At hospital committee meetings these days, the disconnection between medicine as once taught by prerevolutionary physicians and medicine as now codified by compliance-minded, MBA-qualified “medical directors” is startling; the author feels as though she arrived at such meetings by time machine.
In the new “integrated delivery systems,” the organizational chart reigns. Physicians are boxed into defined categories, next to the bottom of the chart, just above the patients; together with the patients (now known as “covered lives”), they form the “medical loss ratio.”
It is a world of paradox. Talk of “ethics” generally means talk of “resource allocation,” often by means once called unethical. One drowns in information, but the key of knowledge is lost. Facilities and personnel are present in excess, and yet they are scarce.
The scarcest item of all appears to be the clinician’s time. Thirty seconds may be too long to spend searching for a reference. In some settings, there may be no time to look in the left ear if only the right one hurts, much less to listen to the patient’s grief or despair. And when can today’s managed provider stop and reflect?
Concepts are imported from industry, such as “six sigma quality”–the goal to reduce errors below 6 standard deviations from the mean of a normal distribution. This means that all but 3.4 out of 1 million patients are supposed to meet a certain indicator, such as timely Pap smears or mammograms, regardless of individual needs and desires.
Quality experts in industry do recognize that one cannot control outputs without controlling inputs–a fact that health policy experts seldom acknowledge. But even if we could control the behavior of patients and physicians, there remains the problem that human beings are not stamped from an industrial die. Even if not totally unique in genetic endowment, each human being has had a different interaction with the world.
As the art of medicine is being lost, the science is also threatened. “Evidence-based” medicine is coming to mean based on the consensus of a committee of experts: the Prussian Geheiin Rath with many heads (and no heart). Clinical reasoning is replaced by following a practice “guideline” from one prescribed information bit to another, and a diagnosis means a number with five significant digits (never mind that the first one is dubious) attached to an appropriate procedure code. The very altar of truth–the autopsy table–is being dismantled.
It is telling that bureaucratic quality assessment is almost always based on process (read compliance) measures such as number of blood pressure determinations or prescriptions for the medication du jour, not outcome measures such as all-cause mortality or ability to function independently. Regardless of the reading on the “continuous quality improvement” dashboard, almost everyone on the front lines of patient care believes that American medicine and health are in decline.
…[Even so,] Medicine is a living thing that will survive and flourish, despite the dinosaurs of “health care delivery,” and long after inhuman systems fail. There are still students who aspire to be physicians, not providers, gatekeepers, resource managers, or box-checkers. There are still those who consider medicine to be a human and a humane endeavor, not an industry.
– Dr. Jane Orient
From the preface to the Fourth Edition of Sapira’s Art and Science of Bedside Diagnosis