Sunday, June 5, 2011

Babette's Feast Vs McBurger Feast


Webster: "That which makes something what it is; characteristic element; basic nature, kind; the degree of excellence of a thing; excellence, superiority."

OED: " of excellence."

ANSI(American National Standards Institute)/ASQ(American Society of Quality ): "The totality of features and characteristics of a product or service that bears on its ability to satisfy given needs."

ISO (International Standards Organization): "The totality of features and characteristics of a product or service that bear on its ability to satisfy specified or implied needs."

The purpose of a blog, or at least this blog is to allow for this 'voice in the wilderness' to HOWL himself hoarse into the vast sea of largely unseen faces and personalities swimming in the contextual richness of the internet. Therefore, until such time as I have posted comments which allow for expansion of my own personal thoughts enriched by the contributions of others, the posts necessarily deal with my own ever expanding set of pet peeves surrounding largely the modern practice of medicine, as medicine is largely all I do.

From this perspective therefore, I am wondering how Quality in medical practice has morphed from the sense of Webster and the OEM  'excellence' to what I take to mean adequate ('...ability to satisfy specified or implied needs.').

When talking about quality as a statistical and medical concept I am fond of what I characterize as the 'Chef Analogy.' If we are talking about food instead of medical care, the corporatist (American Heritage Dictionary: adj Of, relating to, or being a corporative state or system.') as well as the medical practitioner or the patient all understand that a 'quality' meal means a lot more than defined statistical uniformity. For example, take the most exquisite meal you have ever eaten, or re-watch (or watch if you have never seen it) the sublime 'Babette's Feast'  (Babette's Gaestebud) ('s_Feast) (available on NetFlix as a CD). This sense of the gastronomic as art is in my view the true sense of quality.

Now consider the McDonald's Hamburger. If you factor out changes in the McDonald's menu due to the corporatist desire for cultural relevance (increased sales by accommodation to local tastes ('s_products_(international)); then quality in the McDonald's  paradigm (or the ISO/ANSI paradigm), means you eat the same 'great burger' if you are 'dinning' in San Bernardino, California (McDonald's Corporate Headquarters) or in Puerto Williams, Chile (gateway to Tierra Del Fuego and Anarctica)(

Thus the concept of 'quality'  in the modernist  sense, means ideally extermination or at a minimum limitation of variation necessary to obtain satisfaction of 'the defined needs of the product.' Thus, nutritional needs are minimally met by the McDonald's burger, while maximizing corporatist profit, and the product (the burger) has zero variation in composition, weight, fat content, etc regardless of where it is served. However, in comparison to Babette's Feast, one can't argue that the McBurger Feast is a quality meal, in that sublime human and artistic sense that Babette's Feast is a once in a life time experience.

Quality in medicine should mean exceptional excellence in providing for the emotional, biological, and social needs of the patient. It should be a complex, integrated, and multidimensional dance in which the patient leads in that dance. The quality clinical encounter is based on mutual trust and respect in which the needs of the one, the patient, out way the needs of the many (in direct opposition to the philosophy that societal needs for rationing trump the individuals needs for an optimal life or a stance antithetical to "Gemeinnutz geht vor Eigennutz" - i.e., the welfare of the nation takes precedence over the selfishness of the individual) or the few (the physician and other health care agents). The role of the physician in this model of health care is to provide via appropriate use of superior technical care, humanistic empathy and personal shamanistic therapeutic power a complete healing of the patient or an effective mitigation of the symptom complexes of the patient.

The current paradigm for medical practice equates 'quality' to adherence to defined expert consensus measures of outcome, or in fact, no measures of outcomes at all, but rather conformance to a defined quality measure usually based on a high level and simplified description of a clinical state, i.e., Acute MI, Pneumonia, CHF, etc. Utilizing this practice paradigm, the care is 'quality care' if the guideline is slavishly adhered to. For example, I am aware of a case of acute MI in which the patient presented to the cardiac catheterization laboratory and had an acute intervention with door to balloon time well below the 90 minute target (no longer target, but absolute goal). However, unfortunately for the patient, the operator under the time pressures of meeting the 90 minute guideline target, became disoriented, and stent'ed a tight lesion which was not in fact the infarct related artery. The patient arrested during the stent deployment in the wrong vessel, coded, was reanimated but left the infarct with a trashed ventricle. All guideline mandated treatments were met in the case, all drugs given and the time lines adhered to. The hospital reported the case and maintained its 100% compliance rate with respect to door to balloon time. From the standpoint of the system, the case was high quality, all guidelines were met. However, accuracy of placement of the stent is not a metric followed by the quality mavens nor is it easily  and reproducibly measured by the nonspecialist.

In a related case, another cardiologist in my community, took a patient urgently to the cardiac catheterization laboratory and emergently stent'ed two vessels, based on the ED MD's interpretation of the EKG as meeting EKG criteria for ST elevation MI. All guideline treatments were meet and the case contributed to the 100% 90 minute balloon to door time metric for the hospital. I saw the patient in cross cover for the interventional cardiologist. The EKG was misinterpreted, it failed to meet criteria for ST elevation MI, the troponin I elevation was minimally increased and stayed 'flat' during multiple subsequent measurements; the patient, an 80 year nursing home patient with advanced dementia had acute urosepsis complicated by early and mild sepsis syndrome which resulted in his mild troponin I elevation. The lesions stent'ed in the cardiac catheterization laboratory were 'significantly narrowed' but had no markers suggesting unstable plaque. This, this arguably needless emergency procedure was defined as demonstrating 'quality' care as defined by the statistical mechanics who are tinkering with the medieval guts of medical care.

These aberrations are tolerated because to the statistical re-engineers of health care, they have an implicit philosophical belief that on average, more good than harm will come from slavish adherence to 'guidelines.' They feel this situation will be much better than the current system in which a master guildsman (the physician) does what (s)he think needs to be done in the individual case dependent on biomedical reasoning and case based decisions. In a real sense the belief system of the management gurus, gurus who largely are either non-physicians or who self select to leave clinical practice is similar to that of the trial lawyer who believes that by fully conforming to the advocacy system, and by doing everything one side can do to not search for the truth, but rather effectively advocate for opposed views, that on average, more good than evil occurs. This idea that justice or clinical effectiveness is dependent on the performance of groups is the hallmark of these perverse doctrines and philosophies. I am reminded of the old joke that defines a statistician as a man who would put his right foot in bucket of boiling water and his left foot in a bucket of ice water and then claim that on average he was comfortable.

Ideally the law should embrace the quest for truth not simply certify 'justice' as the product of the most impassioned and effective advocacy. Similarly, medicine in its purist form, is the effective therapy for the individual patient and his circumstances on the day of his clinical encounter.

Quality medical care, as defined by the Statistical Medievalist is excellence of care for the individual, not acceptable care for the masses. It is fundamentally, the right diagnosis at the right time utilizing the right treatment that is tailored to the individual circumstances and individual features of the unique patient at hand. It is always recommended and delivered with respect to optimization of the individuals health not produced or performed with an eye to what will maximize the medical economics for the entire class of patient's with this diagnosis.

In reality, the cheapest care, the most cost effective care, is the null case, i.e., no care at all. It remains for the physician to remain focused on the care of the individual. It is a violation of the Hippocratic Oath and an abandonment of the Maimonidian principles of compassionate medical practice to place society and its needs in advance of the needs of the individual patient.