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.
Too often, we suppose that the best way to define and improve quality is to focus on systems, as though quality were simply an engineering problem, like writing a better instruction manual (the occupation of Zen’s Phaedrus). We invest all our faith in task forces, enhanced information technology, and improved policy and procedures manuals. We hire consultants, jigger incentive systems, and mandate training in the hippest quality methodologies.
If quality improvement were simply a matter of methodology, then Phaedrus, the smartest guy in the room, would have perfected it. But Phaedrus’ quest leads him to a quite different conclusion, namely that “The place to improve the world is first in one’s own heart and head and hands, and then work outward from there.” In other words, the love of quality is not something that can be injected into a health professional from the outside. It must be nurtured from within.
This is a powerful message for health professionals, because it places them on a level playing field with those in the very highest echelons of healthcare leadership. It may even give them a leg up. Why? Because quality is born first of the heart, second of the head, and third of the hands. The first order of business is not to conduct a QI project, to earn an advanced certification, or to design systems that force people to pay more attention to quality. Instead it is to care about what matters most.
And what matters most is not a quality scorecard or a financial statement. What matters most is the life and health of each patient, and flowing from it the professional integrity and fulfillment of the health professionals who care for them. The most real thing in healthcare is not found in the board room or the C-suite. Instead it is found in the examination room, at the bedside, and in the hands and heads and hearts of real human beings. It is found in relationships between patients and health professionals.
The best health professionals are here not to be schooled on quality by the experts, but to offer testimony to patients and colleagues, day in and day out, in deed as well as word, about what they know in their hearts quality to be. In the final analysis, the love of quality cannot be taught by outsiders. It is found by listening as closely as possible to the inner voice that recognizes when a patient’s needs are being met.
Consider this true story. A colleague brought his elderly father, who was in the terminal stage of a long illness, to the hospital emergency department. The man was dying. In fact, he would be dead within 12 hours. But the nurse seeing him insisted repeatedly that he receive an influenza immunization. She was so intent on meeting her quality metric (percentage of elderly patients who are vaccinated) that she could not really see the medical and human reality unfolding before her.
Quality initiatives will come and go. So, too, will quality standards, as the science, technology, economics, and culture of healthcare continue to evolve. What will not change, however, is the core commitment of health professionals to care well for their patients. As Zen and the Art of Motorcycle Maintenance reminds us, the real cycle we are working on is not the hospital, the healthcare system, or the government. In Pirsig’s words, “The real cycle you’re working on is a cycle called yourself.”
Richard Gunderman, MD is a professor of clinical medicine at the University of Iowa