Perspectives
Health services administration
Volume 196 - Issue 2

Clinical pathways: a departure from the art of medicine

Authors:  Ralph K Nanan, Alison S Poulton and Bernard L Champion

Med J Aust 2012; 196 (2): 96. || doi: 10.5694/mja11.11391
Published online: 6 February 2012
Is canonical thinking inhibiting the flexibility and innovation required for expert clinical reasoning? The idea of clinical pathways was developed in 1985,1 with the intention of improving patient care and use of health resources. Since then, use of clinical pathways has proliferated, dominating clinical decision making in Australia and abroad. Important features of clinical pathways include a practical focus on the patient journey and a patient-centred multidisciplinary team approach.
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Is canonical thinking inhibiting the flexibility and innovation required for expert clinical reasoning?

The idea of clinical pathways was developed in 1985,1 with the intention of improving patient care and use of health resources. Since then, use of clinical pathways has proliferated, dominating clinical decision making in Australia and abroad. Important features of clinical pathways include a practical focus on the patient journey and a patient-centred multidisciplinary team approach. Clinical pathways are ideally based on best available evidence and expert opinion and should lead to a high degree of consistency for safe and sound decision making for common or serious clinical scenarios. Positive impacts of clinical pathways have been documented, including cost savings from minimising non-indicated investigations or treatments, and improved clinical outcomes and reduced adverse events.2

In this respect, clinical pathways have helped redress an important problem: heterogeneous and inconsistent expert opinion leading to idiosyncratic, erratic or emotive decision making regarding patient management. Significant educational benefit has been attributed to the use of clinical pathways as both a learning tool and a gold standard for clinical decision making. This has led policymakers to mandate their use in some fields, elevating them from simple recommendations to policy directives — deviation from which might place a clinician at risk of legal repercussion.

In many ways, clinical pathways have developed canonical characteristics, representing heuristic rules set by experts based on the best available evidence. Users are expected to unquestioningly accept these expert opinions, creating a situation where the rationale behind decisions is not explained, nor is critical appraisal of it encouraged. This has the potentially negative educational impact of focusing on the “how” but neglecting the “why”. Clinical pathways can often resemble instruction manuals, requiring users to develop technical proficiency over conceptual reasoning skills.

Decision making without reasoning represents a fundamental departure from the traditional art of medical decision making based on first principles, observation, rationality and experience, which are intrinsic to modern sciences. In the long term, this may result in alienation of medical professionals by leading to estrangement between decisions and their rational bases.

The process of developing pathways depends on a scientific methodology that evaluates different types of management to establish best practice. However, the blanket use of clinical pathways may inhibit the flexibility, innovative thought and experimentation that is necessary for the evolution of new and better treatments. Clinical pathways require constant review and updating and are not universally applicable due to variations in medical culture, resources and economics between communities.

The canonical approach has also been implemented in other walks of life. One harmless but widespread example is mathematical skills. Since the advent of electronic calculators, few adults are capable of even simple manual arithmetic. This represents a form of dependent de-skilling. Another more serious example is the reported loss of conceptual skills in civil aviation, where pilots have been found to be unable to revert to manual flight or derive creative solutions to previously unencountered emergency situations.3

In medicine, conceptual thinking has been replaced by canonical thinking in many clinical contexts. An example is the widespread adoption of clinical pathways for managing diabetic ketoacidosis. Many doctors automatically use the pathway for mildly acidotic or non-acidotic ketotic patients who could be more appropriately managed with supplemental subcutaneous insulin. Were such doctors to encounter serious diabetic ketoacidosis without access to the relevant algorithm and support for running an insulin infusion (such as in a small rural health centre), one wonders if they could manage to stabilise the patient.

The problem is that medical decision making requires contextual considerations that cannot be universally captured in algorithms and pathways. Blanket adoption of clinical pathways from early training may lead to as yet unforeseen cognitive disruptions to the lifelong process of experiential learning and acquiring expertise. Geoffrey Norman, one of the founding fathers of clinical reasoning theory, wrote that we “discount the experiential component of clinical expertise, dismissing it as mere pattern recognition and disparaging experts who are guided by experience instead of the latest evidence-based systematic review”.4

At stake here is the art of medicine, acquired over a lifetime’s practice. Many pathways by default refer to experienced clinicians for managing unexpected or unfamiliar situations. But will tomorrow’s experts, beset by a lack of opportunity for conceptual thinking and practising the art of medicine, have an answer?

Authors

  • Ralph K Nanan DrMedHabil1
  • Alison S Poulton MA, MB BChir, MD2
  • Bernard L Champion MB BS, BSc(Med), MMedEd3
  • 1. Sydney Medical School Nepean, University of Sydney, Sydney, NSW.

Correspondence: alison.poulton@sydney.edu.au

Competing interests

No relevant disclosures.

References

Provenance: Not commissioned; externally peer reviewed.

View this article on Wiley Online Library

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