Quality and quantity

The events before death were quick yet dramatic.

There were seizures, some vomiting, prostration, hospitalization, fixed and dilated pupils. Finally, a person I had known since I was very young died of a stroke, all in the space of two days.

The news came from across an ocean, over the phone. At the time, I went into diagnostic mode, asking for the specifics of presentation and assembling the pathophysiological picture as best as I could.

Assembling clinical pictures from cases – bits of data, images and histories – is something I have done for the last year and a half.

Of course, the purpose for the pictures at the moment has much more to do with the illustration of medical concepts and less to do with actual diagnosis and treatment.
A day later, I reflected on my reaction to such an abrupt, unexpected death with equal parts horror and shame.

More than anything, what crystallized for me was the subtle, yet profound perceptive shift that has occurred over the course of my medical education. I was surprised that medical thought processes could take over even when the afflicted person was a close family friend.

In the first two years of medical school, we learn the science, occasionally thinking about people in real situations. In the last two years, we must learn, or relearn, the art of interaction.

They neglected to tell us that to learn the science, we have to forget the people.
The accreditation process for medical education here in the United States has resulted in a group of medical schools and residency programs that turn out, with astonishing consistency, physicians who are merely competent.

There isn’t much separating the great students from the poor students.

In general, those who make it through medical school know the bits of information they’re supposed to know, when and how to apply them, and when to seek help from peers and textbooks.

But for the last several months, I have been fixated on what separates competent doctors from great ones. Because they – in contrast to the difference between students – seem separated by a chasm.

It is that chasm that presents an opportunity to improve the quality of health care in this country, not necessarily by any measurable outcome.

The characteristics of a great health professional have been written about over and over – empathy, intuition, resoluteness, creativity, optimism – but invariably, they are qualities physicians acquire by interacting with people.

The observation and care of patients are inextricable from pretty heady ideas – ideas such as birth, aging and death. And yet, although these ideas excited me during my first few months of medical school, they now couldn’t be further from my mind.

The project of health professions school is a tough one, and there is much out there that seems relevant to good, high-quality health care.

We hear about improving quality and impending physician workforce shortages. But the relationship between more doctors and better health care is always assumed, rarely questioned – quantity over quality.

I echo the experts on regional variations in medical resources, especially doctors, who question such an assumption.

Maybe we should start with quality – medical education suffused evenly with patients and science, sensitivity and efficiency – and then move on to quantity.