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Medicine’s Crises

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Book cover The Virtuous Physician

Part of the book series: Philosophy and Medicine ((PHME,volume 114))

Abstract

In this chapter, I examine the quality-of-care and professionalism crises and conventional attempts, especially in terms of evidence-based and patient-centered medicine, to resolve them. In contrast to these attempts, I introduce the notion of virtuous physician and briefly explore its potential for addressing these crises.

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Notes

  1. 1.

    On average, the amount of money spent individually on healthcare in 2006 was over $7400.

  2. 2.

    David Weatherall also acknowledges a care crisis: “the art of medicine, in particular the ability of doctors to care for their patients as individuals, has been lost in a morass of expensive high-technology investigation and treatment…In short, modern scientific medicine is a failure” (1996, p. 17, emphasis added).

  3. 3.

    Philip Caper (1974) also acknowledged the “elusive” nature of quality-of-care and proposed objective standards for medical procedures to define it, especially standards established through clinical trials.

  4. 4.

    David Rutstein and colleagues proposed another widely recognized definition of quality medical care by defining quality as “the effect of care on the health of the individual and of the population,” where care pertains to “the application of all relevant medical knowledge” (Rutstein et al., 1976, p. 582).

  5. 5.

    Donabedian (1990) identified seven characteristics, or what he called pillars, that define the nature of quality-of-care. The first is efficacy, which represents the ability to affect a cure or to improve a patient’s wellbeing, while the second is effectiveness and involves the realization of a cure or an improvement of a patient’s wellbeing. The next is efficiency, which represents maximal treatment at minimal cost, while the next related characteristic is optimality and pertains to optimal balancing of risks and benefits. Two subsequent characteristics are acceptability, representing patient’s approval of medical goals, and legitimacy, involving society’s sanction of those goals. The final characteristic is equity or fair distribution of medical care.

  6. 6.

    In utter frustration with the healthcare community’s efforts to define quality-of-care precisely or even adequately, Caper (1988) declared a ban on the word quality from discussions on assessing healthcare. In its place, he proposed a pragmatic approach in which interested parties simply measured the “components” of care, such as efficacy and appropriateness.

  7. 7.

    For a summary statement of the IOM report, see Lohr and Harris-Wehling (1991).

  8. 8.

    For a conceptual analysis of quality healthcare definitions, see Harteloh (2003).

  9. 9.

    See also Campbell et al. (2000) for further discussion of the interpersonal dimension of quality medical care.

  10. 10.

    Caper also envisions a unified notion of quality healthcare: “In medical care, its objective [technical] and subjective [interpersonal] characteristics are woven into a single fabric” (1974, p. 1137).

  11. 11.

    Professionalism, along with evidence based medicine and patient safety, is part of a quality-of-care movement in modern medicine (Hafferty and Levinson, 2008).

  12. 12.

    Holly Humphrey (2008) notes that over 1500 articles appeared in the literature during the six years intervening from the founding of the Medical Professionalism Project to her introductory essay for the Perspectives in Biology and Medicine special issue on professionalism.

  13. 13.

    Frederic Hafferty and Dana Levinson (2008) identify such efforts to address professionalism in the practice of medicine by professional communities as the fourth wave of medicine’s professionalism movement. The first three waves include the emergence of professionalism as an issue vis-à-vis challenges such as the commercialization of medicine, attempts to define professionalism, and efforts to measure it.

  14. 14.

    The charter also appeared in the May issue of the European Journal of Internal Medicine.

  15. 15.

    In commentary on the charter, Laine Ross (2006) points out that the charter’s framers marginalized the patient by shifting from a principle of respect for persons to respect for patient autonomy.

  16. 16.

    Hafferty and Levinson (2008) identify such efforts as the fifth wave of medicine’s professionalism movement.

  17. 17.

    Hafferty and Levinson (2008) denote this systems approach as the sixth wave of medicine’s professionalism movement.

  18. 18.

    Importantly, Hafferty and Levinson (2008) argue that medical educators cannot successfully change the current hidden curriculum, with its negative impact on professionalism, without changes to both the formal and informal levels of the medical curriculum.

  19. 19.

    Commentators also debate the proper philosophical framework for articulating EBM. For example, W.V. Quine and Larry Laudan’s philosophy of science represent competing frameworks (Kulkarni, 2005; Sehon and Stanley, 2003).

  20. 20.

    Porzsolt and colleagues identify an additional step after the first step: attempting to answer the clinical question(s) based on a clinician’s current level knowledge or experience (Porzsolt et al., 2003). This additional step helps the clinician to identify how best to incorporate EBM into a patient’s care.

  21. 21.

    For philosophical basis of and issues facing EBM, see Goldenberg (2006), Guyatt and Busse (2006), Howick (2011), and Sehon and Stanley (2003).

  22. 22.

    Although EBM proponents claim they welcome criticism in order to advance EBM’s application to the practice of medicine, opponents claim they are often ignored or marginalized from the discussion (Buetow et al., 2006; Miles and Loughlin, 2006).

  23. 23.

    The general practitioner presented the case study at a Balint group meeting. After he reported the first consultation and the enormity of the patient’s problems, the consensus among the physicians was that the patient simply had too much history to resolve the case in a timely fashion.

  24. 24.

    The challenges facing PCCM pedagogy reflect the criticisms and misconceptions of PCCM (Weston and Brown, 2003c).

  25. 25.

    Robbie Davis-Floyd and Gloria St. John (1998) also advocate a transformative journey for physicians from technico-scientific doctors to holistic healers.

  26. 26.

    The nature or definition of medical humanities is a rather debatable point in the literature (Campo, 2005).

  27. 27.

    William Stempsey (1999) cautions that medical humanities course must provide the conditions for the development of medical students’ critical skills to assess the values that shape medical practice. In addition, Joanna Rogers (1995) warns that medical humanities should apply not simply to physicians and medical school education but to all healthcare providers and their education.

  28. 28.

    Recently, however, Vliet Vlieland (2007) also acknowledges EBM is a possible direction for treating patients with chronic diseases. Moreover, Edward Wagner and colleagues claim that a combination of EBM and PCM is the way to proceed in terms of treating chronically ill patients (Wagner et al., 2005).

  29. 29.

    An intermediate position of the continuum model or the iterative process of the cyclical model also represents EBPCC.

  30. 30.

    Patient’s values and preferences are part of EBM’s evolution (Montori and Guyatt, 2008, p. 1815).

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  1. Dept. Philosophy, Baylor University, One Bear Place #97273, Waco, Texas, 76798, USA

    Dr. James A. Marcum

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© 2012 Springer Science+Business Media B.V.

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Marcum, J.A. (2012). Medicine’s Crises. In: The Virtuous Physician. Philosophy and Medicine(), vol 114. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-2706-9_1

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