E. Ray Dorsey, MD, and George Ritzer, PhD, published a Viewpoint article in JAMA Neurology a year ago that has repeatedly resonated with me. These writers — a neurologist and a sociologist — recognize healthcare can be delivered in an individualized way, given the right conditions.
The writers describe how fast-food management principles have been applied to healthcare and the results of using this style. Four qualities define the McDonaldization of medicine, and each has its benefits and costs. Here is my interpretation of Dorsey and Ritzer’s table, depicting the effects of the fast-food approach on therapy services and therapists.
Dimension – Efficiency
Presentation – Use brief sessions and pre-set frequency/duration of treatment. Use questionnaires rather than observations. Focus on productivity standards. Provide fewer OTs and OTAs to produce more billable units.
Benefit – More patients are processed at a lower cost.
Cost – Patients receive decreased client-centered and holistic care, reduced interpersonal rapport and suboptimal outcomes. Therapists experience burnout.
Dimension – Calculabilty
Presentation – Count and record actions and easily measured outcomes. Evaluation, intervention and outcomes are measured numerically.
Benefit – Data can guide future practice and research.
Cost – Practitioners’ attention and time is diverted to recording data. Reduces care to small, discreet values, losing the big picture view.
Dimension – Predictability
Presentation– Utilize protocols, checklists and templates, plus scripted interviews.
Benefit – Ensures attention to a standardized set of critical factors and actions.
Cost – Can result in rote, automatic care that ignores unique needs and client motivations. Can obstruct building therapeutic relationship. Clinical judgment and creativity are stifled.
Dimension – Control by nonhuman technology
Presentation – Use electronic medical records that dictate clinical reasoning, billing codes and utilization review.
Benefit – Provides systematic, easy storage and sharing of information for patient care, program evaluation and research. Can ensure attention to critical factors and actions.
Cost – Professionals can be preoccupied and frustrated by continuously learning new technology. Interactions with clients are distracted and impersonal. Documentation and clinical reasoning is led or limited by forced choices.
Dorsey and Ritzer wrote, “In medicine, excessive reliance on McDonaldized systems replaces energy and empathy with fatigue and inertia in residents and causes burn- out in physicians. For patients, McDonaldization dehumanizes a very human relationship.”
My experience tells me the same holds true for occupational therapy, and very likely for physical therapy, speech-language pathology and other healthcare practices.
I am often approached by late-, mid-, and early-career colleagues who are dismayed and discouraged. Sometimes I even hear from students who are still doing their pre-career clinical rotations. They are frustrated and scared by productivity standards of 90-95%. They struggle with expectations to document even as they try to provide individualized therapies to patients whose medical needs are complex, and whose human needs are unmet. They feel guilty about following protocols that limit their work to rote and superficial minimums, or that demand intervention at a high pace and frequency that is inappropriate for frail older adults. All the while administrative managers threaten sanctions whenever these licensed health professionals are caught using their clinical reasoning and judgment, or going an extra mile for a patient or fellow therapist in need.
What can we do to reverse or avoid some of the negative effects of fast food healthcare? Here are two ideas.
- Gather feedback from patients regarding their care and the manner in which it was delivered, and take it forward in QA meetings to stimulate constructive planning.
- Start a small private practice on a fee-for-service basis, altogether avoiding the constraints of insurance and seeing people in their own homes and communities.
Developing my own private practice has been a freeing, affirming and meaningful way to practice OT. It’s quite possible to do this kind of practice part-time, while doing more traditional work alongside. Through my private practice I can significantly help people who would not otherwise have accessed essential services. I am able to provide holistic, occupational, client-centered, full-tilt OT, and to develop powerful therapeutic relationships with my clients and their families. I feel clinically challenged at a just-right level, and professionally satisfied.