Values in medicine: what is it really all about?

Prof. Dr Jalid Sehouli likes to think beyond everyday medicine. In this esanum blog contribution he shares his thoughts about the implications of personal values in medicine.

The human being should be at the centre

I like to visualise the topic of "values in medicine" with an example: We tracked a female patient with ovarian cancer to determine how many medical prfessionals had contact with the patient, and by extension, to how many specialties had the patient been exposed to over the course of a 14-day treatment. In total, 144 different people from a wide range of disciplines were involved in her diagnosis, treatment and care. This showed that no disease is a one-person issue that can be cared for by a single discipline.

When we imagine these 144 individuals involved, we logically ask: Where are the procedures and contacts actually coordinated? Where are the platforms that map all this? After all, the classic Diagnosis-related groups (DRGs) always categorise a single disease and sometimes only calculate it superficially according to the apparent severity of the disease and its complications. Here it becomes more than clear that the claim of a holistic approach, as well as the ideal that all disciplines speak to each other, is often not fulfilled. The necessary interactions and structures are not taken into account.

This is a blatant contradiction to the claim of participatory, interdisciplinary and transprofessional decision-making and participation in diagnostics, therapy and post-treatment care. But this should be the essential characteristic of modern and personalised medicine. The human being per se should be at the centre - and not the technology or the disease. That is why we need a new focus of the health system.

After all, in the era of personalised, targeted therapy strategies, we are dependent on explaining things well, and actually taking the patients along with us over the steps to be taken during care. Medical procedures without attention to the necessary communication structures are therefore in strong conflict with our values, to which we feel committed according to Hippocrates. These are exactly the values that our patients often expect.

It's about the doctor-patient dialogue

I had called a clinic in a big city yesterday and there was not a single physician in the entire gynaecological department. The boss had resigned and the three other physicians were sick, and the clinic could not accept any patients. How can this be? I'm afraid this is not an isolated case.

It may sound harsh. But there is always investment in technology, and other (essential) things too often fall down the priority list. Now costs are rising everywhere, energy and medicine prices are increasing, the general context and conditions of treatment is becoming more difficult. How can it be that a conversation about a cancer diagnosis or a cancer recurrence is mapped with a few euros as performance indicators - without content and quality playing a role? This approach reduces the opportunity to invest resources in these very essential conversations. Doctor-patient communication, and its personalised and constant fine-tuning, must surely be the very basis of innovation. The generous funding of apps and other digital options can help, but not replace the all-important human proximity in medicine. It is about the physical doctor-patient conversation!

Physicians are part of a complex medical system that is economised and industrialised. They, too, work under economic pressure. It is a right step here that nursing has been taken out of the DRG. But all other professions have not.

Does medicine have to be profit driven at all?

We know that currently, for example, paediatric medicine and many women's diseases do not seem very attractive economically. And prevention is hardly rewarded at all. But do we only care about diseases that are economically viable? 

I think that an optimisation of resources is necessary for the sake of economy and quality. This includes a centralisation of structures that focus on best-practices, and networks that make prevention measures possible, not only for crisis situations such as the COVID-19 pandemic. One way, I think, will be that not everyone can do everything anymore. If they do certain procedures fifty times a year and not just three times, of course they will be faster and have fewer complications. We will save resources if we work more closely together trans-sectorally in initiatives supporting excellence and best-practices.

If these networks avoid incorrect treatments, then the whole thing will also become more economical. That means investing in quality-focused networks, that cut across disciplines and processes: it's about clinics, practices, professional groups. Network structures across federal states and occupational groups could achieve this. Various European countries are already on this path. They determine what may be operated on, where and under what conditions.

So we have the conflict of values between the economic pressure and the expectations of the staff and patients regarding training and communication. This is not an easy debate to have now. We have to transform this discussion into a message, across the boundaries of the professional groups in the health system.

The question is: Does medicine have to make money at all? That is a decision for society as a whole. We should find a new balance in this discussion of values. So: what is the value of interdisciplinary, cross-professional cooperation? How important is communication with patients to us? And how can we reconcile this with economics? That is certainly a long way to go. But I know that many doctors are striving for it and want to help shape a new and better way of practising their profession.

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