Blog | Monday, August 26, 2019

On casuistry, guidelines and performance measures


Malcolm Gladwell's wonderful podcast “Revisionist History” has just focused three episodes on the Jesuits and their use of casuistry. I was not familiar with the term, so here is one definition:

Casuistry is a resolving of specific cases of conscience, duty, or conduct through interpretation of ethical principles or religious doctrine.

As I listened to these episodes, of course I pondered what this means for medicine. Perhaps I have massaged the idea beyond recognition, but the podcasts did stimulate these thoughts.

The intent of guidelines (at least I think) is to provide a general approach to a medical situation. General approaches have great use, but they do not address the particulars. The excellent physician should have an understanding of the particulars. The particulars are the context of the patient, their social determinants, their other diseases, their health care desires, etc.

As insurers and administrators try to use performance measures to evaluate physicians, they miss the particulars. We care for patients with diabetes or coronary artery disease or no obvious disease. We do not care for a blood glucose or a lipid level or a blood pressure. We have a moral and ethical responsibility to help the patient make the best decisions about their health care now and in the future.

The idea behind guidelines and performance measures makes assumptions that ignore the particulars. We cannot assess a physician with simple measures, because our patients are not simple. We do not treat a simple mechanical construct, rather we interact with complex organic patients.

Used properly, guidelines can help us understand the evidence for testing or treating a particular situation, but they should not dictate our course of action. We must consider each patient's particulars.

Such a course leads to inconsistencies. We always have difficulty determining whether a patient has received the best treatment. The details (particulars) often drive us to treat the exact same situation differently in different patients.

I think we have a responsibility to our patients to develop the wisdom to give them highly individualized care. Measuring that care is complex. Some measures can help guide us, but we should use them carefully. Assuming that adherence to measures developed by well-meaning committees defines good physicians seems to over simplify the physician's role.

As Einstein did not say, “Not everything that counts can be counted.”

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.