The Measure of Everything

Medicine has a word for what ails it. It's not burnout.

A few years ago I sat through a meeting where data was presented on our patient satisfaction scores. The numbers were fine but the conversation that followed had little to do with whether our patients were actually satisfied. It was about the scores themselves and how to move them. At some point I realized that we weren’t talking about patients at all. We were talking about a metric that was supposed to represent a great experience, and the number had become the thing.

Maybe you’ve been to a similar meeting.

Through my career I’ve noticed something I couldn’t quite name — a creeping sense that something in medicine had shifted, something to do with how we talk about value. Then I read an essay in Aeon by the philosopher Julian Baggini, and he gave it a name: instrumentalisation. This is the tendency to strip things that are valuable in themselves of their intrinsic worth, and reduce them to means toward some further end. Medicine has fully absorbed this logic. We can’t defend the value of anything that doesn’t plot on a graph.

Once I heard this word, it described what I was seeing.

As an example, in the last couple of decades, we started talking about rapport with patients as though its value depends on outcome data. You’ve seen the framing: a good therapeutic relationship correlates with better adherence. Empathy improves clinical outcomes.

I understand why this language exists. In an instrumentalist system you have to translate everything into its terms or risk it being dismissed as soft or unserious. But the translation comes at a cost. When you justify being good to your patients because it correlates with better outcomes, you’ve accepted that the relationship needs extrinsic justification. Kindness, on its own terms, apparently isn’t enough.

But do we really need an NIH-funded study to tell us that patients do better when their doctor gives a damn? What does it say about us that the study was considered necessary?

This kind of thing is also found in empathy training and research. As if empathy is a skill you can acquire in a workshop and deploy in twelve-minute increments. The instrumentalist frame turns what should be a basic feature of human engagement (caring about the patient in front of you) into a technique with an evidence base and a revenue cycle implication.

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The second part of this is that once we decide that only measurable things matter, the measures then take over. This leads to a kind of next-level instrumentalisation.

Consider the A1C. It was developed as a proxy for glycemic control—a useful one, I’ll add. A window into what glucose has been doing over the past few months, aggregated into a single number that could guide treatment. But somewhere along the way, the proxy became the goal. We stopped asking whether a patient’s glucose control was serving their life and started asking whether their A1C was at target.

This distinction matters. Patients with erratic glucose, frequent hypoglycemia, or limited life expectancy sometimes ended up with tightly controlled A1Cs and worse lives. The ACCORD trial offered a hard warning about what happens when you chase a number past the point where it still tracks the thing you actually care about. A mortality signal, in a study designed to show benefit. No one disputes that glycemic control matters. What the instrumentalisation of diabetes does is sever the instrument from the outcome, so that hitting the number feels like the same thing as helping the patient. It isn’t always.

Patient satisfaction scores followed a similar arc. The original intent was right: capture whether patients felt heard, informed, respected. I’d argue that this is genuinely important, and not because it correlates with anything. But as we all watched, the score became the target. Physicians started getting graded and compensated on numbers that had no reliable correlation with clinical quality. And the blind pursuit of those measures created perverse incentives, like giving patients what they want, not what they need. The opioid crisis has a satisfaction score subplot that we still haven’t fully reckoned with.

The patient satisfaction cottage industry didn’t cause the epidemic, but the instrumental logic that made satisfaction a compensation metric helped create a world where saying no to a patient carried a professional cost.

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There’s an old philosophical distinction between intrinsic and extrinsic value that medicine used to understand, at least implicitly. Some things are valuable because they lead to something else. And some things are valuable in themselves. A good conversation with a patient where something is understood that wasn’t understood before has intrinsic value for both doc and patient.

I want to be clear that the problem isn’t measurement. I want proven benefits for the interventions I prescribe, and I trust the apparatus of evidence that helps me sort what works from what doesn’t. The problem is what happens when measurement becomes the only language we have for value.

I’m concerned that we’ve lost the language to defend things that matter but can’t be measured.