Regular readers of Brownstone Journal have been graced with insight provided by many authors of diverse backgrounds and experiences. As a physician, I have found those authored by Dr. Joseph Varon to be exceptionally helpful in their insight into the state of medicine today. In particular, his essay, “When Physicians are Replaced With a Protocol,” struck a chord with me.
Perhaps it was my conscience, as I probably bear some responsibility for furthering this viewpoint, at least on a local level. You see, I once was a True Believer. It was plausible. It seemed so believable, so “scientific,” so simple. But it was a vicious hoax that, I am ashamed to say, took me in. Let me tell the story:
In the early 1990’s, medicine was under siege. The cost was rising at a steep rate, and some people saw an opportunity. Rather than looking at the rapid corporatization of healthcare and the proliferation of administrative costs, it was easy to shift the blame to the “providers. We were no longer “physicians,” but providers of a service. In truth, that is what we had become. The Health Equation had been shifted, whether intentionally or by accident. Just a few years before, physicians had directed patients to hospitals. Now, some bright businessperson, probably from The Wharton School or other such academic Ivory Tower, had seen the profit if the hospitals (or other corporate entities like insurance companies or A COMBINATION OF THE TWO) directed the patients to the physicians. It was like some financial martial arts reversal move…A perfect Sumi Gaeshi:
Physicians had spent so much time thinking about their profession that they ignored the broader picture. Their own combination of fear and greed and the lack of critical thinking about the larger arena were fatal, and they and their patients were to pay a dear price.
I remember very plainly a meeting of our “physicians independent practice association (IPA) that was a poor attempt at nascent collective bargaining meeting with the directors of a startup HMO in the area. The leaders were themselves physicians who only a few months before had been our colleagues but were now filling the role of Kapo in the new order of things. They had a financial stake in things, and they knew it. The tagline of their HMO was “No out-of-pocket expenses!” They were the collaborators with the insurance companies and hospital executives. They sold the area employers (at that time health insurance was still a reality) that they could save them money at our expense. Of course, the hospitals were only too glad to take their cut. They told us how things would be from now on: Do as we say or starve.
There was blustering on the part of some of the physicians: We will never sign with you! said the officers of the IPA. As it turned out, they were the first to stampede to sign, hoping to avoid the cutoff and be left in the cold.
What followed was the complete and total gutting of the physician-patient and physician-physician relationship. The marvelous inventions of capitation and gatekeeper were introduced to the equation: The primary care physicians were given a lump sum payment each month for the number of patients who were assigned to them. They were then expected to pay for the care. Any referral to a specialist (such as myself) had to be approved by them and they realized that would cut into their profits as well.
Any semblance of ethical care swiftly went out the window. Basically, only the minimal amount of care was approved, and specialty referrals were sharply curtailed.
I had been given the job of Chief Quality Officer at my main hospital, and a group of us were sent to Intermountain Healthcare in Salt Lake City to a week-long seminar (Advance Training Program in Clinical Quality Improvement) given by Brent James. James is a visionary surgeon who thought that by cutting out the “quality waste” (perhaps 25%) in healthcare by doing “the right thing the first time and every time,” this horrible perversion of healthcare could be cut short. It made everyone (well, almost everyone) happy. The hospital made more profit as their payment under Diagnosis Related Groups (DRG’s) made them on the hook for too much ineffective care, the physicians and nurses were happy because they could actually practice their professions, the payers were happy because they paid less and of course the patients were happy because they knew the BEST care was incentivized. It was great…for a while.
We brought the concept back to our hospital and one could never have imagined the positive energy that came with it. We had a Quality Improvement Council that chartered multiple projects that increased the value of the care we provided while decreasing the cost. The depression of dealing with the HMO’s was stalled and partially reversed. It lasted about 2 years but then the bottom fell out. Suffice it to say that our drive for “doing the right thing the first time and every time” led down a dark and dangerous path.
As Director of Clinical Quality, I had been introduced to the work of W. Edwards Deming and his work on Statistical Process Control in bringing back Japanese production after the destruction of WWII. At the time, many believed that the process of healthcare could be approached in much the same way. From there it was an easy jump to using the concepts of Best Practice and Evidence-Based Medicine to identify the optimum treatment plan for patients and use statistical methods to measure the processes.
The problems were two-fold: 1) it worked some of the time; 2) it was easy. Multiple authors touted the application of such things as Six Sigma and The Toyota Production System to healthcare. I became a Six Sigma Blackbelt and studiously followed the DMAIC (Define, Measure Assess, Improve, Control) wheel.
I failed to realize a few things. We really didn’t really measure quality, but proxy indicators comprised of things we could measure. We often would say, “If you can’t measure it, you can’t manage it” and attribute it to either Peter Drucker or W. Edwards Deming. In truth, Deming said something quite the opposite. The important stuff can’t be measured; you have to manage it. There is ambiguity in the “important stuff.” That probably is because the really important stuff is most often truly complex and not merely complicated.
David Snowden and Mary Boone described this distinction, and everyone interested in healthcare “quality” must understand the difference. Here is a 3-minute video that makes it clear. If we only chase things we can measure, we will miss the important things we can’t measure.
Likewise, I missed an important concept first articulated by Avedis Donabedian almost 60 years ago. Outcome is a delicate dance between Structure and Process:
Unless both are addressed, outcome will be compromised. Importing “Best Practices” may import the process but fail to recognize differences in the structure. Things that work well at the Mayo Clinic may not work when the structure is NOT the Mayo Clinic. That structure is not just the bricks and mortar but the Organizational Culture as well as differences in patient population, climate, diet, etc. This is where other methods, such as Positive Deviance may prove exceptionally helpful.
Rather than seeking to collapse the results around the mean in the bell-shaped curve and minimize variation, it is critical that positive outliers be investigated, as they point the way to innovation.
Other authors such as Harvey Risch and Richard Amerling in The Next Wave is Brave and Toby Rogers in his extensive Substacks (Part 1 and Part 2) eloquently explain the fallacies of “Evidence”-Based Medicine. I would only like to add my own concerns regarding how such slavish attention to what has been “proven” outsources intellectual advancement and increases intellectual entropy. If we are forced to only employ what has been deemed to have “evidence,” we will never progress. Medicine will stagnate as the positive outliers will be ignored or, even worse, actively discouraged.
Imagine if such an approach was employed in the treatment of ulcers! We never would have learned of the causative role played by the bacterium, H. pylori. As it was, the active discouragement of such critical thinking by Barry Marshall and Robin Warren delayed definitive treatment for years.
Even more ominous was the canceling of thought on the early treatment of Covid and the “accepted science” of the gene therapy of the “vaccine.” We are still living in the shadow of this active punishment of critical thinking by the academic medical establishment.
But medicine was not alone in this rush to enshrine and build a temple to mediocrity. Consider the motto of Harvard: Veritas (Latin for “Truth”) or that of my own undergraduate university, Boston College: αἰὲν ἀριστεύειν,(“aièn aristeúein” Greek for “Ever to Excel”). Both seem a cruel joke, and 70% of the United States population agrees.
Just as an increase in entropy causes the death of an organism, it will cause the death of an organization. Medicine has become very, very sick because of this active punishment of the critical thinking necessary for innovation and reduction in entropy. The trust in hospitals and physicians has decreased precipitously from 71.5% in 2020 to 40.1% in 2024. Let that sink in!
Just a few short years ago, “Precision Medicine” was put forward as a way to significantly improve treatment. Now, it is as if it never happened. Instead of pursuing “Truth” and striving “Ever to Excel,” medicine seems to have the tagline, “Good Enough.”
A tragedy, but how to reverse it? How to dismantle this Temple to Mediocrity when so many shareholders have a vested interest in adding new wings?
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