It is popular to talk about the decline of both American education and the country’s healthcare system as though the failings are intrinsic to the people working in them.
For instance, one common refrain holds that doctors are in the pocket of Big Pharma. Supposedly, they are over-prescribing and driving up costs for their own enrichment. At the same time, they fight quality measures because they would rather be paid for volume than reimbursed for their actual clinical performance.
In a similar spirit, a certain peanut gallery asserts that teachers hide behind standardized testing and combat meaningful quality measures because they don’t want to be held responsible for failing children. Public schools are letting the country down by protecting teacher tenure at the expense of hiring competent, effective instructors.
In both cases, entrenched interests like unions and professional associations exert outsized influence to delay change and fight accountability; government is both overly involved and ineffective at everything it attempts, while hard working American families who depend on these institutions are left paying for more than they get.
And so on.
The common thread seems to be that academic and medical professionals are somehow inept, corrupt, and/or fighting efforts to measure and compare their outcomes. The public, meanwhile, is at a loss to hold these ivory-tower dwellers to any standards of quality, efficacy, or affordability. Outcomes suffer, families pay, and the doctors and teachers of the world cash paychecks they don’t always earn. Everyone responsible for the problems in medicine and in education can be found working in their delivery; the people on the receiving end are blameless victims.
You don’t have to personally know a teacher or a physician to recognize that such vitriolic rhetoric is utter bunk. At best, they miss the whole point of measuring performance and devising qualitative metrics. At worst, they foment hostility, ignorance, and blame-shifting that does more to increase the problem than address it.
Fix this: The trouble with making the wrong demands
Parent-teacher relationships are fraught with difficult conversations in part because they have very different expectations for, and encounters with, the students. These often center on issues where parents aren’t taking ownership of behavioral and learning problems that exist in the classroom, but aren’t always apparent at home. Sometimes the relationships teachers have with students devolve into antagonism, rather than partnership: students expect or demand high grades, rather than working to earn them. Parents, more often than not, reinforce these demands, putting more pressure on teachers to acquiesce than on students to perform.
Doctors, likewise, must also have difficult conversations with patients about treatment and outcomes. Amazingly, patients demonstrate a similar tendency to pressure providers into writing prescriptions, ordering tests, and designing care plans according to patient demands, rather than clinical standards. Just as academic administrators often capitulate to student and parent pressure, so do medical administrators, preoccupied with satisfaction scores and reputation management, side with unreasonable patients against providers.
We have institutionalized a pattern of letting patients and students set expectations that relieve them of all accountability and which holds doctors and teachers to similarly unreasonable standards. We expect these professionals to take each and every case, no matter how far behind or out of compliance, and “fix” it. Teachers must take students years behind their classmates in literacy or social skills and get them up to speed by the end of the academic year. Doctors must suspend evidence-based practices and deliver care that meets patients’ expectations (formed in advance of soliciting clinical advice) while simultaneously curing them of all ills.
Matters of lifestyle are to be ignored once a patient sets foot in the exam room, or a student takes a seat behind a desk. The critical inputs of upbringing, maintenance, and personal responsibility, despite constituting the majority of time in an individual’s life, are given less importance than the discrete, limited encounters that occur at school or in the clinic.
The alternative isn’t victim blaming
In the case of both education and healthcare, the most important predictors of success are not what happens in the exam room or the classroom, but what goes on at home. That isn’t to say that teachers and caregivers have no responsibility, impact on quality, or obligation to those they serve. It does, however, suggest that measures of quality that focus entirely on one setting can never capture the full picture.
We know, for instance, that the most important and effective predictors of academic success—across all racial, economic, and geographic lines—is their home environment: whether or not parents are reading to their children, express the value of education, prioritize learning or academic achievement, or reinforce such attitudes. Just reading to a baby even before literacy is on the menu helps in brain development, socialization, and lays a foundation for future learning.
The point of studying and emphasizing this correlation isn’t to put the blame on parents for not being around enough, not reading to their kids, or failing to be effective teachers as well as breadwinners and role models. It is simply to remember that it is at least as unreasonable to expect teachers outside the home to be capable of wearing all these hats, yet that very expectation seems to inform how we approach teacher evaluations and the public image of schools. They are meant to do everything that parents are better positioned and traditionally responsible for doing, and they are expected to do it better with less face time than parents.
Doctors arguably face an even worse status quo. They face liability for undesirable outcomes, whether that takes shape as a low patient satisfaction score or incidences of morbidity and mortality. Physicians and other caregivers face the impossible task of taking ownership of clinical standards and best practices while having to placate a consumer mentality that has no basis in medical literacy. The result is that even as opioid abuse and dependency grow, doctors face unrelenting pressure to give patients whatever drugs they ask for.
From assigning blame to embracing influence
While it might help relieve some of the pressure on teachers and providers, simply shifting all the culpability back outside their places of work is not the answer. The average encounter between a doctor and a patient may only be 15 minutes, but those are 15 hyper-critical minutes. Teachers may have hundreds or even thousands of students among whom they must divide their attention and mediate their influence on a given school day, but they still have a disproportionate opportunity even in this environment to instruct and inspire.
Addiction is almost a perfect case study for how multiple factors need consideration in treating or changing behavior.
Because addiction is a disease, it is not always possible for either physicians or patients to prevent it. As a disease with strong genetic risk factors, there is little value in assigning blame to anyone or anything, be it behavioral, environmental, or chemical. Doctors have little basis to expect patients to simply change their behavior and stop being addicts; in the absence of genetic editing capabilities, addict patients have little basis to expect their doctors to simply “cure” them of their addictions.
That leaves both providers and patients—not to mention patients’ families—with the prospect of treating recovery as a partnership. Both sides share some measure of responsibility for the outcome, but neither can reasonably escape accountability for whatever outcomes emerge.
The notion of student-teacher relationships or doctor-patient relationships as partnerships is not especially novel. In the current atmosphere of blame, distrust, institutional misalignment, and unreasonable expectations, however, it may be a concept we collectively need to revisit. Teachers and caregivers are experts. As experts, they are held to high standards, and those standards should be both achievable, and measurable. The populations they serve have a right to know those standards, but they also have a responsibility to recognize their own role in both creating and reaching those standards.
We can’t set collective expectations for quality, value, or accountability without first accepting the partnerships which underly our healthcare and educational systems. Without them, both blame and praise are just so much more noise distracting us from meaningful work and achievement.