Confronting the Quality Paradox—Part 4
Biomed Central published a collection entitled The Many Meanings of “Quality” in Healthcare 19 June 2015. This collection was cross disciplinary and addressed three broad themes: the practices of quality assurance, giving space to “the story,” and addressing moral complexity in the clinic. This is the fourth of a series of articles dealing with individual papers that resonate with the practice of medicine today.
Heath’s paper, “Arm in Arm with Righteousness” explicitly addresses the challenge implicit in the other papers I have reviewed from this series.
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object…Yet, to date quality in relation to the human being as an object has predominated because this is infinitely the easier option as it is possible to create a normative standard that is able to completely ignore the difficult issues of subjectivity.
She has a wonderful analogy from systems engineer Paul Plsek, which is worth quoting in its entirety.
[He] compares throwing a stone with throwing a live bird. The trajectory of the stone can be calculated precisely using the laws of mechanics, and it is possible to ensure that the stone reaches a specified target. However, it is absolutely not possible to predict the outcome of throwing a live bird, even though, in truth, the same laws of physics govern the bird’s motion through the air…one solution would be to tie the bird’s wings, weight it with a rock and then throw it. This will make its trajectory nearly as predictable as that of the stone, but in the process the capability of the bird is completely destroyed. This seems very close to what happens when we try to measure the quality of healthcare using measures that ignore the presence of human subjects either as patients or as healthcare professionals.
She goes on to make further observations that resonate with many physicians.
Computers allow the processing of unprecedented amounts of data, and they are driving an obsession with measurement and it is being used in a normative and coercive way to define and demonize “deviant” behavior whether among doctors or patients…Biological variation has been appropriated to the causes of commercial profit and of lifestyle and political conformity, and normative quality assurance that focuses on the body as an object is part of this…
The contemporary marginalization of the human subject affects doctors and other healthcare professionals almost as much as patients. Both have been reduced to the interchangeable units with a healthcare industry: the one as a unit of healthcare need, the other of healthcare provision. And as patients have been reduced to these interchangeable units of health need, their access to the system has been systematically prioritized over the need to sustain a relationship with a known and trusted professional, with another human subject.
One of the unresolved tensions in my local community revolves around this last point. Most physicians, but particularly primary care physicians, have more demand for their services than they can see effectively, and have done various things to limit their availability, particularly to new patients. The hospital, on the other hand, sees high availability as absolutely essential for its economic survival, and has tried to expand access by increasing access points, particularly to hospital services. Yet the demand for primary physicians, particularly hospitalists, exceeds the economic realities of hiring scarce talent, which remains limited. Thus the expansion of demand threatens quality of care, whether it is defined with the patient as object or subject.
The evidence on which biomedical science is based has been derived from the analysis of data from populations grouped together by what they have in common—difference is systematically excluded or ignored. Huge advances in understanding and efficacy have been made through these techniques. The ineradicable problem is that data collected from populations can tell us nothing about what will happen to any particular individual. The application of biomedical evidence to the care of an individual will always require the exercise of judgment on the part of both clinician and patient…Hence the quality of primary healthcare is crucially dependent on two phenomena, judgment and human relationships, and for neither of which is there any recognized metric of assessment.
Although Heath focused on primary care, I have actually seen this conflict work out in my community more in specialty care. This may reflect the practical division of labor here as opposed to Great Britain more than anything else. The “consumer” of health care generally wants primary care services the same way that shop—everyday low prices available all the time. As the growth of primary care services in these stores—think CVS or Wal-Mart—shows, the consumer thinks he/she knows what she wants, and personal services are not of value. On the other hand, let that person get the disease they think will kill them, and suddenly they want “the best.” The problem providers have is to decide which kind of service they are going to offer, and most have opted for the Wal-Mart model—it pays better.
I have noticed young medical professionals have not been trained to recognize the truth of the last point cited above. The application of professional knowledge always involves judgment. In specialty care, patients often test the limits of biomedical knowledge. One of my younger associates has recently had two difficult patients for whom the “right” answer was not apparent. This produced a great deal of anxiety that the patient might not get the best possible treatment. Consulting other physicians, including me, only produced a range of opinions, some of which were antithetical. In these cases, the search for biomedical certainty only led to more confusion.
From my perspective, the range of opinions depended upon whether the consultant saw the problem as treating the disease or treating the patient. I have noted an increasing trend at the hospital where the younger consultant will always recommend “standard” therapy for the condition, regardless of the patient’s circumstances. I do not think these young consultants are unaware of the circumstances, but they find it too threatening to stray far from “the path.” Perhaps they are afraid of being seen as “deviant” as suggested in the earlier quotation.
There are other worthy papers in this series, but these are the four that I found most applicable to the practice of medicine today. Do these articles say that quality improvement is worthless and impossible? No, they only point out that relying on these efforts for regulation and payment fundamentally change the nature of medical practice in ways that are deleterious.
We as physicians must objectify the patient to be able to make a diagnosis, but then turn around and view the patient as subject to make educated guesses about the best course of action and the likely prognosis. I like to say that each patient is an experiment of n=1; we don’t get to try two courses of action in an individual and see which one works better. While we don’t like to admit it, our own personalities and opinions invariably color the interaction, even as we strive to include the patient as a partner in decision-making.
For example, I have always been a bit skeptical of “cure” and have understood we are usually in the business of delaying death and disability. As I have gotten older that bias has been reinforced. I still offer dialysis therapy to a lot of people, but I also tell many it probably won’t buy them much time and such time as they get may come with a great deal of suffering. This is an evidence-based, as well as subjective statement, but for the patient it is still all or none, and always will be.
I think the root issue, both for us as individual physicians and for medicine at large is an intolerance of ambiguity. We will almost always take the simple solution, even if it wrong, over a reality that requires us to keep two ideas in mind at the same time—the patient as both object and subject of our intervention and ourselves as both agent and individual. Similarly, we must remain responsive to a distrustful “public” while keeping our “private” doctor-patient relationship true to the goals of our profession. Perhaps rather than obsessing about our scorecards on “quality measures,” we should be concentrating on how we establish and prove professionalism.
18 July 2015
 Swinglehurst D, Emmerich N, Maybin J, Park S, Quilligan S. Confronting the Quality Paradox: Towards New Characterizations of “Quality” in Contemporary Healthcare. BMC Health Services Research 2015;15:240. doi: 10.1186/s12913-015-0851y. Accessed at http://www.biomedcentral.com/1472-6963/15/240, 21 June 2015.
 Heath I. Arm in Arm with Righteousness. Philosophy Ethics Humanities in Medicine 2015;10:7. doi. 10.1186/s13010-015-0024-y. Accessed at http://www.peh-med.com/content/10/1/7, 25 June 2015.
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 5
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.