In medicine and education: “The secret of quality is love”

“The secret of quality is love,”

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, expert in the field of quality measurement.

That’s a rather remarkable statement from a scientist whose expertise was accountability measures and quality control. It’s from a NYTimes article How Measurement Fails Doctors and Teachers by Robert M. Wachter *. The article is a refreshing and needed analysis of why the obsession with scores and metrics is leading medicine and education astray. 

While acknowledging a need for responsibility Wachter believes that the focus on numbers has gone too far and that: “We’re hitting the targets, but missing the point.” There’s no better illustration of this in education than the obsession with test scores. We might ask: “Is our children learning” what exactly?” And does it matter now or in their future how high their scores on standardized tests are?

Education and health care are about people and their infinite variety and frequently uncontrollable variables. However, rising costs, higher expectations and  and disappointing outcomes led to an unrelenting pressure to apply standardized measures.

And so we crunch the numbers, measure and weigh, check off the boxes and fill in the bubbles. Metrics are our friend. And the bigger and more of them the better until we are drowning in data.

There is no doubt that having lots of columns and charts and comparables and benchmarks can be really helpful in intelligent assessment of where we are and where we might focus our efforts. But at times the preoccupation with what can be measured has come at the expense of what can actually lead to improvement.

The best is not the best

Wachter contends that this well-intentioned  exercise has spun out of control with the unintended consequences in medicine of meaningless quality measures (there’s a test list somewhere that seems to put every medical center, hospital and doctor in the top ten of something) and high doctor burn-out rates. The electronic health record that provides undoubted benefits for all concerned becomes a problem in this box-checking scenario. (Emergency room doctors clicking a mouse 4,000 times during a 10-hour shift – hard to imagine.)

In education, of course, it was fueled by the reforming zeal of politicians and the alphabet soup of legislation and programs – NCLB, RTTP,  ESSA and a  “back-to-basics” mindset. Those in search of profit were not far behind and now schools are beset by a proliferating apparatus of testing and test preparation. Teachers have been sidelined and systematically undermined as professionals and the curriculum cribbed and confined.

Children will not be judged by standardized test scores , but by quality of their learning

Educators can dream too!

When schools and teachers are judged by standardized test scores of their students, not the quality of their learning, the curriculum narrows to what can be measured and controlled. In some places this has meant severely reduced time for science, social studies, arts, music, physical education, recess and play. What matters is what can be measured – performance not learning, scores not quality of life. If it’s not on the test – why bother? No time for that.

When teachers resisted or complained their objections were dismissed and their unions and associations attacked as defenders of mediocrity. They were not with the program, they were wedded to the past, stuck in traditional ways. They were afraid of being found out as incompetent. Did they not know the world had changed? And etc. The new shiny world of disruptive change meant that metrics were the key to improvement. The old ways had to be swept aside to make way for success and better test scores.

In its worst and most extreme forms this new way totally dehumanizes teaching. Students must be on track (and literally track with their eyes), sit up straight, pay attention and listen. Scores will be raised by taking in the wisdom of the scripted teacher who is also on track, and tracked, In place of the relationship between and amongst teacher, student and knowledge there’s the one-lane highway – an assembly line of learning.

Wachter points out there is a growing pushback in both education and medicine. The Obama administration has called for limits on student testing and parent resistance to excessive Common Core testing is strong. In medicine the concern is about the loss of eye contact and the common sense, human touch relationship component of doctoring.

Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

And here’s a radical suggestion to help find the balance between and amongst accountability, improvement, change and all the factors that affect outcomes (think poverty for example)

Whatever we do, we have to ask our clinicians and teachers whether measurement is working, and truly listen when they tell us that it isn’t. Today, that is precisely what they’re saying.

To this point read How To Fix The Country’s Failing Schools. And How Not To comparing the efforts to improve schools in Newark and Union City, New Jersey.

Newark’s big mistake was not so much that the school officials embraced one solution or another but that they placed their faith in the idea of disruptive change and charismatic leaders. Union City adopted the opposite approach, embracing the idea of gradual change and working within existing structures.

The secret of quality is love

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

I don’t think this means we should dismiss ongoing efforts to do better. It does not mean behaving as if we always know best. It does not mean believing what has been alleged of Mother Teresa that – because suffering brings us closer to God – we can skip the painkillers and antibiotics.

But if a fervor for business efficiency in pursuit of bogus ends (test scores, checked boxes, student test score driven teacher evaluation) blocks idealism and  altruism –  if it deters good people from entering medicine and teaching –  then we will have made a very poor bargain. Teachers and medical workers need to be compensated well but the motivation for the best of them is not money. Education and medicine are a calling and we should be wary of disrupting that.

* Robert M. Wachter is a professor and the interim chairman of the department of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.”

Feature photo: Wesley Wilson