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?

http://www3.niu.edu/~td0raf1/labor/Story%20of%20Schmidt.htm

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?

What is a Physician to do?

I am recoving for nasal surgery this holiday season and preparing to be both a teacher and a student this spring semester. I am thankful for the opportunity to become a student at Medical College of Georgia while continuing to teach at Albany State University.

In reading about ethics as related to medical care I read recently that ultimately decisions are to be made by the patient and the physician is responsible to fully inform the patient regarding all available options. But if I recall, physicians are also responsible to practice evidence-based medicine in order to do those things that have been shown to be be most effective given the diagnosis. Forgive me if I am missing something, but if the patient chooses the treatment how can the physician be responsible for the patient making choices that are not evidence-based? I have no problem with patients participating in decisions about their treatment. But is it realistic to hold the physician responsible to explain every option and every possible consequence of every option? Given the power of suggestion, is it really in the interest of the patient to be told every awful thing that might possibly be the result of a medical decision? And must a physician identify treatment options that are clearly far beyond the patient's scope of options for reason of cost? Might doing so be said to be unethical behavior? Under some form of managed care, telling the patient want is technically possible but not financially feasible is not going to earn the appreciation of the physician's employer and/or partners.

To me, a professional relationship involves agency and trust. Agency does not require a blind trust. Patients certainly should participate in their care and be as alert as the situation permits. But how can a physician fully inform patients of all choices, follow patients' choices, and also be held accountable to practice evidence-based medicine? We are going to need all the good physicians we can find in coming years. Let's define the practical and ethical responsibilities of physicans in reasonable ways in order not to cause good physicians to seek other lines of employment.