Letters COMMENT & RESPONSE

Applying the Principles of McDonaldization to Medicine To the Editor I read with interest the Viewpoint by Dorsey and Ritzer1 and concur with their erudite observations. However, and unfortunately so, medicine and neurology have changed and will continue to change mercilessly, for better or worse, possibly the latter, while absolutely nothing can be done about it. Each of the 4 basic principles of McDonaldization in medicine can be argued favorably and I will play the devil’s advocate here. I will say that McDonald’s mantra will win in the end—if it has not already. What makes a patient’s visit inefficient? How many of our patients know a good physician from bad? Aren’t too many patients not too pushy (urban-setting uppity crowd armed with a smartphone), while many in rural areas believe and trust the smiling, well-groomed, and well-dressed physician, spotlessly attired but has an empty brain? Given these basic differences and inherent spread of patient personalities, how can we ever achieve a basic efficient patient metric? Do patients admire and prize knowledge; for instance, if you tell them that protein C deficiency is not diagnosed solely by protein C activity but also by protein C antigen levels (both must be low) and possibly supplanted by a strong family history, are they likely to fall in love with you for your knowledge that no one else who diagnosed their condition told them about? Perhaps not. Quantity (over quality), the second pillar of the core principles noted here, has always been the mantra in US medicine ever since the bean counters took over. What else is new? Yes, quality has suffered; we see it all around us. I once asked a finalyear medicine resident rotating in neurology if she knew what cranial nerve was the facial nerve. She said it was the fifth cranial nerve. Yes, we have physicians who have zero clue about

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medicine but equally frustrating is the fact that quality is not rewarded either. You can diagnose migraine as a cerebrospinal fluid leak in a young patient who has been given the runaround by other physicians over the past year or 2 but when you spot the diagnosis, is there some reward other than feeling good about it? Why doesn’t that count as a metric? That is why McDonaldization wins round 2. In regard to predictability, products and services being the same regardless of time or place is largely true; otherwise, we would not have tissue plasminogen activator for stroke. It is a relentless machine, the treatment of acute stroke. We can wax eloquent about patient-centric approaches but there are a lot of acute medicine scenarios that rely on a simple cookbook or the patient is toast. Nonhuman technology, the fourth pillar of this McDonaldization quartet, is unfortunately the only technology that a modern-day physician knows and trusts. An elegant case history presentation, writing skills, or eliciting a sign matter to the recent graduate, but not as much as they did to us who did our schooling in the 1980s or thereabouts. Think of modern-day medicine as a Shinkansen, or the Japanese bullet train. When it hits the station, there is no time to smell the roses or murmur, sumimasen, or excuse me. Step in or step out of the way. Jagannadha R. Avasarala, MD, PhD Author Affiliation: Division of Neurology, Department of Medicine, Greenville Health System, Greenville, South Carolina. Corresponding Author: Jagannadha R. Avasarala, MD, PhD, Division of Neurology, Department of Medicine, Greenville Health System, 200 B Patewood Dr, Greenville, SC 29681 ([email protected]). Published Online: February 15, 2016. doi:10.1001/jamaneurol.2015.4719. Conflict of Interest Disclosures: None reported. 1. Dorsey ER, Ritzer G. The McDonaldization of medicine. JAMA Neurol. 2016;73 (1):15-16.

(Reprinted) JAMA Neurology Published online February 15, 2016

Copyright 2016 American Medical Association. All rights reserved.

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Applying the Principles of McDonaldization to Medicine.

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