AW: [IMPROVEDX] [IMPROVEDX] variations in variability

Kodolitsch von, Yskert kodolitsch at UKE.DE
Fri Nov 4 12:06:49 UTC 2016


Hello Donald,

In the preface to his seminal work Eliot Freidson writes: “In this book I try to show that the occupational organization of the work of one learned profession constitutes a dimension quite as distinct and fully as important as its knowledge, and that the social value of its work is as much a function of its own organization as it is of the knowledge and skill it is said to possess”

It may be too ambitious to recapitulate Freidsons´ comprehensive work in a single e-mail. Instead I attach my personal extracts from his book, and we may discuss further once you looked over my slides.
One remark in advance: Freidson published his book in 1970, and he summarized social studies on the medical profession that dated back into the 1940ties. Therefore, he dealt with the “golden age” of the medical profession, where outside control and skepticism against modern medicine was almost non-existing.
Therefore, his conclusion that the medical profession was structurally unable to catch-up with its own professional ideals needs to be seen against this historical background. Nonetheless, although the social structures of the medical profession have changed since then (in part because of the observations that Freidson reported), the problem remains. And it has grown in some part with the economization of medicine.

Looking forward to an increasingly vivid discussion.
To my mid it would be wonderful if the IMPROVEDX community would read and discuss the sociological view of medical work including its flaws and challenges.

Best,

Yskert

Von: Hess, Dr. Donald [mailto:dhess at susquehannahealth.org]
Gesendet: Freitag, 4. November 2016 11:36
An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; Kodolitsch von, Yskert <kodolitsch at uke.de>
Betreff: [IMPROVEDX] [IMPROVEDX] variations in variability

Hello Yskert:

What are the reasons that the medical profession is structurally unable to catch-up with its own professional ideals?

Regards,

Dr. Donald Hess

From: Kodolitsch von, Yskert [mailto:kodolitsch at UKE.DE]
Sent: Thursday, November 03, 2016 4:15 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] AW: [IMPROVEDX] [IMPROVEDX] variations in variability

Dear Rob,

Yes, clearly you aim primarily at avoiding diagnostic errors.
But, I am trying to promote a view that fighting diagnostic error should be embedded in a couple of issues that go far beyond the narrow description of the problem itself.
The human cognition is always involved, but human communication, human motivation, team collaboration, labor environment, information technologies, and so on are also involved. To approach this, we need some kind of concept about how to address this system.
So, to reduce diagnostic error, we need people to get involved in really doing something about the problem:
You need to think about hospital (or other health) organizations. You need to address human behavior, not just of physicians, but also nurses, managers, transports, lab people, and so on. You need to think about leadership. Who is leader in a hospital. What do you ground leadership on. How important is it to leaders to promote patient safety, and so on. You may read the classic by Elliot Freidson, who explained in his seminal analysis of the organization of the medical profession, why the medical profession in his times (the book was published in 1970) was “structurally” unable to catch-up with its own professional ideals (see: http://press.uchicago.edu/ucp/books/book/chicago/P/bo3634980.html ). These issues are essential, I am deeply convinced.

Clearly, one can try to isolate the problem, and stick to “error” in a narrow sense. Clearly: Check-lists, IT-based solutions, supervision, checking-routines, and so on do have a definitive value. But these “narrow measures” will also not yield ground-braking results if not embedded in a commensurate organizational culture that respects the safety of patients. And again we are back to the organizational system, leadership, strategy. We do not come around a discussion of broader approaches. …
… I firmly believe … this may not be evidence-based (though Freidson indeed carried together impressive data to support this view).

You said that you thought that “making the right diagnosis was ethical within itself”. I do not think so. Making a correct diagnosis does not seem ethical as such. Only if it severs ethical purposes (which is usually but not necessarily does: The Nazi-medicine, for example, did this for criminal purposes). A correct diagnosis used as means to help a patient is ethical; striving vigorously and uncompromisingly to get to a correct diagnosis is ethical when motivated to help a patient; engaging in getting people to think about getting to better diagnostic results (like you do) is ethical, if you do this with the motivation of help patients, but it may also not be ethical in those who do it to increase their own prestige. Therefore, cultivating virtue among physicians in a hospital rather than cultivating prestige and money is important. Imagine a career-orientated physician, who only strives for avoiding diagnostic error to impress his boss rather than to help his patient. What will he do, when he is sure that sloppy work remains undiscovered by his superiors? …

We need a broader view of the problem. I insist.
☺

Best,
Yskert



Von: robert bell [mailto:rmsbell200 at yahoo.com]
Gesendet: Mittwoch, 2. November 2016 18:40
An: Kodolitsch von, Yskert <kodolitsch at uke.de<mailto:kodolitsch at uke.de>>
Cc: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Betreff: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

Thanks Yskert,

Not quite sure about the question. I would go with “What are the best ways to help our colleagues make less errors in diagnosis.”

As an aside I would have thought that making the right diagnosis was ethical within itself.

Once we have clarified what we think are the best ways we can start making progress and doing something. And if  we do not get it right the first time we can change things.

And the "best ways” would include a discussion of conflicts. disclaimers, and litigation issues.

Will take a look at your link - thanks for sending.

Rob
On Nov 2, 2016, at 9:04 AM, Kodolitsch von, Yskert <kodolitsch at uke.de<mailto:kodolitsch at uke.de>> wrote:

I understand your question in essence as the following: “How can we make people act in a desirable way?”
Or: How can we make people go from “is to ought” (David Hume), which may also be formulated as the question “how can we put ethical demands into medical practice?”


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