Friday, January 28, 2011

Scientific Management, Systems Thinking and Evidence-based Practice

It is Friday evening. I am studying for a first set of questions in the course I am taking at Georgia Health Sciences University. The material involves an overview of the challenges of healthcare management and healthcare policy in the United States. At the moment I am wondering if evidence-based management (and evidence based clinical practices) are only new labels for the old scientific management. When Frederick Taylor calculated the optimal size of a shovel for a particular purpose was he not collecting evidence to be used in practice? And in a way were not his instructions to "Schmidt" (so as to get him to handle 47 tons of pig iron per day) somewhat analogous to telling instructing a manager or a physician in the one best way to do something, as derived from evidence? Is it a surprise that physicians resist systems by which they are evaluated upon compliance with procedures, especially when there are conflicts between the interests of particular patients and the financial interests of organizations?

Evidence-based clinical practices are based upon observations of outcomes in large populations of patients. But physicians face their patients one by one. It is the particular patient that a physician is trying to understand so as to diagnosis and treat correctly. Under DRG's (diagnostic related groups), for example, the patient becomes a diagnosis. The correct evidence-based process is based not on the patient as a person but on a diagnosis. Many patients have multiple chronic conditions. If we go to evidence-based practice are we assuming that physicians lack the ability to use his or her systems thinking skills (informed by the evidence of personal experiences) to assess the needs of this patient. Does process ultimately replace cognition? Is the use of professional discretion something to be driven out of clinical processes as is variance in industrial processes?

I value evidence, process, efficiency and economy. But I hope that we are not driving good physicians out of the profession by constraints that may in a way reduce the profession to something of an industrial profession in which obedience is more highly valued than personal insights. Physicians rightly value professional discretion and autonomy. If we come to no longer trust physicians as human beings with advanced knowledge and cognitive skills, can we substitute a trust in evidence-based processes?

1 comment:

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