Harry Freeman
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My concern with clinical pathways is that at this point in time there is absolutely no evidence that they help patients. Certainly evidence is hard to get but since we are now in a climate where evidence is important, it's ironic that clinical pathways simply have to exist rather than have some accountability beyond that.
Pathways are a set of rules that imply the importance of a systematic approach to healing but the system is applied only to procedures rather than to the quality of the relationship between the healer and the patient. The focus worries me.
These procedures are most evident in the United States which is now acknowledged as having some of the biggest problems in healthcare. The most budget expansion and the most obvious inequities. They were introduced to the high cost parts of the system and they are not working, so why transpose them to Australia?.
This change of focus in healing away from the human aspects of it is also happening at university and in other parts of medical training. The Institute of Psychiatry will be using CD Roms in the first year of psychiatric training rather than lectures and tutorials from the year 2000. This is only drawing us away from an acknowledgement of therapist characteristics in healing since I can't believe that computerised learning could create compassionate healers.
Clinical pathways are also playing into the litigation spiral so that every step in a pathway must happen or negligence is presumed to have occurred. Practice driven by a fear of litigation is just going further down the road of mistrust that now increasingly pervades the healing relationship.
I feel that unless there is a sense of gratitude in the person who is being healed - gratitude to the healer, gratitude for the opportunity to examine yourself in a difficult situation - then the healing process itself is naked and bare and unsupported by the essential juice that a person needs to heal.
That sense of gratitude also needs to be marinaded with a sense of privilege in the healer. I don't believe clinical pathways are likely to make doctors feel privileged to be part of the healing process. They are indeed removed from the gratifying elements in the practice of medicine. Clinical pathways can only breed mistrust and increase the feelings of alienation between doctors and patients.
Harry Freeman is a psychiatrist and the director of the Community Mental Health Team at the Richmond Clinic in Lismore.
Discussion
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Clinical Pathways - breeding mistrust |
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Clinical Pathways - breeding mistrust patty willliamson, dewwmsn@aol.com Posted 6/9/2000 3:39 AM I agree. Kris Vanhaecht, kris.vanhaecht@med.kuleuven.ac.be Posted 5/12/2000 12:38 AM Dear Dr. Freeman and Mrs Williamson, When I read your article (and discussion) on clinical pathways, I need to make some remarks. It is 100% correct that there are not a lot of surveys on clinical paths that are evidence-based. But I am sure clinical paths can help to build a patient focussed hospital or a patient focussed team. At the moment we co-ordinate a clinical pathway network within Belgium and the Netherlands (17 hospitals). We are using clinical paths as a patient focussed multidisciplinary care plan with the main focus on quality. I know in the USA they use them for cost reduction. I think we need to focus on the quality of care and not on the procedures itself. Pathways must help us in improving patient care by using them to pilot care (planning and follow up). I do not believe that clinical paths will guide us towards cookbook medicine but will help teams to make plans and do outcome measurement for specific patient populations. Not for all patients but only for predictable patient groups. Pathways will (and are in belgium) helping doctors and nurses to build teams and to help them to work in the same direction, with the same goals. The team itself must make the pathway and working on (developing) the pathway is more important than any other phase in such a project. That is why I do not believe in buying pathways or using pathways developed in other hospitals. The problem with clinical paths in psychiatry is the timeline problem. As you know most of the pathways are day by day plans but that wont work in psychiatry. We will not use a timeline (time-task matrix) but a goalline. When we discuss pathways with psychiatrists they are not able to define the timeline but they know which goal they need to focus on first. So for psychiatry (and also for some rehabilition programmes) we will use a goal-task matrix. As a PhD student (Catholic University Leuven, Belgium) I am preparing a PhD project on pathways. It will be a multicenter study. For specific patient populations the pathways will be different but the outcome indicators (value compass: outcome , service, process and cost) will be the same for the different hospitals. In this way we will be able to do systematic reviews on the data and will not have the problem of small samples. I hope that we will be able to prove that clinical pathways are tools that can help to improve patient care. Best regards, Kris Vanhaecht tel: 0032 16 336971 |
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