Celebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions. It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121. It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years. And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”
Quality is a hot topic in healthcare today. Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers. Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.
In fact, giving an account of quality is so difficult that it drove Zen’s author mad. And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system. The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray. Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.
For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers. We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians. Initiatives intended to reduce error rates turn out again and again to stifle innovation.