A New Stranger at the Bedside: Industrial Quality Management and the Erosion of Clinical Judgment in American Medicine

INTRODUCTION: A NEW STRANGER

in the autumn of 2017, a public dispute broke out among certain physician specialty societies in the United States. At issue was a new, more stringent definition of hypertension (high blood pressure), coupled with more exacting targets for control in both younger and older adults (Whelton et al. 2018). The new guidelines, from the American College of Cardiology and the American Heart Association, received widespread media attention. "Few risk factors are as important to health" as blood pressure, intoned an article in the New York Times, noting that approximately half of all adults would find themselves possible candidates for pharmacotherapy under the new recommendations (Kolata 2017). Generalist medical societies, however, which had published guidelines for older adults earlier in the year, expressed concern and declined to endorse the new standards. A representative from the American Academy of Family Physicians, for instance, claimed the scientific high ground, asserting, "With competing guidelines and recommendations, family physicians have an opportunity to be a guiding light in the darkness of confusion to deliver quality care that's grounded in science and is patient-centered" (Crawford 2017).

Disputes like this have long been fodder for historians, sociologists, and anthropologists studying the politics of defining disease. In many ways, this recent contest is a recapitulation of a common theme that historian Jeremy Greene identifies as "a state where the line between the normal and the pathological [is] a numerical abstraction" (2007, xi). Who gets to draw that line is, of course, a perennial question. Beyond the issue of definition, however, is a more pressing question of medical practice: How do the definitions become operational? Such public disputes are not abstract; they structure clinical judgment at the bedside, with sometimes dramatic consequences for good or for ill. Writing in a major medical journal, for instance, a physician in the Midwest describes the experience of a patient in his mid-eighties, whose fall resulting in a hip fracture spiraled into a nightmare. The author traces the patient's fall to the incorporation of hypertension and blood sugar targets in clinicians' performance expectations, a practice he characterizes as "tyranny." Such guidelines are not just suggestions; they are tools used to regulate clinician behavior and decisionmaking. As such, they powerfully condition what is and is not recommended in the provider-patient encounter. As the physician writes, "His doctor may have received a bonus for adhering to the guidelines, but [the patient] lost his home and independence" (Sarosi 2015, 562).

The political economy of medical guidelines is a relatively new phenomenon. While textbooks are as old as medicine itself, guidelines as an authoritative form of "regulatory objectivity" date only to the post–World War II era, and especially the late twentieth and early twenty-first centuries (Weisz et al. 2007; Cambrosio et al. 2006). By 1990, the number of available guidelines had approximately tripled to 70; by 2012, there were over 7,500 (Upshur 2014). Clinical guidelines are one spoke in the wheel of "quality management" in US health care that has been spinning for at least three decades. Another spoke is comprised of quality metrics for medical providers and organizations. Their exponential growth mirrors the proliferation of clinical guidelines. These measures, numbering in the thousands, cost each individual provider at least $40,000 annually to manage (Casalino et al. 2016). In a fairly short time, quality management has become a substantial micro-industry within health care organizations, complete with ever-expanding authority over clinical practice.

This essay offers a critical account of how the quality management industry rose to prominence in health care, and examines its impact on the nature of clinical judgment. Borrowing David Roth-man's apt concept of "strangers at the bedside" (1991), I argue that quality management is best understood as an integral feature of the "atomic unit of health care," the triad of providers, patients, and "information" (Nelson et al. 2011, 3–4). What comprises the third point on the triangle—"information"—has evolved over time. In Rothman's original formulation, the initial...