close

Вход

Забыли?

вход по аккаунту

?

j.xjep.2017.09.005

код для вставкиСкачать
Journal of Interprofessional Education & Practice 9 (2017) 115e120
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice
journal homepage: http://www.jieponline.com
The aristotelian ethics of collaborative care
a b s t r a c t
Keywords:
Interdisciplinary care
Collaborative care
Health care ethics
Collaborative care is common among health care practitioners, serving multiple benefits for the patients.
Clinical procedures are in place to serve as a checklist, ensuring that the proper means of treatment is
provided. This essay details an Aristotelian ethics that defines teleology, that which achieves the final
good. In the sense of the patient's telos, the rehabilitation clinician should be viewed as a co-laborer in
working towards this end, rather than a means showing that a process was followed. This distinction is
important when determining the optimal care for the patient. The works of Aristotelian ethicists Edmund
Pellegrino and Alysdair MacIntyre are introduced in describing teleology, science, art, virtue, and practice. Two cases are presented that show how, in current practice, collaborative care is used differently in
achieving the final good as defined by the patient. Finally, the model of International Classification of
Functioning, Disease, and Disability (ICF) distinguishes how the viewpoint of physicians can differ from
that of rehabilitation clinicians.
© 2017 Elsevier Inc. All rights reserved.
1. Introduction
Health care practitioners are taught, as part of their school
training, the concept of interprofessional practice. This training includes values and ethics, roles and responsibilities of all providers,
interprofessional communication, and the composition of health
care teams.1 The preparation is designed to improve the quality
of the delivery of health care to the patient when implemented in
both inpatient and outpatient settings. The thought process behind
such a delivery of health care is to introduce various experts and
points of view in treatment of patients. While introducing other
disciplines to collaborate on the plan of care for a patient seems
intuitive, it is not practiced in all clinical settings as students in
health care would expect it to be based on the stress it is given in
academia.
With the intention of treating the impairment, the practitioner
(whether it is the physician, pharmacist, or physical therapist)
has the patient's overall health and function in mind. However,
the mode of treatment in the United States generally aims towards
following the proper means in treatment. This rationalist approach
to treatment emphasizes what should be done with a population of
patients with a particular diagnosis or clinical presentation. This is
similar to the scientific process the physician reads in medical journals. What is a reasonable treatment for a patient with a specific
diagnosis? This methodology is evident in the way many physicians
manage, for instance, the care of a patient with mechanical pain.
The approach typically follows a methodical pattern where the
treatment options begin with the least invasive option (e.g., oral
medication or a referral to physical therapy). Gradually, the patient
will receive more aggressive treatments (injections or surgery) if
the previous ones are unsuccessful.
Conversely, an empirical approach focuses on the patient as an
https://doi.org/10.1016/j.xjep.2017.09.005
2405-4526/© 2017 Elsevier Inc. All rights reserved.
individual with a particular set of values and characteristics that influence decision-making. It is the goal of this paper to argue for the
inclusion of rehabilitation clinicians in treatment of patients not
simply as a means, but rather as a collaborator in attaining the
good of the patient. In doing so, I will be referring to Aristotle's teleology with the patient as the one to define the good life, drawing on
Edmund Pellegrino's explanation of medicine and Alysdair MacIntyre's definition of practice. This will help the reader understand
how the patient's understanding of the good life should enter the
conversation in treating a patient, and how a clinician whose specialty is rehabilitation of the body can be used efficiently in
restoring the patient to that good life. In addition, I will be referring
to several cases throughout the paper to introduce scenarios of
where collaborative care currently works well and seems to
address this telos, as well as instances where opportunities exist.
This change in the mindset of how rehabilitation professionals
should be consulted will assist the physician, and the patient, in
moving closer to the patient's telos.
2. Background
Collaborative care, also termed interprofessional or interdisciplinary practice, is not new to the medical community. It involves
health care providers working collectively as a team to provide
care to the patient. Benefits are believed to include, among others,
increased efficiency, improved patient satisfaction, and better outcomes.2 In discussing a case regarding a medical student placed
with a midwife as part of his educational training, Burcher points
to the issue raised by the student that he was trained to be a physician and not a midwife. Burcher argues that it is an obligation of the
medical educators to incorporate interdisciplinary training into the
educational setting.3 In doing so, each clinician learns what
116
M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120
foundational knowledge other practitioners can bring to the table.
Health care organizations (e.g., hospitals and clinics) implement
policies and procedures that incorporate the use of collaborative
care in treatment for patients. Clinical pathways are sometimes
implemented as guidelines to standardize care with the hope of
improving overall outcomes for an organization. Such protocols,
when implemented from the outset, involve other disciplines as a
sort of checklist to ensure a thorough approach. For example,
when a patient is admitted to a hospital with generalized weakness, the protocol for the admitting physician may entail a referral
to physical therapy to address this weakness. In doing so, the therapist and physician will exchange clinical opinions regarding the
patient.
This process of referring according to previously set clinical
guidelines lends itself to a procedure where the rehabilitation clinician is seen as a means rather than an end. To use the generalized
weakness example, the referral to physical therapy is similar to that
of a referral for imaging studies or for oral medication, where the
physician follows a rational approach by following a set of rules
for what is typically done with a particular presentation. I will
now present Aristotle's version of the good and its relation not
only to the patient, but to the health care provider and to the relationships that result.
3. Telos
In describing his ethics, Aristotle details what leads to a good
and virtuous life by man. The final end, he says, is a state of perfect
happiness and this happiness is part of the intellect. This happiness
and intellect not only separate us from animals, but it is also what
we share with the divine. Achieving this telos of happiness involves
intrinsic virtues that Aristotle lists extensively, emphasizing the
mean between excess and deficiency.4
Applied to health care, the telos of the patient is something that
is intrinsic and unique to each patient. The health of the patient
contributes to this final end. The patient recognizes this telos in
everyday function. When a patient seeks medical care, it is
frequently because hea notices a decline in function, or a loss in
his health status. Upon seeking medical care, the physician will
evaluate the patient in order to determine a diagnosis. This evaluation partly includes a subjective examination where the physician
gathers relevant information to determine symptoms that relate to
the person's problem. However, in this conversation, the physician
must also determine what is good for the patient. The remainder of
the evaluation involves a more objective assessment, where data is
collected then correlated to the patient's subjective report. This correlation results in a plan for the patient that involves restoring the
patient's health, at least to some degree. Since the patient is the
instigator of this conversation, and the primary focus, the patient
must be the one involved not just in consenting to treat, but also
in the conversation of how his function should be restored. It is
with the purpose of achieving the aforementioned telos through
the intellect that the patient and physician must be focused. The
expertise of the physician can help the patient in ascertaining
whether or not function can be fully restored and to what extent.
Understanding a patient's view of the good is arguably challenging for a practitioner to achieve in the course of one office visit.
Emanuel and Emanuel detail four models in the physician-patient
a
For consistency to the paper, the patient will be referred to as male, and the
health care practitioner as female.
relationship: paternalistic, informative, interpretive, and deliberative. While allowing for certain scenarios where each model may
be appropriate (e.g., a patient unable to give consent would enter
into a paternalistic relationship with the physician), the authors
explain that the deliberative model is the optimal relationship insofar as it allows the physician to help the patient choose the appropriate treatment based on his health-related values. In this model,
the “physician must delineate information on the patient's clinical
situation and then help elucidate the types of values embodied in
the available options”.5 The relevance of the relationship is important to mention at this point since the physician's understanding of
the patient's values will allow the physician to recommend the
treatment most aligned with the patient's original goal for seeking
treatment.
This article has two shortcomings that should be mentioned
here. Emanuel and Emanuel note that specialization is a threat to
the deliberative model. They see that some physicians, only seeing
a patient once, may choose an informative relationship with the patient. In this model, the physician gives facts pertaining to the patient's medical condition. He, in turn, must choose the best
treatment option according to his value system, regardless of the
physician's set of values. Where the authors fall short is in the inclusion of other professions in the patient's care at this point that can
better understand the patient's values and move him closer to his
telos. It must be noted, though, that the nature of health care, specifically the rehabilitation sciences, is vastly different in the current
system than it was at the time of publication. Diversity of professions and specialization has changed the context in which these relationships occur.
Second, Emanuel and Emanuel do not mention whether the patient and physician agree on the relationship. Without consent as to
which relationship is optimal given a particular situation, the two
parties may understand differing models of the relationship. For
instance, an older patient who sees a physician as the sage may
take the relationship as a paternalistic one; whereas, the physician
who is more of a learned bioethicist may choose to enter a conversation with the patient regarding his health related values. This
conflict will likely hinder the construal of the health care provider
as she moves closer to understanding the patient's version of the
good.
Similarly, the patient may have a perspective of a virtue that is
unlike the perspective of that same virtue by the physician. The authors do mention that patients frequently select physicians based
on virtues that are similar. Yet, those virtues, as they shape the telos
of the patient, may change based on the patient's condition (e.g., a
patient who suffers a serious injury and has unrealistic expectations of his outcome). The deliberative model mitigates this in a
provider who “integrates the information and relevant values to
make a recommendation and, through discussion, attempts to
persuade the patient to accept this recommendation as the intervention that best promotes his or her overall well-being”.5 Taken
out of context, this citation seems like coercion; however, it includes an understanding of the patient's values and allows the provider to incorporate not only the scientific knowledge, but the skill
of diagnosing and establishing a prognosis. This “art” of medicine
will now be discussed.
In defining the form of medicine, Pellegrino focuses on the end
when it comes to the physician-patient relationship. An interruption in function of the patient results in “a deviation of one's
concept of well-being, a value-laden concept including social function, identity, and interpersonal relationship”.6 The goal of treatment is to move towards the end as defined by the patient and
understood by the physician. This treatment not only involves
treatment of the biological problem with a physical remedy, but
also includes the personal restoration of the patient to an
M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120
acceptable good. This will be discussed later with his description of
medicine as a science, art, and virtue.
For this purpose, the inclusion of physical rehabilitation professionsb seems appropriate in helping the patient's restoration of the
telos. To define these licensed health care professions:
physical therapists are defined as “health care professionals who
can help patients reduce pain and improve or restore mobility”;7
speech-language pathologists “assess, diagnose, and treat
speech,
language,
social
communication,
cognitivecommunication, and swallowing disorders”;8
and occupational therapy is a profession “concerned with promoting health and well-being through occupation. The primary
goal of occupational therapy is to enable people to participate in
the activities of everyday life”.9
From the definitions of these professions that includes terms
such as “mobility”, “cognitive-communication”, and “occupation”,
it is reasonable to say that these professions should frequently be
involved in addressing the telos of the patient. The patient understands his decline in health as a change in function. Through an
extensive evaluation, these professionals, similar to a physician,
include a thorough review of the patient's history. However, the difference would lie in the emphasis on the function of the patient.
The subjective report informs what objective tests and measures
to assess. The nature of the patient's symptoms, for example, in a
24-hour period is reviewed by physical therapists. This will determine what movements and postures to assess. The limitations of
a patient at work will allow an occupational therapist to adapt
his work environment to suit his posture. In a process similar to
that employed by the physician, the clinician will explain how relevant findings correlate with the subjective presentation. Finally, it is
with interaction between the clinician and the patient that goals
are set with timelines.
A valuable difference between the physician and these professions is the frequency of interaction. Whether in an inpatient or
outpatient setting, a patient may be seen weekly, sometimes daily.
While Emanuel and Emanuel did not mention the length of their
four relationships, it can be reasonably assumed that one meeting
between two people for less than an hour would not be ideal for
communicating one's virtues and vision of the good. As a rehabilitation clinician has more frequent meetings with a patient, the patient's version of the good is better understood and matched with
clinical findings. Throughout the course of treatment, the rehabilitation clinician can collaborate with the physician not only to
compare findings and scientific knowledge of the disease,c but
also to become co-laborers in working towards restoring function
of the patient.
In describing the clinical judgment of physicians, Pellegrino refers to the diagnosis, prognosis, and therapy. While he seems to
refer to “therapy” as any treatment, he says, when considering
the therapeutic process, the patient should be perceived as a “lived
body … that experience of our body which cannot be objectified”.6
This is contrasted with the living body, which he equates with simply being alive. For these rehabilitation professionals to focus on the
patient not merely as a diagnosis, but as an individual who only experiences a disease that affects function, the therapeutic process
b
While the list is not exhaustive, physical rehabilitation in this paper will include
the disciplines of physical therapy, occupational therapy, and speech and language
pathology. These are the most commonly found specialties for rehabilitation in hospitals in the United States.
c
Here, “disease” can refer to any pathology or ailment that affects a patient's
health.
117
bridges the biological living body with the functional lived body.
This increased frequency along with the collaboration of professionals expands the opportunity of the providers' ability to discover
the relationships “between the causes of health and disease and the
effects of these causes on individuals”.6
4. Science, art, virtue
In Pellegrino's essay entitled “Anatomy of Clinical Judgment” in
the same text, he examines further the challenge confronted in
medicine with choosing the appropriate action for treatment. Naturally, with the extensive training, health care practitioners have
knowledge of the science of medicine regarding the structure and
its function. In applying this knowledge to a particular patient,
the physician knows that certain subjective and objective findings
correlate to a particular diagnosis. A physical therapist knows
that most patients who lack motion in a certain direction respond
favorably to manual therapy of a particular kind. In this manner,
medicinedand health care, in generaldcan be seen as a science.
This science, while taking a rational, methodical approach in
constantly seeking the right answer with a high level of certitude,
must still be oriented towards the end as defined by the patient.
This variability of the patients' characteristics is a distinguishing
feature of health care when comparing it to a physical science.
In addition to being a science, Pellegrino also claims medicine is
an art in which skills are needed to make clinical decisions. Aristotle
defines art in book VI of Nicomachean Ethics as “a disposition tending to produce with true reason that which may or may not be”.4 He
makes a point to label art as a “production” and not an “action.” An
art produces by “bringing something into existence”.4 To relate this
to health care, a provider has a practical end that is specific to each
patient. In applying the scientific knowledge mentioned previously,
the practitioner needs a particular set of skills to make clinical decisions in order to move this patient closer to restoring his health.
This is what separates, say, a physician treating someone with
nausea and vomiting from a layperson who has read a textbook
on the gastrointestinal system and is giving advice. A physician decides what medical tests and imaging to order. She also determines
that a patient needing medication needs a pharmacist, or a patient
with difficulty swallowing may need a speech-language pathologist. The speech-language pathologist, in turn, must make the decision of when to recommend the patient to begin swallowing foods
of certain consistency.
This distinction of art as a production and not an action is where
the good in the Aristotelian sense of medicine seems to vary from
the good, or beneficence, described by Beauchamp and Childress.
By defining beneficence as “an action to benefit others”,10 their simple version of doing good towards the patient does not take into account the complexity of the values that the patient brings to the
table. These values and habits shape the teleology of the patient,
a final good towards which all action of the medical provider
must aim. This distinction can be explained by a patient diagnosed
with cancer being recommended different treatments from two
separate oncologists. While one treatment may be seen as more
aggressive than the other, both aim to do good by benefiting the patient. With the viewpoint of medicine as an action, either form of
treatment is aiming to do good for the patient by either selecting
a more aggressive form of treatment for eradication, or a less
aggressive option to focus on patient comfort. From the standpoint
of this art as a production, the physician must bring something into
existence; in this case, restoring health of the patient and achieving
the telos as the patient knows it to be. Skills are needed by the
physician in order to make sound clinical judgments. These skills
include, among other things, communication with the patient and
collaboration with other practitioners with whom the patient has
M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120
118
had interaction.
Medicine also is a virtue in order to “heal a particular whose
good is the true end of the whole activity”.6 This Aristotelian
view of virtue blends with the purpose of medicine as acting towards the good of the patient. Using the oncology example in the
last paragraph, the virtuous side of medicine is manifested in the
actual interaction with other professionals and the decisionmaking that follows. Enabling the right therapy for the right patient
at the right time involves not only a skill, but also a virtue to ensure
that the right end is produced.
5. Practice and virtue
Now that I have introduced an Aristotelian sense of virtue as Pellegrino defined medicine as a science, an art, and a virtue, I will
explore this concept of virtue with another Aristotelian, that of
MacIntyre. In order to unpack his interpretation of virtue, it is
imperative to appreciate his definition of practice. Practice is
“any coherent and complex form of socially established cooperative human activity through which goods internal to that
form of activity are realized in the course of trying to achieve
those standards of excellence which are appropriate to, and
partially definitive of, that form of activity, with the result that
human powers to achieve excellence, and human conceptions of
the ends and goods involved, are systematically extended”.11
Let us examine this definition in the context of health care. This
complex social activity of practice begins with a “cooperative human activity,” the interaction of the patient and the provider. Not
only is this a human activity, but it also requires a certain level of
cooperation where expectations by each party seem congruent, to
improve the health of the patient. There are standards of excellence
in the medical community, frequently seen as restoration of the patient to a healthier state. Finally, the internal goods to the practice
of health care is that which cannot be monetized, but can only be
“recognized by the experience of participating in the practice in
question”.11 Mention of the internal goods as part of the practice
adds an intrinsic quality that is greater than the sum of its parts.
This is what differentiates a musician practicing his trade from a
novice picking up an instrument for the first time. In medicine,
this distinguishes a physician making a diagnosis, prognosis, and
prescribing therapy from someone reading a textbook and determining appropriate treatment.
This description of practice is similar to Aristotle's view of a production and how it differs from just an action. This practice is more
than just a set of skills. It is a using these skills to achieve an end.
Collaborative care can be seen as such a practice, with the name
alone hinting at a human cooperation.d The aim of this interdisciplinary care is to achieve excellence, which is the human conception of the end. The patient is the source of this telos, and should
be involved in this human cooperation for the practice to reach
its standard of excellence.
Then, the discussion must be had as to what is the internal good
that is attained with collaborative care and can it be achieved by a
group rather than by an individual. The first part can be answered
in the power of the group. In treating a patient, each practitionerdthe physician, the physical therapist, the occupational therapist, and the speech-language pathologistdhas an understanding
of what the patient's final good is. In isolation, the practitioner
will work towards improving her understanding of this good and
d
The word “collaborate” is derived from the Latin verb collaborare, literally
meaning “to labor together” (www.merriam-webster.com/dictionary/collaborate).
aim treatment towards it. As a group, however, the professionals
will collaborate with each other to better understand the end and
good involved. Each practitioner's relationship with the patient
can bring a new construal of the telos towards which they are moving. A characteristic of the achievement of this internal good is “a
good for the whole community who participate in the practice”.11
MacIntyre incorporates this into his definition of virtue, which is
“an acquired human quality the possession and exercise of which
tends to enable us to achieve those goods which are internal to
practices and the lack of which effectively prevents us from
achieving any such goods”.11 Building on his description of practice,
he details how technical skills are needed for a virtue, which someone can “acquire” through training. Yet, the understanding of the
internal good must be present as well. This description of virtue
and integration of practice is complementary to Pellegrino's
description of medicine as a virtue. It is “acquired” through both
formal and informal training of the provider, allowing the internal
good of health care to be realized. This applies to both the practice
of health care by an individual and to practice of health care by a
group.
6. Cases
Next, I will apply these concepts of Aristotle's teleology, Pellegrino's medicine, and MacIntyre's practice to two drastically different
cases. The former will show where collaborative care is provided,
whether intentionally or not, with an Aristotelian approach. The
latter will present an opportunity for interprofessional care earlier
in the process, with the hopes of streamlining care by incorporating
rehabilitation professionals as a collaborator.
6.1. Case 1 e Mr. S
Mr. S is a 72 year old R-hand dominant patient who is seen by a
neurologist on an outpatient basis following discharge from a hospital for an acute ischemic cerebrovascular accident (CVA). Mr. S is
married to an independent 67-year old partner, and they live in a 2
story house with the bedroom on the first level. He has a bathtub
with an overhead shower. He reports difficulty bathing, feeding
himself, and accommodating stairs but denies difficulty swallowing
or with his memory (this is confirmed with his spouse). He also denies pain or dizziness, but mentions he does occasionally feel
“light-headed.” He feels “winded” with walking around the house.
His past medical history includes hypertension and tobacco use,
although he claims to have quit smoking “years ago.” The patient
mentions he has a goal of wanting to walk the neighborhood
with his wife and to attend his grandkids' athletic events.
This R-sided CVA left him with L-sided hemiparesis of the upper
and lower extremities. His examination shows independent use of a
R hemi-walker, and his vitals are as follows:
Blood pressure: 144/88
Pulse: 86 beats per minute
Respiratory rate: 15 breaths/minute
O2 sats: 97%
In addition to medical management of his medications for
continued control of his hypertension, the physician refers Mr. S
to physical therapy and occupational therapy. The physician asks
the patient to return to the doctor's office in 2 months. Upon evaluation, the physical therapist reports back to the physician that she
will be addressing Mr. S's dependent gait, endurance with walking,
and transfers from the bed and chair. The occupational therapist intends on addressing his ability to bathe and feed himself, as well as
other activities of daily living that she notices could be done more
M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120
efficiently to minimize his fatigue.
After every 2 weeks of treatment, the therapists collaborate in
person with each other and with the physician in order to understand the patient's constantly changing goals. At the first such
meeting, it is relayed that the patient has updated goals to play
bocce with his friends, and to begin a regular fitness program at a
local gym to reduce the risk factors associated with CVA occurrence.
6.2. Case 2 e Mr. L
Mr. L is a 45 year old with reports of low back pain that has been
present for three months. This pain is worse with prolonged sitting
and is present with certain movements, such as bending forward to
put on his shoes. His past medical history is unremarkable for prior
back pain. He denies any radicular symptoms or any numbness or
tingling. The patient wishes to get dressed and sit at work without
pain. This is the second visit to see the physician, who initially prescribed him a non-steroidal anti-inflammatory oral medication one
month ago. The patient reports no change in symptoms since the
last visit. The physician refers the patient to physical therapy and
explains that if therapy is not successful, she will order further imaging to be done.
Following three weeks of treatment by a physical therapist, the
patient returns with a mild improvement in symptoms and that he
is now able to put on his shoes without pain, and his pain with
sitting at work is slower in onset. The therapist has communicated
electronically with the physician via a progress note to detail what
treatment has been provided and the progress made towards functional goals. The physician notices an updated goal of the patient
being able to play basketball again, something that was previously
unknown to her. At this point, the physician must make a decision
on how to judge the success of the rehabilitation of the patient thus
far. She must decide whether to advise the patient to continue with
therapy or to order further imaging tests to determine the source of
pain.
6.3. Case analyses
These cases present two distinctly different patient presentations and different approaches in decision-making. The first case
considers a health care team who collaborates on a regular basis
with the rehabilitation team. In order to determine the good of
the patient, each provider gets input at different points in care by
communicating with the patient. As the level of function for that
patient changes, so too can the patient's understanding of an attainable telos. For a patient suffering a devastating CVA, the end goal for
Mr. S was to casually walk the neighborhood and attend sporting
events. As his condition improved, the telos was redefined to a
more active state. This was with the guidance of a rehabilitation
team who saw him more frequently and developed a closer relationship. The deliberative model was used to interpret the patient's
health related values.
Also, this case shows the art of collaborative care. By working
together towards the good, the practitioners come closer to
bringing health into existence. In doing so, the power of the group
(an intrinsic good of interdisciplinary care) is realized.
The case of Mr. L shows a more rational utilization of rehabilitation by the physician. In what is sometimes typical to a patient presenting with mechanical pain, the selection of treatments will
follow a methodical approach. In this case, that is seen in the order
of oral medication, physical therapy, and imaging. The level of
communication here is not the “complex form” of a human activity
that is expected by professional collaboration. Rather, it is a oneway communication that does not involve a sharing of ideas
regarding the patient's perception of the good. Alternatively, the
119
physician and therapist can communicate more directly and have
a conversation where there is an exchange of thoughts and ideas
of the patient as to their understanding of the end goal for the patient. While the deliberative model may be used here, collaborative
care can improve everyone's understanding of the telos and what is
attainable.
In asserting that collaboration is more effective than not, this
argument may seem insignificant compared to some of the larger
debates in the medical community. However, the case of Mr. L is
common in the outpatient clinical setting. Low back pain is a common ailment affecting up to 80% of the population.12 The management of and treatment selection for patients with this diagnosis
still challenges many clinicians, even calling into question the relationship of imaging studies with clinical presentation.13 For something as challenging as low back pain, understanding the patient's
version of the good, particularly as it relates to function, will more
accurately explain how the clinical presentation of pain affects the
patient's everyday life.
7. Challenges
Despite what some may see as obvious benefits to collaborative
care, there may be some instances where challenges exist. I will
describe here two threats to this interdisciplinary practice. First,
the providers' respective understanding of the patient's telos may
not be in agreement, causing confusion as to which version is correct. To illustrate this point, imagine a physician specializing in orthopaedics seeing her father as a patient. The physician, being a
close relative, may have a clear understanding of the patient's
version of the good based on the prior relationship. If the patient
is then referred to an occupational therapist, who tries to communicate her version of the patient's good to the physician, the therapist and physician could have differing views of the patient's good
as it pertains to his health. In this case, the therapist does not bring
a clearer understanding of the telos compared to that of the physician. Rather, she merely provides another interpretation of the disease from the standpoint of her specialty.
Second, the telos of each practitioner can cause conflict. What a
physical therapist values as relevant to a patient's overall good may
not be seen as equivalent in the eyes of the physician. Furthermore,
the goods relevant to each profession and to each individual provider may clash. What may be an internal good to a speechlanguage pathologist may not be seen as a good to a physician or
to another rehabilitation clinician. This pluralism that is inherent
in society can not only be present as two clinicians interact as individuals, it also can be a result of training that is unique to each
profession.
8. Conclusion
What has been explained here in this essay is an attempt to
justify the use of collaborative care not just to be seen as a means
but as an effort for all providers to have a better understanding of
the patient's telos. What is proposed is not a change necessarily
in practice or a specific modification to the process of health care
delivery. Rather, I propose a change in the mindset of the physician
in understanding how the rehabilitation staff can be seen as colaborers in understanding the patient's good. The patient's version
of the telos gives the health care provider the understanding of how
the patient's condition affects his daily life. I offer that working in
partnership will move not only the physician closer to an understanding of the good, but also move the patient closer to that good.
Using the physical therapist, occupational therapist, and speechlanguage pathologist as a means can still, at times, be successful in
treating the patient's problem and moving him closer to health and
120
M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120
Fig. 1. The International Classification of Functioning, disability and health (ICF).
Reprinted from Towards a Common Language for Functioning, Disability, and Health: ICF.
Geneva, Switzerland: World Health Organization; 2002 with permission of the World
Health Organization.
his good. Protocols and clinical pathways are established to treat
the majority of patients at a particular time and frequently improve
the patient to the point of moving him closer to a healthier version
of himself, successfully managing the condition. However, what is
defined as “successful” to the provider may not be the same for
the patient. An ever-changing telos from one patient to the next
will ensure that. The checklist approach will only confirm that
the proper process was followed, not that the goal was the good
of the patient.
In an effort to measure health and wellbeing of individuals and
at the population level, the World Health Organization developed a
model International Classification of Functioning, Disease, and
Disability (ICF).14 This model (Fig. 1) attempts to define one's health
condition by relating the patient's disease to constructs such as
how the body functions, the activity level of the patient, and his
level of participation in society.
In developing the ICF model, the patient understands his good
from a perspective of activity and participation in society. For
instance, in the case of Mr. L, the patient seeks medical help because
of his back pain with sitting and with getting dressed. However, in
the course of treatment over several visits, the physical therapist is
able to garner another goal from the patient, that of playing basketball. While these seem, on the ICF model, as activities, they also
represent levels of his participation in society. These are his ability
to work and his recreational level with others.
The physician typically approaches the patient from the left side
of the diagram through body structure and function and how this
relates to his activity level, with consideration of the patient's
participation level in society. The rehabilitation clinician,
conversely, addresses the patient's disorder from the right side of
the diagram by assessing the patient's functional activity level
and relating this to his participation in the community, all while
considering how his bodily function correlates with these. While
there may be challenges as stated previously, collaboration among
these professionals in working towards the good of the patient, as
seen with the help of the ICF model, can best relate the patient's
disease with his subjective report that pertains to the activity and
participation paradigms.
Addressing interdisciplinary care as a collaborative process with
an aim towards the good, rather than as a means, appears more
challenging. It envisions each encounter with the patient as a
way of perfecting the relationship and moving closer to his virtues.5
The uniqueness of each encounter is more laborious than following
pre-set clinical guidelines. However, in moving toward perfecting
this understanding of the patient's telos, the clinician moves closer
to the right treatment for the right patient at the right time. Rehabilitation professionals, with their scientific knowledge and art
form of restoring function for the patient, have established a practice of health care that has an internal good, as well. Collaboration
that includes these professionals for the right reason can result in
optimal care for the patient.
References
1. Panel IECE. Core Competencies for Interprofessional Collaborative Practice: Report
of an Expert Panel. Washington, D.C.: Interprofessional Education Collaborative;
2011.
2. Yeager S. Interdisciplinary collaboration: the heart and soul of health care. Crit
care Nurs Clin N. Am. 2005;17(2):143e148.
3. Burcher P. Interprofessional training: not optional in good medical education.
AMA J Ethics. 2016;18(9):898e902.
4. Apostle HG. Aristotle's Nicomachean Ethics. 1984.
5. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship.
JAMA J Am Med Assoc. 1992;267(16):2221e2226.
6. Pellegrino EDT. D.C. A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions. New York: Oxford University Press;
1981.
7. Who Are Physical Therapists?; 2015. http://www.apta.org/AboutPTs/. Accessed
11/20/2016.
8. Speech-language Pathologists - about Speech-language Pathology; 2016. http://
www.asha.org/Students/Speech-Language-Pathologists/. Accessed 11/20/16.
9. Definition of Occupational Therapy; 2016. http://www.wfot.org/aboutus/abouto
ccupationaltherapy/definitionofoccupationaltherapy.aspx. Accessed 11/20/16.
10. Beauchamp TL. The 'four principles' approach to health care ethics. In: Ashcroft
RD A, Draper H, McMillan J, eds. Principles of Health Care Ethics. second ed. West
Sussex, England: John Wiley & Sons; 2007:3e10.
11. MacIntyre A. After Virtue. third ed. Notre Dame, IN: University of Notre Dame
Press; 2007.
12. Manchikanti L. Epidemiology of low back pain. Pain physician. 2000;3(2):
167e192.
13. O'Sullivan P, Caneiro JP, O'Keeffe M, O'Sullivan K. Unraveling the complexity of
low back pain. J Orthop Sports Phys Ther. 2016;46(11):932e937.
14. Jette AM. Toward a common language for function, disability, and health. Phys
Ther. 2006;86(5):726e734.
Michael D. Markee
Saint Louis University, 3437 Caroline St., Suite 1026, St. Louis, MO
63104, United States
E-mail address: [email protected]
6 January 2017
Документ
Категория
Без категории
Просмотров
2
Размер файла
279 Кб
Теги
2017, 005, xjep
1/--страниц
Пожаловаться на содержимое документа