Quality is a difficult word. The current Administration ensures us we will have a quality health care system. The IOM report on Comparative Clinical Research guarantees us quality results. Is is the same word. Well I suggest we recall Alice in Through the Looking Glass:
"Humpty Dumpty took the book, and looked at it carefully. `That seems to be done right -- ' he began.
`You're holding it upside down!' Alice interrupted.
`To be sure I was!' Humpty Dumpty said gaily, as she turned it round for him. `I thought it looked a little queer. As I was saying, that SEEMS to be done right -- though I haven't time to look it over thoroughly just now -- and that shows that there are three hundred and sixty-four days when you might get un-birthday presents -- '
`Certainly,' said Alice. `And only ONE for birthday presents, you know. There's glory for you!'
`I don't know what you mean by "glory,"' Alice said.
Humpty Dumpty smiled contemptuously. `Of course you don't -- till I tell you. I meant "there's a nice knock-down argument for you!"'
`But "glory" doesn't mean "a nice knock-down argument,"' Alice objected.
`When _I_ use a word,' Humpty Dumpty said in rather a scornful tone, `it means just what I choose it to mean -- neither more nor less.'
`The question is,' said Alice, `whether you CAN make words mean so many different things.'
`The question is,' said Humpty Dumpty, `which is to be master - - that's all.'
Does a word mean whatever we want it to mean, is quality something we can define and hold true to. Quality is not objective, for what one person considers important another rejects. It is not subjective, for when we collect a group of people we can ask them does A have quality and for an overwhelming majority it does or does not. Perhaps quality is akin to pornography, we know it when we see it.
Quality health care may mean we just are treated like humans, respected and considered. Quality health care is not there when you wait to see a physician and the office help shout out your formal given "Abraham" instead of Abe or Mr. Smith. You may recall that the only time you were called by your formal first name was when your mother was seeking to reprimand you for some infraction. But alas for poor quality medical office help.
Now Pirsig, the author of Zen and Motorcycle Maintenance, ZMM, has in his writings looked closely at quality. It is not that I am a fan of the Metaphysics of Quality, his fan cub if you will, but he clearly laid out issues of quality and its problems.
Pirsig says:
"The definition was: "Quality is a characteristic of thought and statement that is recognized by a nonthinking process. Because definitions are a product of rigid, formal thinking, quality cannot be defined." The fact that this "definition" was actually a refusal to define did not draw comment. The students had no formal training that would have told them his statement was, in a formal sense, completely irrational. If you can’t define something you have no formal rational way of knowing that it exists. Neither can you really tell anyone else what it is. There is, in fact, no formal difference between inability to define and stupidity. When I say, "Quality cannot be defined," I’m really saying formally, "I’m stupid about Quality.""
This was his beginning of the non-definition. But an important beginning. For quality health care is not measured in QALYs and the like, it is how a person feels. A difficult task.
Pirsig goes on:
"He singled out aspects of Quality such as unity, vividness, authority, economy, sensitivity, clarity, emphasis, flow, suspense, brilliance, precision, proportion, depth and so on; kept each of these as poorly defined as Quality itself, but demonstrated them by the same class reading techniques. He showed how the aspect of Quality called unity, the hanging-togetherness of a story, could be improved with a technique called an outline. The authority of an argument could be jacked up with a technique called footnotes, which gives authoritative reference."
"There’s an entire branch of philosophy concerned with the definition of Quality, known as esthetics. Its question, What is meant by beautiful?...he saw that when Quality is kept undefined by definition, the entire field called esthetics is wiped out—completely disenfranchised—kaput. By refusing to define Quality he had placed it entirely outside the analytic process. If you can’t define Quality, there’s no way you can subordinate it to any intellectual rule. The estheticians can have nothing more to say. Their whole field, definition of Quality, is gone."
Indeed esthetics, and aesthetics does read onto to what quality is, it is a perception, not a measurable quantity.
Pirsig ends with:
""What moves the Greek warrior to deeds of heroism," Kitto comments, "is not a sense of duty as we understand it...duty towards others: it is rather duty towards himself. He strives after that which we translate ‘virtue’ but is in Greek areté, ‘excellence’—we shall have much to say about areté. It runs through Greek life." …Quality! Virtue! Dharma! That is what the Sophists were teaching! Not ethical relativism. Not pristine "virtue." But areté. Excellence.
Dharma! Before the Church of Reason. Before substance. Before form. Before mind and matter. Before dialectic itself. Quality had been absolute. Those first teachers of the Western world were teaching Quality, and the medium they had chosen was that of rhetoric. He has been doing it right all along…Plato hadn’t tried to destroy areté. He had encapsulated it; made a permanent, fixed Idea out of it; had converted it to a rigid, immobile Immortal Truth. He made areté the Good, the highest form, the highest Idea of all. It was subordinate only to Truth itself, in a synthesis of all that had gone before. ..That was why the Quality that Phædrus had arrived at in the classroom had seemed so close to Plato’s Good. Plato’s Good was taken from the rhetoricians."
Quality in health care is indeed the arete of Pirsig, yet indefinable, yet we know it when we engage it. The biggest problem in health care will be quality not cost. A dying patient will respect the "quality" of his health care provider based on the respect he obtains in those final moments, not by how long he survives as a result of chemicals and operations. Death with dignity means a quality death. Life with dignity is a quality life.
Aesthetics is how we see the world looking outward. Quality is how we perceive the effects of the world on ourselves. An ethical person is one who deals with others in goodness and fairness. A quality physician is one who is perceived by the patient as having been dealt with dignity and respect.
I do not sense that anyone in Congress has the slightest idea about what quality care is, cost and political gain are their sole motives. Pity!
"Humpty Dumpty took the book, and looked at it carefully. `That seems to be done right -- ' he began.
`You're holding it upside down!' Alice interrupted.
`To be sure I was!' Humpty Dumpty said gaily, as she turned it round for him. `I thought it looked a little queer. As I was saying, that SEEMS to be done right -- though I haven't time to look it over thoroughly just now -- and that shows that there are three hundred and sixty-four days when you might get un-birthday presents -- '
`Certainly,' said Alice. `And only ONE for birthday presents, you know. There's glory for you!'
`I don't know what you mean by "glory,"' Alice said.
Humpty Dumpty smiled contemptuously. `Of course you don't -- till I tell you. I meant "there's a nice knock-down argument for you!"'
`But "glory" doesn't mean "a nice knock-down argument,"' Alice objected.
`When _I_ use a word,' Humpty Dumpty said in rather a scornful tone, `it means just what I choose it to mean -- neither more nor less.'
`The question is,' said Alice, `whether you CAN make words mean so many different things.'
`The question is,' said Humpty Dumpty, `which is to be master - - that's all.'
Does a word mean whatever we want it to mean, is quality something we can define and hold true to. Quality is not objective, for what one person considers important another rejects. It is not subjective, for when we collect a group of people we can ask them does A have quality and for an overwhelming majority it does or does not. Perhaps quality is akin to pornography, we know it when we see it.
Quality health care may mean we just are treated like humans, respected and considered. Quality health care is not there when you wait to see a physician and the office help shout out your formal given "Abraham" instead of Abe or Mr. Smith. You may recall that the only time you were called by your formal first name was when your mother was seeking to reprimand you for some infraction. But alas for poor quality medical office help.
Now Pirsig, the author of Zen and Motorcycle Maintenance, ZMM, has in his writings looked closely at quality. It is not that I am a fan of the Metaphysics of Quality, his fan cub if you will, but he clearly laid out issues of quality and its problems.
Pirsig says:
"The definition was: "Quality is a characteristic of thought and statement that is recognized by a nonthinking process. Because definitions are a product of rigid, formal thinking, quality cannot be defined." The fact that this "definition" was actually a refusal to define did not draw comment. The students had no formal training that would have told them his statement was, in a formal sense, completely irrational. If you can’t define something you have no formal rational way of knowing that it exists. Neither can you really tell anyone else what it is. There is, in fact, no formal difference between inability to define and stupidity. When I say, "Quality cannot be defined," I’m really saying formally, "I’m stupid about Quality.""
This was his beginning of the non-definition. But an important beginning. For quality health care is not measured in QALYs and the like, it is how a person feels. A difficult task.
Pirsig goes on:
"He singled out aspects of Quality such as unity, vividness, authority, economy, sensitivity, clarity, emphasis, flow, suspense, brilliance, precision, proportion, depth and so on; kept each of these as poorly defined as Quality itself, but demonstrated them by the same class reading techniques. He showed how the aspect of Quality called unity, the hanging-togetherness of a story, could be improved with a technique called an outline. The authority of an argument could be jacked up with a technique called footnotes, which gives authoritative reference."
"There’s an entire branch of philosophy concerned with the definition of Quality, known as esthetics. Its question, What is meant by beautiful?...he saw that when Quality is kept undefined by definition, the entire field called esthetics is wiped out—completely disenfranchised—kaput. By refusing to define Quality he had placed it entirely outside the analytic process. If you can’t define Quality, there’s no way you can subordinate it to any intellectual rule. The estheticians can have nothing more to say. Their whole field, definition of Quality, is gone."
Indeed esthetics, and aesthetics does read onto to what quality is, it is a perception, not a measurable quantity.
Pirsig ends with:
""What moves the Greek warrior to deeds of heroism," Kitto comments, "is not a sense of duty as we understand it...duty towards others: it is rather duty towards himself. He strives after that which we translate ‘virtue’ but is in Greek areté, ‘excellence’—we shall have much to say about areté. It runs through Greek life." …Quality! Virtue! Dharma! That is what the Sophists were teaching! Not ethical relativism. Not pristine "virtue." But areté. Excellence.
Dharma! Before the Church of Reason. Before substance. Before form. Before mind and matter. Before dialectic itself. Quality had been absolute. Those first teachers of the Western world were teaching Quality, and the medium they had chosen was that of rhetoric. He has been doing it right all along…Plato hadn’t tried to destroy areté. He had encapsulated it; made a permanent, fixed Idea out of it; had converted it to a rigid, immobile Immortal Truth. He made areté the Good, the highest form, the highest Idea of all. It was subordinate only to Truth itself, in a synthesis of all that had gone before. ..That was why the Quality that Phædrus had arrived at in the classroom had seemed so close to Plato’s Good. Plato’s Good was taken from the rhetoricians."
Quality in health care is indeed the arete of Pirsig, yet indefinable, yet we know it when we engage it. The biggest problem in health care will be quality not cost. A dying patient will respect the "quality" of his health care provider based on the respect he obtains in those final moments, not by how long he survives as a result of chemicals and operations. Death with dignity means a quality death. Life with dignity is a quality life.
Aesthetics is how we see the world looking outward. Quality is how we perceive the effects of the world on ourselves. An ethical person is one who deals with others in goodness and fairness. A quality physician is one who is perceived by the patient as having been dealt with dignity and respect.
I do not sense that anyone in Congress has the slightest idea about what quality care is, cost and political gain are their sole motives. Pity!
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