“The customer does not have to understand. The customer is the customer.”

Philip Crosby 19801

“Quality isn’t asserted by the supplier; its perceived by the customer.”

John Guaspari 19882

“Make a habit of discussing a problem on the basis of the data and respecting the facts shown by them.”

Kaoru Ishikawa 19923

“We must trust to nothing but facts. These are presented to us by Nature and cannot deceive. We ought in every instance to submit our reasoning to the test of experiment.”

Antoine Lavoisier 1743–17944

“The truth is that medicine … is sensitive to outside influences.” [… including politics.]

Oliver Wendell Holmes 1809–18945

These five quotations relate to four forces that can shape medical care and its quality: the marketplace (voice of the customer), the scientific facts (two quotes), politics and provider perceptions.

To understand the reality of healthcare delivery, we need to look for the interplay of root cause, social forces at work. These include patient choice in the marketplace, politics, data about the actual process and outcomes of care and provider perceptions. This series of articles has focused on individual martyrs and heroes. In this story there is no such person—and that is one of the points we want to make. It is rare that the often hidden forces of patient choice, politics, data and provider perception can be clearly seen. A century of hindsight helps us to understand what went on at Cook County Hospital in Chicago, Illinois, USA, which provided homeopathic and regular medicine services. Data from this hospital and modern statistical analysis allow for a unique comparison of these two forms of treatment in the 1880s.

Homeopathy originated in Germany with the writings of Samuel Hahnemann (1755–1843). The basic work is his Principles of Rational Medicine, published in …