“The patient is the one with the disease.” This medical aphorism, often quoted as rule number four from Samuel Shem’s 1978 novel, The House of God, has probably been around as long as medicine itself. Its point is that doctors need to learn to accept their own vulnerability and fallibility before they can devote themselves fully to the care of their patients. And so long as medicine was built on the relationship between two parties, patients and doctors, the rule worked reasonably well.
More recently, however, the party is being transformed into a crowd. A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology. Who is the third party? Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.
This third party usually does not see individual patients. Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals. It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue. Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased. And when it falls ill, both patients and doctors suffer.
Before patients and doctors can respond effectively to such pathologies, they must first recognize that they exist. One of the first steps in recognizing a disorder is applying a name to it, and one physician who has taken up this challenge is Adam Ratner, MD, one of the founders of the San Antonio-based non-profit, The Patient Institute. Ratner, who has been struggling to clarify the nature of these pathologies for many years, believes that healthcare is in the midst of an unrecognized epidemic.
Ratner’s compendium of healthcare disorders runs into the dozens, but exploring just a few of them illustrates the value of the general concept. He calls one of the most prevalent disorders hypermetricosis, the belief that the act of measuring makes things better. The symptoms are everywhere: doctors and other health professionals are being required to spend more and more time obtaining and reporting data, such as vaccination, smoking cessation, and diabetes control rates.
The problem, however, is that such measures do not define good medicine. A good doctor is defined by more than just a set of statistics. A good doctor is also caring, curious, dedicated, and a good listener. When hypermetricosis takes hold, more and more time and resources are focused on the measurable, at the expense of everything else. “In extreme cases,” Ratner says, “the condition can degenerate into malignant hypermetricosis, in which the human side gets lost completely.”
Another such disorder is hypermechanosis. Many third parties envy the kinds of productivity and quality gains that have been achieved in other industries through the application of various forms of statistical process control. For example, six sigma focuses on reducing variation, usually treated as error. If only we could run medical practices the same way Toyota manufactures automobiles, Southwest flies airplanes, and Disney treats its theme park visitors, proponents argue, we could revolutionize healthcare.
But every patient with colon cancer, congestive heart failure, and low back pain is not the same, and this makes it problematic to treat reducing variation as the top priority. Patients and doctors are not identical to one another to the same extent as brake rotors, take offs, and roller coaster rides. As a result, the effort to equate quality improvement with reduction in variability may often do more harm than good. Says Ratner, “We must never treat human beings as widgets.”
A third disorder is hyperbureaucrosis, which in some cases can progress to malignant hyperbureaucrosis. It tends to arise from a sense that the healthcare system is broken. In fact, the afflicted argue, the so-called system may not be a system at all. So they seek to systematize it, moving authority away from those on the ground, patients and doctors. By centralizing authority, they aim to bring healthcare under the authority of those who see it from a much higher vantage point.
The problem, however, is that making medicine more systematic may in many cases undermine the care of individual patients. Too often it forces doctors and other health professionals to spend so much time memorizing, complying with, and proving that they comply with third-party regulations that they have little time and energy left to care for patients. “In some cases,” Ratner says, “those suffering from this disorder end up equating quality with compliance, as opposed to good patient care.”
A final disorder really represents a class of maladies, collected together under the general rubric of malalignment disorders. Among the groups whose goals and incentives may be malaligned are patients, doctors, hospitals, and payers. For example, most patients want to get better, or to avoid falling ill in the first place. But hospitals and health systems often want to increase their market share and profitability.
Problems arise, for example, when increasing market share and profitability take precedence over the needs of individual patients, or when physicians are incentivized to adopt practice patterns that benefit their employers but not their patients. “In the final analysis,” Ratner says, “good health care should be defined by the needs of each patient. And the people most likely to be focused on patients are the ones who know each patient best – individual health professionals.”
What does all this mean to patients? Ratner believes the answer can be nicely encapsulated in a few words of advice. “The next time you see a doctor spending more time looking at a computer screen than the patient, charting care according to an algorithm rather than the specific clinical situation, following orders rather than writing them in the chart, or devoting more attention to the needs of the hospital or health system than to those of the patient, ask your doctor one simple question.”
“Could you be suffering the effects of hypermetricosis, mechanosis, bureaucrosis, or some variant of a medical malalignment disorder?” In other words, is the third party the one with the disease? If the answer is yes, then a conversation is in order. Such a conversation should begin with the realization that measuring, mechanizing, bureaucratizing, and realigning incentives are never the top priorities. “If we want truly good medicine,” Ratner says, “we need to recognize that sometimes it is the hospital and the health system – not the patient – that is suffering from the most serious disorder.”