There are limits in both music and medicine. Go beyond those limits, and disaster is inevitable.
Imagine a small orchestra, comprised of talented, highly trained and dedicated musicians who studied and practiced for years to master their instruments, and then rehearsed and performed as a group for over a decade. Their music is not flawless, but when performing their practiced repertoire they are consistently outstanding. They are rightly proud of their work, and insightful about the perpetual need to practice, improve and grow. They are also proud of their well-deserved high standing in the musical community and happy to be recognized by their audiences as always worth hearing.
Over several years they are first asked and then required to meet multiple standards other than musical excellence. They are expected to perform more pieces at each concert so they play faster and faster. When the demand for more pieces cannot be met by playing faster, they first skip parts of pieces and then start playing more than one piece at a time. They are expected to play different instruments and styles outside their core training. They have to add other forms of entertainment during their concerts, variously dancing, singing, juggling and painting while still performing complex musical works. The harder and more complex each musician’s task becomes, the less well he is able to stay in touch and tune with the rest of the orchestra and they stop playing as a team and become a group of individual musicians performing simultaneously. New musicians who join the group, though every bit as skilled and dedicated as the original troupe, are neither trained and practiced in the repertory of the group, nor allowed to practice between performances. Initially their skill and dedication allows them to maintain a reasonable standard of quality, but they know in their professional hearts that their music is suffering. It pains them, but they focus on their favorite pieces and passages and soldier on. As the demands relentlessly accelerate, the quality of the music steadily declines. At first the errors are small and detectable only by the musicians, but they grow inexorably in size and number. Gradually the product changes from high quality music to multi-media performance to comedic camp to cacophony and at some point neither they nor their audiences see it as art.
Now imagine a small primary care practice, comprised of talented, highly trained and dedicated clinicians who studied and trained for years to master their skills, and then worked and bonded as a close-knit team, caring for patients and managing their office for several decades. The care they provide is not perfect, but they consistently deliver outstanding comprehensive and continuous primary care from cradle to grave, inpatient and outpatient, for patients and their families. They are rightly proud of the care they provide, but mindful of the need to study, keep up with new science, and learn from their patients. They are also proud of their excellent reputation in the medical community, and happy to be recognized by their patients as caring, competent and conscientious clinicians.
Gradually, the focus on artful and patient-centered health care is replaced by a focus on efficient, standardized, system-centric care. They are expected to do more and more things not part of their training or core competence: data entry, forms, ritualistic tasks to satisfy payors, accreditors and their employer. Medical care itself becomes exponentially more complex. The need to generate revenue requires that they work faster and faster. They begin to take short cuts, skipping parts of what they normally do and using check boxes and copy-paste to generate notes that meet documentation standards but are less and less clinically useful. Eventually the pace increases to the point where they start doing several things at once, none of them optimally. The need to fulfill external requirements and generate revenue progressively compromises their ability to focus on the patient and the quality of the care provided. Patient relationships, which depend heavily on time and communication, suffer greatly which is traumatic for both patients and their clinicians. Communication among clinicians becomes harder and harder, and care fractionates. They are expected to use tools poorly suited for their work, tools that are neither consistently maintained nor properly tuned. Excellent new clinicians added to the team are not mentored, and no trained or integrated in the team’s protocols and best practices. The once close-knit team steadily devolves into a collection of increasingly frustrated and isolated individuals. As the demands continue to increase and the focus shifts steadily from quality to volume and from the patient to secondary metrics, both care and the perception of care deteriorate. At first the missteps are infrequent and minor, visible only to the clinicians themselves, and the clinicians take solace in the rewarding moments they experience with individual patients. For years, their skill and dedication keep this doomed juggernaut from catastrophe, but steadily and unavoidably both the size and frequency of the errors increase. When the impossibility of excellence and the inevitability of harm become inescapably obvious, morale and care deteriorate in a death spiral to the point where the goal is no longer quality patient care but simply meeting targets and getting from one weekend to the next.
The musicians and the clinicians in this dark tale have fallen prey to a combination ofBaumol’s cost disease and the slippery slope of the normalization of deviance. It is more common than you think and more painful than I can express.