On Efficiency in Medicine

“Efficiency” has become the be-all and end-all of our culture. In a world defined by technique, efficiency is an unassailable defense against opposing viewpoints: one has only to say, “Well, this way increases efficiency,” to silence all the naysayers and get everybody’s heads nodding in agreement.

So my attention was riveted when I heard a physician wiser than I say, “All the efficiencies of the last fifteen years have reduced the time between patient and physician.” It was an offhand remark, mentioned in passing.

I thought, Wait a minute. Efficiency is a good thing. But less time with my patients or my doctor doesn’t sound like necessarily a good thing.

I went to my old Webster’s Collegiate Dictionary, Tenth Edition. “Efficiency” means “effective operation as measured by a comparison of production with cost (as in energy, time, and money).” “Efficient” means “productive of a desired effects.”

So “Efficiency” doesn’t equal “Good,” or even “Better.” In fact, “Efficiency” by itself says nothing about an activity’s moral content. Whether something is morally right or wrong depends not just on the means but on the desired effects, the ends we wish to achieve. If  we are more concerned with increasing the efficiency of our projects than with the content or outcome of those projects, we are in danger of spending our time “committed to the quest for continually improved means to carelessly examined ends.”

“Efficiency” seems to have taken the driver’s seat in medicine. In my work as a physician I daily hear exhortations to increase efficiency, and new projects — no matter how onerous — justified by, “This will improve efficiency.” But is it possible that improving certain means (= increasing efficiency), without considering other means or the ends towards which those means tend, might actually be detrimental?

Returning to the physician’s statement above, we must ask, “What are the ends of medicine?” The answers are Legion, and depend largely upon whom one asks. To some, it may simply be “health.” To stakeholders and bean counters, it might revolve around profit and return on investment.

Several studies indicate that a good relationship with a trusted physician is very beneficial for health, particularly for those with chronic diseases. So a better relationship with a physician would be an efficient way to achieve the ends of health, and “Efficiency” might mean more time spent with patients building meaningful healing relationships.

But if one measures efficiency in medicine only in terms of “the amount the doctor bills for his services per hour,” then more time spent with individual patients actually decreases efficiency.

If we make out “Efficiency” to be an ultimate good, and if we define it as cost per unit of time, then we will have destroyed medicine and remade it into something barely recognizable as the vision of Hippocrates (and Jesus). I maintain that this process has already advanced far, that we are steadily improving the means to poorly examined ends, and that we must reexamine the ends of medicine before we consider redesigning the means.

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Susan Haack
Susan Haack
8 years ago

If efficiency by definition is determined by production, then we must ask–and answer—what exactly is being produced (a question which relates to your comment about “poorly examined ends”)? Part of our problem is that since we have abdicated control of the profession to third party payors, we are no longer able to define those ends ourselves. Instead they are defined for us by those who control the purse-strings, not those involved in the “once-moral-art-now-business” that is medicine. And as I mentioned in another comment on the hospice update, neither living nor dying–nor caring–are efficient processes. There is only one thing efficient in this scenario: medicine as a moral art has been efficiently eliminated.

Jon Holmlund
Jon Holmlund
8 years ago
Reply to  Susan Haack

I agree with this post and with Dr. Haack’s response here as well as to my last post on the SD Hospice. I’ll only respond here. The challenge seems so complex, that it’s hard to address adequately in any one exchange. Regarding hospice, one hopes that good palliative care would become routine as part of good medicine, and would not need a separate reimbursable entity. I guess; that seems awfully easy to say. More generally, how does one distinguish best medical care practices, determined by physicians exercising good judgement based on appropriate data, from truly “wasteful” or ineffective medical practice? And is it possible to do so in a “bottom-up” fashion that is driven by practitioners whose first loyalty is to the care of the patient, served by business people who can help them innovate and organize to provide the best care possible in a financially sustainable way? And do “top down” approaches–notably the drive to larger “systems” (public or private) necessarily war against good medicine? Finally, is the decision to socialize (publicly or privately) costs in the complex, technologically-rich enterprise that is modern medicine an unavoidable decision that sets an unavoidable “efficiency trap?” Again, easy to ask, easy to ask in a way that sounds rhetorical, hard to answer.

And all of that still addresses means, not ends. Maybe we need to hear more from Dr. Gibes in future posts on a restatement of the ends of medicine.