On the Genealogy of Quality

How many doctors are eagerly awaiting MIPS and MACRA so they can provide “better care?”  These programs are the latest quality initiatives to come out of CMS in order to have “a steadfast focus on improving outcomes.” And so I tell my patient, “Don’t worry,” as I click through numerous computer screens, “I am ensuring the quality of your care right now.”

Outside of medical professionals, most people see quality as a more visceral attribute, something akin to what is described in Zen and the Art of Motorcycle Maintenance, where “quality exists as a perceptual experience before it was ever thought of descriptively.”  Perceptual versus descriptive.   The absurdity of clicking through screens to ensure quality highlights the circularity of our conventional medical definition of quality.  The quality measure and the outcome are inextricably linked.  By stating that CMS is focused on outcomes, the leap to using specific numbers to measure those outcomes is logical.  But are the outcomes associated with “quality?”  Only if we have already defined quality as those measures that lead to certain outcomes!  When I speak to fellow physicians, they rarely think that their patients’ A1C numbers reflect the quality of the medical care.  More importantly, patients themselves almost never equate their A1C with the quality of care they are receiving.  

Friedrich Nietzsche argues in On the Genealogy of Morality that analyzing the origins of terminology can help us elucidate hidden assumptions.  In his classic work he contrasts an older aristocratic duality of good/bad, in which good is that which is noble and life-asserting, while bad means simply the lack of good.  Later, in the modern world, good/bad became good/evil, and good took on the meaning of kindness and Christian virtues.  He is showing how a second set of values can co-opt a prior set through the use of its terminology.  When I look at “medical quality” today, I believe a similar assimilation has occurred.

In 1974 “medical quality” was defined as efficacy, appropriateness and the caring function. (Caper, NEJM).  But the emotional power of derivative institutions such as “Quality Improvement,” the Institute for Medical Quality, and your own hospital’s “Quality Department,” do not stem from this straightforward definition.  “Quality” attains a nearly mythic power in modern medicine because of its earlier, more ancient connotations, its atavistic perceptual level.  Yet, since we cannot define, and therefore cannot discuss, our emotional attachment to quality, we let efficacy be its proxy.  Because everyone intuitively supports “quality,” we secondarily sign on to the idea that efficacy must reflect it.

How did we get to this point where “quality” has two such polarized meanings?  For the purposes of discussing quality I see three separate eras in Western medicine.

  1. The age of the guild: Medicine originated as an artisanal craft, honed by generations of skilled experts, and passed on in a linear chain.  We still see vestiges of this era in our discourse, “Who did you train with?”  The training process functioned as the guarantor of quality.  We celebrate the mythic heroes of this age in Hippocrates, Osler and others.
  2. The age of evidence: From good teachers, the guild eventually also wanted good methods, and eventually Evidence Based Medicine was born.  The standards of EBM were internally created, that is the guild of medicine itself developed the tools and the standards to create “evidence.”  However, once the concept of standards was accepted, even though they were internal standards, the small leap to external standards was natural.  The external agencies mandating standards initially took them from the guild’s own standards, i.e. A1C numbers for diabetes control.  But soon the idea of standards was used to apply conditions external to the guild, such as hospital readmission rates.  These were an entirely new type of quality standard, one that was inherently external to the doctor-patient relationship and that might ultimately be of little concern to either the doctor or to the patient.  These standards were thought to be of concern to society as a whole, or at least to those paying for the medical care.
  3. The age of alignment: The body of evidence – the quality criteria – are now nearly universally accepted by doctors and patients as the ideals for medical care.  Patient visits are now spent achieving, and aligning with, these metrics.  The doctor’s note consists of check marks for which metrics are met.  Even the “history,” presumably that part of note that might be allowed to be subjective, has quality metrics — 4 elements required for a 99214.  The provider dutifully clicks 4 boxes in the electronic record, the coding auditor issues a congratulations, “thank you for your excellent (i.e. high quality) note.”

Unlike Nietzsche, this essay is not a polemic to return to the older view of quality.  Medicine as a guild was not necessarily better, but it was different, and we need to be conscious of those differences.  As a profession we have lost something, and that loss is leading to physician burnout.  The larger health system has created quality as a descriptive concept, but stays stuck in the old conception that the medical guild will assure its implementation.  The expansion of descriptive quality is exponential, and I see no end in sight.  

One of the foundational articles on quality from 1988, “Defining quality in medical care” (Health Affairs, 1988) proposed, “In the interest of serious dialogue… I propose that we ban from our vocabulary the word ‘quality’ as it applies to medical care.”  If we had done so, we would not have parasitic Quality departments and instead might have Efficacy departments that add value to medicine in their own terms.  Efficacy is a straightforward term that does have a hidden agenda, and we need to pay attention to efficacy in medical treatments.  Quality would remain the “Zen” of patient care, integral to the patient encounter and defined by the ineffable interaction between the healer and the healed.  

Quality, I know it when I experience it, and it’s not in MIPS or MACRA.

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