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QUALITY FOR WHOM? EFFECTS OF PROFESSIONAL RESPONSIBILITY FOR QUALITY OF HEALTH CARE ON EQUITY* VICTOR W. SIDEL, M.D. Chairman, D)epartment of Social Medicine Montefiore Hospital and Medical Center Professor of Community Health Albert Einstein College of Medicine Bronx, N.Y.
THIS conference until this, its final afternoon, has been concerned with the concepts and methods of measuring the quality of health care. At this session the panelists have been asked to explore some of the long-term effects and implications of these concepts and methods, and professional responsibility for them. My analysis will center about the effects on equity of care of professional responsibility for the quality of health care and will be presented under four headings. I) The definition of the quality of health care depends on the definer's view of society and of his or her place in it. Before one can speak of the high or low quality of a service, and certainly before one can speak of the long-term implications of various definitions of quality or of methods for its control, one must have a goal in mind. High quality is perceived as the extent to which a service conforms to an ideal model; the model in turn depends on the purpose the observer seeks for it. Each observer, therefore, will define and measure the quality of the service according to his view of its goals. For either the manufacturer or the user of a product the goals may be relatively straightforward, even if they are often very different. The manufacturer, for example, wants the product to produce a profit and to last a relatively short time so that replacements will be needed; the consumer wants the product to cost as little as possible and to last as long as possible. The goals-even for products-of course, may be more complex. The manufacturer may be concerned with his reputation for *Presented in a panel, Long-Term Implications and Effects, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24 and 25, 1975.
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producing a long-lasting or highly functional product and the consumer may be more concerned with conspicuous consumption than with usefulness or durability. Quality, in short, is in the eye of the observer. However hard it may be at times to define quality in goods, it is usually harder to define quality in services. Let us explore for a moment two very diverse examples of providers of services, an orchestra and a plumbing company. Health-care services in some ways resemble both of these examples and in other ways fall between the two. The quality of an orchestra may to one observer rest on its ability to produce technically perfect music. To another observer the measure of quality may lie in the orchestra's effect on its audience, be it contentment, ecstacy, or the desire to move particular mountains. To yet another, the quality of an orchestra may lie in the number of people it reaches with its music or by the number of jobs it creates. For sonic observers the critical question may be whether those the orchestra reaches and those it employs lack other opportunities for listening to music or for productive employment, so that the opportunities the orchestra provides are an important factor in the redistribution of resources. The musician, the listener, the affluent, the poor, the conservative, the liberal, and the radical vill have differing views of the purposes of an orchestra and, therefore, differing definitions of its quality. Some of the different ways of judging the quality of a plumbing contractor are remarkably analogous: e.g., technical skill, outcome of work, satisfaction of clients, accessibility of services, and provision of employment. Both examples illustrate that each observer's definition of the purpose of a service and, therefore, of its quality depends basically on his or her view of the nature of society, its purposes, and his or her own place in it. Arising from this are certain basic questions about the society and its services: For whom are services to be provided? To what end are they given? More specifically and more importantly: Are the services directed toward those who already have much or toward those who have relatively little? Are the services directed toward redressing this imbalance or do they, in effect if not in conscious design, widen the existing gap between those who are wealthy and those who are poor? To take an example from another field: Newv York's educational Vol. 52, No. 1, January 1976
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television station, WNET, was recently attacked hy Benjamin L. Hooks, the only black member of the Federal Communications Commission,1 The station, which has been lauded by miany for the "high quality" of its productions, was criticized by Air. Hooks for being relevant only to a highly intellectual, largely white audience and for doing little or nothing for other audiences which he considered to be in greater need. Those who praise Channel I3 for its quality apparently view technical perfection, high intellectual content, and provision of diversion for special groups as valuable ends, Those who criticize it have a different view, They see the need in our society to provide services for those who have the least as primary and wish to use the tools of television, among other means, to work for a redistribution of resources. 2) The definitions of quality and the methods of its assessment which are chosen by health-care professionals are usually determined by professional and technical factors; these are not necessarily congruent with the definitions of quality which are relevant to patients or members of the community or to broader definitions of health. To return to the issues of the quality of health care, those xvho, for the most part, have claimed responsibility and authority for it areas the title of this conference indicates-the health-care professionals. When methods of determining quality are devised largely by professionals it is not surprising that they reflect the professional's viewv of the goals of the health-care system.2 What might these goals be? One might be the development or preservation of a health-care system in which the professional person's self interest is protected-in which he or she is well-paid, well-honored, or has the feeling of being needed by the patient or the client, However, most professional healthcare personnel seenm to have mixed motivations or, at least, manage to present their self-interest in a relatively enlightened form. Another of their goals for health care, therefore, may be to provide what they consider to be the best possible care for the illnesses of their patients. Since professional people are the products of the intellectually oriented process which selected them and the institutionally oriented, technology-centered process which educated them, it is no surprise that they all too often define quality in mainly technical and professional terms. Most medical audits and peer reviews fall into this category, Bull. N. Y. Acad. Med.
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Many professional people, of course, go beyond this definition of quality. They are concerned not only with the techncial care of the patients who come to them, but with the care of what has come to be called the whole patient. Dr. Mack Lipkin's paper at this conference is a good example of this point of view. It is concerned wvith whether the health-care process has uncovered the emotional, economic, or social factors in the patient's illness and in his or her care. But this view of the purpose of the health-care system is essentially limited, although Dr. Lipkin himself unually goes beyond this in his concerns, to the provision of services for those patients who seek medical care: the sick or the worried well. The professionals who go beyond this view constitute a relatively small number, and usually have little power in organized medicine and, therefore, in PSRO or other audit programs sponsored by established medical institutions. Members of this group may consider the goal of the health-care system to be to give the best possible care to all those who need care in the community-not just to those who appear for care, Their definition of quality, therefore, will include outreach activities and other methods of instituting maximal availability and accessibility for health-care services. Beyond that are those professionals who think that one element of quality health care is what is done for the community to keep its people healthy, Their definition of quality includes not only what the health worker does in the area of prevention for those patients who come for care (which the physician oriented to the individual patient or to technical problems will usually consider), but also whether or how the professional participates in health-protection and health-promotion activities for the community. Finally, there are the handful of professionals who take literally the definition of health given by the Preamble to the constitution of the World Health Organization-"Health is a state of complete physical, mental and social well-being"-and who, therefore, view the goals of the health-care system in quite different terms. Their views of the goals of health care-and, therefore, their measurement of its qualitybecome inseparably intertwined with their views of the function of society. These views of society, of course, range from right to left; this group includes those who subscribe to the individualistic philosophy of Ayn Rand,3 those who view society in terms of classical liberal Vol. 52, No. 1, January 1976
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freedoms and rights,4 the students of John Rawls who see society as having responsibility for redistributive justice,' and the radical analysts who criticize the economic7 and structural nmaldistribution of power and resources in health care and who seek rapid, major changes. Such observers see quality in terms that the conventional peer-reviewv or medical-audit committee rarely discusses: WN ho should have power in the system? Who should get the jobs? Who should determine policy? To what extent should the health-care system tend to make people more or less dissatisfied with their position and role in society and their share of the common wealth? In addition to the goals of professional people, another group of considerations enters into the choice of methods for determining the quality of care: the precision, reliability, and reproducibility of the measurements. Some events are relatively easy to measure from the patient's record, for example, whether an electrocardiogram (ECG) was taken for a patient with chest pain, how well that ECG was read, whether the finding was recorded on the chart, and whether the diagnosis reflected this finding. In general it is much more difficult, for exemple-even if standards were agreed upon-to determine whether and how the health worker explored the patient's anxiety with respect to his or her pain and whether and how the health worker helped the patient with his or her anxiety. Measures of so-called patient compliance with the health-worker's instructions9-" and measures of the patient's satisfaction with care12-'4 can get at some of these issues, but these are usually much more difficult to implement than the other forms of audit or quality control. It is of interest that when these evaluations are done there is usually little correlation between the quality of care perceived by the patient and the quality determined by nonparticipating professionals based upon the medical record.' Dissatisfaction with various measures in the process of care has led, as noted in this conference, to attention to various measures of clinical outcome. But the outcome of care is also difficult to determnine, even if one limits the measurement to short-term outcome in specific tracer conditions.' Factors such as the extent of disability and the patient's quality of life are difficult to quantify and, even if they were not, the patient may have internal or external reasons for not wishing to provide an accurate picture. Further, frequently it is impossible to relate the outcome to any specific element of the process of medical care, and Bull. N. Y. Acad. Med.
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often the outcome may be totally unrelated to medical care at all.17 Most difficult of all to measure and to relate to a specific form of care is the impact of medical care on the community. A specific effect on specific problems has been determined for certain types of public health measures-such as the effect of fluoridation on tooth decay in children or the effect of immunization on the incidence of specific diseases-and for certain forms of health-care organization, such as the effect of comprehensive care programs on the prevention of rheumatic fever.'8 But these studies can rarely if ever determine the total positive or negative effect of a given procedure or program on the community. Some thought has been given to the development of a broader approach to the evaluation of impact,19-22 including in some cases attempts to measure the effects of medical care on the over-all quality of life, but most of these ideas are, of course, extremely difficult to implement. In short, because measuring anything other than the most concretely technical elements of the process and outcome of care remains so difficult, technically related measures are used. The rationale is analagous to that of the classic inebriated gentlemen looking for his money under a street lamp. When asked what he has lost there his response is: "I lost my wallet down the street, but the light is better over here." 3) The definitions and methods used by professional peoplethrough their effect on the content, availability, and accessibility of care-will tend to emphasize the use of technology, to reduce the equity of health care, and, ultimately, to diminish rather than enhance the health of the community. In a situation of limited resources, emphasis on one aspect of quality must detract from or drive out other criteria. There is certainly no need to have the total allocation of resources for health care in the United States-still the most affluent nation in the world-limited to its current level. I agree heartily with those who believe that our resources should be expended on socially useful purposes rather than on war, highways, cigarettes, or obscenely high incomes for star athletes, business executives, or physicians, but even a utopian society in which these and other abuses are corrected will need to allocate limited resources among various socially useful services. For the foreseeable future in the United States as well as in other societies the definition and Vol. 52, No. 1, January 1976
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measurement of quality that is used will help to determine how resources are allocated and, therefore, will determine which elements of health care will thrive and which will get relatively short shrift, I shall separate the shifts in priorities that may result front the emphasis on certain kinds of assessments of quality into three areasthe content, availability, and accessibility of care-and shall uise as examples the impact on ambulatory care. With regard to content, emphasis in the audit on technical performance (as by a check-list of procedures that should be done for a patient with a given diagnosis or presenting problem) is likely to reduce the time and motivation that a health worker has for full exploration of the emotional or social background of the patient's illness and for preventive medicine. It is easy to say piously that the health worker should do both, but if one activity is being audited effectively and the other is being audited ineffectively or not at all, it is clear which activity most health workers will concentrate on; this is another form of what is called "defensive medicine." It is not coincidental that the concentration of attention will be on technical, dependency-producing medicine of exactly the kind that Ivan Illich23 and other critics find so dysfunctional with respect to health. Certain kinds of emphasis in audits also may affect the availability of ambulatory care when resources are limited. If the audit is concerned only with the quality of services that are given to patients who actually see the health worker or, even worse, of the services given to patients with specific and easy-to-audit problems, the time needed to provide such patients with so-called high-quality services can easily fill the total available time, thus decreasing the health-worker's availability to other people in the community. Finally and most subtly, an emphasis in audit on technical quality may reduce the accessibility of care, Even if cost factors which limit the accessibility of care were removed by health insurance wvith cornprehensive coverage and universal entitlement, there are other barriers to care, particularly for the poor and the poorly educated. Problems related to transportation, the impersonality of complex institutions in distant places, and the time spent away from children at home or from earning at work all help determine whether a person will get care. If mechanisms of audit, by their emphasis on high technical quality, cause an increasing number of aspects of care to be shifted out of the Bull, N. Y. Acad. Med.
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neighborhood into large, forboding, impersonal, and distant institutions, it is likely that any improvement in technical quality will be more than overshadowed by the decrease in perceived accessibility for an already disadvantaged group of people. If professional people carry the major responsibility for assessing the quality of health care and if they use the methods which are now being touted for determining that quality, the existing inequities in the content, availability, and accessibility of care are likely to be exacerbated. The combination of professional responsibility and authority for the control of quality with our present methods is unlikely to improve-and probably will worsen-the existing over-all maldistribution of power and resources in our society. This probably will increase the powerlessness and alienation felt by many people in our communities. Thus, there would be pressure away from equity rather than toward it. The long-term implication of professional responsibility and authority for the control of quality combined with the methods which were described at this conference is that health, as the World Health Organization has defined it, is likely to be decreased. These criticisms of conventional concepts of the assessment of the quality of care exemplifies the kind of criticism which increasingly is being leveled at currently fashionable methods of cost-benefit analysis and similar techniques of management. These techniques stress the evaluation of process and of limited measurable types of short-term outcome and often ignore outcomes which are more difficult to measure in quantitative terms and the long-term effects of a given policy. Alfred North Whitehead long ago labelled this type of thinking as the "fallacy of misplaced concreteness." The U.S. Department of Defense introduced techniques of this sort under Robert McNamara; the techniques developed a life of their own and were in part responsible for the tragedy of our policy in Vietnam. The lesson is that if one considers only certain parts of the cost and only certain parts of the results, one may indeed end up with what is seen as efficient short-term management. However, one also may end up with unforseen costs and long-term results which neither those whom the system is supposed to serve nor those who manage it had intended. It is more important to decide where one is going and whether one needs a train at all than to make the trains run on time. Those who use these techniques are not unaware of this problem. Vol. 52, No. 1, January 1976
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For example, Charles J. Hitch wrote in i960 in The Economics of Defense in the Nuclear Age.24 Whatever the particular problem, military or civilian, it is fairly obvious that in choosing among alternative means to our ends, we need to scan the ends themselves with a critical eye. New techniques and types of equipment may be extremely efficient in achieving certain aims, but these aims may be the wrong ones -aims that are selected almost unconsciously or at least without sufficient critical thought. Far too often, those who determine the means thereby continue to determine the ends, while insufficient control of either determination is exercised by those who should be the beneficiaries but are often the victims of the decisions. 4) If quality control by professionals is harmful to health over the long run, how and by whom should control be exerted? Unfortunately, the obvious implication of my argument, that the responsibility for maintenance of the quality of health care must be turned over to the community which it serves, is difficult to achieve. Putting medicine back into the marketplace of free enterprise, as economists such as Milton Friedman and Martin Feldstein have at times suggested, is no solution. Even if it were acceptable on ideological grounds, medicine is a field characterized by scarce resources, imperfect information on the nature of the product, and monopolistic practice, all of which are classically recognized-even by its defenders-to contravene the effective use of the free market. Chipping away at some of these characteristics-e.g., by providing more information to healthcare consumers about the training of their doctors as was recommended by Rhoda Karpatkin at this conference-is certainly valuable, but is unlikely to change the basic conditions. Taking medicine out of the marketplace completely, with members of the community controlling the quality of services which are publicly operated and, therefore, are fully accountable to the public, is equally difficult. First, the urban communities served by doctors or by health-care institutions are usually heterogeneous, and it will be difficult to find a commonality of social purpose and, therefore, of criteria by which the quality of care is to be measured. Even if that commonality of social purpose is reached, given the power structure of most communiBull. N. Y. Acad. Med.
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ties in the United States, the criteria developed by those likely to be chosen to monitor quality are even less likely to stress equity than are professionally-determined criteria. Exchanging criteria based on private self-interest for criteria based on professional self-interest may not be a good bargain, at least in the short run. Second, most members of poor communities and many members of affluent communities are abysmally ignorant of even the function of their own bodies, not to speak of the intricacies of modern health care in the United States. Exchanging criteria based on ignorance for criteria based on professional self-interest may not be a good bargain, at least in the short run. Third, most community members, especially members of poor communities, are unwilling to take the time to become knowledgeable or to make considered decisions on community health-care issues unless there is a secondary gain such as the power to grant jobs. Perhaps they have been conditioned by the long period during which they had no effective method for influencing their health care. Perhaps they are influenced by the need to do more renumerative or pleasurable things with their time. Even affluent people, for example those who have served on the boards of voluntary hospitals, have been taught that health-care institutions are run by professional corporate managers or doctors and that laymen have little to contribute other than philanthropy or lending their prestige to the institution. Exchanging criteria established by uninterested or cynical nonprofessionals for criteria established by involved and dedicated professionals may not be a good bargain, at least in the short run. Fourth, community members often feel intimidated by professional people, either directly or by the threat that the professionals may leave the community rather than work under the effective control of laymen. Exchanging criteria made by intimidated and anxious nonprofessionals for criteria made by self-confident professionals may not be a good bargain, at least in the short run. Incidentally, these and similar difficulties are analogous to those which have made decentralized community control of schools so difficult to implement. In the short-run, it is likely (but let it be noted, not at all certain) that nonprofessionals taking over the responsibility for the quality of health care will lead to a lower quality of care by almost any criteria. Vol. 52, No. 1, January 1976
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This is not a reason for giving up on the principle. Unless we begin to try to break down some of the barriers to effective nonprofessional control of quality we shall remain mired in the morass in which we now find ourselves. Part of the immediate professional responsibility for the quality of health care is to educate and motivate people in the community to play an increasingly large part in that process. In the short-run, of course, the professionals themselves will have to take major responsibility for seeing to it that some reasonable standards are maintained. In so doing, they will have to lean over backward to avoid the seduction of professional self-interest. They will have to balance the over-all needs of the community against the needs of patients with specific problems. They will have to pay special attention to the education of patients and members of the community as suggested by George W. Melcher and Rhoda Karpatkin in this conference. They will have to protect patients from being killed or maimed by gross overuse, underuse, or misuse of the technology now in the hands of health-care workers. They will have to respond to the academicians or specialists, who use code words like excellence, first-class, or high quality to prescribe for others what they themselves do (or say they do or wish they did) for limited numbers of patients, by asking: For whom and for what purpose does this represent excellence? In the long run, however, health-care professionals can only be technicians, consultants, or, at most, junior partners in the process of quality control. It is of interest that this principle of management by the people themselves-which is not limited to quality control but also includes the planning and delivery of health services-increasingly has been viewed as important in technology-poor countries.2527 The principle was well stated by Dr. Frantz Fanon with reference to Algeria in his essay "Medicine and Colonialism": "The people who take their destiny into their own hands assimilate the most modern forms of technology at an extraordinary rate."28 Of course, it was also said earlier and more metaphorically by Mao Tse-tung in his essay "On Practice:" "If you want to know the taste of a pear, you must change the pear by eating it yourself."29 Although in many ways it will be more difficult to implement, the principle is equally valid in technologically over-developed countries such as the United States. Here, as elsewhere, the professional responsibility for the quality of health care should be to help those who Bull. N. Y. Acad. Med.
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receive health services to increasingly take over the responsibility and authority for maintaining and improving the quality of their own health care. Perhaps it would be appropriate in this bicentennial season to close with the words of Thomas Jefferson: "I know no safe depository of the ultimate powers of the society but the people themselves; and if we think them not enlightened enough to exercise their control with a wholesome discretion, the remedy is not to take it from them but to inform them in their discretion."80 ACKNOWLEDGEMENTS I am grateful to Daniel Drosness, Estelle Holt, Howard Kelman, Susan Mates, Michael Osband, Sumner Rosen, Lisa Rubenstein, Ruth Sidel, and Frederick H. Sillmnan for their comments and suggestions.
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REFERENCES O'Connor, J. J.t Does WNET cater 10. Geertseni, H. R., Gray, R. M., and only to rich, white intellectuals? N\Terw Ward, J. R.: Patient non-compliance York Times, March 30, 1975. within the context of seeking medical Friedson, E,,tProfessional Dominance: care for arthritis. J. Chronic. Dis. 26: The Social Structure of Medical Care. 689, 1973. New York, Atherton, 1970. 11. Blackwell, B.: Drug therapy and paSade, It. M.: Medical care as a right: tient compliance. New Eng. J. Med. A refutation. New Eng. J. Med. R85: 289:249, 1973. 1288-92, 1971. 12. Zyzanski, S. J., Hulka, B. S., and CasKennedy, E. M.t In Critica.l Condition: sel, J. C.: Scale for the measurement The Crisis it America's Health Care. of "satisfaction" with medical care: New York, Simon and Schuster, 1972. Modifications in content, format and Rawls, ,J: A Theory of Justice. Camscoring. MIed. Care 12:611-20, 1974. bridge, Muss., Harvard University 13. Lebow, J. L.: Consumer assessments of Press, 1971. the quality of medical care. Med. Care Bryant, J.;. Principles of Distributive 12:328, 1974. Justice as a Basis for Conceptualizitg 1 1. Becker, M. H., Drachman, R. H., and a Health Care Systemn. Unpublished Kirscht, J. P.: A field experiment to manuscript adapted from a presentaevaluate various outcomes of continuity tion to the Christian Medical Commisof physician care. Amer. J. Public sion, World Council of Churches, Gehealth 64:1062-70, 1974. nevatr, July 1973, 15. The Quantity, and Costs of Medical Waitzkin, H. and Waterman, 13.: The and Hospital Care Secured by a SamExploitatiom of Illness in Capitalist Sople of Teamster Families in the New ciety. New York, Bobbs-Merrill, 1974. York A rea. New York, Columbia UniHealth Policy Advisory Center: The versity School of Public Health and American Healeth Empire. New York, Adminiistrative Medicine, undated, p. Random Iflouse, 1970.
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Gilbln, 11. F. and B3arsky, A. J.: I)iagnosis and nmnnage(ment of patient non-
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79. 16. Kessner, D. M. and Kalk, C. E.: A Strategy for Evaluating Health Services. Washington, D.C., Inst. of Med.,
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National Acadermy of Sciences, 1973. 17. Brook, R. H.: Critical issues in the assessment of quality of care and their relationship to HMO's. J. MIed. Educ. 48:114-27, 1973. 18. Gordis, L.: Effectiveness of conmprehensive care programs in preventing rheumatic fever. New Eng. J. Med. 289:331-35, 1973. 19. Kerr, M. and Trantow, D. J.: Defining, measuring, and assessing the quality of health services. Public Health Rep. 84: 415-24, 1969. 20. Starfield, B.: Measurement of outcome: A proposed scheme. Health Soc. 52:39-50, 1974. 21. Caper, P.: The meaning of quality in medical care. New E1ng. J. lied. 291: 1136-37, 1974. 22. Cochrane, A. L.: Effectiveness and Efficiency: Random Reflections on, health Services. London, Nuffield Provincial Hospitals Trust, 1972. 23. Illich. I.: Medical Nemesis: The Ex-
propriation, of Heealth. London, Calder and Bovars, 1975. 24. Hitch. C. J.: The Econiomics of 1)efensi.e int the Xuclear Age. Cambridge, Mass., Harvard ULniversity Press, 1960. 25. Newell, K. W.: Helping people to hell) themselves. lWorld Health: pp. 3-7,
April 1975. 26. Newell, K. W., editor: Health By The People. Geneva, WHO, 197;5. 27. Sidel, V. W. and Sidel, R.: Serve The People: Observationis on Medicine ini the Peoples Republic of China. Boston, Beacon, 1974. 28. Fanon, F.: Medicine and Colonialism. In: A J)ying Colonalism. New York, Grove, 1967, p. 9. 29. Mao Tse-tunng: On Practice. In: Four Essays oni Philosophy. Peking, Foreign Languages, 1966, p. 8. 30. Jefferson, T'.: Letter to Williamii Chlarles Jarvis, September 28, 1820. In: Bartlett, J.: Familiar Quotations. Boston, Little, Brown, 1955, p. 375b.
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QUALITY FOR WHOM? EFFECTS OF PROFESSIONAL RESPONSIBILITY FOR QUALITY OF HEALTH CARE ON EQUITY* VICTOR W. SIDEL, M.D. Chairman, D)epartment of Social Medicine Montefiore Hospital and Medical Center Professor of Community Health Albert Einstein College of Medicine Bronx, N.Y.
THIS conference until this, its final afternoon, has been concerned with the concepts and methods of measuring the quality of health care. At this session the panelists have been asked to explore some of the long-term effects and implications of these concepts and methods, and professional responsibility for them. My analysis will center about the effects on equity of care of professional responsibility for the quality of health care and will be presented under four headings. I) The definition of the quality of health care depends on the definer's view of society and of his or her place in it. Before one can speak of the high or low quality of a service, and certainly before one can speak of the long-term implications of various definitions of quality or of methods for its control, one must have a goal in mind. High quality is perceived as the extent to which a service conforms to an ideal model; the model in turn depends on the purpose the observer seeks for it. Each observer, therefore, will define and measure the quality of the service according to his view of its goals. For either the manufacturer or the user of a product the goals may be relatively straightforward, even if they are often very different. The manufacturer, for example, wants the product to produce a profit and to last a relatively short time so that replacements will be needed; the consumer wants the product to cost as little as possible and to last as long as possible. The goals-even for products-of course, may be more complex. The manufacturer may be concerned with his reputation for *Presented in a panel, Long-Term Implications and Effects, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24 and 25, 1975.
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producing a long-lasting or highly functional product and the consumer may be more concerned with conspicuous consumption than with usefulness or durability. Quality, in short, is in the eye of the observer. However hard it may be at times to define quality in goods, it is usually harder to define quality in services. Let us explore for a moment two very diverse examples of providers of services, an orchestra and a plumbing company. Health-care services in some ways resemble both of these examples and in other ways fall between the two. The quality of an orchestra may to one observer rest on its ability to produce technically perfect music. To another observer the measure of quality may lie in the orchestra's effect on its audience, be it contentment, ecstacy, or the desire to move particular mountains. To yet another, the quality of an orchestra may lie in the number of people it reaches with its music or by the number of jobs it creates. For sonic observers the critical question may be whether those the orchestra reaches and those it employs lack other opportunities for listening to music or for productive employment, so that the opportunities the orchestra provides are an important factor in the redistribution of resources. The musician, the listener, the affluent, the poor, the conservative, the liberal, and the radical vill have differing views of the purposes of an orchestra and, therefore, differing definitions of its quality. Some of the different ways of judging the quality of a plumbing contractor are remarkably analogous: e.g., technical skill, outcome of work, satisfaction of clients, accessibility of services, and provision of employment. Both examples illustrate that each observer's definition of the purpose of a service and, therefore, of its quality depends basically on his or her view of the nature of society, its purposes, and his or her own place in it. Arising from this are certain basic questions about the society and its services: For whom are services to be provided? To what end are they given? More specifically and more importantly: Are the services directed toward those who already have much or toward those who have relatively little? Are the services directed toward redressing this imbalance or do they, in effect if not in conscious design, widen the existing gap between those who are wealthy and those who are poor? To take an example from another field: Newv York's educational Vol. 52, No. 1, January 1976
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television station, WNET, was recently attacked hy Benjamin L. Hooks, the only black member of the Federal Communications Commission,1 The station, which has been lauded by miany for the "high quality" of its productions, was criticized by Air. Hooks for being relevant only to a highly intellectual, largely white audience and for doing little or nothing for other audiences which he considered to be in greater need. Those who praise Channel I3 for its quality apparently view technical perfection, high intellectual content, and provision of diversion for special groups as valuable ends, Those who criticize it have a different view, They see the need in our society to provide services for those who have the least as primary and wish to use the tools of television, among other means, to work for a redistribution of resources. 2) The definitions of quality and the methods of its assessment which are chosen by health-care professionals are usually determined by professional and technical factors; these are not necessarily congruent with the definitions of quality which are relevant to patients or members of the community or to broader definitions of health. To return to the issues of the quality of health care, those xvho, for the most part, have claimed responsibility and authority for it areas the title of this conference indicates-the health-care professionals. When methods of determining quality are devised largely by professionals it is not surprising that they reflect the professional's viewv of the goals of the health-care system.2 What might these goals be? One might be the development or preservation of a health-care system in which the professional person's self interest is protected-in which he or she is well-paid, well-honored, or has the feeling of being needed by the patient or the client, However, most professional healthcare personnel seenm to have mixed motivations or, at least, manage to present their self-interest in a relatively enlightened form. Another of their goals for health care, therefore, may be to provide what they consider to be the best possible care for the illnesses of their patients. Since professional people are the products of the intellectually oriented process which selected them and the institutionally oriented, technology-centered process which educated them, it is no surprise that they all too often define quality in mainly technical and professional terms. Most medical audits and peer reviews fall into this category, Bull. N. Y. Acad. Med.
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Many professional people, of course, go beyond this definition of quality. They are concerned not only with the techncial care of the patients who come to them, but with the care of what has come to be called the whole patient. Dr. Mack Lipkin's paper at this conference is a good example of this point of view. It is concerned wvith whether the health-care process has uncovered the emotional, economic, or social factors in the patient's illness and in his or her care. But this view of the purpose of the health-care system is essentially limited, although Dr. Lipkin himself unually goes beyond this in his concerns, to the provision of services for those patients who seek medical care: the sick or the worried well. The professionals who go beyond this view constitute a relatively small number, and usually have little power in organized medicine and, therefore, in PSRO or other audit programs sponsored by established medical institutions. Members of this group may consider the goal of the health-care system to be to give the best possible care to all those who need care in the community-not just to those who appear for care, Their definition of quality, therefore, will include outreach activities and other methods of instituting maximal availability and accessibility for health-care services. Beyond that are those professionals who think that one element of quality health care is what is done for the community to keep its people healthy, Their definition of quality includes not only what the health worker does in the area of prevention for those patients who come for care (which the physician oriented to the individual patient or to technical problems will usually consider), but also whether or how the professional participates in health-protection and health-promotion activities for the community. Finally, there are the handful of professionals who take literally the definition of health given by the Preamble to the constitution of the World Health Organization-"Health is a state of complete physical, mental and social well-being"-and who, therefore, view the goals of the health-care system in quite different terms. Their views of the goals of health care-and, therefore, their measurement of its qualitybecome inseparably intertwined with their views of the function of society. These views of society, of course, range from right to left; this group includes those who subscribe to the individualistic philosophy of Ayn Rand,3 those who view society in terms of classical liberal Vol. 52, No. 1, January 1976
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freedoms and rights,4 the students of John Rawls who see society as having responsibility for redistributive justice,' and the radical analysts who criticize the economic7 and structural nmaldistribution of power and resources in health care and who seek rapid, major changes. Such observers see quality in terms that the conventional peer-reviewv or medical-audit committee rarely discusses: WN ho should have power in the system? Who should get the jobs? Who should determine policy? To what extent should the health-care system tend to make people more or less dissatisfied with their position and role in society and their share of the common wealth? In addition to the goals of professional people, another group of considerations enters into the choice of methods for determining the quality of care: the precision, reliability, and reproducibility of the measurements. Some events are relatively easy to measure from the patient's record, for example, whether an electrocardiogram (ECG) was taken for a patient with chest pain, how well that ECG was read, whether the finding was recorded on the chart, and whether the diagnosis reflected this finding. In general it is much more difficult, for exemple-even if standards were agreed upon-to determine whether and how the health worker explored the patient's anxiety with respect to his or her pain and whether and how the health worker helped the patient with his or her anxiety. Measures of so-called patient compliance with the health-worker's instructions9-" and measures of the patient's satisfaction with care12-'4 can get at some of these issues, but these are usually much more difficult to implement than the other forms of audit or quality control. It is of interest that when these evaluations are done there is usually little correlation between the quality of care perceived by the patient and the quality determined by nonparticipating professionals based upon the medical record.' Dissatisfaction with various measures in the process of care has led, as noted in this conference, to attention to various measures of clinical outcome. But the outcome of care is also difficult to determnine, even if one limits the measurement to short-term outcome in specific tracer conditions.' Factors such as the extent of disability and the patient's quality of life are difficult to quantify and, even if they were not, the patient may have internal or external reasons for not wishing to provide an accurate picture. Further, frequently it is impossible to relate the outcome to any specific element of the process of medical care, and Bull. N. Y. Acad. Med.
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often the outcome may be totally unrelated to medical care at all.17 Most difficult of all to measure and to relate to a specific form of care is the impact of medical care on the community. A specific effect on specific problems has been determined for certain types of public health measures-such as the effect of fluoridation on tooth decay in children or the effect of immunization on the incidence of specific diseases-and for certain forms of health-care organization, such as the effect of comprehensive care programs on the prevention of rheumatic fever.'8 But these studies can rarely if ever determine the total positive or negative effect of a given procedure or program on the community. Some thought has been given to the development of a broader approach to the evaluation of impact,19-22 including in some cases attempts to measure the effects of medical care on the over-all quality of life, but most of these ideas are, of course, extremely difficult to implement. In short, because measuring anything other than the most concretely technical elements of the process and outcome of care remains so difficult, technically related measures are used. The rationale is analagous to that of the classic inebriated gentlemen looking for his money under a street lamp. When asked what he has lost there his response is: "I lost my wallet down the street, but the light is better over here." 3) The definitions and methods used by professional peoplethrough their effect on the content, availability, and accessibility of care-will tend to emphasize the use of technology, to reduce the equity of health care, and, ultimately, to diminish rather than enhance the health of the community. In a situation of limited resources, emphasis on one aspect of quality must detract from or drive out other criteria. There is certainly no need to have the total allocation of resources for health care in the United States-still the most affluent nation in the world-limited to its current level. I agree heartily with those who believe that our resources should be expended on socially useful purposes rather than on war, highways, cigarettes, or obscenely high incomes for star athletes, business executives, or physicians, but even a utopian society in which these and other abuses are corrected will need to allocate limited resources among various socially useful services. For the foreseeable future in the United States as well as in other societies the definition and Vol. 52, No. 1, January 1976
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measurement of quality that is used will help to determine how resources are allocated and, therefore, will determine which elements of health care will thrive and which will get relatively short shrift, I shall separate the shifts in priorities that may result front the emphasis on certain kinds of assessments of quality into three areasthe content, availability, and accessibility of care-and shall uise as examples the impact on ambulatory care. With regard to content, emphasis in the audit on technical performance (as by a check-list of procedures that should be done for a patient with a given diagnosis or presenting problem) is likely to reduce the time and motivation that a health worker has for full exploration of the emotional or social background of the patient's illness and for preventive medicine. It is easy to say piously that the health worker should do both, but if one activity is being audited effectively and the other is being audited ineffectively or not at all, it is clear which activity most health workers will concentrate on; this is another form of what is called "defensive medicine." It is not coincidental that the concentration of attention will be on technical, dependency-producing medicine of exactly the kind that Ivan Illich23 and other critics find so dysfunctional with respect to health. Certain kinds of emphasis in audits also may affect the availability of ambulatory care when resources are limited. If the audit is concerned only with the quality of services that are given to patients who actually see the health worker or, even worse, of the services given to patients with specific and easy-to-audit problems, the time needed to provide such patients with so-called high-quality services can easily fill the total available time, thus decreasing the health-worker's availability to other people in the community. Finally and most subtly, an emphasis in audit on technical quality may reduce the accessibility of care, Even if cost factors which limit the accessibility of care were removed by health insurance wvith cornprehensive coverage and universal entitlement, there are other barriers to care, particularly for the poor and the poorly educated. Problems related to transportation, the impersonality of complex institutions in distant places, and the time spent away from children at home or from earning at work all help determine whether a person will get care. If mechanisms of audit, by their emphasis on high technical quality, cause an increasing number of aspects of care to be shifted out of the Bull, N. Y. Acad. Med.
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neighborhood into large, forboding, impersonal, and distant institutions, it is likely that any improvement in technical quality will be more than overshadowed by the decrease in perceived accessibility for an already disadvantaged group of people. If professional people carry the major responsibility for assessing the quality of health care and if they use the methods which are now being touted for determining that quality, the existing inequities in the content, availability, and accessibility of care are likely to be exacerbated. The combination of professional responsibility and authority for the control of quality with our present methods is unlikely to improve-and probably will worsen-the existing over-all maldistribution of power and resources in our society. This probably will increase the powerlessness and alienation felt by many people in our communities. Thus, there would be pressure away from equity rather than toward it. The long-term implication of professional responsibility and authority for the control of quality combined with the methods which were described at this conference is that health, as the World Health Organization has defined it, is likely to be decreased. These criticisms of conventional concepts of the assessment of the quality of care exemplifies the kind of criticism which increasingly is being leveled at currently fashionable methods of cost-benefit analysis and similar techniques of management. These techniques stress the evaluation of process and of limited measurable types of short-term outcome and often ignore outcomes which are more difficult to measure in quantitative terms and the long-term effects of a given policy. Alfred North Whitehead long ago labelled this type of thinking as the "fallacy of misplaced concreteness." The U.S. Department of Defense introduced techniques of this sort under Robert McNamara; the techniques developed a life of their own and were in part responsible for the tragedy of our policy in Vietnam. The lesson is that if one considers only certain parts of the cost and only certain parts of the results, one may indeed end up with what is seen as efficient short-term management. However, one also may end up with unforseen costs and long-term results which neither those whom the system is supposed to serve nor those who manage it had intended. It is more important to decide where one is going and whether one needs a train at all than to make the trains run on time. Those who use these techniques are not unaware of this problem. Vol. 52, No. 1, January 1976
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For example, Charles J. Hitch wrote in i960 in The Economics of Defense in the Nuclear Age.24 Whatever the particular problem, military or civilian, it is fairly obvious that in choosing among alternative means to our ends, we need to scan the ends themselves with a critical eye. New techniques and types of equipment may be extremely efficient in achieving certain aims, but these aims may be the wrong ones -aims that are selected almost unconsciously or at least without sufficient critical thought. Far too often, those who determine the means thereby continue to determine the ends, while insufficient control of either determination is exercised by those who should be the beneficiaries but are often the victims of the decisions. 4) If quality control by professionals is harmful to health over the long run, how and by whom should control be exerted? Unfortunately, the obvious implication of my argument, that the responsibility for maintenance of the quality of health care must be turned over to the community which it serves, is difficult to achieve. Putting medicine back into the marketplace of free enterprise, as economists such as Milton Friedman and Martin Feldstein have at times suggested, is no solution. Even if it were acceptable on ideological grounds, medicine is a field characterized by scarce resources, imperfect information on the nature of the product, and monopolistic practice, all of which are classically recognized-even by its defenders-to contravene the effective use of the free market. Chipping away at some of these characteristics-e.g., by providing more information to healthcare consumers about the training of their doctors as was recommended by Rhoda Karpatkin at this conference-is certainly valuable, but is unlikely to change the basic conditions. Taking medicine out of the marketplace completely, with members of the community controlling the quality of services which are publicly operated and, therefore, are fully accountable to the public, is equally difficult. First, the urban communities served by doctors or by health-care institutions are usually heterogeneous, and it will be difficult to find a commonality of social purpose and, therefore, of criteria by which the quality of care is to be measured. Even if that commonality of social purpose is reached, given the power structure of most communiBull. N. Y. Acad. Med.
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ties in the United States, the criteria developed by those likely to be chosen to monitor quality are even less likely to stress equity than are professionally-determined criteria. Exchanging criteria based on private self-interest for criteria based on professional self-interest may not be a good bargain, at least in the short run. Second, most members of poor communities and many members of affluent communities are abysmally ignorant of even the function of their own bodies, not to speak of the intricacies of modern health care in the United States. Exchanging criteria based on ignorance for criteria based on professional self-interest may not be a good bargain, at least in the short run. Third, most community members, especially members of poor communities, are unwilling to take the time to become knowledgeable or to make considered decisions on community health-care issues unless there is a secondary gain such as the power to grant jobs. Perhaps they have been conditioned by the long period during which they had no effective method for influencing their health care. Perhaps they are influenced by the need to do more renumerative or pleasurable things with their time. Even affluent people, for example those who have served on the boards of voluntary hospitals, have been taught that health-care institutions are run by professional corporate managers or doctors and that laymen have little to contribute other than philanthropy or lending their prestige to the institution. Exchanging criteria established by uninterested or cynical nonprofessionals for criteria established by involved and dedicated professionals may not be a good bargain, at least in the short run. Fourth, community members often feel intimidated by professional people, either directly or by the threat that the professionals may leave the community rather than work under the effective control of laymen. Exchanging criteria made by intimidated and anxious nonprofessionals for criteria made by self-confident professionals may not be a good bargain, at least in the short run. Incidentally, these and similar difficulties are analogous to those which have made decentralized community control of schools so difficult to implement. In the short-run, it is likely (but let it be noted, not at all certain) that nonprofessionals taking over the responsibility for the quality of health care will lead to a lower quality of care by almost any criteria. Vol. 52, No. 1, January 1976
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This is not a reason for giving up on the principle. Unless we begin to try to break down some of the barriers to effective nonprofessional control of quality we shall remain mired in the morass in which we now find ourselves. Part of the immediate professional responsibility for the quality of health care is to educate and motivate people in the community to play an increasingly large part in that process. In the short-run, of course, the professionals themselves will have to take major responsibility for seeing to it that some reasonable standards are maintained. In so doing, they will have to lean over backward to avoid the seduction of professional self-interest. They will have to balance the over-all needs of the community against the needs of patients with specific problems. They will have to pay special attention to the education of patients and members of the community as suggested by George W. Melcher and Rhoda Karpatkin in this conference. They will have to protect patients from being killed or maimed by gross overuse, underuse, or misuse of the technology now in the hands of health-care workers. They will have to respond to the academicians or specialists, who use code words like excellence, first-class, or high quality to prescribe for others what they themselves do (or say they do or wish they did) for limited numbers of patients, by asking: For whom and for what purpose does this represent excellence? In the long run, however, health-care professionals can only be technicians, consultants, or, at most, junior partners in the process of quality control. It is of interest that this principle of management by the people themselves-which is not limited to quality control but also includes the planning and delivery of health services-increasingly has been viewed as important in technology-poor countries.2527 The principle was well stated by Dr. Frantz Fanon with reference to Algeria in his essay "Medicine and Colonialism": "The people who take their destiny into their own hands assimilate the most modern forms of technology at an extraordinary rate."28 Of course, it was also said earlier and more metaphorically by Mao Tse-tung in his essay "On Practice:" "If you want to know the taste of a pear, you must change the pear by eating it yourself."29 Although in many ways it will be more difficult to implement, the principle is equally valid in technologically over-developed countries such as the United States. Here, as elsewhere, the professional responsibility for the quality of health care should be to help those who Bull. N. Y. Acad. Med.
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receive health services to increasingly take over the responsibility and authority for maintaining and improving the quality of their own health care. Perhaps it would be appropriate in this bicentennial season to close with the words of Thomas Jefferson: "I know no safe depository of the ultimate powers of the society but the people themselves; and if we think them not enlightened enough to exercise their control with a wholesome discretion, the remedy is not to take it from them but to inform them in their discretion."80 ACKNOWLEDGEMENTS I am grateful to Daniel Drosness, Estelle Holt, Howard Kelman, Susan Mates, Michael Osband, Sumner Rosen, Lisa Rubenstein, Ruth Sidel, and Frederick H. Sillmnan for their comments and suggestions.
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REFERENCES O'Connor, J. J.t Does WNET cater 10. Geertseni, H. R., Gray, R. M., and only to rich, white intellectuals? N\Terw Ward, J. R.: Patient non-compliance York Times, March 30, 1975. within the context of seeking medical Friedson, E,,tProfessional Dominance: care for arthritis. J. Chronic. Dis. 26: The Social Structure of Medical Care. 689, 1973. New York, Atherton, 1970. 11. Blackwell, B.: Drug therapy and paSade, It. M.: Medical care as a right: tient compliance. New Eng. J. Med. A refutation. New Eng. J. Med. R85: 289:249, 1973. 1288-92, 1971. 12. Zyzanski, S. J., Hulka, B. S., and CasKennedy, E. M.t In Critica.l Condition: sel, J. C.: Scale for the measurement The Crisis it America's Health Care. of "satisfaction" with medical care: New York, Simon and Schuster, 1972. Modifications in content, format and Rawls, ,J: A Theory of Justice. Camscoring. MIed. Care 12:611-20, 1974. bridge, Muss., Harvard University 13. Lebow, J. L.: Consumer assessments of Press, 1971. the quality of medical care. Med. Care Bryant, J.;. Principles of Distributive 12:328, 1974. Justice as a Basis for Conceptualizitg 1 1. Becker, M. H., Drachman, R. H., and a Health Care Systemn. Unpublished Kirscht, J. P.: A field experiment to manuscript adapted from a presentaevaluate various outcomes of continuity tion to the Christian Medical Commisof physician care. Amer. J. Public sion, World Council of Churches, Gehealth 64:1062-70, 1974. nevatr, July 1973, 15. The Quantity, and Costs of Medical Waitzkin, H. and Waterman, 13.: The and Hospital Care Secured by a SamExploitatiom of Illness in Capitalist Sople of Teamster Families in the New ciety. New York, Bobbs-Merrill, 1974. York A rea. New York, Columbia UniHealth Policy Advisory Center: The versity School of Public Health and American Healeth Empire. New York, Adminiistrative Medicine, undated, p. Random Iflouse, 1970.
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79. 16. Kessner, D. M. and Kalk, C. E.: A Strategy for Evaluating Health Services. Washington, D.C., Inst. of Med.,
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National Acadermy of Sciences, 1973. 17. Brook, R. H.: Critical issues in the assessment of quality of care and their relationship to HMO's. J. MIed. Educ. 48:114-27, 1973. 18. Gordis, L.: Effectiveness of conmprehensive care programs in preventing rheumatic fever. New Eng. J. Med. 289:331-35, 1973. 19. Kerr, M. and Trantow, D. J.: Defining, measuring, and assessing the quality of health services. Public Health Rep. 84: 415-24, 1969. 20. Starfield, B.: Measurement of outcome: A proposed scheme. Health Soc. 52:39-50, 1974. 21. Caper, P.: The meaning of quality in medical care. New E1ng. J. lied. 291: 1136-37, 1974. 22. Cochrane, A. L.: Effectiveness and Efficiency: Random Reflections on, health Services. London, Nuffield Provincial Hospitals Trust, 1972. 23. Illich. I.: Medical Nemesis: The Ex-
propriation, of Heealth. London, Calder and Bovars, 1975. 24. Hitch. C. J.: The Econiomics of 1)efensi.e int the Xuclear Age. Cambridge, Mass., Harvard ULniversity Press, 1960. 25. Newell, K. W.: Helping people to hell) themselves. lWorld Health: pp. 3-7,
April 1975. 26. Newell, K. W., editor: Health By The People. Geneva, WHO, 197;5. 27. Sidel, V. W. and Sidel, R.: Serve The People: Observationis on Medicine ini the Peoples Republic of China. Boston, Beacon, 1974. 28. Fanon, F.: Medicine and Colonialism. In: A J)ying Colonalism. New York, Grove, 1967, p. 9. 29. Mao Tse-tunng: On Practice. In: Four Essays oni Philosophy. Peking, Foreign Languages, 1966, p. 8. 30. Jefferson, T'.: Letter to Williamii Chlarles Jarvis, September 28, 1820. In: Bartlett, J.: Familiar Quotations. Boston, Little, Brown, 1955, p. 375b.
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