It's the quality that counts

BMJ 1998; 317 doi: (Published 15 August 1998) Cite this as: BMJ 1998;317:480
  1. George Dunea, attending physician
  1. Cook County Hospital, Chicago, USA

    Quality, according to Mr Jack Lynch (author of a grammar and style guide on the worldwide web) may well be “the most abused and overused word in business English ….The word is a noun, and means a characteristic or a degree of excellence. Do not use quality as an adjective, as in quality product. Use well made, good, useful, or something similar. Never use as an adverb, as in quality-built product. Perhaps best advice is: never use quality.”

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    All this is well and good for grammarians and writers. But among the healing professions, especially in places where the buffalo roamed freely when Dr Samuel Johnson already conversed so brilliantly with his illustrious friends at the Turk's Head, “quality” has become the indispensable qualifier, usually linked to “health care” or “assurance.” Best pronounced in one gulp with the noun it is supposed to qualify, it often means the very opposite of what might be expected.

    For if the adjective is truly the enemy of the noun, then medical care should require no qualifier and no advertising. You tend to become a bit paranoid about this sort of thing, but all too often “quality” in this context refers to some largely irrelevant measurement (“indicator”) or to medical care that tends to be mediocre and impersonal. Invented by businessmen equally at home in sausage making or selling shoes, “quality” often signifies that you won't have your own doctor, that you will have to hang around for hours in emergency rooms, that a gatekeeper will have to authorise your having your appendix removed, or that the students will take care of you at that famous institution whose doctors are advertised to be at the cutting edge of science.

    The false adjective has also been linked to “assurance,” in an endeavour supposed to reassure the people that the funds devoted to medical care are being well spent. These programmes are often initiated by generally well meaning but naive doctors or medical associations under the excuse that “if we don't do it they will,” meaning the government. Starting with guidelines and suggestions that quickly become mandates and regulations, these initiatives tend to become self perpetuating, an opportunity for dinners, for travel, for the more assertive members telling others what to do, and for providing some revenue or occupational therapy for doctors who have retired, have no patients, or find clinical practice tedious and exhausting.

    Thus the cost of running these programmes, of collecting data and preparing reports, of inspections for compliance and of the defensive medicine this engenders is incalculable. And what a waste to have doctors spending their days reviewing often illegible charts and armies of nurses and coordinators busily assisting them, fussing over minutiae but failing to uncover those truly egregious errors that retrospective chart reviews rarely uncover. “Does it really take a committee of 20 people to decide if a patient with congestive heart failure was treated correctly?” recently asked one of the few remaining unbelievers, adding that “never before have so many people put in so much time to achieve so little.”

    Yet a search on Alta Vista shows 3257 documents listed under “quality health care.” There are mastheads, programmes, guidelines, commissions, an alliance, consumer guides and advisory services, reports on “total quality care,” position papers, statistical and analytical tools, information sites, a journal calling for papers, and hints on how to measure it and how to know when you have found it. Mr Lynch and his grammarians may well be fighting a losing battle.