Between clinical freedom, responsibility and trust in care
It is truly lost in the mists of time that a conversation that, more than audits, more than quality manuals and even more than certifications hanging in the corridors, changed the way I look at procedures. It was a conversation with Bill Palma, then chairman of the Joint Commission International commission, who had taken first the AO of Busto Arsizio and then Humanitas Mater Domini of Castellanza to accreditation of excellence.
I came to that dialogue with an almost “genetic” wariness. As a good humanist, raised in a medicine that made relationships, clinical intuition and personalisation of care its identifying trait, I found it hard to trust procedures, protocols and checklists. Yet we had written them down. In abundance. Perhaps in excess. We had ISO certification, we had produced documents, flows, operating instructions. But inside, an uncomfortable question remained: are we really improving care or are we just learning how to describe it better on paper?
Like many doctors, I probably still had to go through a cultural transition. Bill's response was as simple as it was unsettling, delivered with that dry and direct pragmatism typical of Americans:
Procedures and protocols do not take away the freedom of doctors and nurses, especially the good ones. Instead, they serve to enable them not to make mistakes — or at least to do less damage — the less good ones.
At the time, I did not immediately understand the deeper meaning. It seemed to me an elegant but partial answer. Procedures, I thought, are a protection for the patient, that much is clear. But how can it be true that they do not limit the professional's freedom of choice? If I have to do something in a certain way, codified, standardised, am I not less free to personalise the therapy? Am I not in danger of turning medicine into a sequence of repeated acts, valid for everyone and therefore, paradoxically, for no one?
È it is only with time that I have realised that the trap does not lie in the procedures, but in the idea we have of them.
A procedure is not è a dogma.
&Eegrave; a frame. A reference. A shared starting point. I can deviate, I can adapt, I can choose differently. On one condition: that I can explain why I did it. That I make my clinical reasoning explicit. That I transform experience and intuition into a reasoned decision.
In that moment everything came together.
Freedom is not about doing what you want.
The professional freedom is about choosing and being accountable for your choice.
.
Nothing moreù scientific. Nothing could be more honest.
You do something different, but you have to be able to say why.
And here, too, the thought comes to mind: that's all we need.
And yet itè not so obvious. For to say “perché” is to expose oneself.
It means taking responsibility. It means putting your name under a decision, accepting that that choice can be discussed, analysed, sometimes criticised. And that, in today's healthcare world, is scary.
We live in complex systems, under constant pressure, with high workloads, often insufficient resources and an emotional climate that oscillates between urgency and defensiveness.
In this context, the procedure can become a refuge: I followed the protocol. A phrase that sometimes protects, but at other times hides. Not always behind the formal adherence to a guideline there is a real act of care; sometimes there is only an attempt to reduce personal risk.
But this is not the point of the procedures.
Their authentic sense è twofold.
For the è less experienced, the procedure è a guide.
For the experienced, it è a reference to be passed consciously.
In both cases, it è a quality tool, not a limitation of care.
The real distinction is not between humanity and technology, as is often said, but between automatics and thought.
Between the’act performed becauseé “is done so” and the’act chosen becauseé “è the right thing for this patient, at this moment”. The procedure does not erase the humanity of care; if anything, it forces it to declare itself, to take shape, to come out of the implicit.
In this sense, the procedures are also a cultural tool. They call for professional maturity. They call for a healthcare that knows how to distinguish between error and fault, between reasoned deviation and negligence. They call for organisations capable of embracing critical thinking, not just conformity.
Maybe this is where the real difficulty lurks: responsibility is a burden not everyone is ready to bear. It is easier to take refuge in rigidity, to turn the procedure into an immutable law, than to use it as what it really is: a tool in the service of care.
And then the ultimate meaning of the procedures becomes clear only if we look at it from this perspective. They do not serve to make healthcare more bureaucratic, but to make it more fair. They do not serve to take away freedom, but to tie it inextricably to responsibility. They do not serve to extinguish clinical intelligence, but to ask it to show itself, to make itself explicit, to become shared heritage.
Maybe, in the end, the true humanistic act is not to reject procedures, but to inhabit them with thought, conscience and courage.
Because healthcare that does not have the courage of responsibility is neither safe nor truly human.
