Benchmarks and standards for contemporary medical, professional practice
The challenges of contemporary medical professionalism posed by over-standardised clinical decision-making and artificial intelligence
Currently, AI applied to medicine cannot meet the following quality of care requirements:
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Weighing ethical standards in clinical decision-making, because this also entails philosophical reasoning;
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Delivering eco-biopsychosocial care, because combining health promotion, prevention, curative care, and, in particular, psychological therapy, (and tailoring them to the individual,) is not an exercise suitable for algorithms and standardisation;
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c.
Avoiding the medicalisation of non-medical issues, because [21], clinically, this is a biopsychosocial decision and collectively, a political and social one.
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d.
Negotiating clinical decisions with the patient and her/his family, in line with person-centred care because agreeing on therapeutic objectives and conduct (in the framework of goal-oriented care) [22] entails mutual adjustment, egalitarian roles and non-verbal communication [23];
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Using evidence-based medicine (EBM) clinical guidelines critically and creatively, because conflicts of interest among experts often plague clinical guideline design and simultaneous treatment of multiple diseases strains their straightforward implementation [16, 24];
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Acquiring and improving manual, technical, behavioural, and communication skills, because their effective transmission assumes actual physical demonstration and supervised practice;
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Delivering continuous care to ensure that patients complete their treatment or actually use the referral hospitals, because defaulter tracing systems must be complemented by effective doctor-patient dialogue;
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Leading an inter-professional team, because leadership requires motivational skills and sensitivity to local cultural norms.
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Coordinating health care across institutional divides, because that requires negotiation between, among others, GPs and hospital specialists;
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Improving health services’ organisation, because creativity is needed to derive managerial priorities from critical clinical incidents including, for example, “near misses”;
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Collectively developing professional know-how adapted to local epidemiology, because predictive values of signs and lab tests depend on disease prevalence and patients’ mixes that aren’t available to AI designers.
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Reflecting on personal clinical performance to achieve lifelong improvements in providing high quality care, because this exercise applies to all the above-listed domains, and is an insightful process.
The complexity of these tasks justifies the need for a human interface between suffering and health risks on the one hand and their therapeutic and/or prophylactic solution on the other, and mandates that this agent be a high-level, perceptive professional.
Consequently,
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To protect and advance medical professionalism in the modern world, the medical culture should embrace the tasks that AI does not do well (including knowledge and ethics] and thus be a priority for health management, policy, medical education, and research;
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AI ought to be designed and used to support the medical profession and not the reverse. For this, practicing physicians must be included in the development and evaluation processes of AI tools.
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Public health and health management sciences should focus on the delivery of eco-biopsychosocial, person-centred and continuous care; on professional, personal development, on teamwork organisation; on care coordination; on knowledge management and in particular on the prudent use of evidence-based medicine.
Since physicians need to tackle individual and collective health problems simultaneously, our analysis has focused on one important aspect of contemporary medical professionalism, namely, the integration of clinical medicine and public health medicine in practice and theory. Notice that each article in this series addresses a different aspect of this topic.
The quality of health care builds on human emotions and sentience
Professional empathy (compassion) is based on a process whereby physicians relate the patient’s suffering, life-goals, risks, and eco-biopsychosocial condition to their own life experiences.
Most medical tasks require the empathy on the part of the physician because, to comply with prescribed treatments, follow lifestyle advice, and use recommended services, patients must be intimately convinced of their relevance and potential effectiveness. That is why doctors and patients need to discuss, negotiate and agree on the determinants of the patient’s suffering and nature of the risks entailed, as endorsed by the person-centred care delivery concept [25].
In general, the same rules ought to apply to negotiating public health programmes with individual communities. But these programmes, that typically carry risks for some in the community and benefits for others are, in general, much more complex. Discussing them in detail is therefore beyond the scope of this paper.
In conducting such negotiations, doctors need to act with self-effacement for the following reasons:
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Professional ethical tenets may be in conflict with each other and these contradictions may give rise to self-serving interests. Without a clear ethical standpoint, physicians tend to react to opposing quality of care considerations, such as a patient’s autonomy and security, or between treatment effectiveness and efficiency, according to distinctly unprofessional considerations, such as whether the patient is rich or not, to optimise their income [25].
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Regulation and control have severe limitations when it comes to healthcare, especially when personal decisions, made in private, are at play [26, 27].
In medicine, exercising empathy and compassion frequently depends on working conditions and income, although less than one might think. In fact, money may even degrade empathy when
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Delivery of care is conceived as commercial transactions since such a commercial relationship assumes the doctor’s negative, pecuniary identification with her/his patient: the more money the patient-buyer loses, the more the doctor-seller wins; and
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Clinical decisions are linked to the physicians’ material income – for example the (managed care) ‘pay-for-performance’ technique widely in use in HMOs and PPOs – because it focuses the doctors’ attention on the financial aspects of clinical practice.
This does not mean that physicians should not be adequately paid, but rather that health policies ought to minimise financial incentives in clinical decision-making. They should also make explicit as to how they will enhance the physicians’ propensity to altruism – their human, socially [28] and genetically [29, 30] determined altruism.
When invited to list intangible incentives, physicians point to having sufficient time for discussion with colleagues and patients, professional autonomy, teamwork, intellectual progress, or social recognition, but tend to forget professional ethics. They should not. If treating medical ethics as an incentive is indeed counter-intuitive, (because, being a feature of quality care, ethics is an output and not an input in healthcare delivery) the assimilation of ethical norms and the adoption of social values can be [31], and must become central factor in physicians’ motivation and behaviour.
That emotions and ethical considerations are conditions for quality of care has structural implications for medical and public health education, management and policy. It is a proposition that is discussed in various points in this paper.
How can doctors best adopt a jointly, clinical/public health practice?
Firstly, doctors shouldn’t act as economic agents - since the Hippocratic oath is incompatible with neoclassical economics:
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Doctors should enter the patient’s house solely for the good of the patient. All Hippocratic oath versions include an altruistic benevolence tenet that assumes the physician’s ‘selflessness’, ‘disinterest’ or ‘self-effacement’.
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By contrast, methodological individualism justifies commercial medical practice by hypothesising that humans are beings who generally make rational decisions to optimise their benefit/utility. That they are incompletely informed and restrained in making rational choices (that is, limited by the tractability of the decision problem, the cognitive limitations of the mind, and the time available to make the decision), as the neoclassical economists admit, does not change the case.
Secondly, alongside clinical duties, doctors (sometimes in managerial positions) can build and lead teamwork; reflect on practice; contribute behavioural models and promote their colleagues’ professional motivation; coach, educate, train; improve the organisation of their health services; coordinate and evaluate health care; contribute to disease and health risk control; do operational research; and lobby for appropriate health policy design. And, in community-oriented health centres, they can be involved in primary care practices. When physicians inter-relate this to their clinical or disease control practice, they also use their knowledge and experience fully to optimise their impact on the environment. In such a role, doctors could be called “manager-physicians”. Although the term manager is traditionally reserved for persons entrusted with decision-making aimed at achieving their institutions’ predetermined goals most efficiently, our proposed definition assumes that professional ethics should prevail over institutional missions in the doctors’ mind [32].
In fact, any doctor
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can adopt the role of “manager-physician” provided that s/he is motivated. This is a rewarding role provided education, research, and good management are professionally valued.
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should adopt this role because the opportunity cost of not adopting it can be measured in terms of avoidable suffering and mortality [33].
Doctors ought thus to become “manager-physicians” independently of, or prior to, the adoption of ad hoc institutional policies, without having necessarily been commissioned to act as such: for the sake of a professional ethic designed to optimise doctors’ impact on community health.
Knowledge and ethics for integrated medical/public health practices
Over the past 50 years, European policies often encouraged clinicians to introduce interventions that result in collective, positive health spin-offs. These include
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Prescribing antibiotics wisely to reduce nosocomial infections and resistance in hospitals;
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Interpreting lab tests and imaging with semi-quantitative assessment of predictive values [34];
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Shortening the ‘doctor’s delay’,Footnote 3 for example in diagnosing resurgent infectious diseases or in early detection and optimal management of pregnancy bleeding, or of adolescent mental conditions.
To optimise their positive impact on population health, clinicians should systematically broaden their role in the prevention of environmental risks,Footnote 4disease-specific prevention, health education, community-oriented medical practice and health services organisation.
Admittedly, this integrated clinical practice carries a (manageable) risk. While European public health specialists have generally designed disease control programmes incorporated in medical practice in such a way that it protects quality of care, these priorities were not passed on to international cooperation activities in LMICs [20]. The result was large-scale, catastrophic consequences for access to care and its quality [35]. For example, the cooperation agencies set up regional supervisory structures specific to each disease control programme (tuberculosis, AIDS, malaria, maternal health, etc.). In the case of public sector in sub-Saharan Africa, professionals were held accountable to a number of specialised supervisors who each saw only the value of their own programme - to the detriment of a primary health care view including the bio-psychosocial quality of medical care.
Integrated clinical/public health practices call for a new epistemological approach to medical knowledge in order to optimise the impact of clinicians on community health while delivering individualised treatments - and symmetrically, to optimise the impact of public health physicians (and programmes) on individual and family health [36]. This goes for medical ethics: clinical and public health ethics should be merged because medical practice should focus on ‘joined-up’ clinical and public health values [33].
Integrated, medical knowledge and ethics is not only coherent science but also professional because eco-biopsychosocial, person-centred clinical decisions, communication, manual and behavioural skills, reflectivity, provider’s personal development and morals are not easy to standardise but typically situational.
Strengthening professional ethics in health systems
Physicians face ethical issues every day: in simply deciding on a lab test (where to determine the cut-off between false positives and false negatives), on the use of medical equipment, or whether and to whom to refer a patient. In striking a balance between their clinical, conviction ethics and managerial, responsibility ethics, physicians, need guidance on ethical clinical decision-making. They need a theory of human resource management designed to promote professionals’ intangible motivations, empathy, and self-effacement which are otherwise part of a physician’s personal history, genetics, identity [37]; prevailing social values and health systems characteristics.
Specifically, such theory would aim to equip physicians who are in managerial and educational functions with psychological guidance to strengthen ethical, medical practice in their hospital or health centre; it would highlight policies that are supportive to this endeavour; and analyse manager-physicians’ needs to promote self-effacement and compassion, I.e.
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A ‘hardware’ that permits human interaction, for example; teamwork, coaching or technical supervision. Notice that to support more intense personal interactions, some health care service structures favour dialogue and cooperation more than others [38, 39].
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A ‘software’, that is to say an interaction model conceived to understand the psychology rooting ethical medical behaviour. The mechanisms that provide the psychic energy to forgo material benefits in clinical decision making link the self-interpretation of the physician’s biography (sometimes called ‘role identity’), his/her (political, philosophical, cultural, religious, etc.) belonging identities, and professional identity.
Some benchmark examples of healthcare management that supports medical professionalism and ethics follow:
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Treating physicians, health professionals, and inter-professional teams not just as the objects of health development strategies, but also their subjects. This is why physicians and health professionals must co-manage non-commercial health services.
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Addressing physicians’ intangible motivations, above and beyond resolving the tension between effectiveness and efficiency that is inherent in any production process: in particular, physicians must be able to decide on the weighting of the quality of care criteria they use in each individual clinical situation.
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Viewing physicians’ personal progress as a health system output and not merely an input to the quality of care. Health services must aim to develop medical professionalism for the physician’s self-esteem and self-realisation.
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Managing professional knowledge, its development and transmission as an organisational priority. In practice, health services shouldn’t focus only on scientific excellence, but also on professional excellence e.g. skills, problem solving capacity and ethics.
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In respect of continuous medical education, this has to involve the transmission of a professional culture in order to advance personal development, rather than merely transmitting competencies.
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Involving health services inter-disciplinary training and education.
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Promoting professional ethics, for example, with ad-hoc inter-professional team debates, clinical case reviews and bottom-up strategies in health services, e.g. care coordination and promotion of professionals’ reflectivity.
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Accepting sufficient variability in the implementation of clinical guidelines [40], for example, with opposable decisions: in the French health system, clinical guidelines define what is forbidden in contrast to “command and control” regulations in the UK NHS, where guidelines define what must be done in defined clinical situations.
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Shifting from a disease-oriented paradigm to a clinical ‘goal-oriented’ paradigm, where therapeutic priorities are defined jointly by the doctor and the patient. Goal-oriented decision making is especially important in patients with multi-morbidity, where the multiplicity of problems to be solved and the potential contradictions existing between their solutions make considering ‘least worse’ scenarios inevitable [24].
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Promoting health services system-level thinking, leadership and management. For example patients’ utilization of health services ought to be planned; services should ensure that patients can access the referral structure; services ought to make certain that clinical information accompanies patients through their care journey and the decentralised use of medical technology and drugs should be optimised.
Health and research policies thus ought to recognise the essential difference between the industrial/commercial (generic) and the “bespoke” (or “custom-tailored”), professional/social management of health services:
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The former aims to standardize production processes, thanks to the intervention of high-level technicians, which allows the delegation of tasks to machines and low-skilled workers, and at the end of the day, savings and gains.
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The latter manages production processes as craftsmanship, by which each product care is unique by its eco-biopsychosocial characteristics and the possibility of being negotiated between the doctor and his patient. Such ‘bespoke’ management aims as a priority to improve the professionalism of caregivers, their intangible motivation to practice ethically, their knowledge and their personal development.
The industrial management of health services ought to be banned out of respect for the interpersonal nature of doctor-patient relationships, and the idiosyncrasy of professional development even if the quest for efficiency also features the ‘bespoke management’.
Medical heuristics: professional vs. scientific knowledge discovery
Professional knowledge aims to reduce uncertainty in decision-making, increase efficiency in action, relevance in evaluation; stimulate reflexivity; and require the practice to meet ethical standards. Heuristics is defined as any approach to problem solving, learning, or discovery employing a practical methodology that is not guaranteed to be optimal but sufficient for immediate objectives. The heuristic peculiarities of research aimed at discovering new professional knowledge in clinical medicine, public health and health care management distinguish professional medical research from scientific research. Sadly, the latter has completely supplanted the former [41].
Caring (and educating) are idiosyncratic, value-based, person-to-person processes that largely elude probabilistic methodologies. Biomedical sciences largely ignore the implementation of clinical decisions, which are only included within an articulated knowledge system such as (clinical) epidemiology, when the decisions studied can be standardised. For their part, social sciences reach their limits here: descriptive, interpretative methods cannot inform the quality of gestures and speech nor the management of the patient’s suffering and risks in what each of them are, in themselves, unique. Medical, professional research is normative in that it is intended to yield knowledge that is to be given as advice. Without intending to provide advice, the scientific data and descriptions that the researcher publishes offer only random guidance to the practitioner and their relevance is entirely dependent on the any similarities between the environment of the authors and the reader. Strategies are action models to improve clinical and public health practice. They are multi-resource and multi-stage in essence. Action learning and action-research are necessary to conceive, develop and lead them because their very complexity makes trial and error necessary. The validation of a strategy requires repeated experience and its reproducibility assumes a correlation of the environment, which is why the research must sufficiently describe it. To participate to medical action-research, the investigator needs professional proficiency – a requirement that is often difficult in academic settings.
Criteria to assess the relevance of publicly funded medical (clinical and public health) research can be derived from the differences identified between professionally - targeted, and scientific medical research. First, participatory action-research is a research methodology necessary to validate professional knowledge about medical, clinical or public health practice. To support such research, professional teaching methods entail, among other requisites, demonstrations, rotations and/or coaching. Then, with consequences for the development of academic careers and their knowledge content, professional experience ought to be treated as an essential pre-condition for researching clinical, management and public health practice. This is because researchers must be able to identify objectives relevant to professional practice and have sufficient professional credibility to introduce changes within their healthcare organization.
Health systems and policy research: objectives, methods and results in health care market evaluation
Since 1980, the commoditization of health care represents the paradigm of health systems reform. The impact of these reforms on healthcare and professional culture and status has been massive [42]:
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Commercialised medical practice follows the privatisation of health financing as insurers and banks take over the management of health services and remunerate physicians, because their profitability depends on the vertical integration of healthcare production lines.
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The commoditisation of health care and its financing reduces access to care, undermines professional ethics and care delivery, and increases mortality and morbidity amenable to care – and probably triggers international migrations [43]. For these reasons not only should commercial medical practice be banned but the appropriate regulation and control of private non-profit and government health services is needed.
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The presence and weight of commercial care financing in total health expenditure should be strictly limited. Publicly-managed health funding ought to be the general rule, as in Europe between 1945 and 2000. Failure to do so could create in HICs the dire health and economic consequences, and the instability that is already visible in most LMICs and in the USA.
Methodological insights for the international comparisons of health systems can be derived from a critical policy analysis. In order to produce knowledge on policies relevant to patients,
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Policy and health systems research needs to mobilise and generate the knowledge that is directly relevant to ethical medical practice and to publicly oriented, non-profit management.
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To study health policies, the methodologies ought to be qualitative/interpretative but include nested quantitative, probabilistic studies.
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They ought to be generally inductive: evaluations in health systems and populations, and public health analysis of clinical practice, care quality and accessibility all are prerequisites enabling the questioning of official, functionalist discourse and the study of the true determinants of public policies through the combined lenses of history, economics, sociology.
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Health systems research ought to be independent of industrial and foundation financing, because interference of vested interest is inevitable. Commercial actors who invest in foundations should not be both the judge of, and subsequently party to, any policy deliberation. Conflicts of interest are inevitable if researchers are asked to evaluate the parties that finance them.
Policies for professionally delivered healthcare as a human right
The mission of public policies, health systems and publicly-oriented health services ought to enforce the public’s inalienable right to access ethically, professionally delivered health care in universal health systems. To achieve such objectives, the political leverage of doctors and patients and, in general, of providers and citizen’s coalitions is decisive. However, such coalitions pre-suppose that both patients’ and physicians’ organisations make reciprocal, conceptual and material concessions. To clarify such negotiations, it is necessary to understand the contemporary health care political economy that threatens access to care and at the same time jeopardizes ethics, medical professionalism, and the physician’s social status. In any case, negotiators should rely on public health criteria to explore physicians’ and patients’ common and opposing interests in policies that support the human right to ethical, professional care [44].
For example,
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Physicians’ organisations naturally tend to promote their members’ income and autonomy. To successfully negotiate with patients’ associations, they ought to widen their concerns to include: the population’s access to quality healthcare, the nature of medical practice (professional or commercial), and the promotion of professionalism and medical ethics in healthcare services.
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Patients’ organisations and mutual aid societies (such as the Belgian and French sickness insurance funds) tend to defend access to care but overlook important quality of care issues. They should agree with physicians’ organisations that sufficient time needs to be allocated to consultations and the practitioners' administrative work be strictly limited. Because quality of care incorporates the physician’s ethical motivation, these organisations might easily be persuaded that professional autonomy and the physician’s facilitating role in inter-professional teams is essential to care excellence. Doctors’ remuneration ought to be of an acceptable level in public service; and non-clinical, medical activities (such as continuing medical education; audits and evaluation; coaching and technical supervision; team work; and clinical coordination) should be appropriately financed.
If individual and collective healthcare delivery is to be effective, clinical medicine and public health should be integrated in practice and theory. Health care commoditisation, financing and the emergence of artificial intelligence alter the historical mission of medicine and challenge the status of physicians and other health professionals, with major epidemiological and demographic implications. Self-interest jeopardises professional ethics. Rapid changes in the ecosystem can quickly make whole strands of medical knowledge obsolete. As a result, a weakened medical professionalism undermines the human right to good health care.