Berwick’s Rules, Wennberg’s Windfall and the Quality-Industrial Complex
Quality and value are important. But are they best achieved through professionalism or regulation? In 1996, Donald Berwick co-authored an important book, “New Rules,” which set forth the manifesto for how and why health care was to be regulated. The following statements, grouped into paragraphs, are from that book.
BERWICK: “Physician control of knowledge has allowed practitioners to shape both the demand for medical technology and its supply. One motivation for doing so may have been that the monopoly of knowledge and the inhibition of the patient’s role furthered the profession’s own economic interests. Another, and more probable explanation is that the espoused ethic of medicine eliminated all influences on the healing relationship except for the physician’s commitment to the patient.
Today, this isolated relationship in no longer tenable or possible. No longer is the physician, paternalistically committed to the patient, the driving force in medical care. Health care has become an industry, with numerous loci of authority well beyond the doctor’s office. Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. The relationship of the patient to the doctor is less important. In these circumstances, the need for regulation is greater, not less.
Regulating for improved medical care involves designing appropriate rules invested with authority. Their primary function is to constrain decentralized, individualized decision making. Strict regulations reduce the autonomy of health care professionals and thereby improve safety.”
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Your point was brought home to me in the late ’70’s when our social worker began to refer to our patients as “clients”; it was viscerally offensive and denigrated the dyad: the private relationship between doctor and patient.
S.I Hayakawa pointed out long ago that the word is not the thing, the map is not the place.
Semantics shape our decisions and propel our actions. “Patients” should and do get more commitment than “Clients”. Words do matter; as has our Hippocratic oath.