American physicians struggle with contrasting demands of performance. It’s the clinical trifecta of 21st century clinical medicine.

Providers are:

• Required to be productive.
• Expected to deliver care with a high level of satisfaction.
• Increasingly accountable to quality metrics.

The problem is that productivity can be at odds with satisfaction. Satisfaction may be at odds with quality. And the three create a precarious clinical intersection.

Take, for example, the man with degenerative disc disease struggling with chronic pain (but without focal neurologic symptoms). Desperate for a fix, he finds a surgeon paid to cut with a doting staff and a grand piano in the waiting room. Drawn to the service and a physician who he sees as a man-of-action, the patient reciprocates with high satisfaction scores. But what happens when the numbers tell us that, despite pianos, surgery doesn’t predict for better outcomes?

We’ll have some explaining to do.

My friends outside the U.S. have suggested that they live comfortably at this intersection of productivity, satisfaction and quality. I want to believe them but I’m not convinced.

American medicine is stuck between an Industrial Age medical mindset of productivity and a 21st century of reality of better less. While we work to serve competing masters, I suspect our health care system will need to decide where our allegiance lies.