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Example 3: Flow charts
Some health programs make extensive use of flowcharts, or algorithms. These
are charts designed to help health workers diagnose illnesses by guiding them
through a series of yes-or-no questions.
A few studies done under ideal conditions have shown that health workers make
more accurate diagnoses with flow charts than when using more conventional
methods. However, some programs have had disappointing results with flow
charts. They have found that the charts often make for a less personal relationship
between the health worker and the sick person. Also, some health workers with
limited formal education find flow charts difficult or confusing.
Our biggest objection to flow charts
has to do with the question of who
has control. Flow charts provide
a means of keeping control over
diagnosis and treatment in the hands
of the professionals who design the
charts. Little decision making or clinical
judgement is expected of the health
worker. The hidden message in most (low
charts seems to be, “We don’t trust you.
Your role is to follow instructions. Not to
think. Not to lead!”
This lack of trust is also reflected in
the fact that the most frequent final
command of many flow charts is “Refer
to doctor at once.” Often no other
information or advice is provided, even
though early emergency treatment by a
community health worker might save the
person’s life.
In spite of the fact that they are
sometimes used to limit the health
worker’s diagnostic role to one of
mechanically following instructions, flow
charts can be a helpful learning tool.
Some programs have successfully used
A TYPICAL FLOW CHART-from Take Care of
Yourself, by Donald M. Vickery, M.D. and |ames F.
Fries, M.D., Addison-Weslcy, 1976.
flowcharts to help health workers learn to ask appropriate questions and approach
diagnosis in a logical, step-by-step way. But many have found that once those skills
are learned, their health workers work just as accurately with, and greatly prefer,
simple lists of signs (as in Where There Is No Doctor).
As with any other health technology, the appropriateness of flow charts must be
judged on social as well as medical grounds. A key question to ask is, “Does the
use of this technology encourage or discourage initiative, critical thinking,
and problem-solving skills?”
As we have seen, flow charts can be used to help health workers develop
independent mastery of the problem-solving process. Or they can be used to keep
the health worker dependent on the decisions of professionals. Which way they are
used will depend largely on the program’s trust and respect for health workers and
whether they want them to be followers or leaders.