In the early 1900s, the Mayo brothers expressed that "The best interest of the patient is the only interest to be considered." Medicine was a dramatically different environment over 100 years ago. It may be more difficult to "live" this message today, with the overlays of regulations, the licensing/credential bodies, codes of conduct, and organizational cultures, but we must in order to sustain our humanity in medicine.
It was 12 years ago when I wrote my first Editorial for this journal. I remember the Publisher requesting I take out one sentence, as it crossed over too much from health care to a political tone. Now, in 2015, I see less distinction between political issues, health care issues, social issues, and humanitarian issues. From Case Management Standards, to case management books and manuscripts, one can see the connection between the "macro" (policy, regulations) and their effect on the "micro" (the individual).
Although not all changes in governmental regulations roll over to the case management task list, many (most?) do. The regulation, itself, will often determine how best it must be "met," but that is not the whole story of case management. Neither is how we must practice, given the plethora of licensure requirements, certification standards, ethical codes of conduct, organizational policies, and even the culture of the facility/agency you are working for. At times, it is dizzying to keep it all balanced. Even the term used for a thorough assessment is all inclusive: biopsychosocial-spiritual assessment. Case management is political, is medical/biological, and is social-all inclusivity is necessary to impact case management in the way we would want our families to be "case managed."
The truth is, we don't yet know the "whole" story of case management-any more than we know the whole story of medicine. One famous quote the medical perspective came from the Mayo brothers: "The best interest of the patient is the only interest to be considered." This was said in the very early 1900s in a medical environment far different than today's. In the case management heart, we know this is/should be true. But like medicine, case management has changed dramatically where we must consider so much more than the "best interest of the patient." So sad, yet so true.
Consider the changes in medicine: in 1905, Robert Koch won the Nobel Prize in Physiology/Medicine for his work related to tuberculosis. This research stemmed the tide of the current practice of Plombage-one treatment for tuberculosis where a surgeon would create a cavity in the patient's lower lung and fill it with a foreign material. This would effectively make the upper, infected lung collapse. Here was the theory-the collapsed lung would assist in the healing process. During this time, they also gave morphine for teething and mercury for syphilis. But the early 1900s were not all bad science. In 1901, different blood types were discovered. Alzheimer's disease was identified by Alois Alzheimer. The electrocardiography (ECG/EKG) was developed. The link between vitamins and diseases such as scurvy and rickets was discerned. It becomes more technical from there, with heart-lung machines (iron lung for polio), vaccines, even a kidney transplant done with a set of twins. But real regulations were beginning in 1965, when Lyndon B. Johnson signed the Social Security Act that the stage was (eventually) set for diagnosis related groups and the regulations that are currently ours to implement.
The best interests of the patients-yes. But during that time, doctors did not have to answer to regulatory agencies, nor insurance companies telling clinicians the "status" or the number of days authorized. They did not give a thought to many of the issues that must be integrated into practice today.
Changes in case management, itself, may not be as intense as the changes within medicine; however, the changes in case management have been on a lightning-fast trajectory. And case management as we know it today may be much younger than medicine, we already see that some of the regulatory changes are antiquated, such as the 3-day stay in a hospital prior to nursing home discharge, which was written when length of stays were much longer than today. Even the more recent two-midnight rule was a response from the "observation status" from the 1980s and superimposed onto other regulations, thus is a moving target for change.
Case managers of the early years learned by the seat of their pants and tried to keep the whole gestalt of case management balanced. It was a somewhat easier time. But let's not lose sight of why we became so passionate-even though the evolution of case management is changing/has to change.
Human respect must thread through all the tasks, templates, and technology; it must infuse those aspects of case management that are political. Even if we cannot do everything for the patient, or even everything the patient states they require, we can still infuse the most important aspect of case management ... the ability to go beyond hearing and really listening, because maybe it is still true-that the best interest of the patient is the most important consideration. I must continue to believe this; it dilutes the more technoregulatory side of case management and speaks to the heart.
case management history; medical history