Monday, November 4, 2013

Health Professionalism: More than Following Algorithms

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Sir William Osler (1849 – 1919)

I use--and perhaps overuse--this quote by William Osler, who is considered to be one of the fathers of modern medicine.  As a physician, I have always believed that understanding the patient, and not only the illness, is the key to effective therapeutics. However, today there are many who believe that the future of effective therapeutics lies in use of standardized approaches and in computerized systems --rather than in the ability to understand the person who has the disease. 

There are those who even believe that we are approaching the point at which doctors, nurses and other health professionals may be unnecessary.   The belief is that as evidence-based algorithms get more sophisticated--and computers and apps provide the platforms for their use--the need for a professional disappears.  Yet I worry about the loss of professionals and the loss of professionalism.  I am not the only one to worry.  A recent article in The Journal of the American Medical Association (JAMA) and a recent blog from the American Journal of Nursing suggest that I am not alone in my concern that blind faith in technology and algorithms may not provide a panacea. 

In the JAMA article “The Optimal Practice of Evidence- Based Medicine,” three physicians from the Mayo Clinic state that “research evidence is necessary but insufficient for making patient care decisions.” They go on to say that “careful attention to the bio-psychosocial context of patients and to their informed preferences when crafting treatments requires expertise and practical wisdom.”  Their article focuses on incorporating patient preferences into guidelines, however they also argue for a certain expertise and judgment that is part of professionalism.  They make the point that “guideline panels should rarely formulate strong recommendations.  Panels should become much more comfortable with ambiguity, both in the tradeoffs involved and in the recommendations given, and explicitly report how patient preferences and context were considered in formulating the panels’ recommendations.”  Presumably, if the guidelines are partially based in ambiguity and patient preferences--which vary from patient to patient and are part of the puzzle--an experienced professional who can customize those guidelines is a critical element of good care. 

In a blog post from the American Journal of Nursing, Karen Roush, a nurse practitioner, discusses her experience working in a retail clinic. She ultimately left that position because, she says, “the computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer…The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence.”  She spoke of her slavery to the computer leading to bad medicine:  “It interferes with two really important skills – critical thinking and intuition based on experience.” 

Ms. Roush, in speaking about critical thinking and intuition based on experience, is talking about elements of healthcare professionalism.  Professionalism implies a certain moral commitment and an ethical approach that is individualized and transcends any particular job a professional may hold.  Lynne Kirk, in a 2007 article in the Proceedings of the Baylor University Medical School, gives a variety of definitions of medical professionalism and notes that all the definitions share a focus on patient welfare, altruism and trust:  “Market forces, societal pressures and administrative exigencies must not compromise this principle.”  Definitions of medical professionalism also share a commitment to patient autonomy, which implies being honest with patients and empowering them to make their own appropriate medical decisions.  

Tom Lee from Harvard and Partners Health System in Boston makes this point, as well, in a Health Affairs  blog post-- “Patient Experience Will Drive a Renewal of Professionalism”--in which he advocates for more robust measurement of true patient preferences and patient experience.  He writes: “My strong belief is the emerging focus on measurement of the patient experience takes health care in the right direction, one that will restore and give new pride to physicians and other clinicians.”  Notice he uses the word “restore” in acknowledging that in our present medical world, professional pride may be lost.  He goes on to say that we have to understand patients’ needs.  “Measuring patient needs is the right focus for physicians and other clinicians. It is the essence of professionalism.  What is not the core of professionalism is performing high volumes of services that are reimbursed under the fee for service system.  Nor is reducing spending on populations of patients under capitated contracts.  Neither of these business objectives are inherently wrong, but these financial strategies are of limited relevance to any thoughtful sense of professionalism for clinicians.”
Accolade Health Assistants®, when helping clients with needs that are clinical and social and psychological and financial, have to maintain professionalism at all times.  We are professionals helping people and to be effective, we will always use and communicate best practice, evidence-based protocols.  At the same time, we will always customize those protocols so that the autonomy and unique aspects of every person is respected.  We will, as an organization, work to better develop our own algorithms and evidence-based protocols that address our clients’ social, emotional and financial needs in relation to their clinical needs.  At the end of the day, we will also use our own critical thinking--and even intuition based on experience--as Karen Roush says, to help meet the needs of those people we help every day.