PROCESSI DECISIONALI IN MEDICINA TRA STANDARDIZZAZIONE E INDIVIDUALIZZAZIONE DELLA CURA. ANALISI DI UN CASO

Decision-making processes in medicine between standardisation and individualisation of the care. A case study In recent years western medicine is facing multiple transformations. On the one hand the continuous exchanges between biology and medicine gave birth to “biomedical practices”, defined by a regulatory objectivity which enlightens the construction of collective types of knowledge that combine people (doctors, researchers, administrators, patients) and objects (entities, tool, techniques, protocols). On the other hand, the process of standardisation of the work has recently spread to the tertiary sector, to the services and to medicine: the birth, in the early nineties, of the evidence-based medicine has made clinical practice more uniform through the use of tools that incorporate “indications” on the criteria with which exams are prescribed and therapies, surgery and other part of the care process are planned. Through an organisational ethnography, the research investigate how therapeutic appropriateness is defined and characterised in medical practices and how objects and tools for decision-making, as organisational artefacts, are contributing in building up types of knowledge and information that shape the definitions of individual therapeutic pathways. The analysis of medical decision-making practices highlight that the standardisation operated by evidence-based medicine is informed by the compromise between general scientific instances and situated organisational issues: the implementation of standards at the individual level, thus, results from the coordination among actors, artefacts and the issues that they incorporate and that inform the decision-making process. This does not depend explicitly from the plan included in the evidence-based medicine tools, but is the effect of the alignment (not completely random, nor even predetermined) of objects, parameters, standards and people, through what has been defined as the “heterogeneous management of patient’s trajectories” and that results from the coordinated action of an heterogeneous network of elements that rises through local compromises and regulations. The therapeutic appropriateness is thus defined from within a social action net based on relationships that connect human and non-human agents to care practices. These in turn result from a precarious coordination of budget issues, respect for procedural formalities, aesthetic imperatives and scientific and organisational standards. In such a context, protocols and guidelines act as systems of organisational classification that build targets of therapy recipients, and that become, in the decisional practice, solutions in search of problems.