live Alone, and Die Alone, Too.” The New York Times June 25, p. 10A. 9 2 Letter of Intent – Sample 4 environments and neighborhood conditions that foster withdrawal from social life and inhibit the development or maintenance of social contacts. Following the research style associated with Michael Lipsky, I will continue to use fieldwork in “street-level bureaucracies” to examine responses to social isolation by service organizations, local governments, and community groups. How do local governments coordinate service responsibilities between, for example, departments of health, human services, aging, transportation, and police? Are there successful programs for targeting vulnerable people who live a lone, or places with concentrated populations of vulnerable people living alone? What kinds of special programs can medical providers use to integrate isolated patients with key support networks? How can formal social policies and informal caring practices achieve synergy and make meaningful improvements in the everyday lives of the isolated? This project will last three years. I will conduct archival research and fieldwork in New York City and Chicago, and doctoral students will contribute to the study by assisting with interviews, spatial statistics, and archival work. I plan to write several articles and a book about social isolation in American life. I have already received significant interest from major commercial and academic presses. The book will be a genuine crossover text, addressed to a public audience but also to scholars in health, policy, and social science. I will also follow-up on the publication by consulting with health agencies, city governments, medical practitioners, and service providers interested in applying the findings to their work. 3 Letter of Intent – Sample 5 3. Statement Of The Objectives For The Proposed Research There is now substantial scientific agreement that a range of exposures and experiences early in life can affect health in later life. The proposed project is grounded in the idea that a lifecourse approach to health offers crucial insights into understanding how average health and health inequalities in populations are generated and manifested over time. Our program of research will apply current knowledge from a range of lifecourse sciences — such as medicine, biology, public health, sociology, and developmental psychology - to better understand average levels, secular trends and inequalities in health, both within and between countries. This multi-disciplinary lifecourse perspective on levels, trends and inequalities in health will be subject to rigorous empirical testing using a unique combination of both individual and aggregate level data. We have assembled a collection of datasets from the US and UK that present some unique opportunities for these lifecourse investigations. The findings from this research will have immediate policy relevance for the long-term health of the growing number of poor and disadvantaged children in both the US and UK. More than any other developed nations, these two countries can be singled out as having the largest growth in child poverty and disadvantage over the last 20 years. Our findings will extend and strengthen the inferences which can be drawn from lifecourse epidemiology and will inform health and social policy of relevance to both poor and rich countries. In addition to a series of academic journal articles, we propose to write a book with a working title of “Linked Lives: The Lifecourse Approach To Population Health”, that situates our findings within the multidisciplinary traditions of the lifecourse approach. 4. Significance Of The Problems Being Addressed Within the sociological and psychological traditions, understanding the structuring of advantage and disadvantage across the lifecourse has long been a central concern. In particular, the way in which earlier and later experiences structure overall life trajectories has informed understanding of the social patterning of opportunity and outcome. In contrast, most etiological health research within the last 50 years, especially in chronic disease epidemiology, was focused on cross-sectional or shorter longitudinal studies of proximal adult biological and behavioural risk factors. In the last decade however, lifecourse epidemiology has become a prominent research paradigm that has re-focused etiologic health research toward understanding the effects of exposures and experiences that happen over the entire lifespan and even operate across generations. There is now a growing scientific consensus that factors acting from before conception (e.g. maternal health), through gestation (e.g. 1 Letter of Intent – Sample 5 maternal diet and smoking, intra-uterine growth), at birth (e.g. birth dimensions) and through childhood (e.g. nutrition, leg length and infections) to early adulthood (occupational exposures and health-related behaviours) and then middle-age (health related behaviours, physiological risk factors such as obesity) directly or indirectly influence health outcomes in later life. There is a mounting, but as yet somewhat fragmentary body of evidence, on the exact mechanisms through which these etiological factors influence later health, but it is clear that there is potential for health effects either through exposures acting at critical stages of the lifecourse or through accumulating across the lifecourse. To give two examples: first, social circumstances in childhood are a key determinant of stomach cancer risk in later adulthood through influencing hygiene practices in early life and thus the acquisition in childhood of Helicobacter Pylori infection which many years later triggers the disease. Second, the nutrition, growth and health-related behaviours of mothers may influence the intrauterine growth of their offspring, fetal anatomical and physiological development, and through this their later cardiovascular disease risk. 5. Key Questions for Population Health We believe there are three key issues in population health that cannot be adequately understood unless a lifecourse approach — explicitly recognising that influences on health across the life cycle are strongly shaped by birth cohort, and time -varying social and economic circumstances — is applied. These are: 1) What factors determine secular trends in health within countries? Life expectancy at birth in the United States and the United Kingdom has almost doubled over the last 100 years. Even for those who survive to older ages, life expectancy has improved significantly. Those currently 65 and older can expect to live 6-7 years longer than they did their counterparts at the turn of the century. Life Expectancy at the Beginning of the 20 Century United States United Kingdom Women: 46 Men: 48 Women: 49 Men: 45 Life Expectancy at the End of the 20 Century Women: 79 Men: 74 Women: 80 Men: 74 2) What factors account for the substantial health differences between rich and poor countries? Life expectancy in many poor countries is still lower than it was in the US or U.K. at the turn of the century. 3) What factors explain the widening inequalities in health seen in the United States, Britain and many other countries. The ratio of the worst to best mortality deciles in the U.K. is now over 2, whereas it was around 1.6 fifty years ago. We consider it unlikely that a completely unrelated set of factors can account for these three major health phenomena. The lifecourse approach offers ways to conceptualise how these health phenomena are generated by a set of factors acting at 2 Letter of Intent – Sample 5 different stages of the life cycle of the population; and through understanding how the lifetime experience of these factors is differently shaped in different birth cohorts, in rich and poor countries, and between the rich and poor within these countries. 6. Key Activities • We will undertake an integrative literature review of lifecourse research in diverse disciplines, including medicine, epidemiology, sociology and psychology. • We will do extensive comparative lifecourse analyses of individual-level data from both US studies (Alameda County Study; Tecumseh Community Study) and UK studies (Boyd Orr, Caerphilly, West of Scotland). These are all large, population-based studies that all have long-term follow-up of health outcomes; multiple health indicators over time; information on socioeconomic position from various stages of the lifecourse, and extensive measures of behavioral, psychosocial and biological risk factors measured at multiple points in time. • We will examine national and regional data on levels, long-term trends and inequalities in population health in the US and UK. We will examine the extent to which it is useful to interpret these levels, trends and inequalities through a lifecourse explanatory framework specific to the economic and social context of each nation or region. • Within the limitations of the international time-series data on health, we will examine how a lifecourse explanatory framework is also relevant for understanding levels and emerging trends in population health within those countries, and the widening health inequalities between rich and poor nations. • Finally, we will apply the knowledge generated from our research to considering what a lifecourse framework would predict for the future health of the growing number of disadvantaged children in the US and UK, and the contribution this may make to future levels and inequalities of overall population health in these two countries. 7. Contribution to Health Policy The research proposed here has immediate implications for policy concerned with the future health of disadvantaged children in the UK and US. This research will help show the extent to which poor starts in life can or cannot be overcome, which stages of the lifecourse may be critical and which health outcomes, behaviors and psychosocial states are likely to be sensitive to particular forms of socioeconomic disadvantage at different stages of life. In addition, our research will do much to strengthen the conceptual basis of attempts to identify key targets for health improvement interventions in both rich and poor countries. 8. Time line and Budget We are requesting grant support for a 3 year period. 3 Letter of Intent – Sample 6 Project Title: Improving the Cancer Care Experience For Rare Cancer Survivors I am writing this letter of intent to apply for an Investigator Award in Health Policy Research. I have been closely covering for nearly two years a remarkable medical and scientific story, the transformation of cancer from a veritable death sentence to what doctors increasingly view as a chronic health condition. This year, 1.3 million Americans will be diagnosed with cancer. They will also have a better chance of surviving the disease than ever before. Incredible strides have been made in the way cancer is both treated and detected, and the National Cancer Institute recently released statistics that show fewer people are dying from cancer. There is a growing understanding of the biology of the disease that has led to the development of exciting new drugs-such as Avastin, Herceptin, and Erbitux-that while not always able to completely eradicate a tumor, frequently keep it in check, extending a person's life. But unfortunately, a large and growing number of people with cancer have not benefited from this seachange in the way cancer is diagnosed and treated. These are the people who get what are considered" rare" cancers, cancers that affect fewer than 100,000 people a year. Added together, they represent close to half of all the new cases of cancer in this country, meaning that we are not doing as well as we could against this implacable foe. Despite all the remarkable advances in recent years, for these cancer survivors, the prognosis still remains grim. They have the lowest five-year survival rates. They are given chemotherapy treatments that are not based on any research about their specific tumor. The pharmaceutical companies that drive most of the clinical trials for new drugs in this country aren't paying attention to rare cancers because the market is so small. Single institutions, even ones that are major cancer centers, don't usually see enough patients to generate statistically meaningful data, and there is no mechanism to encourage them to pool their data with others. Researchers who are interested in a rare cancer and have creative ideas often find they can't get any funding to test their theories, from either the 1 Letter of Intent – Sample 6 government or private foundations. The implications of this are clear: the exciting advances that have transformed the treatment of so many prominent cancers are not happening in many of the rarest cancers. This is the topic that I want to research with the Investigator Award. Over an 18-month period, I plan to study the challenges and obstacles that are preventing people with rare cancers from fully benefiting from our nation's long-running war on cancer. I will explore in-depth through meetings and interviews with the leading researchers, National Cancer Institute officials, prominent cancer survivor advocates and lobbyists, founders of support groups for people with rare cancers, policy-makers, and other experts what has to change so that everyone, no matter what kind of cancer he or she has, gets a fighting chance to prevail over the disease. I first became interested in the plight of rare cancer survivors when working on an article. I profiled Andy Martin, a third year medical student at Tulane University Health Sciences Center who was studying his own cancer in the lab. "If I don't study it," he told me, "there is no one else that is going to do it." It disturbed me that although more than $1 billion is spent on cancer research every year, there is virtually no money available to do narrow, specialized research. In Mr. Martin's case, there were very few studies and little research being done on sinonasal undifferentiated carcinoma, or SNUC, the disease that eventually killed him. There are believed to be fewer than 100 cases a year, according to the medical literature. Mr. Martin told me that one of the most frustrating aspects of his treatment was making tough decisions without any data or trial results upon which to base his choices, something that has made an enormous difference for breast and prostate cancer survivors. One of the projects Mr. Martin began before he died was trying to develop a model that would enable major academic centers around the country that see patients with SNUC to collect and share data, in the hopes that this would lead to breakthroughs in better understanding this cancer. As part of my own study, I would examine such proposed models to try to find ones that work and how to most effectively implement them. The findings from my research would have important and immediate health policy relevance. Based on my reporting, I truly believe that we are close to reaching a kind of "tipping point" when it comes to rare cancers, and that my project could make a tremendous difference. Already, the National Cancer Institute has acknowledged that it needs to find a way to do more to study rare cancers. One of the heads of a research arm of the institute told me recently that he was disconcerted to realize that the bulk of his group's research portfolio consists of projects on breast cancer, colon cancer, cervical cancer, prostate cancer, and lung cancer. More unusual cancers in other organs often get no funding at all, he said, and something needs to be done to find a way to bridge these gaps. At the Lance Armstrong Foundation, one of the leading national cancer survivor support and advocacy groups, I was 2 Letter of Intent – Sample 6 told that there is growing recognition that the psychological needs of survivors of rare cancers are often different than other cancer survivors and are currently not being met. The foundation said it wants to find ways to address this problem. Concrete proposals, a better understanding of the key issues, and realistic suggestions on how to move forward in helping people with rare cancers could both fuel and shape this emerging interest. This is what my project has the potential to contribute. There is a quiet but growing understanding among some cancer investigators that figuring out what goes wrong in rare cancers could yield important discoveries that might also apply to more common forms of cancer. There was great attention paid to a recent announcement by a group of researchers in Cleveland and San Francisco who for the first time found that there may be a link between prostate cancer and a virus. They made this discovery by looking at a group of men who have a rare strain of prostate cancer. In these men, the presence of the virus was more pronounced and easier to detect than it was in the general population of men with prostate cancer. And yet, if this finding is confirmed by other research groups, it could lead to better treatments and earlier detection methods for everyone, not only by giving researchers an important new clue in how to prevent one potential cause of the disease, but also clues for what to look for in unraveling the disease process of other cancers. This is the same approach that yielded one of the most exciting and important breakthroughs in treating lung cancer, a very common cancer that had long proven resistant to standard treatments. Investigators tried to figure out why a small subset of patients did well on a new cancer drug. When searching for clues about what set them apart from the majority of patients, they found that most of them had a particular genetic mutation. Now all lung cancer patients are tested for this same mutation and lung cancer specialists say drugs that target it will help them live longer. It is another example of how focusing more attention on rarer cases can help push cancer research forward. It is my belief that my project has the potential to encourage and bolster the idea of the importance of looking for clues in people with rare cancers and then applying these insights to common cancers as well. Improving the cancer experience for those with rare cancers will have two important policy results: it will lead to advances in cancer treatment for everyone, and it will finally bring some of the benefits of the cancer revolution to rare cancer survivors who until now have largely been left behind. The grant that I am seeking would help cover my salary during this period so that I could work full-time on this project, without other reporting obligations that I currently have at the newspaper. It would help fund my travel in researching this project, and in arranging and convening a stakeholders meeting of the key players and 3 Letter of Intent – Sample 6 organizations that would be the most likely to implement my findings. It would enable me not only to study for the first time the reasons why survivors of rare cancers are so ill-served, but to find a mechanism to help them that could be adapted by the policy-makers and cancer survivor groups who have the expertise and experience to make a difference and advocate for reform. In focusing on achieving practical, readily applicable suggestions, I anticipate this project will appeal to policymakers and lead to changes that will improve how rare cancer survivors are currently treated. As a professional reporter, I bring a unique set of skills and contacts to this project. I am a tireless and relentless researcher who is not easily discouraged, and is used to tracking down a tough story. As someone who regularly covers the issue of cancer, I have already developed an extensive network of sources and contacts in the government and private sector as well as at pharmaceutical companies, advocacy groups, and among cancer survivors who will help me reach a rich and true understanding of the problems. The recognition for my work on issues surrounding cancer survivors, and the platform that the newspaper has given me to do ground-breaking work on this topic, offer me the unique opportunity to get a national hearing for my findings and ideas. I anticipate interest by the newspaper in the findings that emerge from my research. This is a topic of national importance and newsworthiness and I plan to write about many of my important findings. My articles about cancer survivors appear regularly on the front page of the newspaper. This, in turn, will help generate additional attention and interest by national policy-makers in this issue. I also plan to incorporate many of the findings of the research into a book that I will write about cancer survivors. I intend to publish the book with a commercial publisher in order to reach the widest possible audience. The book will help draw further attention to this project and to finding a way to jumpstart research, clinical trials, and new approaches to treating rare cancers. 4 Letter of Intent – Sample 7 This letter of intent indicates my interest and willingness to apply for a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. 3. Statement of Objective: To assess whether private purchasers can be significant catalysts for desired reductions in medical errors and improvements in quality, as envisioned by the Institute of Medicine in its recent reports. 4. Description of Problem and Significance: Two recent reports by the Institute of Medicine’s Committee on Quality of Health Care in America, To Err is Human: Building a Safer Health Care System (2001) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001), identify serious problems facing the American health care system. Although both reports contain vast amounts of detail on medical errors and health care quality, the general message of each report is strikingly simple; namely that health care in the United States is under performing, and that major system changes are needed if Americans are to receive the high quality care that our system is capable of providing. Unfortunately, the solution is not so simple, and both the ‘Errors’ and ‘Quality’ reports provide detailed recommendations for policymakers, health care providers, insurance companies, purchasers and patients. In particular, a fair amount of the focus in both reports is devoted to public and private sector health care purchasers, and the role they play in driving error reduction and quality improvement. For example, after identifying six aims for the future health care system (safety, effectiveness. patient-centeredness, timeliness, efficiency, and equity), the ‘Quality’ report gave purchasers the following charge. To effect this set of changes, purchasers and health plans, for example, should eliminate or modify payment practices that fragment the care system, and should establish incentives designed to encourage and reward innovations aimed at improving quality. Purchasers and regulators should also create precise streams of accountability and measurement reflecting achievements in the six aims. Moreover efforts should be made to help health care consumers understand the aims, why they are important, and how to interpret the levels of performance of various health care systems. (IOM, 2001, page 13). Clearly the Institute of Medicine expects that purchasers will implement the changes necessary to improve the health care system. The obvious questions are whether purchasers are up to the task, and whether they are capable and willing to be catalysts for an improved future health care system. The answers to these questions are crucial, because if purchasers are not capable of stimulating the level of change envisioned by the IOM then policymakers and regulators need to consider alternative approaches for reengineering the American health care system. The proposed research seeks to explore in detail the 1 Letter of Intent – Sample 7 capabilities and role(s) of purchasers for re-shaping the future health care system- Results from the proposed study will be used to assess the likelihood that the IOM goals for error reduction and quality improvement will be met. 5. Specific Research Questions: 1. What specific changes in purchasing activities have individual purchasers and organized purchasing coalitions made to effect reductions in medical errors and improvements in quality? How have these changes been implemented? Have they worked? For example, have health plan contracts been re-written? Have financial and non-financial incentives been used? Are purchasers actively studying or recommending changes to care and delivery processes? Has the impact of purchasing interventions been measured? 2. Are purchasing activities focused at the level where medical errors and improved quality occur, or are they focused too broadly? Are purchasers providing appropriate incentives and monitoring change at the appropriate level in the care or service process (i.e., physician offices, group practices, hospitals)? Are health care practitioners and health organizations aware of purchaser activities? Are they responsive to purchaser activities? 3. How do purchasers vary in their willingness and ability to influence reductions in medical errors and improvements in quality? Are specific characteristics (e .g., size of the firm, economic condition of the firm, membership in local or national purchasing coalition) more indicative of active purchasing practices than others? What internal and external barriers prevent purchasers from becoming more actively involved? 4. What is the relationship between health benefit contracting and contracting with other product and service suppliers? Is health benefits contracting viewed similarly as contracting for other production inputs, or are health benefits viewed differently because they are not related to the firm’s core business? What barriers exist to having the firm devote serious attention to health benefits contracting? Does the firm believe there is a strong relationship between health and workplace productivity, and that quality health care can significantly improve productivity? 6. Summary of Proposed Activities: The proposed research will be executed by studying and collaborating with three established health care purchasing groups. including the National Business Coalition on Health and a subset of its members known as the V-8 group, the Leapfrog Group, and a group of purchasers participating in an AHRQ conference convened to develop a tool for empirically measuring the value (i.e. return on investment or cost-benefit) of disease management programs . The decision to focus on purchasers already engaging in some level of purchasing activity is a deliberate one, and although not a broadly generalized sample of private purchasers, will yield valuable information about the impact the nation’s most active purchasers are having. 2 Letter of Intent – Sample 7 Stated differently, if these highly organized purchasers are not having success, then the IOM and policymakers might want to revisit the assumption that reductions in errors and improvements in quality will be driven via purchasers. Prior studies that have sought to understand the activities of individual purchasers or coalitions have typically collected survey data or have conducted interviews regarding the types of activities that purchasers are engaged in. For example, studies have examined how frequently purchasers collect HEDIS or CAHPS data, provide employees with health plan report cards, or require hospitals and health plans to be accredited. Few studies have closely examined the process or impact of these activities, or have closely observed the contracting and negotiating relationships between purchasers and providers. The proposed research is stronger than existing studies because the investigator will not just be a passive observer, but instead will be actively involved in designing and evaluating purchasing activities, and will participate in meetings between individual members of purchasing coalitions (through affiliation with NBCH), contract deliberations between purchasers and health plans (NBCH’s V-8 Group) and hospitals (Leapfrog), and will analyze data collected as part of the V-8 Group’s standardized request for information (RFI). This level of participation is possible because the investigator already has relationships with NBCH and Leapfrog. Additionally, the investigator has access to purchasers and health plans participating in a conference to develop a tool for empirically measuring the return on investment of disease management programs. The proposed research will utilize quantitative and qualitative research methods, including case studies, interviews, and surveys of individual purchasers, coalition leaders, and corporate and health plan executives. 7. Anticipated Contribution to Future Health Policy: The IOM’s action plan for reducing medical errors and improving quality relies heavily on the assumption that public and private purchasers will change purchasing behaviors and become significant catalysts for driving health system change. By examining the activities of existing dedicated and active purchasers, the investigator will directly assess whether purchasers can meet the IOM’s expectations. If the study results indicate that the activities of purchasers are not achieving their intended results, then the findings can inform alte rnative policy approaches and/or suggest possibilities for redesigning purchasing activities. Moreover, information gleaned from the active subset of purchasers to be studied can be shared with less active or inactive purchasers, thereby educating those purchasers on the benefits of taking a proactive role in driving system change via purchasing. 8. Length of Project and Proposed Budget: A three-year time period is proposed to allow the investigator to develop baseline observations and observe the effect of incremental changes resulting from alternative purchasing strategies. 3 Letter of Intent – Sample 8 I am applying for this award to complete the research and writing of a book exploring the impact of 20th c. consumer culture and consumer movements on American medicine and public health. My objective is to provide a historical overview and critique of the many ways that the dynamics of modern consumerism have affected American health and health care policies. By so doing, I hope to contribute a historical perspective to current policy debates about how consumer rights, preferences, and choices should be honored in the medical marketplace of the 2lst century. Describing doctors as providers and patients as consumers has become ubiquitous in the last ten years. Critics wrongly assume that this linguistic shift has been precipitated solely by the late 20th c. turn toward a more competitive, market-driven medicine. In fact, as my book will show, thinking of patients as consumers — that is, actors whose decisions about spending on health-related products and services have profound implications for their health, their relations with physicians, and the nation’s economy — long predates the rise of managed care. Debates about the relationship between consumerism and health care emerged in the early 1900s as both modern medicine and mass consumer culture came of age in the United States. Between 1910 to 1940, American medicine rode its scientific revolution to an unprecedented degree of autonomy and authority. During the same decades, national corporations conducted increasingly aggressive advertising campaigns to stimulate demand for massive output of consumer goods, including many products, from cigarettes to over the counter drugs, widely recognized as having direct implications for health. My book looks at a range of debates produced by the maturation of modern medicine within a rapidly expanding consumer culture, including: the connections between new patterns of consumption and rising rates of cardiovascular disease and cancer, or so called “diseases of affluence”; the influence of new forms of news, entertainment, and advertising on popular understandings of health and disease; and the impact of a rising consumer consciousness on traditional doctor-patient relationships. I am particularly interested in the implications for medicine and public health of certain habits of mind encouraged in a mass consumer culture, among them the premium placed on newness, an intensified interest in fashion, a preoccupation with the body, a heightened 1 Letter of Intent – Sample 8 emphasis on service, and a tendency to define personal identity in terms of purchases. This new consumer consciousness, I argue, profoundly affected conceptions of health promotion, disease prevention, and medical care. My book explores these changes in three important domains: first, in the ways lay people think about spending and health, from buying self help manuals to choosing a doctor; second, in the conceptions patients and physicians have of medicine as a professional service, distinct from yet still embedded in a larger marketplace of goods and services; and third, in the role reformers and policy makers assign to the category of “patient/consumers” in their attempts to rectify what economists refer to as medicine’s “market failures.” By examining changing views of medicine’s special place in the modern marketplace of consumer goods and services, my historical investigation will contribute to a much needed re-examination of the rise and fall of twentieth century medicine’s cultural authority in the wake of the managed care revolution. As historians and sociologists have emphasized, physicians achieved a privileged economic position in the early 20th c.; they were exempted from common forms of market discipline, such as cost-benefit analysis, competitive advertising, and open discussion of price, due to their highly technical knowledge and personal relationship to their clients. While I agree that the doctor/patient relationship did (and does) occupy a unique position in the expanding world of modern goods and services, I believe scholars have overstated 20th c. American medicine’s isolation from larger currents of modern consumerism. So long as medical livelihoods depended upon patients’ willingness to patronize their services, especially prior to the rise of voluntary health insurance plans, physicians had to respond to a complex calculus of consumer judgments about health-related spending. Of course, when the need for care was acute, as in the case of a life-threatening ailment or injury, patients had little time for such calculation. But the vast majority of medical services and products were selected under less urgent circumstances that allowed prospective consumers more time to contemplate their expenditures. In a culture that increasingly tied consumption choices to individuality and autonomy and urged consumers always to “get their money’s worth,” choices about health care became freighted with new meanings. And no matter how loudly and often medical leaders proclaimed that their high-minded professionalism kept any tendency toward low-minded commercialism firmly under control, many lay people continued to believe quite the contrary. The book looks first at tensions produced by the interplay between the new medicine and the new consumerism as they emerged in the decades from 1910 to 1940, then traces the evolution of those tensions from the post war period through the l970s. I will argue that although the spread of voluntary hospital and medical 2 Letter of Intent – Sample 8 insurance plans mitigated some of these tensions in the prosperous post-WWII years, conflicts surrounding consumers’ views of health-related products and medical services remained; in the combustible atmosphere of the 1960s, they would flare anew, providing the popular backdrop for the new regulatory trends of the late 20th c. To make this argument, I am using a wide array of sources, including the records of the AMA, consumer groups, medical economists, the FTC, the FDA, and last but not least, advertising agencies that excelled at the “health sell.” While my methods and sources are historical in nature, my research questions are informed by wide reading in other areas of scholarship, including health economics. I have studied health economics to become familiar with how economists think about the distinctiveness of the medical marketplace and consumer demand in health care. I also use the now extensive literature on consumer culture that has recently appeared in history, sociology, anthropology, and women’s studies. While little of this work focuses specifically on health care or doctor/patient relations, it offers new insights into the theory and practice of modern consumerism, especially the role of media and advertising in influencing the definition of needs, desires, and preferences. During my year at the National Humanities Center, I completed approximately two thirds of the research and drafted about one half the book. (Papers drawn from this project are marked by an asterisk on my CV.) Since then, I have completed rough drafts of several more chapters, despite teaching and serving as an administrator. I still need to do some archival research to fill in the “back story” of my narrative, particularly in Chicago, where I need to use both the Morris Fishbein papers and A.M.A. archives. I also need shorter visits to New Brunswick (the Consumers’ Research archives), Westchester (Consumer Union archives), and Yale University (papers of early health economists). I am requesting two years of support. During year one, I would like to be released from all teaching obligations, which would allow me to finish the book manuscript and submit it to a university press. During year two, I would revise the manuscript as needed and complete other prepublication work. My budget include funds to buy out my teaching obligations; funding for a research assistant for both years, research trips; copying and books. In my scholarship to date, I have demonstrated an ability to provide sophisticated, balanced historical treatments of topics central to contemporary health policy. I believe that Impatient Consumers will be one of the most policy relevant works I have ever done. Over the last few years, the presentations I have made on this subject have attracted unusual interest and enthusiasm from physicians, medical students, and lay audiences. In tackling 3 Letter of Intent – Sample 8 head on how the American obsession with consumers and consumerism has played out in the field of health care, I seem to be speaking to concerns that many citizens feel today. I believe this project meets the program’s objective of supporting research that contributes to a better informed discussion of contemporary health issues and policy concerns. 4