Chapter 2 The context for clinical decision making in the 21st century
In this chapter we consider the broad context of the 21st century within which professionals think and act. We look specifically at trends and patterns that have significance for clinical reasoning and decision making. We illustrate the current clashes of values and therefore of discourse in use by government, by health care, in education, in health management, in the media and by the public.
It seems to be commonly accepted that the world of the early 21st century is characterized by fragmentation and uncertainty. The global village that we all now inhabit enables on a daily basis the rapid spread of intimate knowledge of both current and potential major disasters. This frequent reminder of our vulnerability is distinctly destabilizing and anxiety-generating. Increasingly blurred national boundaries, problems of world aid and the complexity of balancing economic demands with the decreased resources of the public purse all have implications for consumers and providers (Higgs et al 1999). The major implication of these factors is our inability to cope with anything but ‘now’ and anyone but ourselves. This increasingly drives professionals to seek answers to such questions as ‘Why?’, ‘Why not?’, ‘Why now?’, ‘Who is to blame?’, and is reason enough for professionals to be ready with explanations of their clinical reasoning and decision making and able to articulate their explanations in a language appropriate to the listener or situation.
The terrible imbalances between the needy and impoverished developing world and the wealthy and self-absorbed West are clear. (And the Third World is not entirely located geographically separately from the Western world, but rather is often inside it.) Bauman (2000, 2005) has caught the spirit of life in the West in the 21st century in his term ‘liquid modernity’. This mercurial ‘liquid modern age’ metaphor captures well the values and desires that are the current mark of the prosperous West. These values and desires involve considerable opposition to and rejection of the attitudes that predominated in the second half of the 20th century (such as the vision that puts others first, the sense of mystery of things beyond us, and recognition of the fallibility of human knowledge). They also challenge the ideals of service and moral responsibility that many professionals still have and, we would argue, should cling to, since exploring our clinical thinking is helped by having ideals to aspire to and a standard of expertise for which to strive.
Bauman’s ideas, though extreme, certainly highlight current trends. In the liquid modern world, shortcuts are sought in order to do away with avoidable and resented chores or pass them on to others (outsourcing, delegation, restricted job specifications). A focus on – indeed an obsession with – the enjoyment of present goals and desires obscures the importance of the short term and obliterates the significance of the long term. Even consumerist values have changed. Durable and long-lasting products and possessions which used to be seen as attractive are now rather seen as liabilities. Long-term employment is increasingly considered an entanglement or a pipe dream. Solidity (including the strength of human bonds) is resented as a threat. Commitment augurs ‘a future burdened with obligations’; and ‘the prospect of being saddled with one thing for the duration of life is downright repulsive and frightening’ (Bauman 2005, p. 40–41).
In this liquid modern age, things are expected to last for a fixed term only. Motives are characterized by impatience for the fulfilment of self-gratification rather than by the caution, patience and delay that attend both ‘waiting’ and the concern for others beyond ourselves. Today, these things somehow suggest inferiority. ‘Rise in social hierarchy (status) is measured by the rising ability to have what one wants (whatever one may want) now – without delay … time is a bore and a chore, a pain, a snub to human freedom and a challenge to human rights, neither of which must or needs to be suffered gladly’ (Bauman 2005, p. 38). Today’s consumerism is not about the accumulation of things but their one-off enjoyment. As Neuberger (2005, p. xviii) writes: ‘we have become demanders, not citizens; we look to ourselves rather than to society as a whole … the idea of an obligation to society, beyond the demands we ourselves wish to make, has become unfashionable.’
Where health care is still concerned with commitment – to patients, to best possible care, to persistence, to resilience, to carefulness and to obligations arising from and through multi-professional teamwork – the liquid modern age seeks instant gratification and constant movement (which goes beyond fluency and flexibility to volatility, fragmentation and short life span of knowledge, tasks, work groups, etc.). Indeed, it apparently values not only the meretricious but also the ability to skate swiftly on thin ice rather than conduct oneself with the steadfastness of careful attention to detail or consideration for others.
It also seeks to foster ‘loose knit organizations that could be put together, dismantled and reassembled as the shifting circumstances require – at short notice or without notice’ (Bauman 2005, p. 44). Consider, for example, the independent treatment centres in the UK and how these are diminishing the role of NHS (National Health Service) hospitals (see Ribero, in Sylvester 2005). Politics play a key role in such shifting healthcare structures, with grand new plans and promises being the hallmark of each new government. In many such moves there is considerable loss: of institutional wisdom that avoids repeated errors and ill-advised quick fixes; of human motivation based in shared ownership of decision making and goal pursuit; and a clear, at least mid-term, sense of direction.
Thus, in the liquid modern world, established knowledge and know-how have a short life, and tradition and experience are no longer valued. Indeed, in the UK, for example, successive governments have declared history as of no importance and have uncritically pursued ‘modernization’ as a mantra for compulsive and impulsive change. In this atmosphere, hardly any form keeps its shape long enough to warrant trust and to gel into long-term reliability. ‘In the volatile world of instant and erratic change the settled habits, solid cognitive frames and stable value preferences’ (Bauman 2005, p. 44) are cast as handicaps.
Yet the fundamental relationship that enables healthcare practitioners to manage patient care is trust. The ‘fiduciary relationship’ which establishes trust is fostered by the ability of practitioners to explain professional matters articulately and clearly to all parties and to take proper account of their own values as well as the needs and values of all those involved or influential in patient/client care (including those providing services to other clients beyond the direct clinical context, e.g. in schools, community settings and industry). It is particularly hard to maintain this standard, given the general failure of trust and aversion to risk that occurs, in a world where health professionals ‘do not trust the politicians not to blame them when things go wrong’ and where society believes that ‘politicians lie when they … [promise] various services for all of us’ (see Neuberger 2005, p. xix). But trust is essential, and professionals have to have the integrity to do all they can to earn it, even if they feel undervalued.
We believe that, ironically, the current drive for ‘modernization’ combined with a distorted bureaucratic form of ‘political correctness’ are bringing with them a world-wide drive for sameness or cloning which is using management control mechanisms to ensure that everyone is treated the same, behaves the same, adheres to the same ideas and which therefore has little room for creativity and individuality. There is something deeply undemocratic about bureaucrats imposing their values, their endless anxieties about ‘conflicts of interest’, their rule-book ways of working and their watchdog approach to accountability on professionals. As responsible members of a profession, their role is precisely to argue their moral position, utilize their abilities to wear an appropriate variety of hats on different occasions with proper transparency and integrity, and exercise their clinical thinking and professional judgement in the service of differing individuals while making wise decisions about the relationship between the privacy of individuals and the common good.
However, the new capitalism of the West is certainly set to impose this bureaucratic approach on ever wider realms, fuelling both avarice and a demand for a dubious ‘transparency’ that renders everything about us relevant to the world at large and which arises from a distorted view of equality and diversity. As Bauman writes, quoting Dany-Robert Dufour: ‘Capitalism dreams of not only pushing the territory in which every object is a commodity … to the limits of the globe, but also to expand it in depth to cover previously private affairs once left to the individual charge (subjectivity, sexuality)’ (Bauman 2005, p. 45). A recent ePress Kit, The Future of Health Care, by Deloitte & Touche USA (2006) stated ‘The outlook among U.S. hospital administrators is more positive about the financial future of their facilities. At the same time … [the report writers noted] that thin margins translate to a need for closer scrutiny of all hospital operations to boost revenues and reap cost savings through enhanced efficiencies.’
The new ‘modernized’ world of work in the West is seated firmly within the liquid modern age and mirrors its values. It is, as Sennett points out, based on a very unrepresentative business model, that of internet startups and dot.com. entrepreneurs (see Garner 2006).
Sennett, who has studied society and culture for several decades in Britain and America, writes of the challenges facing us all today that ‘only a certain kind of human being can prosper in unstable, fragmentary conditions’ (Sennett 2005, p. 3). He argues persuasively that in Britain in the 21st century, the Labour government has been seduced by the superficial glamour of hot-desking and the short-term, no ties mentality of dot.com companies and is trying to impose it wholesale on the public sector. He adds: ‘There is something bizarre about taking the conditions of an IT [information technology] startup firm and thinking you can run a hospital or a university that way. He notes that when New Labour talks about reforming the public sector – and they are endlessly bringing in one new policy after another without allowing anything to bed in – they are not talking about making it do what it does better. As he points out, it takes time to learn how to make things work through trial and error, but if you change it constantly you never find out what works and what does not. It is like a form of ADHD (attention deficit hyperactivity disorder) (see Sennett 2005, Garner 2006).
O’Neill (2002) made the same point when she suggested that the particular system of accountability that has been foisted on us by what we would call the human resources industry ‘actually damages trust’. ‘Plants’, she wrote, ‘don’t flourish when we pull them up too often to check how their roots are growing: political, institutional and professional life too may not flourish if we constantly uproot it to demonstrate that everything is transparent and trustworthy’ (p. 19).
Both ‘liquid modernity’ and the ‘dot.com mentality’ emphasize short-term fixes in the abstract, rather than long-term relationships with people. Lack of stability is par for the course, and there is endless shifting around of both ideas and products to make them catch the eye and sell better. Further, as Sennett points out, the business world favours young people who have no commitment and no sense of commitment, and encourages a culture that does little to bind community together. Under the pressure of more vested and glamorous priorities, calm rational and humane thinking are sidelined. Society’s ‘managed’ acceptance of the diminishing importance of maintaining the continuity of care for a given patient is a major example of how the climate of the times seduces us to go along with ideas and values that we could not actually defend in cold blood.
Thus we see that the modernization of everything that moves has produced a system geared up to institutions shedding their responsibilities to employees and not making long-term commitments (such as pensions). It is all about how quick you can be rather than how seriously you take the problem. And as Sennett shows, in Britain (unlike Finland and Sweden) there is no political discussion of what is happening. However, we are optimistic that this is a ‘self-limiting disease’. With Sennett, as quoted in Garner, we believe that this new capitalism is ultimately doomed because more and more people will come to understand that it is not about reforming the system but deforming it. As Sennett says perspicaciously, ‘This [realization] will be the drama of the coming decades’ (Garner 2006, p. 12).
Coincidentally with all this, healthcare professionals will need to maintain their integrity and their moral commitment to their patients, and will thus take a lead in establishing and enacting important values in health care. To do so they will need to understand better both the importance of their clinical reasoning and its role in developing that essential core of professional practice, namely professional judgement, and they will need to engage actively in continuing education. But initially at least they are likely to find the climate of health care in the Western world less than comfortable and encouraging.
The context of clinical decision making in the 21st century is strongly influenced by changing policies and patterns of health care. The Fourth European Consultation on Future Trends, held in London in 1999, considered the prospects for implementing the WHO HEALTH21 policy framework (Barnard 2003). Two key practical issues were identified. Firstly, there is a need to break down the barriers between the curative services of clinical medicine and the services provided by many other health workers under the heading of ‘public health’. Secondly, there is a recognition that while endeavouring to build policies, service development and professional practice on strong knowledge foundations, it is important to remember that policy and service provision environments are never static and the knowledge context of health care is highly dynamic. The consultation predicted a complex, volatile and stressful future for policy makers and implementers.
But while these ideas are unquestionably important, the language which presents them as ‘workforce’ issues and systems problems reveals priorities that are far from sympathetic to professionals’ humanistic values. For example, the UK Pathfinder report of the ‘Policy futures for UK health’ project has identified six issues to inform UK health policy to 2015 (Barnard 2003):
Healthcare systems in many countries face changing patterns of disease and disability, changing locations for health services provision, an increased focus on chronic diseases, and an increase in the need for complex disease management strategies. The pattern and location of healthcare provision is changing, with shorter hospital stays, an increase in outpatient/short-stay surgery, and an increasing percentage of healthcare expenditure (over 75% in Australia) on health care outside of hospitals (Horvath 2005). Horvath argues that medical education is not keeping up with these trends. In conjunction with these trends are demographic changes (e.g. ageing populations, an increase in multicultural populations) which bring concomitant challenges and demands to healthcare provision.
The healthcare needs of society are also changing. Patients’ expectations are shifting from wanting to be told what to do to wanting to be involved and informed about treatment options (Lupton 1997). Trede (2000) argues that more patients want to be taken seriously as people, rather than ‘conditions’, and this shift in patient role and expectations requires a parallel shift in clinicians’ roles. Given the rise in incidence of chronic illnesses, with no cure commonly available in the near future, the role of clinicians is being and needs to be transformed from that of technical expert and authoritarian advisor to that of collaborative partner (Trede & Higgs 2003). This may prompt a return to a ‘therapeutic relationship’ in which the true value of each patient is the central motivator for care (Fish & de Cossart 2007), and where ‘the power of medicine [and all health care] then becomes the power letting go control, [and] using knowledge of the limitations of medical work to encourage the patient to take part in the shared task of trying to understand and deal with the illness that affects his or her personal being’ (Campbell 1984, p. 28).
By discourse, we mean ‘the [choice of] vocabulary and language structures that we all use to refer to the world as we see it, or to shape the meanings we make of it. The discourse we use daily indicates our mindset and our particular ways of thinking about, or seeing, “reality”’ (see Fish & Coles 2005, p. 62). Discourse is shaped by our personal and professional values. But these ways of seeing our world are tacit, and are rarely subjected to critical scrutiny. As a result they can exercise a hidden and potentially subverting influence over our lives and work. This is evident in the section above where the language of policy sounds familiar and apparently unquestionable.
Indeed, as Niblett (2001, p. 206) has pointed out, in order to understand a particular period or era, we need to be acquainted not, as one might expect, with its widely stated public opinions, but rather with the doctrines which have in everyone’s minds become unchallengeable facts and an inevitable part of the life of the time. The problem is that people not only cease to ‘see’ these ‘doctrines’ as mere ideas, but they come habitually to view most other things through them, and this then leads to routine acceptance of certain metaphors as the only way to characterize the current world.
We suggest, for example, that management discourse has clandestinely taken over and is now quite inappropriately dominating how professionals see their practice. Metaphors from the world of industry, manufacturing and training (rather than images that conjure up professionalism, commitment to service, to human care, and to education rather than training) have become so familiar that we no longer challenge them. Indeed, we fail to notice their power in describing one thing in terms of another, until eventually we employ them quite unthinkingly as ‘the given’, even while with another voice we would roundly reject their implications once they were pointed out. Here are some examples: delivering health care and the management of care; health care as a product or package to be purchased; outcomes-related care; testing the product against specification; risk management; stakeholders; and cost efficiency and effectiveness.
Much of the thrust of this trend comes from recasting health care as an industry, and from managers’ over-protective response to the current ‘risk-aversion climate in society’. Neuberger (2005, p. vii–viii) offers this phrase as a signal that the world has unthinkingly embraced ‘rules and regulations, well founded, well meant, even theoretically sensible that yet lead to an extraordinary situation in which a care worker cannot change a light bulb for fear of the consequences’, which in turn makes the lives of vulnerable people more difficult than they need to be. She adds later: ‘It is as if we are trying to create a risk-free society, which we know in our heads and hearts is impossible. The result is that we restrict and regulate, hoping to make terrible things impossible whilst knowing we cannot, and in the process, deterring the willing and kind’ (p. xi–xii). Risk-aversion, she argues persuasively, ‘will make for bad services, where no one will do what seems natural and kind in case they get accused of behaving improperly or riskily’ (p. xix).
What is lost here are these ideas: care-centred health care; health care as a process rather than a product; compassion for the individual; responsibility for more than just ourselves; sympathetic and humane decision making rather than patient management; well-founded trust between patient and professional; and an acceptance by all involved that life cannot be risk-free and will remain complex and uncertain. This would constitute what Campbell (1984, p. 114), in an earlier discourse, called ‘a tipping of the balance away from predominantly self-satisfying motives … towards a gratuitous concern for the welfare of others which does not deny self-interest but which from time to time at least, breaks through egotistical boundaries.’
Management discourse drives and sustains the same pattern of ideas at the level of governmental control of the professions. In addition to using the above terminology, government documents now refer to professionals as ‘manpower’, ‘human resources’, and ‘the workforce’, and encourage the notion that clinical practice is the ‘shop-floor’ of ‘the health industry’. What these metaphors (which arise from the apparently ubiquitous but unexamined desire to see health care in consumerist terms) are leading to is well captured by Tallis (2004, p. 243) in terms of medicine but applying equally across health care:
The patient as client or customer in the shopping mall of medical care will see the doctor as a vendor rather than as a professional. There will be an increasing emphasis on the accoutrements that make the first experience, or the first encounter, customer-friendly. The key to the doctor-as-salesman will be the emphasis on those aspects of customer care that give the patient a feeling of ‘empowerment’.
But what of those who cannot assert their rights so robustly? Will they be forced to receive whatever the system sells them? How does that fit with high-sounding healthcare goals such as the UK NHS philosophy of ‘the best possible care for the greatest number of people’ (see Neuberger 2005, p. xvii)?
Indeed, society in the Western world at the beginning of the 21st century seems to prioritize (value) uncritically only that which is superficially evident, measurable and able to be speedily executed. It has fallen into the trap that MacNamara’s fallacy illustrates (Broadfoot 2000, p. 219):
The first step is to measure whatever can easily be measured. This is OK as far as it goes. The second step is to disregard that which cannot easily be measured or to give it an arbitrary quantitative value. This is artificial and misleading. The third step is to presume that what can’t be measured easily really isn’t important. This is blindness. The fourth step is to say that what can’t easily be measured really doesn’t exist. This is suicide.
A key example of an important ‘immeasurable’ in health care is the real experience and goals people have for their own health:
Health potential can be best achieved when patients’ personal integrity remains intact, their quality of life is enhanced, and when they gain an improved sense of control over their health with long-term sustainability wherever possible. (Trede & Higgs 2003, p. 67)
The world of commerce thrives on manipulating numbers and on clever advertising using witty and memorable catchwords. These disarm criticism, gain our passive acceptance and absorption, and create the climate the market needs while pretending it is responding to consumers’ wishes. In health care now it is interesting to note how consumerist catchphrases, initially advanced by bureaucrats, have been so quickly accepted as unchallenged and unalterable ‘facts’. All this poses questions about the nature of health professionals’ expertise, autonomy and responsibility.
As several writers have argued, recognition of their membership of a profession obliges healthcare workers to seek to serve the public in ways that properly acknowledge their moral and ethical responsibilities (see Fish & Coles 2005; Freidson 1994, 2001; Higgs 1993). In concurring with this, we see the work of a professional as involving far more than visible skills. It frequently involves making difficult and complex clinical decisions that result from extensive but invisible exploration and weighing of apparently equal but seemingly incompatible priorities. It also demands that professionals take account in this of their own values and preferences and may even have to set these aside for the greater good of the patient.
The arguments in respect of not merely behaving like a professional, but actually being a member of a profession, are well illustrated by the statement in Box 2.1 of what membership of a profession entails. We see here the challenges that professionals face, the expectations that the public should be able to have of professionals in the provision of services, and the demands that need to be met in order to reach high levels of professional status and performance.
Box 2.1 Membership of a profession (adapted from Fish & Coles 2005, p. 110, with acknowledgement to Freidson 1994)
This statement highlights the commitment to high-quality health care expected of all health professionals. But such commitment and the integral clinical reasoning of which it is a part are commonly hidden from view. Some aspects of professionalism may be inferred from visible behaviour, but much of it is not in the public domain unless the professional places it there. This invisibility puts health professionals at a considerable disadvantage in a world where there is a strong tendency for patients, managers, the media and the public to see and unhesitatingly judge quality solely on the basis of the observable. Professionals are indeed ‘under siege’ (see Fish & Coles 1998). And ironically, this hidden realm is a place where incompetence, deception and unethical behaviour can remain unchallenged.
Responses to these contradictory dilemmas include increasing levels of bureaucratic scrutiny in the form of programme and institution accreditation (with an emphasis on counting the easily countable) and moves by professional organizations to rethink their roles and responsibilities in this changing world. For example, this is why we welcome the recent report from the British Royal College of Physicians (2005) on medical professionalism in a changing world. Their arguments (with which we concur and would apply across the health professions) might be summarized thus:
Medical practice is characterized by the need for judgement in the face of uncertainty. A doctor’s medical knowledge and skill may provide the explicit scientific and experiential base for such judgement. But medicine’s considerable unpredictability and complexity calls for wisdom as well as technical ability. Since this is invisible, doctors’ decisions are neither transparent nor easily accountable. This means that they must be clearer about what they do, and how and why they do it; must show a commitment to inquire into and review their clinical thinking and decision making; and must be aware of the qualities that make up their professionalism and its implications for their own practice.
But such endeavours will not be easily accomplished. The climate of the 21st century is distinctly unfriendly to members of professions. It has, for example, erected considerable barriers to the very humane approaches to caring that probably brought professionals into health care in the first place. Neuberger (2005, p. xii–xiii) refers to nurses ‘being unwilling to offer a dying person a drink in case they choke, thereby risking legal action against themselves, or, more likely, the hospital … . Because of the requirements of the Health and Safety Executive, nurses cannot even lift an elderly person who has fallen out of bed … [having instead to wait until] suitable hoists have been found.’ She points out that although none of this ‘is necessarily wrong in itself’, the ‘cumulate effect of a risk-averse culture results in an erosion of simple kindness … pushes out common sense … [and] has increased a natural human reluctance to get involved.’
This context sharply illustrates why there is now a greater need than ever before for healthcare professionals to be able to unearth and consider all the priorities in each patient case, to come up with good clinical decisions and sound professional judgements, and to explain how they have been reached. In short, it now requires them to make explicit and explore both the implicit and tacit in their practice, and to be able to articulate them (often on the spot) to a wide variety of audiences.
In professional practice, context is paramount. Every patient encounter is individual. Each case, while not being unique, is certainly particular to the one patient and all those involved. How the practitioner(s) are influenced by and read the context will affect their interpretation of the case (see Fish & de Cossart 2007). Thus, ‘the activities that practitioners engage in are intelligible only by reference to their own understandings of what they are doing and the tradition of conduct of which they are a part’ (Golby & Parrott 1999, p. 9). Good practice is thus context-specific (and as we shall see later, professionals’ understanding of this situation is more significant than the level of their skill).
Thus, making sense of health professionals’ clinical reasoning (both for themselves and those with whom they share it) depends both on the individual context of the case and on the broader climate in which it has occurred.
In the UK (as across healthcare systems in much of the rest of the world) politicians have for the last 25 years, under successive governments, progressively dismantled and privatized the UK National Health Service, gradually turning it from a welfare system into a public limited company (see Dyson 2003, Pollack 2005). This has involved orchestrating a huge change in values, and it has by and large been achieved by stealth.
Pollack argues, with thoroughness and persuasiveness, that health care has become once again a commodity to be bought rather than a right to be demanded. She declares: ‘the dismantling process and its consequences are profoundly anti-democratic and opaque’ (Pollack 2005, p. i). She points out that the catchphrases endemic to the political discourse (‘public–private partnerships’; ‘modernization’; ‘value for money’; ‘local ownership’) conceal the complexity of [the NHS’s] transformation into a market. She demonstrates how the complexity of health care allows this transformation ‘to be buried under a thousand half-truths’, while the systematic nature of the change is ‘hidden in the rhetoric of “diversity” and “choice”.’ She illustrates this process both at an overall level and in detail in terms of three core sectors of health care: hospitals; primary care and long-term care for the elderly.
In similar spirit, but employing a rather more managerial perspective, Dyson (2003) analyses the failings of the NHS and proposes a more durable system for health care in the UK. He proposes six underpinning premises:
This last point brings us to another of the major characteristics of UK health care in the 21st century: the increase in working across professions in partnership, the increasing development of new professions, and the increased demand for interprofessional or multidisciplinary teamwork. These developments give healthcare practitioners yet another reason for improving their articulation of all those invisible elements of their practice, in the interests of being better understood by those whose profession uses different language and may embrace different values, and also by those in professions that abut each other’s territory.
As a major and flourishing ‘industry’, the NHS is already attracting glances from the big capitalists from America and Europe who could well asset-strip the current system and may leave the ‘customer’ having to travel vast distances for the range of care that the NHS used to provide in nearby hospitals, centres and surgeries. While healthcare professionals are required to base all their work on evidence-based practice, governments bring in change after change, untested, unresearched, undebated. And alongside this, many members of the public and the media persist in their expectations of clinicians providing perfect solutions and maintain unintelligent or unrealistic ideas about the nature of clinical practice (see e.g. Fish & Coles 2005, Tallis 2004).
Despite all that, there is a profound (if unthinking) affection in the UK for the NHS:
Despite the worries about quality and standards, and worries as to whether the service will be there for us when we it need it most, the NHS is still highly trusted and much loved … The welfare state may have its difficulties, but the UK population still believes in it … The way it works may change … But by providing health services relatively cheaply and efficiently to the whole population, the NHS is part of the glue that holds British society together. (Neuberger 2005, p. vii).
Healthcare professionals need to know where they stand in all this. They need as never before to be able to explain their values and philosophy, and they need to be able to do so in a variety of ways to meet the needs of a variety of listeners.
Chronic disease currently accounts for more than 80% of Australia’s overall disease burden (Horvath 2005). To address this shift in emphasis from infectious disease to chronic disease management, a National Chronic Disease Strategy is being developed to serve as a framework for healthcare management across a broad range of diseases, including asthma, cardiovascular disease, diabetes, cancer and arthritic conditions. This strategy incorporates:
Health professionals working with patients with chronic diseases face changes in their practices:
All these factors have significant implications for the education and practice of health professionals. A major consideration is the development of clinical reasoning capacity and strategies that are suited to this population. Collaborative decision making has an important part to play in this context (Edwards et al 2004), building both on the principle of the right of persons and communities to participate in decision making affecting their health as outlined by the World Health Organization in its global strategy of ‘Health for All’ (WHO 1978) and on the demonstrated improvement in outcomes from genuine collaborative approaches to health care (Lorig et al 1999, Neistadt 1995, Shendell-Falik 1990, Werner 1998).
Evidence-based medicine is another aspect of medicine that provides a high motive for professionals needing to be able to explain their clinical reasoning and decision making. A highly distorted but commonly held version of evidence-based practice has given rise to absolutist expectations from patients about treatment. This ignores the original intentions, as stated by those who introduced the concept of evidence-based medicine, that medicine (and by association, health care generally) still depends crucially on the judgement of the professional. This:
requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient choice, [and] it cannot result in slavish cook-book approaches to individual patient care. External evidence can inform, but never replace, individual clinical expertise and it is this expertise that decides whether external evidence applies to the individual patient at all, and if so, how it should be integrated into a clinical decision. (Sackett et al 1997, p. 4)
The processes of clinical thinking and decision making are the centre of the expertise of health care professionals, who need to be ready to respond on the spot to questions and challenges to their decisions and actions. Time and thought need to be routinely available for them to explore the tacit and the implicit in their practice. Unearthing these invisible elements is an important part of their work, not a luxury add-on.
Because the demands for visible, measurable outcomes and accountability are ubiquitous, competencies are assumed to be the proper basis of training and assessment for healthcare professionals. Competencies are skills, and skills are visible. This emphasis on the visible and measurable has been further supported by the demands of health care’s risk management industry and its proliferation of protocols in response to the encouragement by the media and lawyers that the public should rush to litigation whenever possible. But although skills are necessary, they are not a sufficient basis for professional conduct. And their inculcation in professionals is short-term and overly expensive. Fish and de Cossart (2006) argue that an approach to the development of the practice of healthcare professionals that is based only on improvement in and extension of their skills is short sighted, morally bankrupt, dangerous and a false economy.
The myth that underpins training in the health professions is the idea that skills are generic, and once learned in one place can be unproblematically applied (will ‘transfer’) to all others. Were this so, training in skills would be the perfect (and cheap) long- and short-term solution to ‘continuing professional development’. But good practice in a profession is context-specific. Skills need to be adapted every time they are used. And what aids their appropriate adaptation is adherence to sound principles that have been thought out and understood. So the preparation and development of professionals must include changing their understanding (education). Understanding involves the capacity to reflect on and apply reasoning to new problems; the capacity to modify skills to deal with similar but significantly different problems; and an awareness of why this modification is appropriate (Wilson 2005, p. 69).
By engaging in clinical reasoning and exploring the invisible dimensions of their practice, professionals extend their own education. Intelligent managers should see the economy and value in such pursuits as this; patients should recognize their gain from it; and the public should be reassured by it.
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