I was listening to NPR's Marketplace Morning Report today and heard that Hershey has an eye on the British confectioner Cadbury. Now, I love Cadbury Crunchies, the ones that you can only get in the UK, and dread the prospect of having them disappear. But that is off topic. The story talked about how the company, Cadbury, has become more efficient since it hired an American CEO, and it is looking to further those efficiencies. In this context the word "efficiency" was kind of like fingernails on a blackboard. Here is why.
When we talk about efficiency in the business world, we are basically talking about getting as much profit as possible. This profit is wrung out of the system by reducing production costs to the maximum extent possible and by charging the top price that the market allows. Some of the ways in which the US companies have increased their efficiencies over the last 30 years are 1). by moving manufacturing to developing nations, where labor is extremely cheap, 2). by reducing the US workforce to the bare minimum through increased use of automation (and don't we all look forward to talking to a computer when we are looking for customer service on the phone!), and 3). keeping down the US workers' wages at their 1975 levels, even as the productivity has grown exponentially.
So, now I come to my concerns about healthcare. Efficiency is one of the domains identified originally in the Institute of Medicine's report "Crossing the Quality Chasm" as a measure of a functional healthcare system. Since then, the Commonwealth Fund has consistently given a poor grade for efficiency in their annual report card. And there is no question that the system as it stands today breeds inefficiency.
On the other hand, I worry that in our traditional American single-minded zeal we will go overboard on efficiency in healthcare purely in the business sense. The Six Sigma models and similar lean techniques are designed for the world of business. Medicine, I would argue, is a densely cognitive field, and despite the illusion that computerization will obviate the need for human attention, we should always demand that a human being, not a computer, is thinking about our medical picture in a holistic way in our hour of need. So, while we really do need to get rid of the considerable amount of blubber in the system as it exists today, we should never tolerate the adoption of the the traditional business view of efficiency. We must be vigilant against reproducing the curve above in our healthcare system. And as much as health IT is seen as the holy grail of medicine, let us not work under the woeful misapprehension that this valuable and necessary tool can replace medicine's practitioners, who spend their careers cultivating the art of medicine, as well as the science. And if you do not believe that there is art to medicine, you have never had a serious encounter with it either as a clinician or as a patient.