Thursday, January 14, 2016


Efficiency – The Bitch Goddess of Medicine
The moral flabbiness born of the exclusive worship of the bitch goddess – SUCCESS.  That – with the squalid cash interpretation put on the word success – is our national disease.
William James (1842-1910), in a letter to H.G. Wells,  1906

If you follow the rhetoric  of management and policy experts, you might believe that EFFECIENCY, at any cost, even if it produces INEFFECIENCY  and INEFFECTIVENESS, is the only way to improve health care.   That is why EFFICIENCY, as manifest in computer-generated data and the EHR,   has become the bitch goddess of medicine.   In its own way,   EFFECIENCY has become a national clinical disease.
See a patient every 10 to 15 minutes,  check EHR data boxes,  click the practice  computer indicating you’re ready for the next patient,  and the system will become more efficient and measureable health care will improve.
So sayeth  some ObamaCare  advocates,  primarily government bureaucrats concerned  with health care “value” (outcomes/bucks spent) based on “population health.”    These bureaucrats have no other choice.  They administer public funds and must account for and document every penny.  They must prove the health system  is “efficient.” However. while doing so , the bureaucracy  produces a Bitch Goddess stepchild,  DOCUMENTATION.  The government always wants more documents than it can possibly use.
In today’s January 14  New England Journal of Medicine,   Harvard medicine professors,  Pamela Hartzband, MD,  and Jerome Groopman, M.D.,   a husband and wife team,   cast doubt on the medical efficiency theory in an article entitled, “Medical Taylorism,” 
Fredrick Taylor ,  was  the original efficiency expert.  In his 1911 book,   The Principles of Scientific Management,  Taylor  advanced the theory  that every job could and should be scientifically studied, measured, timed, and standardized to maximize efficiency and profit.     
Hartzband and Groopman  believe the standardization and measurement  theory of Taylor  “cannot be generalized to all of medicine, least of all to many cognitive tasks.” 
They point out, “Good thinking takes time, and the time pressure of Taylorism creates a fertile field for cognitive errors that can result in medical mistakes.”

Setting time limits on patient visits and determining the optimal time for patient-doctor interaction  doesn’t work in medicine.  Neither does using EHRs for limiting the duration of visits and standardizing their content.  Structuring the visit around the demands of the EHR, asking specific questions and  checking answer boxes to show the “value” of care simply doesn’t work.  It doesn’t save time,   decreases practice  productivity,  increases the clinical workload, and takes time away from patients.  
There is no “one best way” to document the patient encounter or to make it more efficient.
Hartzband and Groopman cite the words of a Boston Neurologist.  Martin Samuels on patients.
“They come from many different backgrounds; conservative,  liberals, academics, business people, doctors, politicians, and more often all the time various combination of these.  But they all have one characteristic in common.  They all want a different kind of health care for themselves and their families they profess for everybody else.”  
Patients  want unpressured time with their doctor and individualized care rather than generic protocols for testing and treatment.

Efficiency  is defined as finding the best possible way to do something with  the least possible time or effort.    Efficiency differs from effectiveness, which is about doing the right thing no matter how much time it takes.
Hartzman and Groopman conclude.  “ Good medical care takes time, and there is not one best way to treat many disorders.  When it comes to medicine, Taylor was wrong; ‘man must come first, not the system.’ ”
And not the tool of the government bitch goddess of EFFICIENCY, the EHR.

No comments: