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A conundrum lurks near the center of important institutions that serve society. While membership in such an institution often requires an unusual skill set, that skill set never characterizes the institution; in fact, it must be subordinated to a greater task that society assigns to the institution. For instance, Supreme Court justices possess unusual intelligence and vast knowledge of constitutional law, but these gifts must be subordinated to society’s need for just decision-making. The Senate hearings are a formal attempt to insure that a nominee both has the skill set and accepts the subordination. History abounds with other examples. General Macarthur possessed all of the military virtues and exercised them successfully in three wars, but President Truman relieved him when he placed those virtues ahead of the role our society assigns to military officers no matter how great their prowess. Truman decided that Macarthur failed the ultimate test of a general officer; he was insubordinate to civilian authority.
Medicine has long been an important institution, and many physicians have unusual skills that fit them to serve society. This essay explores the relationship between these skills and the role society currently assigns to them. It argues that for a variety of reasons we physicians have not sufficiently subordinated our individual gifts to our current societal mandate. In the United States, the result is medical care too sharply focused on providers, and not enough on patients. We begin by discussing our individual gifts, how they are nurtured in training and lionized by society. We then examine how our gifts and some aspects of our medical culture militate against seeing our patients as customers, distort our understanding of quality assurance, and therefore interfere with effective service. Finally we offer some ideas to redress the imbalance between our skills and our customers’ needs.
Our craft requires a special intimacy with patients and, coupled with the natural fear of suffering and death, it is not surprising that our society lauds our long study and our willingness to confront on their behalf the sad and frightening aspects of the human drama. This was true in the time of Galen and Miamonides, and it is even truer now that we have effective treatments. They call us by a special title, provide legal protection for our relationship with them, and even make jokes about how we act like God and vice versa. Since they entrust us with their lives and those of their children, they want us to be exceptional; they expect it. In ancient times, we could only offer comfort, and so they probably chose us for our social skills. Now they choose us primarily for our scientific abilities, but successful clinicians retain those elements of humanism that have always attracted the suffering.
Thus, members of society value us as they value their own lives, and in wealthy Western societies that value has reached stratospheric heights. In the long perspective, this trend is a perfect reversal of the Reformation obsession with spiritual salvation at any cost, including widespread murder, to achieve eternal life. Our secular society is as driven by physical survival as our medieval ancestors were driven by the spiritual variety. Given this parallel we should not be surprised that society, with our help, has invested us with the miracle, mystery, and authority of the Grand Inquisitor. But as you may recall in Dostoyevsky’s tale, while the Grand Inquisitor fully accepted his role[1], he deeply understood its limitations. How have we physicians fared?
II.
Well, first we must decide who the “we” is, and it obviously includes individual physicians and the medical institutions that choose, train, and represent us. About a hundred years ago, Osler, Halsted, Welch, and Kelly synthesized the elements of modern medicine that still deeply influence us today[2]. The timing was no accident. This was the beginning of “modernism” as intellectual historians define it, the time of Gerard Manley Hopkins in poetry, Picasso in art, Mahler in music, Einstein in physics, and Joyce in literature. They and others at the time framed much of societal discourse for the next century. Our medical forbearers made a deal first with a few wealthy donors and later with our entire society. They agreed to improve medical science for all of us if society would support their institutions. This turned out to be one of the best deals our society ever made, witness the extraordinary development of medicine and surgery since then and the resulting improvements in well-being and longevity. They not only set the scientific standards we would all follow, but they set the cultural standards as well. We would be highly intelligent, carefully selected in training, and fanatically dedicated to our responsibilities. We would be vastly different from the poorly apprentice-trained physicians of the time, and our institutions would be temples dedicated to our science, not the charnel houses that passed for hospitals then. This brilliant vision melded perfectly with the incipient revolution in science and industry that would characterize the next century. We physicians would indeed become the modern Grand Inquisitors, literally taking histories, deciding fates, and occasionally in moments of clarity, leaving a cell door open.
For the prospective as well as the practicing physician, this was and still is a heady brew. If we are to serve our fellow man so directly, we must be intelligent, studious, dedicated, and eventually able to wrap ourselves in the modernist mantle of our predecessors. And so many of us are indeed the exceptional individuals society demands. For a long time the formula worked, and in many ways, it still does. The society lavishes nearly 15% of its GDP on our efforts, and medical school admission remains highly competitive. Our individual incomes may not be what they were, but we still earn far above the norm, and mammon always fit the demotic world of Wall Street better than the sanctuary of healers.
If physicians are such exceptional individuals working within such a successful social compact, why do we claim that we have not sufficiently subordinated our skills to societal need? The short answer is that society has changed, medical institutions have changed, and physicians have yet to fully construct adequate responses to these challenges. Let us examine a few aspects of this new order.
First, society has changed. The era of docile consumers is over. They are far better educated than a century ago and, through the internet and mass media, they have access to more information. They want a dialog with us, they want to know options for treatment, and they want to know our results. Healthcare businesses have recognized medical consumerism as anyone who watches the evening news can testify. These businesses directly market drugs for complex illnesses to consumers, and suggest that consumers ask their doctor about them. For another example, the most important structural change in residency training in the past twenty years, an enforced reduction in working hours, came not from professors, but from society following the Zion case in New York. Academic centers resisted this intrusion into their polity, but consumers, while lauding our work ethic, resisted care given by the sleep-deprived, and won.
Second, our medical institutions have become exponentially complex tangles of basic science, technology, government regulation, care delivery, training, finance, fund raising, and ethical concern, but their governance often remains enmeshed between the Oslerian values of physician leaders and the caveat emptor values of business leaders inside and outside the academy. In the past few months, we have witnessed the prestigious Cleveland Clinic (a $3.8 billion business) providing substantial clinical and academic support for a device used to treat atrial fibrillation at a time when several of the involved physicians had substantial financial stakes. Their patients were not informed. We have also seen the University of Medicine and Dentistry of New Jersey agree to Federal monitoring of its finances after widespread fraudulent billing. These examples do not necessarily show evildoing so much as they show the enormous complexity of running multibillion dollar medical businesses in an age of consumerism and government oversight. The best and most harrowing description of how institutional complexity affects patients may be found in Berwick’s essay, Escape Fire[3]. All healthcare providers should read it annually.
Third, and perhaps most important for this discussion, we physicians have not developed a mindset that preserves the crucial values of our founders, discards the outmoded ones, and seeks sturdier methods to serve our customers. A complete description of this mindset is beyond the scope of this essay and may not yet be formulated, but its philosophical basis exists[4]. It will certainly retain the founders’ scientific rigor and fierce dedication, but it will reject some of the Grand Inquisitor hauteur and medieval guild qualities that are no longer useful, and perhaps never were. These latter are part of what we entitled “physician exceptionalism.” This is the misguided notion that, because we may be exceptional as individuals, with unusual knowledge and training, we, rather than the customer, should be the center of attention. Hospital practice is rife with examples. For instance, surgeons and anesthesiologists insist on their individual setups and instruments to perform the same operations in a given hospital. This compels operating room staff to focus on the various needs of the caregivers rather than on the patient. Postoperative orders also often vary among surgeons for the same type of procedure leaving nurses to assess patients with more physician variables than necessary. The idea that surgeons and anesthesiologists within a given institution would agree on anesthetic, operative, and postoperative management to simplify care is too often an alien concept, but it would benefit customers. At present, we value our personal algorithms more than we value standardizing and simplifying the care of those we serve.
A similar lack of customer focus often plagues the various components that serve patients in a medical center. These components form a process that delivers care, but the process requires coordination. A patient’s procedure may be delayed or cancelled because floor nursing was too busy to prepare the patient on time, because the operating room lacks staff, because the assigned anesthesiologist is tied up, because the surgeon is late, or because the ICU is short of beds. These all seem like legitimate issues, but try to imagine how a Dell assembly plant would function if similar process problems were an acceptable part of building computers. The chaos we inflict on patients and indirectly on ourselves would not be tolerated in a well-run business.
Of course manufacturing differs vastly from patient care but, before dismissing the parallel, ask what techniques are used to improve each process. In medicine, morbidity and mortality conference is the corrective rubric. In this heuristic and historic exercise, the relevant physicians present and discuss complications and deaths. It centers on the physicians’ thoughts and actions and usually excludes other members of the delivery team. It serves its purpose in academic settings, but is largely pro forma in the private setting because practitioners are loath to judge colleagues lest they be judged. In both cases, it is essentially anecdotal and does nothing to improve system performance or process. Process problems arise continuously when people work together under changing circumstances. They are solved only when all team members and leaders identify snags in performance and jointly solve them.
Business leaders call this continuous quality improvement. It is systematic, not anecdotal, and it lies near the heart of successful customer service. A good business thrives on performing well for customers, not because it is noble, but because competition demands it. It does not dwell on the nature of its own institution except as altering it increases customer satisfaction. The leaders cannot succeed unless their whole organization continues to evaluate and solve the customers’ problems, and no one will know whether the solutions worked unless results are measured against previous performance. Medical quality assurance is doctor focused and qualitative; business quality assurance is customer focused and quantitative.
My own field provides another example. The American Board of Thoracic Surgery requires recertification every ten years. In an effort to improve the process, the Board evaluated three options[5]:
1. Accept the status quo, assuming that the present program adequately addresses the issues.
2. Audit practice performance pitting one physician’s performance against another’s.
3. Change to a program documenting participation in a valid process of assessment and improvement in quality of care as measured against evidence-based standards.
Guess which one they chose. The words should provide a clue. If you were evaluating me to operate on you, would you like to know my operating results for the last decade, or would you be comforted to know that I “participated in a valid process…” etc? This is quality assurance centered on surgeons’ sensitivity about outcomes, not on the consumers’ rights to vital information. The decision to choose the third option is particularly telling at a time when State legislatures are demanding public reporting of coronary bypass outcomes. Such behavior is guild, rather than customer, oriented.
You may have noticed that in the course of this essay I have interchanged the words “customer” and “patient” rather freely, challenging you to rethink both concepts. Patients, of course, are people who seek medical attention, and when we provide information and treatment, we act selflessly in their best interest as we perceive it. This moral act is our center, and at this locus, patients empower us to affect their destiny. But at the penumbra of this center, patients are also customers, and they have every right to expect the prompt, courteous service they would demand in the world of caveat emptor where they determine their own destiny. Poor customer service erodes the moral center because it reduces the patient’s autonomy more than necessary. As consumerism grows, it may play an increasingly important role in determining how we deliver care[6].
The founders’ compact with society succeeded beyond imagination, and it continues to provide wisdom. Its greatest failing is one of emphasis. Understandably, for its time, it centered too much on physicians and their institutions because both so desperately needed development. At present, physicians are indeed distinguished, our institutions are hypertrophied, and customers, then so grateful for any improvement, now rule. How can we redress the compact to account for these changes?
III.
We must recognize that we cannot characterize any modern medical system as a mechanism that can be adjusted. There are too many stakeholders with conflicting interests. Whether state run or privately financed, today’s medical systems are great sprawling contraptions not unlike democracy itself, and they defy radical change and resist comprehensive adjustment. The only method for reform is what Karl Popper called “piecemeal social engineering.” He used this term to describe how democratic governments experiment with change, evaluate the results, and plan further changes. This process is slow and unsteady, but has a far better track record than the utopian schemes he demolishes in The Open Society and Its Enemies[7]. Medicare itself is just such an experiment that now requires revision because its costs will soon exceed our capacity to pay. Physicians who understand the need to change our compact with society will focus on what they themselves can redress.
First we must see our service the way customers see it, and teach our trainees to do the same. This will cause us to revamp our ideas about quality assurance, and we will recognize that our customers are not just the object of quality assurance, but also important members of the team. If we ask, they will tell us how to improve. Second, we must restructure medical quality assurance to include everyone who serves our patients. Most of our failures are not complicated intellectual puzzles or judgment errors; most of them are process problems that we can solve only if our team members help us to identify them and offer corrections. Third, we must aggressively embrace information technology. Right now, Wal-mart knows more about its fertilizer inventory around Dallas than we know about whether our hospitalized patients are getting the correct medicines and meals. We have permitted too much emphasis on high technology devices and too little on electronic infrastructure to improve medical records, scheduling, and care delivery. It is likely that the latter will save more lives[8]. Finally, we must redirect our professional societies towards those we serve rather than ourselves. This will reduce suspicion among consumers that we place our interests ahead of theirs.
Such changes are already in progress in many parts of our medical system, but they will come faster and better if we embrace them. This will require us to give up some of the autonomy that always seemed to be a part of our heritage. We will look more like team leaders than Grand Inquisitors, more fitting for our time, and we will more successfully subordinate our exceptional gifts to the role society now assigns us.