The One Best Way
Pamela Harzband and Jerome Groopman recently published an editorial in The New England Journal of Medicine entitled “Medical Taylorism.” They make some of the same points I was trying to make in the series entitled “Confronting the Quality Paradox.” They point out that Frederick Taylor, sometimes called “The Father of Scientific Management,” believed
“…there is one best way to do every task and that it is the manager’s responsibility to ensure that no worker deviates from it…Taylorism has begun to permeate the culture of medicine.
Advocates lecture clinicians about Toyota’s “Lean” practices, arguing that patient care should follow standardized systems like those depoyed in manufacturing automobiles…
Meanwhile, the electronic health record…has become a key instrument for measuring the duration and standardizing the content of patient-doctor interactions in pursuit of “the one best way.” Encounters have been restructured around the demands of the EHF: specific questions must be asked and answer boxes filled in to demonstrate to payers the value of care…
We believe that the standardization integral to Taylorism and the Toyota manufacturing processes cannot be applied to many vital aspects of medicine…The inescapable truth of medicine is that patients are genetically, physiologically, psychologically, and culturally diverse.”
It is somewhat surprising to me that the New England Journal, which is often thought of as the best place to publish breakthrough articles, chose to publish this article, given that it points out the limitations of the scientific method in the practice of medicine. Of course, I agree. While I have advocated the benefits of “standardized” methods, particularly in the operation of dialysis units, the point I always try to make is that we should be trying to standardize those things where it makes sense for patient care, but no more.
I also think the growing “patient dissatisfaction” and certainly the “provider dissatisfaction” with the current state of medical care delivery, evident in numerous reports, represents an emotional response to a dimly received, and poorly articulated threat. One of our core beliefs is that each of us in a distinct, and unique, individual. For sure, the way our kidneys operate in health is the same, but at the level of the “intact organism” there is plenty of evidence, from the immune system for example, of our individuality. What Hartzband and Groopman have called medical Taylorism, and what I have described as the tyranny of the accounting systems, are both efforts to articulate this threat.
Now the people paying for health care, who usually are not clinicians, and not quite as sure of this notion of individuality, are looking for some impersonal way to decide what to pay for and what not to pay for. A lot of the push to adopt ICD 10 was based on its “increased specificity.” This, in turn, might lead to determining which codes “justified” which procedures and diagnostic tests and how often. The resistance was based on the notion that this increased coding specificity still does not capture complex clinical realities, particularly the uncertainties. Is the patient’s kidney disease on the basis of hypertension or diabetes, or some mixture of the two? Is it worth a kidney biopsy to make a more specific diagnosis? (No.) I could go on, but I think the point is clear.
Having had the opportunity to participate in some conversations about these issues with insurance companies, I understand the complexities from their perspective as well as from the clinician’s. Simply ignoring the problem, as we clinicians are prone to do, is not a tenable answer—it is really covert abdication of our responsibility to advocate for what we believe constitutes good medical care. An interesting thought experiment, though, is to always ask—would I be happy with the processes if or when I or my family needed to have care? The answer sometimes seems like Congress’ response to insurance reform. The ACA is good enough for the hoi polloi, but we have opted out with our own “Cadillac” smorgasbord of options. Hmmm…
28 January 2016
 Hartzband P, Groopman J. Medical Taylorism. N Engl J Med 2016;374(2):106-108. doi:10.1056/NEJMp1541402.
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 4
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.
Confronting The Quality Paradox - Part 5
Productivity in Healthcare Part 1
Many are focused on efficiency and productivity in healthcare without a clear understanding that the two are not interchangeable. This article introduces the two concepts as they are commonly used.
Productivity in Healthcare Part 2
The conflict between productivity and efficiency is examined from three perspectives using the care of dialysis patients as the case study.
Productivity in Healthcare Part 3
The conflict between productivity and efficiency is contributing to widespread physician malaise, which has negative implications for health care improvement.