The metric, the dialectic, and the chart electric

The metric, the dialectic, and the chart electricKjell Benson, MD | Physician | April 4, 2017

Scientific thought abolished foolish superstition, yet somehow the over-reliance on measurement and mechanization also had a downside.  

The Enlightenment project, dominant in Western thought since the Medieval Age, created a new scientific future where mechanization and measurement improved innumerable lives.  Yet, the elimination of magical thinking also created a sterility of thought that enabled Nazism in Europe. 

“Sterility of thinking” is a good phrase to describe how medicine has evolved into a metric-driven semi-automated algorithm-based practice. Metrics are guaranteed not to be sensitive or caring, yet that’s exactly what we need from our doctors. 

Western scientific medicine epitomizes the enlightenment process as it replaces superstition with rational diagnosis and treatment.  

…unless the superstition is related to addiction.

Then, all the blame falls on the “dangerous” and “addictive” drug, as though this particular drug had the magic power to drag people out of their normal lives straight into addiction and death.

As modern medicine measured more and more with the goal of improving health, we also created the “quality metric.”  Rather than being subject to the vagaries of non-standard care, rather than individual doctors perpetuating treatment myths, we created the temple of evidence-based medicine, and measured the dimensions of the temple with quality metrics.  

The electronic record then burst open the dam of myth in medicine and allowed us to measure, well … everything.  We now know what being a good doctor means because we measure blood pressures, and we know if patients have less than 140/90.  We know if you are talking to your patients about flu shots because it is in the electronic chart.

And yet … Benjamin’s eerily prescient warning about progress has also come to pass.  “For the Enlightenment, whatever does not conform to the rule of computation and utility is suspect.”  The art of medicine, whatever that might mean, is not measurable, and teeters on the verge of extinction.

Increased control over the body ended up bringing about domination over bodies:

  • paternalism,
  • futile end-of-life care,
  • polypharmacy … and
  • pay-for-performance.

Pay-for-performance promises the quantification of the entire patient-physician relationship and then its optimization as providers become rational profit-maximizers.  

Rather than the comforting hand of the healer, the invisible hand of the market will guide improved patient care.  So goes progress.

The ability to measure “quality” practically defines what it means to be “scientific”; science is that branch of human knowledge which measures things.  

I fear that pay-for-performance represents the enlightenment run amok, “scientism” rather than science, with the loss of the realization that medicine is ultimately a humanistic profession, and not scientific.

Is not medicine by definition “humanist”?  Will we succeed in merging the scientific and the relational, or will medicine end up separating patients and their healers?

Author: Kjell Benson is a hospitalist.

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