How the postmodern ethos challenges medical professionalism

Postmodern cultural values have seriously impacted medical care and the patient-physician relationship. Corporate control of medical care, computerization of medical information and consumerism in the clinical encounter, plus the destruction of the myth of the physician are all embodiments of postmodern values.

Postmodern thinkers such as Foucault, Lyotard, Levinas, and Bauman offer powerful insights  that can be applied to understand how current values have changed medical practice, including issues such as electronic heath records, the patient-centered medical home, clinical practice guidelines, pay for performance, and other recent policy implementations.

The rise of governmental, quasi-governmental, and private organizations that exert computerized, bureaucratic control over medical practice and education challenge the essence of medical professionalism, as they divert authority from the physician to the institution. Bureaucratic implementation of quality measures, and connecting these measures to reimbursements, focus attention and reward on only a few easily measured parameters of quality of care.

As a result, more difficult aspects of quality of care are ignored. These include individualizing medical care for particular patient characteristics, making accurate diagnoses, and establishing meaningful rapport with patients. The development of clinical practice guidelines is a social phenomenon and is hence socially constructed, even if serious attempts are made to base them on available clinical evidence.

Empaneled experts reach decisions that are the product of social discourse that are inevitably subjected to power relationships that are often implicit.  Ignoring this aspect of decision making imperils the optimization of medical practice and deifies a set of rules that are often helpful for a majority but imperils outliers in patient populations.

Elsewhere I have detailed how applying the guidelines of the American College of Chest Physicians for atrial fibrillation to patients with end-stage renal disease may harm them through the use of warfarin that can contribute to the lethal condition of calciphylaxis.

There is a need to acknowledge the importance of clinical wisdom in addition to adherence to practice guidelines. The focus on profits in the health care industry needs to be examined and tempered, and clinicians need to reclaim some of the professional authority that has been ceded to remote, impersonal bureaucracies.

As I note in the epilogue of my book, The Ethos of Medicine in Postmodern America: Philosophical, Cultural, and Social Considerations:

The effort to preserve a humane professional identity for medical practitioners is essential to maintaining a worthwhile and effective ethos of medical practice in the 21st century. Impersonal bureaucratic rationality will never suffice to comfort the sick, ease their suffering, and heal their wounded spirits. The computer, the corporation, and the consumerist model will not accomplish that. We still need men and women to face the suffering of the sick and patiently, personally provide that comforting and healing in an inter-subjective fashion with compassion, expertise, knowledge, humility, and respect. We cannot permit the Silicon Cage to envelop medical practice and vanquish the human spirit from the clinical encounter.

Arnold R. Eiser is a professor of medicine, Drexel University College of Medicine, Philadelphia, PA, and author of The Ethos of Medicine in Postmodern America: Philosophical, Cultural, and Social Considerations.

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  • Peter Elias

    Discussing postmodernism is always challenging, because different people define it very differently. In fact, individuals often define it differently, depending on what they are discussing at a given moment.

    That said, I see two aspects of postmodernism and its impact on medicine that warrant recognition.

    First would be the rejection of Truth as a concrete, immutable, and scientifically ‘knowable’ entity that, once discovered, is universally valid for all people in all situations, potentially allowing those who (claim to) know the truth to determine what is right for (all) others. If modernist scientific realism is replaced by an understanding that our ability to identify Truth is limited both by our cognitive and technical tools, and by our existence within it, if we can remain humble about our ability to differentiate being right from wrong, and if we can understand that conscious ignorance (recognizing what we don’t know) is a better touchstone than knowledge, then postmodernism can be a very positive force, in medicine as in other domains. For example, it could protect us from the absurd notion that a group of self proclaimed experts can look at limited and flawed data and generate guidelines which are reliable enough to tell all clinicians how to treat all patients. (I call this medical totalitarianism by algorithmic overlords and see it as the core flaw of most current Quality Initiatives. This is why I prefer the term evidence-informed medicine to the term evidence-based medicine.)

    Second would be the danger inherent in abandoning the anchor of basic principles. If there is no discoverable Truth, then there may also be no universal human values, and there is no reason that corporate, political or financial power is wrong to impose their self serving values on humans.

    I certainly agree with this:

    “Impersonal bureaucratic rationality will never suffice to comfort the sick, ease their suffering, and heal their wounded spirits. The computer, the corporation, and the consumerist model will not accomplish that. We still need men and women to face the suffering of the sick and patiently, personally provide that comforting and healing in an inter-subjective fashion with compassion, expertise, knowledge, humility, and respect.”

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