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.
