On Casuistry, Guidelines and Performance Measures

Malcolm Gladwell’s wonderful podcast – Revisionist History – has just focused 3 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 fo 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 measur...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs