Zen and the Art of Health Maintenance

Zen and the art of health maintenance

Richard Amerling, MD
March 2004

“Peace of mind isn’t at all superficial, really; it’s the whole thing. That which produces it is good maintenance; that which disturbs it is poor maintenance.”

Robert Pirsig; Zen and the Art of Motorcycle Maintenance; 1974

While listening to a colleague lecture about quality assurance in the dialysis unit, it occurred to me that perhaps he didn't have any idea what he was talking about. I suddenly realized what was missing from the debate over the quality of medical care--a viable definition of quality. Traces of Robert Pirsig's seminal novel, "Zen and the Art of Motorcycle Maintenance," which I read in 1974, came rushing back. In it, the protagonist (author) literally went insane in pursuit of this. He asks his philosophy students to define quality, and they come up short. He tells them,

“I think there is such a thing as Quality, but that as soon as you try to define it, something goes haywire. You can’t do it.”

After a few days he comes up with,

“Quality is a characteristic of thought and statement that is recognized by a non-thinking process. Because definitions are a product of rigid, formal thinking, quality cannot be defined.”

Of course, he is not satisfied by this non-definition, and pushes further to an epiphany:

”Quality couldn’t be independently related with either the subject or the object but could be found only in the relationship of the two with each other. It is the point at which subject and object meet. Quality is not a thing. It is an event. It is the event at which the subject becomes aware of the object.”

More later.

The major problem with current concepts of quality in health care is that they are tied to outcomes. Outcomes are measured, to the extent they can be, and then practices or procedures associated with good outcomes are retrospectively labeled as high quality. Several large flaws are inherent in this methodology.
First is the retrospective nature of the process. Retrospective studies, which the medical literature is full of, are difficult to interpret at best. This is because many other variables may have influenced the outcome, but were not controlled for. The only way to safely conclude that a given treatment made a difference is by performing a double blind, placebo-controlled study. These prospective studies form the core of scientific medicine and distinguish it from so called alternative medicine. If more patients in the treatment group respond favorably, and the difference in response rates between the two groups rises to statistical significance, we can conclude that the treatment is effective. If the difference is only slight, however, we cannot come to that conclusion. What is always fascinating about these studies is that the placebo works, sometimes in a large number of patients. Likewise, the placebo group often reports similar side effects as the active group. Very often interventions that seemed effective when viewed retrospectively have proven to be ineffective when tested prospectively.

Another large flaw in the ‘good outcome=quality’ process is that populations can differ widely. A group might have a good (or bad) outcome that is completely unrelated to any treatment effect, but rather is due to the inherent health of the population. This is one reason why the so-called ‘health maintenance organizations’ may have decent ‘quality’ reports: their patient population has been pre-selected to be relatively healthy. In such a group it matters little what sort of care is provided, as they will tend to do well regardless. Traditional quality=outcome measures will tell little about the actual process of health care within these organizations. Harvard Medical School may well be able to boast of the success of their graduates. Does this mean the quality of the education at Harvard is superb, or that the entering class is handpicked from the cream of the cream of undergraduate applicants, who would succeed in any setting?
The third major problem with this approach is that it is based on the study of large populations, whereas physicians deal with individual patients, one at a time. Even well designed, double blind, prospective studies (which form the basis of what is called ‘evidence-based medicine,’ or EBM) can be difficult to apply to the individual. All they do is give a statistical likelihood that a given patient will respond favorably to the treatment studied. Physicians must exercise judgment in choosing whom to treat and with what, and then follow assiduously to monitor the effects of treatment (office EBM). The outcome=quality approach produces ‘guidelines’ which, if followed, ought to lead to good outcomes, i.e., good ‘quality.’ However, the ‘guideline’ thesis has never been tested. Do patients treated according to guidelines do better than those treated as individuals by their own physicians? Guidelines are completely useless when dealing with a new problem. They are too-often misused as mandates, with real life consequences for medical malpractice and reimbursement policy.

Back to Pirsig.
Earlier in the book he talks of an instruction manual for a bicycle that states,

“Assembly of Japanese bicycle requires great peace of mind.”

Then he explains,

“Technology presumes there’s just one right way to do things and there never is…the art of the work is just as dependent upon your own mind and spirit as it is upon the material of the machine. That’s why you need the peace of mind.”

He then uses the craftsman analogy to shoot an arrow through the heart of the guidelines movement, 20+ years in advance:

“Sometime look at a novice workman or a bad workman and compare his expression with that of a craftsman whose work you know is excellent and you’ll see the difference. The craftsman isn’t ever following a single line of instruction. He’s making decisions as he goes along. For that reason he’ll be absorbed and attentive to what he’s doing even though he doesn’t deliberately contrive this. His motions and the machine are in a kind of harmony. He isn’t following any set of written instructions because the nature of the material at hand determines his thoughts and motions, which simultaneously change the nature of the material at hand. The material and his thoughts are changing together in a progression of changes until his mind’s at rest at the same time the material’s right.”

The quality is in the interaction between craftsman and his work. A good interaction produces an excellent result. This could just as easily be describing a doctor performing an evaluation of a patient. Quality is directly linked to caring:

“…care and Quality are internal and external aspects of the same thing. A person who sees Quality and feels it as he works is a person who cares. A person who cares about what he sees and does is a person who’s bound to have some characteristics of Quality.”

Now we get to the Zen of health maintenance. Quality in healthcare occurs at the cutting edge between subject and object, the doctor-patient interaction. Anything that enhances this relationship improves Quality; anything that interferes with it destroys Quality. If the interaction between patient and physician is positive, craftsmanlike, serene, and secure, this will afford the physician the best possible chance of figuring out exactly what is wrong with the patient. The patient will feel the caring, and that, in fact, begins the healing process.
When seen in this light, the factor that has most interfered with the doctor-patient interaction is the interposition of third party payers between doctor and patient. The most egregious example is the so-called ‘health maintenance organization.’ Most pay physicians a modest monthly sum to assume primary care duties for patients. This creates a strong financial incentive to avoid seeing any of these patients. Any visits are likely to be short, stressful affairs with much negative emotion on both sides. These organizations also specialize in erecting barriers to secondary and tertiary care.
They also, along with Medicare and Medicaid, have effectively removed money from this basic relationship, which also helps destroy Quality. In Medicine, money is essential to Quality. Money buys a pleasant office, helpful staff, the latest equipment, books, computers, education, and, most important, time. Time spent with a patient, or thinking about a patient, is the sine qua non of a good patient-physician interaction. Current levels of physician reimbursement have made it all but impossible to spend adequate time with patients.

Quality in healthcare has been destroyed by various third parties stripping money away from physicians and other providers of care, such as nurses and hospitals. Parallel with the wholesale destruction of Quality we have witnessed the rise of various “quality initiatives,” “quality indicators,” “quality assurance committees,” “treatment guidelines,” and the like, all of which completely miss the point, and in fact make things worse by diverting even more time and money away from actual caring. The decline in quality has been accompanied by a decrease in the ratio of caregivers to total health care workers. The ballooning administrative sector is choking off the clinical sector.

The ideal setting in which to experience the art of health maintenance is the private physician’s office, where care is rendered for a fee, to be paid directly by the patient to the physician. This fee solidifies the relationship between doctor and patient. It commits the physician to do his utmost to promote the patient’s well being, and it places the patient firmly in control. It guarantees that the physician works for the patient and is responsible to him, rather than a third party. It assures complete confidentiality. Of course, nothing prevents patients from purchasing insurance to protect them from catastrophic illness or injury. But this should always remain external to the doctor-patient relationship, lest it interfere with Quality.
In the hospital setting Quality means more and better nurses, who are liberated from mind-numbing paperwork, so they can spend more time with their patients.
Across the country, increasing numbers of physicians are severing their ties to third party payers, opting to recreate the sort of high quality private practice that made American
Medicine the envy of the world. Let the trend continue. And let us make Robert Pirsig’s fabulous book required reading for everyone involved in health care.

The Physicians' Declaration of Independence

The Physicians’ Declaration of Independence

July 4, 2004

When in the Course of human events, it becomes necessary for one Profession to dissolve the Financial Arrangements which have connected them with Medicare, Medicaid, assorted Health Maintenance Organizations, and diverse Third Party Payers and to assume among the other Professions of the Earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of Mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident: that the Physician’s primary responsibility is toward the Patient; that to assure the sanctity of this relationship, payment for service should be decided between Physician and Patient, and that, as in all transactions in a free society, this payment be mutually agreeable. Only such a Financial Arrangement will guarantee the highest level of Commitment and Service of the Physician to the Patient, restrain Outside Influence on Decision-Making, and assure that all information be kept strictly confidential. When a Third Party dictates payment for the Physician’s service, it exercises effective control over the Decision-Making of the Physician, which may not always be in the best interest of the Patient. The Third Party then intrudes heavily into the sacred Patient-Physician relationship and demands to inspect the Medical Record in a self-serving attempt to satisfy itself that its money is being spent in accordance with its own pre-ordained accounting principles.

The Financial Arrangements between Physicians and the Third Parties have become so destructive to the Patient-Physician relationship, and to the Medical Profession as a whole, that it is the Right, and Obligation, of the Members of the Profession to abolish them. Prudence will dictate that arrangements long established should not be changed for light and transient causes; and accordingly all experience has shown, that Physicians are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations evinces a design to reduce them under absolute Despotism, it is their Right; it is their Duty, to throw off such arrangements, and to provide new Guards for their future security.

Such has been the patient sufferance of this Profession; and such is now the necessity that constrains them to alter their former Financial Arrangements. The history of the present system is a history of repeated injuries and usurpations, all having in direct effect the establishment of an absolute Tyranny over the Medical Profession. To prove this, let Facts be submitted to a candid world.

o The Tyranny began during the Second World War, when Companies, suffering under Wage and Price Controls, were forced to lure workers by offering Health Insurance Benefits. This benefit, in lieu of cash, received favorable tax treatment and was allowed to continue after the War, even with the removal of the Wage and Price Controls. This system created a strong incentive to use Health Care and set the stage for massive Health Care Cost Inflation.

o Slowly, insurance changed into payment for all Health Expenses, minus a small and shrinking deductible, which led to further Inflation, and a call to control costs.

o The Government decreed that Employers must offer Employees the option of a Health Maintenance Organization. Thus were born the HMOs: Private Insurance Entities designed to ration Health Care for their Members. These Organizations received Tax-favored treatment that allowed them to survive in spite of their horrendously flawed concept.

o The Government, in 1965, in its Infinite Wisdom, decreed that the Poor and The Elderly should receive Health Care Benefits funded entirely by the Taxpayer. Thus came into existence Medicaid and Medicare. Medicaid, from the Conception, paid Physicians such a lowly wage that few participated, thereby creating a Two-Tiered System. Medicare payments to Physicians were initially fair and reasonable, and many Physicians participated in Medicare. Both Systems flooded the Health Care Marketplace with Money, which fueled Inflation even more.

o Alarmed by the Health Care Cost Inflation that it had engendered, the Government set out to restrain costs, principally by limiting fees to Physicians. These Price Controls had the effect of increasing Health Care Inflation, as Volume of Services went up, and Quality went down.

o With each new round of Controls, Regulations and Paperwork multiplied many fold. This caused Physicians great Anguish, and took more time away from the Patients, with attendant loss of Quality and increase in Health Care Inflation.

o Government policies continued to favor the HMO, which were turned to in the hope they would tame Inflation. These Organizations simply skimmed Money off the Premiums as Profit, but which they called “Savings.” They spent less on Health Care by denying or limiting access to Specialists, Procedures, Hospitals, and High Technology. Since this strategy mostly delayed care, it was ultimately more expensive. Thus did the Premiums again start to rise.

o The HMOs paid the Physician by Capitation; Physicians could stay profitable by having large numbers of Capitated Patients, which they would see rarely, if at all! There were other Financial Incentives to Physicians to limit their Patients’ access to Tertiary Care. These incentives set Patient against Physician, thus destroying this Sacred Trust.

o Remuneration for Physician services by the Government and the HMOs has dwindled to the point of Unprofitability and has compelled the Bankruptcy of increasing numbers of Practices, and the search for Other Sources of Income by Physicians. No other Profession in the United States is denied the ability to raise fees to cover increasing costs of doing business.

o The Government, becoming increasingly desperate that all its strategies to control costs had failed (because they themselves were the cause of Cost Inflation!) resorted to Criminal Prosecutions of Individual Physicians and Hospitals for alleged Fraud. The Regulations being so Arcane and Vague, a simple Billing Error could be interpreted as Fraud. Most of those so pursued, being financially unable to defend themselves, simply capitulated and paid Huge Sums to the Government. Some were imprisoned.

o The Goverment passed a Massive Bill called HIPPA, which forced Doctors and Hospitals to spend billions to comply, with absolutely no positive impact on Patient Care.

o The Government passed a law called SGR which automatically lowers Physician Payment when total spending and volume increase, virtually assuring a downward spiral in Payments.

o The Government and HMOs now conspire to limit fees to Physicians by a diabolical machina known as "Payment for Performance," based on "Practice Guidelines." In addition to insulting our Ethic, this system will close the circle between the Central Payment for Care and the Central Prescription of Care. Thus do we completely lose our Professional Autonomy.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A System whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a Free Profession.

We, therefore, the undersigned Physicians of the United States of America, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name of our Patients solemnly publish and declare, that we will withdraw our participation in all above-described Third Party Payment Systems. Henceforth and Forever, we shall agree to provide our services directly to our Patients, and be compensated directly by them, in accordance with the ancient customs of our Profession. As has always been true of our Profession, our charges will be adjusted to reflect the Patients’ ability to render payment. Nothing prevents any patient from purchasing and using Insurance. The Patients’ medical interactions with us will remain completely confidential. We pledge the highest level of Service and Dedication to their Well-Being.
And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

Richard Amerling, MD; New York, NY
January, 2009


I wrote this in the hope it would be spread; it ended up on the website of the Association of American Physicians and Surgeons (an excellent group). Please feel free to copy, quote, print, and sign!

Welcome to Unconventional Health

Each new generation claims to have a monopoly on the truth. With maturity comes an appreciation of the transitory nature of truth, particularly in medicine. A cursory review of the history of medicine exposes the dangers of following conventional wisdom. We look back with disdain on physicians in the 18th century who bled George Washington to death in an attempt to cure his epiglottitis. Yet, even with the explosion of medical technology and pharmacotherapy that we have witnessed over the past 50 years, much of medical practice today remains guesswork. The wise physician today understands that future generations will judge him just as harshly, if not more so!
This blog will be devoted to challenging conventional wisdom in health care and related topics. Over the next few months I will post articles looking at current trends in medicine with a contrarian bent. Please read, enjoy, and comment!