The Global Outcomes Movement: Is it Compatible with Medicine?

 

Editor's Note: Parallel Paper Presentation from CBHD's 2009 Annual Conference, Global Bioethics: Emerging Challenges Facing Human Dignity

 

Abstract: Over the last twenty years, the so-called outcomes movement has come to dominate the health-care industry in all developed and many developing countries. The outcomes movement refers broadly to an approach which focuses on health-care or educational outcomes—outcomes which are measurable endpoints, and which can be evaluated in aggregate, using statistics. The healing process itself is viewed as a black box, containing too many variables for explanation and analysis. What is of interest are measurable inputs and outputs only. Offshoots of the outcomes movement, such as evidence-based medicine (EBM) and competency-based medical education, are so ubiquitous that it is no longer possible to read a medical journal, sit in a medical school classroom, or read a hospital document without encountering these terms. This approach to health care is radically opposed to the traditional practice of Hippocratic medicine, for two reasons. First, the outcomes movement privileges “objective” statistical knowledge over the individualized phronetic knowledge employed by physicians, and discounts the individual patient and the physician-patient relationship.

This approach also ignores a large body of literature in cognitive science and expertise and represents a fundamental misunderstanding of the practice of medicine. For example, it is well-known that human expertise cannot be captured or contained within a set of heuristic rules. Second, the world view which undergirds the outcomes movement is strongly positivistic and behaviorist. There is no place within it for Hippocratic friendship, the narrative of illness, or humanity.

We will look at these two characteristics, the claim to objectivity and the scientistic turn, by examining competency-based medical education in some detail. The effects of this now-mandated system on the medical profession will be discussed.

 

Suggested reading:

ACGME Outcome Project, at http://www.acgme.org/Outcome/

Brooks, M.A. (2009) Medical Education and the Tyranny of Competency. Perspectives in Biology and Medicine 52:90–102.

Tanenbaum, S.J. (1999) Evidence and Expertise: The Challenge of the Outcomes Movement to Medical Professionalism. Academic Medicine 74:757–763.

 

Podcast Episode: 
125