The Mcdonaldization of Medicine

Opinion

VIEWPOINT The McDonaldization of Medicine

E. Ray Dorsey, MD, AsputforthinTheMcDonaldizationofSociety,“theprin- length of patient visits can result in equal care that does MBA ciples of the fast-food restaurant are coming to domi- not address individual needs. Department of nate more and more sectors of American society,”1 The final dimension of McDonaldization is control Neurology, University including medicine (Table). While designed to produce of humans by nonhuman technology,1 which is increas- of Rochester Medical Center, Rochester, a rational system, the 4 basic principles of McDonaldiza- ingly applied to both physicians and patients. In fast- New York. tion—efficiency,calculability,predictability,and control— food restaurants, machines, not workers, control cook- often lead to adverse consequences. Without mea- ing. In medicine, resident physicians now spend far more George Ritzer, PhD, sures to counter McDonaldization, medicine’s most time with computers (40%) than with patients (12%).4 MBA cherished and defining values including care for the Billing codes and policies, which specify the length and Department of Sociology, University of individual and meaningful patient-physician relation- content of visits, dictate the care that patients receive, Maryland, College Park. ships will be threatened. influence clinicians, lead to unnecessary procedures, and McDonaldization’sfirstdimensionisefficiency,orthe can adversely affect patient health. The electronic medi- effort to find the optimal means to any end. While cal record controls interactions between physicians and efficiency is “generally a good thing,”1 irrationalities patients by specifying what questions must be asked and develop in the march toward ever-increasing efficiency. what tasks must be completed, thereby substituting the For example, while the drive-through window is effi- judgment of a computer for that of a physician. Conse- cient, its popularity often leads to long lines and errors by quently, physicians increasingly serve the needs of hard-pressed employees. Similarly, McDonaldized clin- “meaningful use” criteria and electronic medical rec- ics often employ less expensive and skilled clinicians to ords, which interfere with patient care, decrease pro- reducethetimephysiciansspendwithpatients.Thegains fessional satisfaction, and are often inefficient.5 These in efficiency, however, accrue to those pushing rational- nonhuman technologies can reduce fast-food workers ization. From the patient’s perspective, the visit may be and physicians to robots and customers and patients to inefficient. The visit length increases while time with the automatons.1 physician (and his or her role as an empathetic clinician) Despite their irrationalities, efficiency, calculability, decreases. predictability, and control are beneficial. For example, Calculability, or an emphasis on quantity rather standardizing central venous catheter placement than quality, has spread throughout medicine. As in improves health by reducing catheter-related blood- fast food, quantity is often a poor surrogate for quality. stream infections.6 Like fast-food restaurants, medi- Medical schools voluntarily provide data to be ranked cine should not be inefficient (searching for a patient’s on admission rates and average Medical College medical record), incalculable (no measurement of Admission Test scores, even though the former can be outcomes), unpredictable (open-heart surgery inflated and the latter have little predictive value.2 without protocols), and uncontrolled (no code of phy- Similarly, physicians and hospitals are subject to more sician ethics). The problem is excessive reliance on metrics, many of limited utility. Even quality measures, these principles. such as length of stay, confuse quantity with quality. Left unchecked, McDonaldization results in Patients are not immune to calculability as the care “unreasonable systems that deny the humanity, the they receive is increasingly a function of cost and human reason, of the people who work within them or financial return to the system. Like fast-food restau- are served by them.”1 In medicine, excessive reliance on rants that compete on number of customers served, McDonaldized systems replaces energy and empathy insurers compete on number of lives covered. with fatigue and inertia in residents and causes burn- Predictability is the assurance that products and ser- out in physicians. For patients, McDonaldization dehu- vices will be the same regardless of time or place. The manizes a very human relationship. drive toward predictability leads to the irrational ho- Antidotes to the McDonaldization of medicine mogenization of medical care. For example, while clini- are available. Micropractices combat the drive toward cal guidelines are valuable, they lead to greater pres- efficiency by reducing overhead and enabling patients sure on clinicians to treat all patients the same, as the and physicians to spend more time together. Incorpo- recent breast cancer screening controversy highlights.3 rating the input and preferences of patients can help Corresponding Thisapproachisantitheticaltopatient-centeredcarethat change reimbursement policies from calculating Author: E. Ray Dorsey, is responsive to the preferences, needs, and values of costs to delivering value for patients, which will MD, MBA, Department of Neurology, individual patients. Predictability can also undermine increasingly be needed as the number with chronic University of Rochester quality. Many fast-food restaurants eschew using fresh neurological disorders increases. Reducing subsidies Medical Center, 265 potatoes because frozen potatoes lead to more uni- for institutional care and expanding training and Crittenden Blvd, CU form fries. Similar trade-offs in medicine to achieve con- reimbursement for care in the home can reduce the 420694, Rochester, NY 14642 (ray.dorsey sistency can lead to poorer medical care. For example, homogenization of care that stems from an over- @chet.rochester.edu). scripted histories, overuse of checklists, or uniform emphasis on predictability. jamaneurology.com (Reprinted) JAMA Neurology Published online November 16, 2015 E1

Table. Dimensions of McDonaldization of Medicine

Example Dimension Description Fast Food Medicine Efficiency Choosing the optimal Drive-through window, limited Minute clinics, broader use means to achieve menu, self-ordering register, of medical assistants, robotic a given end finger foods, customers clear surgery, brief visits with their table physicians, patients complete questionnaires Calculability Calculating, counting, and Big Mac, supersize options, “Big Med,” medical school quantifying means and ends, No. of hamburgers sold, precise rankings, RVUs to measure with quantity serving as a measurement of hamburger size productivity, ICD-10, length surrogate for quality (9.843 cm) of stay, 30-d readmission rates Predictability Services and products being Extensive use of logos, Extensive use of logos, very similar from one time standardized appearance of standardized order sets, and place to another time stores, use of frozen products, checklists and templates, and place assembly-line food production, clinical pathways, scripted scripted interaction with histories and physicals customers Control Increased control of humans Factory farms of chicken and Billing codes, electronic through use of nonhuman cattle, hormone-treated animals, medical record, debt burden, Abbreviations: ICD-10, International technology precut and preprepared food, formularies, utilization Statistical Classification of Diseases automated soft-drink dispenser, review and Related Health Problems, Tenth uncomfortable chairs Revision; RVUs, relative value units.

Control by nonhuman technologies can be mitigated by limit- not to serve the public or the profession but “to develop and pro- ing the size of bureaucracies, ensuring electronic medical records vide valid and reliable procedures for certification and mainte- improve care, and reducing the financial burden of young physi- nance of certification.”7 Rather than burden psychiatrists and neu- cians. Enforcement of antitrust laws can limit the size and scope of rologists with onerous requirements of uncertain value, the board bureaucracies, which often have an irresistible drive for control, and could promote public service and professional ideals by asking its ensure consumer choice. Vendors of electronic medical records that memberstoengageinactivitiestoimprovethehealthofsociety.Such benefit from taxpayer incentives must be accountable to produce work could be caring for those with limited means, helping ensure technology that facilitates better care and not simply more con- the neurological well-being of young athletes, or preparing families trol. Finally, increasing residency compensation or reducing train- for the increasing burden of Alzheimer disease. If we are going to ing would enable greater autonomy for future physicians to poten- count in medicine, let it not be the number of medical records re- tially choose fields that are more aligned with societal interests. viewed but rather the number of lives touched, minds stimulated, Neurology is not immune from McDonaldization. For example, and hearts moved. The struggle against the McDonaldization of the mission of the American Board of Psychiatry and Neurology is medicine will be both increasingly necessary and ennobling.

ARTICLE INFORMATION 2. Julian ER. Validity of the Medical College and their implications for patient care, health Published Online: November 16, 2015. Admission Test for predicting medical school systems, and health policy. http://www.rand.org doi:10.1001/jamaneurol.2015.3449. performance. Acad Med. 2005;80(10):910-917. /pubs/research_reports/RR439.html. Accessed July 14, 2014. Conflict of Interest Disclosures: None reported. 3. Hartzband P, Groopman J. Keeping the patient in the equation: humanism and health care reform. 6. Pronovost P, Needham D, Berenholtz S, et al. An Additional Contributions: Denzil Harris, BA, N Engl J Med. 2009;361(6):554-555. intervention to decrease catheter-related University of Rochester School of Medicine and 4. Block L, Habicht R, Wu AW, et al. In the wake of bloodstream infections in the ICU. N Engl J Med. Dentistry, Rochester, New York, assisted in the 2006;355(26):2725-2732. preparation of the manuscript and John Markman, the 2003 and 2011 duty hours regulations, how do MD, University of Rochester Medical Center, internal medicine interns spend their time? J Gen 7. American Board of Psychiatry and Neurology, Rochester, New York, provided thoughtful critique; Intern Med. 2013;28(8):1042-1047. Inc. Mission and history. http://www.abpn.com they received no compensation. 5. Freidberg MW, Chen PG, Van Busum KR, et al. /about/mission-and-history/. Accessed September Factors affecting physician professional satisfaction 3, 2015. REFERENCES 1. Ritzer G. The McDonaldization of Society. 7th ed. Thousand Oaks, CA: Sage; 2013.

E2 JAMA Neurology Published online November 16, 2015 (Reprinted) jamaneurology.com