Are doctors overrated
Instead of program medicine: more confidence in the medical judgment
Doctors should insist on treating their patients individually.
Federal Medical Association President Hoppe: Evidence-based medicine has its place, but it should not be overrated. Photo: Georg Lopata
Otherwise the way to rationing is mapped out.
As before, health is the most important good in the judgment of the population. And the individual doctor comes first on the scale of valued professions. This is what the opinion polls show with great regularity. The reason that doctors are valued so highly is that patients or potential patients expect help from them with their individual health problems, because they have confidence in their medical and human abilities. This is a differentiated process of interaction between individual people.
What the population understands by health ranks on a broad scale. This ranges from “living with the disease” to “a state of complete physical, mental and social well-being” according to the definition of the World Health Organization (WHO) from 1946. The WHO definition of health has been highly praised, but has also been heavily criticized. The main criticism was directed against taking the concept of health so broadly. The WHO definition was valued because it clearly stated that health - to use two old-fashioned terms - encompasses body and soul.
That sounds banal. But anyone who follows today's health policy discussion will quickly notice that health and its counterpart disease are increasingly defined more narrowly. For doctors, the state or semi-state administration of treatment processes that goes along with it is an important process. The roots of this paradigm shift lie in an overestimation of the so-called evidence-based medicine (EbM), which is now not only the basis for various guidelines for dealing with certain diseases, but also the disease management programs (DMP).
Guidelines concern the individual patient-doctor relationships, DMP the medical care of large population groups. The protagonists of such program medicine see far too little that doctors treat sick people with more or less defined diseases; rather, they see patients as owners of diseases with which the corresponding programs have to be worked through like checklists. Patients become statistical variables, as if each patient were to be compared with another “carrier” of the same disease.
This philosophy is based on a very mechanistic conception of medicine and medical practice, namely on the assumption that medicine is a natural science. But medicine is not a natural science. It cannot be it at all; because in the real natural sciences there are only facts, in medicine we talk more about what should be and what shouldn't be. Medicine is also only partially theoretical, it is essentially a practical science, an empirical science, a human science, which is also based on the findings of other sciences - such as natural sciences, but also psychology, engineering, social sciences, communication sciences, the Humanities - served. Doctors only have to deal with what is probably the correct knowledge and with short half-lives, depending on the subject. Valuations also play an important role in all decision-making processes, both for patients and doctors.
The character of medical science can therefore never be that of an exact natural science. The convinced guideline representative will in principle immediately agree with this view. Nonetheless, some doctors, but even more so among health politicians and especially their political advisors, have come to believe that medical care, indeed the entire service process, can be controlled by planning specifications for individual patient care. Of course there are clinical pictures in which diagnostic and therapeutic measures can be processed algorithmically, so to speak, because relatively exact if-then decisions are possible. If the intended or desired results are achieved with pinpoint accuracy through these measures, such a system at least comes very close to scientific thinking.
The credible doctor
But when it comes to many questions that arise in the medical care of sick people, such a process does not correspond to reality. In most cases, the doctor can only assure the patient that he will use the greatest possible care in the selection of treatment proposals and the implementation of treatment measures, but a therapeutic result can never be predicted with certainty or even promised. This applies all the more, the more complex the therapeutic measure is and the more the whole person should be included as a somatic, psychological and social being. In addition, medical considerations, decisions and actions are subjectively influenced. This even applies to what are actually clear statements, such as measuring and weighing.
So when doctors speak of evidence-based medicine to the public and patients, they should combine this with the necessary relativization; otherwise they promote the mechanistic conception of medicine and medical action and thus undermine one's own trustworthiness.
With the broad definition of medicine described, it is made clear that doctors, despite their sophisticated specializations and the technical and medicinal aids, do not execute program medicine, but that they bring individual judgment into patient care and thus do not want to give up their role as bearers of hope. Doctors can only do this credibly if competence, discretion, acceptance of the role of patient advocate, compliance with the principle of "nihil nocere" and the certainty for patients that mercantile aspects are insignificant for the medical decision remain the basis of their professional practice.
Contrary to all claims, the disease management programs in Germany mean for the affected patients and their doctors a severe restriction of the traditional freedom of therapy, which is particularly evident from the original intention to make the remuneration of doctors dependent on careful compliance with the programs. The protagonists start from a mechanistic idea of the processes in patient care. EbM programs are seen as actions to be ticked off in a relatively narrow corridor in order to actually be able to control performance expenditures. The claim that disease management programs are only an aid to the care of the chronically ill and that individual patient-doctor control is not endangered in individual cases is not comprehensible and also not credible.
These critical objections to guidelines and the DMPs based on them in no way deny the usefulness of guidelines that are properly applied. The decisive factor is how guidelines are drawn up and how they are applied. The German Medical Association and the scientific and medical societies have been trying for years to bring order to the diversity of the appearance of guidelines. The following are key words:
- the development of quality criteria for guidelines
- the establishment of the clearing process for guidelines
- the conceptual clarification of standards, guidelines, guidelines and recommendations and their significance for medical care as well
- Social and liability law implications.
Internal and external evidence
Of course, guidelines must follow the criteria in evidence-based medicine. EbM is only an aid to solving an individual patient problem. An evidence-based guideline states: On a global average, something is right. The doctor, on the other hand, has to decide what is right on a case-by-case basis. An evidence-based guideline is therefore the result of a system assessment. The medical decision is a case-by-case assessment.
The concrete application of an evidence-based guideline can only take place after the patient problem has been identified. In this phase, the internal evidence of the doctor or the medical team initially dominates. This results from medical knowledge, practical experience and information from the specific patient-doctor relationship. External evidence is added when the individual treating physician or the medical team ask themselves: What does the rest of the world say about this question, what, for example, do other experienced physicians, case descriptions in the literature, randomized controlled trials, textbooks, the Cochrane centers and say other? The answers obtained in this way from the external evidence are to be critically assessed for the individual case with regard to their validity, their clinical relevance and specific applicability in the individual case. A decision must then be made as to which external evidence is to be integrated into the internal evidence and which is not.
In the near future, the decisive factor will be whether internal evidence from doctors or external evidence from program makers in health care will dominate. Or to put it another way: Will the orientation towards statistical thinking or the medical judgment enjoy the higher confidence in the people in this country?
Trust in doctors, and in the health system in general, will also depend on the extent to which economic guidelines are allowed to dominate medical care. Orientation towards guidelines and disease management programs is intended to ensure medical and economically efficient care. However, since the resources are limited, it will hardly be possible to prevent the medically necessary from being adapted to the financial possibilities and thus not guaranteeing the optimal care that medicine and doctors could provide.
With such a development, the patients are in an almost hopeless position. Those who are enrolled in a disease management program are usually cared for according to one and the same scheme. Although this means that the quality of treatment is largely the same, it also means that there is limited comparability in terms of benchmarks. If patient associations or self-help organizations have also been involved as sponsors in the decision-making of disease management programs, it will be difficult for patients who need or desire special services that are not part of the program to get justice in court.
The way to the rationing of health services is thus mapped out by such medicine according to program. We doctors have to resist this if we want to continue to have the trust of our patients.
Prof. Dr. med. Dr. H. c. Jörg-Dietrich Hoppe
President of the German Medical Association
Instead of program medicine: more confidence in the medical judgment
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