Two thoughtful healthcare analysts (a physician and an economist) wonder about health care quality:
@ethanjweiss I agree. If nobody can assess quality or productivity in any way,* that’s a deep problem, isn’t it?
— Austin Frakt (@afrakt) May 26, 2015
They are not alone. Even though the Institute of Medicine’s 2001 epic poem mobilized legions of missionaries of quality, it is far from obvious that we have clarity about the overall aim of the crusade.
Our eyes may have been opened to the sins of medical errors, the shame of healthcare disparities, the wastefulness of therapeutic inefficiencies, and the guilt of runaway costs, but if quality care is in fact the goal, and not a pretext for bureaucratic do-goodism, agreement on its meaning seems to be of the essence lest the campaign to “cross the chasm” turn instead into a crossing of the Styx.
When confusion seems evident, reflecting on first principles may be in order. Here, then, is a medical version of Tolstoy’s Three Questions:
1. What is health?
Bewildering as it may be, the medical profession has currently no ready answer to this fundamental question.
Thirty five years ago, ethicist and philosopher Arthur Caplan edited a collection of texts on the subject. The end result was closer to a cacophony of viewpoints than to a symphony. Ten years ago, another tome was published but it was no closer than the first one to give even a mere hope for consensus.
The medical dictionary’s definition of health as “absence of disease” is obviously inadequate, for disease itself refers back to the concept of health. Still, it is not nearly as preposterous as the WHO’s famous 1946 declaration:
Health a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Preamble to the Constitution of the WHO).
Can we confidently aim for healthcare quality if we cannot assuredly define health or delineate disease?
2. What’s a doctor to do?
Avowedly a profession, Western medicine may have abandoned all claims to abide by self-regulated conduct.
Having granted the State power to issue medical licenses, doctors have granted the State a say in what they can or cannot do. And having granted third parties the task of paying their income, doctors have granted third parties influence in what they will or will not do.
The end result? A sad mode of practice where physicians divided from their patients must constantly battle amidst various competing and conflicting interests—some of them self-serving.
Can we convincingly claim to foster the patient’s best interest without addressing the evident erosion of medical professionalism?
3. Who is the patient?
For Abraham Flexner, our healthcare system founding father, the nature of the human being presented no great difficulty. In his lauded report, he explained that medical education should hinge on laboratory sciences because “the human body belongs to the animal world (Flexner report, p.53).”
Accordingly, one must begin the study of medicine in a very specific way:
First year: anatomy, including histology and embryology; physiology, including bio-chemistry. Second year: pharmacology, pathology, bacteriology, physical diagnosis. (Flexner report, p61)
That Flexner’s 1910 proposal would become the entire nation’s model of medical education for the next 100 years is testimony to the power of bureaucracy to perpetuate ideas in suspended animation.
More important, however, is that Flexner’s philosophical position—popular at the time, whether taken in a monist or dualist interpretation—has framed today’s medical anthropology. Thus, the idea of man as a heap of biological material has become the default mode of thinking about medicine and healthcare.
Can we convincingly promote safety and foster quality when our medical anthropology offers such a rudimentary sketch of what a human being is?
The answer to the three questions need not come from a hermit on top of a mountain, but unless we come to terms with them, we can only get more of what is currently alleged to foster quality care: mistaken analogies, false doctrine, coercive regulations, elitist rationing, divisive ethics, epistemic incoherence, runaway medicalization, and many other troubles we have yet to discover.