Comments on The McDonaldization of Medicine (and OT)
Last month I read a “Viewpoint” article from JAMA Neurology that I found so spot-on, I couldn’t wait to share it with you. These writers, a neurologist and a sociologist, explained why it’s becoming so hard to deliver client-centered services in many settings. I immediately posted the article on AOT’s Facebook page, only to discover a couple of days later that it had been converted to pay-to-read only. It was not my intention to frustrate you!
If you can, I encourage you to read the original text. You may have to purchase it, unless you can access a database that carries JAMA Neurology. I happen to have saved the article before it was locked down, so I will now translate it as it relates to OT.
The writers describe how fast food management principles have been applied to health care, and the results of this style of doing things. 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 occupational therapy services and those who provide them.
| Dimension | Presentation | Benefit | Cost |
| Efficiency | Brief sessions and pre-set frequency/duration of treatment; Questionnaires rather than observations; Focus on productivity standards; Fewer OTs and OTAs to produce more billable units | More patients processed at lower cost | Decreased client-centered and holistic care; Reduced interpersonal rapport; Suboptimal outcomes; Therapist burn-out |
| Calculabilty | Counting and recording actions and easily measured outcomes; Evaluation, intervention and outcomes are measured numerically | Data can guide future practice and research | Practitioners’ attention and time diverted to recording data; Reduces care to small, discreet values, losing the big picture view |
| Predictability | Protocols , Checklists and templates, Scripted interviews | Ensures attention to a standardized set of critical factors and actions | Can result in rote, automatic care that ignores unique needs and client motivations; Can obstruct building therapeutic relationship; Clinical judgment and creativity are stifled
|
| Control by nonhuman technology | Electronic medical records that dictate clinical reasoning; Billing codes; Utilization review | Systematic, easy storage and sharing of information for patient care, program evaluation and research; Can ensure attention to critical factors and actions | 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 |
Dr. Dorsey states, “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.” I think that the same holds true for occupational therapy.
What can we do to reverse or avoid some of the negative effects of fast food health care? While it is unlikely that any OT will single-handedly influence big healthcare to change its ways, here are a few ideas from Dr. Dorsey’s article that may inspire you:
- Gather feedback from patients regarding their care and the manner in which it was delivered, and use this for improving program and practices.
- Provide services in the home
- Start a small private practice on a fee-for-service basis, avoiding the constraints of insurance
I can say from my own experience that developing my own private practice has been a freeing, affirming and meaningful way to practice OT. I have found that it’s quite possible to do this kind of practice part-time, while doing more traditional work alongside. Through my Bright Futures 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.
I am not really trying to evangelize for everyone to start a practice just like mine (although you may want to take a look at our website at <www.b-futures.com>, because there really is a great need for OTs to help adults with post-high school transition needs), but I do think that there are many of us who could deliver true, authentic OT to all kinds of people whose lives would be hugely improved.
Let me know if you’d like to talk about your ideas! Here’s how: http://www.authenticot.com/?page_id=259
Dorsey, E. R. , Ritzer, G. (2015).Viewpoint: The McDonaldization of medicine. JAMA Neurology, Published online November 16. 2015.
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