The Future of Medicine

The CLAHRC WM Director participated in a panel discussion recently on “The Future Doctor”. So what does the future hold for young doctors?

We live in an exciting time of scientific discovery in the life sciences. A number of technical/scientific changes are in train. Many of these are not disruptive in that they can be easily incorporated in existing working patterns. For example, there is much justified interest in molecular diagnosis, but stratification of treatment by genetic testing is just another type of sub-group. Even a method to slow down cellular ageing, thereby extending lifespan, would be socially and individually important, but would not change medical practice in any fundamental way.

However, there are other technological changes afoot that will prove ‘disruptive’. Discoveries in the realm of brain and mind that could revolutionise the nature, not just the content, of medical work. Thus, working out the basic mechanisms behind schizophrenia or finding a treatment for Alzheimer’s would be ‘game changers’. Much testing may be done at the bedside using chip-based molecular sequencing and bed-side ultrasound, replacing much of what currently happens in labs and radiology departments. Information technology is perhaps the prime candidate for a development that would truly disrupt medical practice. The idea that the doctors diagnostic skill might be supplanted, or at least assisted, by machine has been around since Tim de Dombal’s famous studies in the 1970s.[1] The fact that it has been slow in coming, does not mean it will never come; just as Babbage’s computing machine presaged Turing’s computer by over half a century.

Such massive technological breakthroughs aside, it is social, not just technological, factors that will change what it is like to be a doctor. Of course doctors in all countries are living within a kaleidoscope of changing policies that often pre-occupy them – new regulations for Medicare in the US, and weekend working in the English NHS, for example. Here we are concerned with the more fundamental drivers for change – those that lie behind the policies.

1. Balance between regulation and inspiration.
Taylorism has come to medicine. Frederick Taylor came up with a theory of scientific management before the Second World War – processes should be broken down into their component tasks, and performance of each task should be measured and rewarded accordingly. Sub-specialisation, of course, opened the door to Taylorism, and empirical demonstration of differences in performance across services then drove a kind of medical ‘scientific management’. It has gone too far. Too many targets can ‘crowd out’ commitment and innovation.[2] Flair in making a difficult diagnosis, showing compassion, and balancing competing objectives in looking after patients with multi-morbidity cannot be regulated by targets and incentives – professionalism needs to re-assert itself and medical schools must grow beyond their obsession with scientific achievement and lead the way. Alternatively, they will quite properly lose their control of medical education. Regulators will never go away, but they must learn to take a back seat – they are the safety net, not the trapeze.

2. Skill substitution
Medical hegemony has gradually been chipped away from all sides. Nurses, the new profession of physician assistant, and pharmacists, have been given a role in both diagnosis and therapy. Doctors are expensive, so it makes sense to steward the resource, and encourage skill substitution. The medical profession should not oppose these developments, but take a lead in defining a cognitively elite role for doctors as systems thinkers, managers, and communicators. Yet many seem to be heading as fast as they can go in the opposite direction, becoming gifted technicians or super specialists. For example, there are specialists for diseases of the pituitary gland. Such a clinician assumes responsibility after the diagnosis (the difficult bit) has been made. It is possible to imagine medicine squeezed out of existence between computers replacing the cognitively-demanding aspects of medicine and other professions taking over the routine and narrow work currently done by sup-specialists. The CLAHRC WM Director does not believe such a dystopian world will come to exist, but argues strongly for the return of the generalist. It is true that there is a relationship between volume of cases treated and quality, but only on a narrow definition of quality. What is the point of treating every individual condition perfectly if the resulting polypharmacy proves lethal?

3. Psychological care
But the biggest medical abrogation of responsibility lies not in the in arena of holistic physical care, but in total care of patients – something we have blogged about previously.[3] Too often the CLAHRC WM Director has heard doctors, particularly surgeons, say something akin to “I ask the nurse to do that, they are so much better at it.” Is this not an admission of rank incompetence? When the CLAHRC WM Director was in practice, the surgery – which had been difficult during training – become quotidian. The fascination, reward and challenge lay in looking after the patient, body and soul.

In conclusion, regulation and monitoring are here to stay, but they are woefully inadequate as a means to ensure high quality practice. Such practice requires holistic care for the body and mind. The target culture should be tamed. The doctors of the future need to be carefully nurtured. Their education should be an inspiration, building resilience and a sense of dedication. Ideally, one would select applicants for medical school based on likelihood of exhibiting these traits. In reality, the science of selection is in its infancy.[4] Perhaps it is a holy grail. But the doctors of the future are going to have to escape from the solipsistic sub-specialist net that has been made for them. This is particularly problematic in the UK where we have a narrow science-based A-level system. Two ideas – require the International Baccalaureate examination as an entry criterion and/or insist on previous broad base under-graduate degrees, as in North America.

— Richard Lilford, CLAHRC WM Director

References:

  1. de Dombal FT, Leaper DJ, Staniland JR, McCann AP, Horrocks JC. Computer-aided Diagnosis of Acute Abdominal Pain. Br Med J. 1972; 2: 9.
  2. Woolhandler S, Ariely D, Duke JB, Himmelstein DU. Why pay for performance may be incompatible with quality improvement. BMJ. 2012; 345: e5015.
  3. Lilford R. Improving Hospital Care: Not Easy When Budgets are Pressed. January 23 2015.
  4. Brown CA & Lilford RJ. Selecting Medical Students. BMJ. 2008; 336: 786.
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