There are many misnomers in American medical English. Patients walk into your clinic (from Greek kline, bed) to learn whether their scan was negative (good) or positive (bad). Those who have severe chronic pain may ask for their pain medicine (that relieve pain, not cause it), usually opioids. Some physicians would call them pain-seeking (though what they are seeking is relief). If they don’t get a prescription, they may rate their doctor poorly on a patient satisfaction survey, which is a big thing if you are into quality improvement. Quality improvement. There’s a misnomer.

Quality improvement in medicine is by definition limited to improving things you can measure, i.e. quantify, i.e. judge by criteria that are the ying to quality’s yang. Those measures may be valid or not, and may improve patients’ lives, longevity, etc. (or not) but they are not quality. Because they are measures. Numbers. You know, quantities.

The movement is dangerous in at least three ways. Firstly and most obviously, many of the things being measured haven’t been validated in prospective trials. They are either (poor) conjecture—like tight glycemic control for type II diabetics assumed to help because of good outcomes in type ones (since, you know, a skinny teenager and a morbidly obese 60-year-old are similar that way.) Or they came out of a corporate think-tank cocaine-fueled outside-the-box brainstorming session, like patient satisfaction scores¹.

Secondly, even if they were the best measures in the world, tying them to promotion and compensation would have the unintended consequence of having practitioners loose sight of all other aspects of medicine, including the patient. There are many accounts of how it can happen—this one from Dr. Centor comes readily to mind—but since (1) identifying and (2) addressing the patient’s actual problem is difficult to measure objectively, it is not one of the benchmarks.

And finally, wherever there are numbers and money, techniques will evolve to game the system. David Simon’s account of how this happens in law enforcement is applicable. Want fewer central line infections? Enact a policy not to draw blood cultures from central lines! Too many nosocomial urinary tract infections? Urinalyses on admission for everyone! Hospitals create teams with dozens of people whose only job is to find new and better ways to do this. And they have to—because everyone else is doing it. A depressing amount of time, money, and effort wasted because of pointless exercises of anonymous pencil-pushers.

This is how you get to a near 3000% increase in the number of hospital administrators over 30 years. I am sure they are all good people, with good salaries, but they are, for the most part, insignificant. An epiphenomenon induced by someone’s desire to turn healthcare into an industry, forgetting that the six sigma ideology that works so well for toaster ovens can’t be forced onto moist, squishy, and fragile humans.

Which is also a good working definition of quality improvement.

They let us peek into the sausage factory last week.

Nominally, the lecture was about RVUs¹. An accountant type in a pinstripe suit explained why the government came up with the concept and how more RVUs translate to mo’ money for the hospital. Then he showed us a table. This is how much RVUs an average ophthalmologist makes in an hour. Here is an orthopedic surgeon. See here at the bottom? That’s an internist. This is how much you’re worth to us, scum².

Then there was a chart. This is the last fiscal year. This solid line here are monthly RVUs for an average hospitalist. The dotted line is for a single physician in the practice. See how it’s always above the solid line? That’s good. We love that person.

We had medical students and interns just three months into training listen to this. It was blood-curdling.

Not because the hospital organized the lecture, mind you. It is a very good thing they did it, and it is good for doctors in training to realize as early as possible in what kind of a healtcare system they are expected to work. What is frightening is that there needs to be an entity, let’s call it administration, which views the hospital as a production plant and physicians as line workers who need to maximize outputs, optimize efficiencies and do other newspeak claptrap.

Administration usually lies—appropriately—on the ground floor, far removed from that other sausage factory of actual patient care. It looks at pie charts and histograms and RVU tables and keeps coming up with new and exciting ways to increase production while wondering why those bumbling doctors at the bottom of the list can’t do whatever the top performing docs are doing to keep the hospital in the black.

It’s modern medicine, it’s complex, it’s expensive, it requires that level of organization and detachment—you might be tempted to say. Yes, you could indeed say that, if not for the lonely example of every other country in the developed world which does it differently than the US.

But never mind that. With all the shenanigans the Congress has been up to this week, that end of the equation is unlikely to change. What administrators should do—and I understand the banality of the following advice—is see real physicians interacting with real patients for at least and hour each week. Interns being bombarded by page after page—from critical to comical—while trying to figure out a 15-minute window to eat, get coffee and use the restroom⁴. Residents finishing a 24+ hour ICU shift that started with three codes and ended with a difficult end-of-life care discussion, with central lines placements and intern supervision—but no sleep—sprinkled in between. Attendings getting yelled at while trying to explain to family members why they need to pay for the medications out of pocket or bring their own³.

One hour. Each week. Mandatory. To put things in perspective.