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Those who have used numerical scores have pointed out much loss of information in the use of overall judgments,38 and that numerical scores, cumulated from specified subscores, give a picture not only of the whole but also of the evaluation of individual parts. Rosenfeld22 has handled this problem by using a system of assigning qualitative scores to component parts of care and an overall qualitative score based on arbitrary rules of combination that allow for the all-or-none attribute of the quality of medical care. As already pointed out, a high degree of agreement was found between intuitive and structured ratings in the Rosenfeld study22 and between qualitative and quantitative ratings in the study by Peterson et al.18
A review of the studies of quality shows a certain discouraging repetitiousness in basic concepts, approaches and methods. Further substantive progress, beyond refinements in methodology, is likely to come from a program of research in the medical care process itself rather than from frontal attacks on the problem of quality. This is believed to be so because, before one can make judgments about quality, one needs to understand how patients and physicians interact and how physicians function in the process of providing care. Once the elements of process and their interrelationships are understood, one can attach value judgments to them in terms of their contributions to intermediate and ultimate goals. Assume, for example, that authoritarianism-permissiveness is one dimension of the patient-physician relationship. An empirical study may show that physicians are in fact differentiated by this attribute. One might then ask whether authoritarianism or permissiveness should be the criterion of quality. The answer could be derived from the general values of society that may endorse one or the other as the more desirable attribute in social interactions. This is one form of quality judgment, and is perfectly valid, provided its rationale and bases are explicit. The study of the medical care process itself may however offer an alternative, and more pragmatic, approach. Assume, for the time being, that compliance with the recommendations of the physician is a goal and value in the medical care system. The value of authoritarianism or permissiveness can be determined, in part, by its contribution to compliance. Compliance is itself subject to validation by the higher order criterion of health outcomes. The true state of affairs is likely to be more complex than the hypothetical example given. The criterion of quality may prove to be congruence with patient expectations, or a more complex adaptation to specific clinical and social situations, rather than authoritarianism or permissiveness as a predominant mode. Also, certain goals in the medical care process may not be compatible with other goals, and one may not speak of quality in global terms but of quality in specified dimensions and for specified purposes. Assessments of quality will not, therefore, result in a summary judgment but in a complex profile, as Sheps has suggested.1 2b1af7f3a8