Gray Matters:
Analysis and Ambiguity

Drawing on peer review and professionalism, some quality-improvement efforts tap into physicians’ intrinsic motivations for giving their patients the best possible care. How can we scale up such promising approaches and create and sustain a spirit of inquiry?

Proliferating measures of health care quality may distract clinicians from what matters to individual patients and from larger public health problems. Has the quality-improvement movement gone astray by ignoring the complexity of both high-quality care and physicians’ motivations?

Decades into the quality improvement movement in U.S. health care, the fix for the system has become a massive, cumbersome, time-consuming, demoralizing system in its own right — and we don’t even know whether it is improving care.

When Paul Farmer died in February, it became clear to the world that he had saved millions of lives. He did so by valuing every life equally and refusing to accept constraints. Many of us enter medicine hoping to change the world; Farmer actually did it.

To the extent that Covid vaccine hesitancy reflects deeper, longer-standing fractures in medicine’s relationship with the public, its exploration provides an opportunity to improve patient care in ways that go far beyond the pandemic.

About 27% of Americans say they definitely or probably won’t get a Covid vaccine, even if it’s free and deemed safe by scientists. The behavioral obstacles to widespread vaccination are thus as important to understand as the scientific and logistic hurdles.

Since human behavior — including wearing or shunning masks — will determine the ultimate toll of the Covid-19 pandemic, communication strategies that bridge our partisan divide over science may prove as important as any novel therapeutic.

For some clinicians, the pandemic offers an opportunity to take on the hero’s role as never before. But those who can’t must confront not only shame and guilt, but also the loss of their primordial story. Who are you, if you can’t be the hero you imagined yourself to be?

As the pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for people with non-Covid disease? Some physicians predict that “the toll on non-Covid patients will be much greater than Covid deaths.”

As the Covid-19 pandemic spreads, we’ll continue to be plagued by resource constraints that will compromise our ability to protect ourselves, our patients, and our communities. But as Washington’s response reminds us, the professional spirit marches on, unconstrained.

Physicians in northern Italy have learned some painful lessons about rationing care during an epidemic. As health care systems work out ethical allocation principles, it seems clear that only with transparency and inclusivity can public trust and cooperation be achieved.

With a clear understanding of his terminal prognosis, W.B. wanted to donate his organs before he died — but the legal and ethical hurdles proved insurmountable. In Canada, where medical assistance in dying is now legal, some patients are able to fulfill this last wish.

As debate about U.S health care begins anew, with particular focus on a “Medicare for All” type insurance design, it’s worth considering why weighing the complex but real trade-offs involved in health policy remains so politically challenging.

The announcement that Hahnemann Hospital would soon close came as a shock to many people. Is the hospital a casualty of the push to optimize the distribution of limited resources — or a cautionary tale about the greed and corruption underlying our health care ills?

Before Joe, a psychiatry resident, was killed, distinguishing between work born of love and that born of duty was his life’s theme. His struggle to practice medicine in a way that was meaningful to him may offer one antidote to the spiritual crisis of physician burnout.

If Roe v. Wade were overturned, morbidity and mortality due to unsafe abortion, including self-induced abortion, would increase, especially among disadvantaged women. We don’t know how many women died from abortion attempts before Roe, but we should recall what we do know about what killed them.

The news that Chinese scientist He Jiankui had attempted to edit the CCR5 gene in the germline of two embryos led to a swift backlash in the scientific community. But the rogue experiment may inspire broader discussion about the fraught ethical issues involved.

In cases in which the “bystander effect” seems to be at play in medicine, inaction by a group of clinicians usually takes the form of tacit acceptance of the status quo when the status quo isn’t working. What can social psychology teach us about such group failures?

Because physicians often set the cultural tone of the hospital, it’s worth considering barriers to health care professionals’ “psychological safety” for which we’re largely responsible. Why doesn’t it always feel like everyone caring for a patient is on the same team?

Why, when there are so many easy ways to communicate, is fragmentation of patient care more common than streamlined collaboration among clinicians? And what are the barriers to better collaboration that could improve care?

The world outside medicine can be full of unscripted caring from people who are happy for the mere opportunity to help. Many of us become doctors precisely for such opportunities. So why has it become so hard to translate this impulse into truly caring for patients?

Governments in dengue-endemic regions are facing a dilemma: a new dengue vaccine could prevent many cases of severe illness, but it could simultaneously cause other cases in children previously unexposed to dengue. What is the right thing to do?

By casting physician–industry interactions as a moral issue, the conflict-of-interest movement has subverted rational weighing of trade-offs. The resulting "gotcha quest" has paradoxically resulted in an erosion of public trust in medicine and science.