Quality Healthcare Requires the Personal Touch

August 25, 2014
Daniel Essin, MA, MD

Healthcare - like education - relies heavily on people and as such, can never become the ideal smoothly running machine that many dream of.

There is intelligent life in the universe! Some of it resides at The New York Times. David Kirp [Aug. 16, 2014] says: "Teaching Is Not a Business." He echoes some of my main themes - themes that require repetition until intelligent life gains more of a foothold in medicine. People are responsible for putting the "care" in healthcare, not computers and high-tech gadgets, not government agencies, and certainly not corporations.

Just as some have opined that business practices like "lean" and Six Sigma are the "fix" for a broken healthcare system, Kirp observes, "Today's education reformers believe that schools are broken and that business can supply the remedy... [but] It’s impossible to improve education by doing an end run around inherently complicated and messy [and I would add, unpredictable] human relationships ... This [business] approach might sound plausible in a think tank, but in practice it has been a flop."

Business, today, has narrowed its focus to a particular philosophy: automation and statistical quality control are the magic sauce needed to improve quality, decrease production costs and maximize "shareholder value." Everything else is on the chopping block including workers, working conditions, and the salaries and benefits of those workers that remain after the chopping is over.

The business view depends on several key assumptions:

1.) The inputs (raw materials) are of uniform quality;

2.) The inputs are available, anywhere, in any required quantity, just-in-time; and

3.) The process of transforming the input into an output (production) can be broken down into a sequence of discrete steps, each of which is capable (with the application of sufficient technology) of being made perfectly reproducible and predictable.

The key to a perfect product is to arrange a sequence of predictable, perfect procedures that will result in a predictably perfect product. This applies whether the product is a car, a bar of soap, or a package to be delivered.

In education and in medicine, both the inputs and the steps in production (the machinery) are people. Neither the inputs nor the machinery are either uniform or predictable. A "personal touch" is required to produce the desired output. Each student or patient requires a manufacturing process that is custom tailored to their (non-uniform) condition and needs.

The big problem with the "personal touch" is that you can't automate it therefore you can't "control" the quality, in the business sense. Neither the students/patients nor the teachers/physicians exhibit the kind of uniformity to make automation feasible; and they (hopefully) never will.

Nevertheless, some (especially those afflicted with certain forms of OCD) dream of a utopia in which order and consistency prevail - a world devoid of non-uniformity and unpredictability. Some dream of "clean" kids' rooms devoid of underwear on the floor. Some dream of an orderly, regulated society that functions like clockwork and that is willing and able to satisfy the whims of the captains of industry or a dictatorial political system. Some dream of a system of healthcare delivery that will exclude no one and will somehow be affordable to all.

Some in government, industry, or religion fervently believe that their dreams are everyone's dreams and, even if they are not, they should be. Thus energized, and because they have power, they institute schemes to force their dreams on others.

There is a fine line between the unbridled free-market and a heavily regulated, paternalistic government. Both, however, and too often, end up abusing people through their excesses and over-zealousness.

Moderation is difficult to achieve in practice. Perhaps we are doomed to oscillate wildly from one extreme to another. Science, and the kind of thinking behind evidence-based medicine, is supposed to be a bulwark against such excesses. The best, and only, defense seems to be skeptical of grand schemes, avoid opinion masquerading as fact, and to think clearly and act independently. In short, contribute to an increase in the number of intelligent life forms in the universe.

The current crop of government healthcare schemes and regulations, along with the EHRs that they mandate, justified by whatever meager benefit they might produce, have wandered into the realm of bureaucratic excess. It's time for less hype, less frenzied and dictatorial policies. It's time for more basic research and above all, more thought.

Next time, I'll describe an example of how the pursuit of uniformity can drive organizations to ignore the "care" part of healthcare.