When pressed to define medicine through a single goal, we would default to say: improve the quality of patient lives. This definition used to be simple enough. Not anymore.
Before, a healthy lifestyle and timely clinical intervention defined a good quality of life. When the latter was needed, we assumed that more was better. If a patient developed a stroke, then we believed more interventions would lead to better outcomes. We created protocols, fashioned stroke centers, and deployed mobile technology – all to do more, faster.
When that wasn’t enough, we standardized what quality meant. We created quality surveys using questions to quantify this newfound standard of quality through metrics like quality-adjusted-life-years (QALYs). It seemed so straightforward. We would continue to advance technologically, implement the latest widgets, and measure it all through standardized quality metrics.
But there’s one problem. Eventually, we would come to a point where quality doesn’t mean the same thing to you or to me. Whereas before quality had a simple, straightforward definition, after inundating healthcare with enough of it, we find after some point that it varies significantly per person. It’s always been this way. We just chose not to believe it. We assumed quality would always converge to one standard framework. The pandemic proved us wrong.
COVID-19 made apparent what was always present in medicine. Not everyone sees quality the same way. But medicine has an insidious way of enforcing an implicit sense of conformity. And at long last, we’re finally at an impasse.
If a patient dies of a heart attack, a myocardial infarction, but was diligent in taking care of her health and compliant with her medications, then we would lament the fact that, despite her conscientious lifestyle, she passed. We see it as an abject tragedy. But if a patient dies of a similar condition, and instead exhibited an unhealthy lifestyle, then we would mix a sense of loss with a moralized sense of – “she had it coming”.
We look at quality the same way. The proof is in the words we use to describe medical care – “the nurse did everything he could” – “the doctor made all the right decisions”. So when things go right, we assume all the actions taken that led up to that result were right as well.
We presume a cause-and-effect relationship when it comes to clinical quality. Yet the road to quality is anything but straightforward. The road we thought was linear and straightforward has now curved a bit. And the veering is starting to show. Vaccine hesitancy has always been a fringe movement, but now it’s gaining mainstream acceptance. When people are asked about their vaccine status, it’s now acceptable to say – “I don’t trust it” – “they’re not being honest about the side effects”.
There are ramifications to this. When fewer people get vaccines, their overall effectiveness decreases. Vaccines work as a balance, weighing the overall benefits of herd immunity against the individual risk of getting it. With every person deciding not to get the measles vaccine, it becomes incrementally weaker for those who decide to get it, and that much easier for endemic outbreaks of measles to occur.
Quality should now be understood in the same way. It’s a balance between standardized models of care and the individual who agrees with those models.
It’s not an outcome, defined through a standard set of actions and decisions that are then implicitly followed. That paradigm is long gone. Much like how patients are open about their lack of trust in healthcare, they now feel free to express that quality means different things to different people, depending on each patient’s level of engagement with the healthcare system. Each patient creates his or her own balance.
That might appear logical enough. But through the eyes of evidence-based medicine, it’s medically unreasonable. All of healthcare hinges on the following presumptions. Data is valid because we believe it to be. The strength of evidence derives from data’s validity. And clinical protocols work because we believe in the evidence.
Sadly, these presumptions are weakening by the day and damn near emaciated. Patients no longer see clinical data as gospel, nor think of clinical decisions are absolute medical truths. They see both clinical data and decisions as factors to balance in their pursuit of their own version of clinical quality. Individual decisions to balance alongside proposed clinical care.
Medicine will have to account for the change in perceived quality of care. Since patients make medical decisions differently, they see quality as a balance. Sometimes that balance is not even. Particularly now, with America’s recent wave of populism evoking strong beliefs of individualism. It’s time we accept this shift in thinking and treat patients through this new frame of mind. After all, the better we understand how patients think of medicine, the better care we can provide care for them.
