BY: PAUL HOFMANN, DrPH, FACHE
Dr. Hofmann is vice president, Provenance Health Partners, Moraga,
CA.
In health care, as in other fields, overcoming the barriers created by conventional
wisdom is never easy. Although the mere labeling of a concept or practice as
"conventional wisdom" immediately raises questions about its credibility, three
basic reasons why it achieved initial legitimacy exist: the idea appeared to
be sensible at the time; those in authority endorsed and supported it; and no
persuasive data in opposition were offered and accepted.
Consider the following once commonly held beliefs:
- Complementary, alternative, and integrated medicine are ineffective and
should not be taught in Western medical schools, should not be provided to
patients with serious medical conditions, and should not be covered by insurance.
(Denigrated by practitioners of Western medicine for generations, alternative
therapies have gradually been acknowledged as exceptionally effective for
various conditions.)
- The physician, by virtue of training and experience, is best qualified
to determine what is in the patient's best interests. (In the United States,
the unquestioned authority of physicians to make decisions on behalf of patients
is no longer prevalent. Patients or their surrogates have become pivotal in
determining clinical treatment decisions.)
- The presence of nonmedical people in the delivery room is inappropriate,
compromises the ability of trained professionals to perform their responsibilities,
and creates unacceptable risks for the patient, staff, and family. (Today,
fathers and/or others are welcome in the delivery room.)
- The development of new medical technology will help significantly reduce
the cost of medical treatment. (Although clear exceptions exist, most new
technology has resulted in higher — not lower — costs.)
- Clinically competent professionals have the intuitive competency and aptitude
to be effective managers and department heads. (Many clinicians appointed
to administrative roles have belatedly recognized that they lack management
skills and are not prepared to deal with personnel, financial, or other critical
administrative issues.)
- Because taking every reasonable measure to extend life expectancy is a
medical imperative, any patient in cardiac or respiratory arrest should receive
cardiopulmonary resuscitation (CPR). (Patients now have the well-established
right to stipulate that CPR not be attempted.)
- When a patient receives CPR, all family members should be required to leave
immediately; the presence of family members impairs attempts at CPR and could
cause severe emotional trauma. (Recent medical journals have published compelling
evidence supporting the value of permitting one or two family members to remain
in the room when CPR is initiated.)
- Diagnostic procedures should be ordered and interpreted only by physicians.
(Tests for pregnancy, diabetes, HIV, and other conditions are now frequently
performed by consumers.)
- Voluntarily disclosing medical errors is an invitation to litigation by
the patient or the patient's family. (Studies have confirmed that timely disclosure,
a genuine expression of regret, and a commitment to make an appropriate settlement
reduces rather than increases the likelihood of litigation.)
Admittedly, some hazards are associated with questioning or disputing an idea
or practice that has not yet been designated pejoratively as conventional wisdom.
Influential groups frequently have a vested interest in perpetuating the status
quo. The reasons may be economic and/or related to preserving power, authority,
and prestige. In addition, sociologists have long confirmed that people often
resist or fear change.
Three stages to truth have been postulated; it is first denied, then self-evident,
and finally exploited. What can or should we do to identify and expose ideas
or practices in health care that are enjoying the false security of unchallenged
acceptance?
If we are genuinely interested in accelerating the rate at which once-unassailable
beliefs are debated, then several developments must occur.
- We must encourage constructive criticism, and sincere critics should not
experience unfair repercussions. To maximize innovative thinking, an organization's
culture must support the objective examination of traditional, long-established
practices. Active pursuit of cost-effective alternatives will not happen unless
the staff is convinced that such practices can be challenged with relative
impunity.
- We should voluntarily disclose real or potential conflicts of interest
when they result in promoting an individual or institutional health care provider's
self-interests over those of patients or communities. Hidden agendas can easily
conspire to repress valid options to existing policies and procedures.
- We should conduct periodic audits, or the equivalent of legislative "sunset
reviews" (stipulating an objective evaluation by a certain date), to confirm
that the initial rationale for selected practices is still defensible.
- Whenever possible, we should replace medical and hospital jargon with simple
English to avoid intimidating patients and their families. Speaking plainly
demystifies the world of medicine and further empowers health care consumers.
We must be as vigilant in overcoming the barriers to innovation as are the
individuals who consciously or unconsciously work to protect the status quo.
Ideas and practices do not achieve the mantle of conventional wisdom without
strong advocacy, but we risk the welfare of many if we do not promote healthy
skepticism and prudent debate.
Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.