What is the role of the doctor in the 21st century? It is an interesting question, and one I was asked to have a stab at answering at an Oxford medical school seminar. I was expecting a large turnout of anxious students, fretting over whether they’d have jobs in a few years, but instead the hall was packed with silver-haired academics. The students, it seems, were stressing over the next day’s Objective Structured Clinical Examinations.
Last month’s article dealt with the rise of robots in healthcare, but operators will still be needed for them. Likewise, stem cell technology may one day reduce the need for emergency surgery (‘I’ll just pop next door and grow a new arm’) but people will still be needed to choose who gets the stem cells. And the people we trust most to make difficult rationing decisions are doctors. Perhaps we’ll all end up working for NICE!
No one will ever take the uncertainty out of medicine, which is why we’ll always need someone to take the emotional hit for the unpredictability of illness. That’s what doctors do best—accept the buck as it is passed along the line—but it takes its toll on even the most saintly of us and, as expectation rises, so does the risk of burnout.
There are also clear, if misplaced, economic threats to doctors. We know that chronic disease mops up three-quarters of health resources in all countries. In America, diabetes alone accounts for 32% of the Medicare budget but is managed consistently well in only 8% of patients.1It might be argued that the QOF was exactly what was needed to prevent and manage chronic diseases to a very high standard. We were ‘incentivised’ to do it, did a very good job, and have now been pilloried for picking up our incentives.
Current thinking is that doctors are too expensive, and that anyone with an algorithm can manage chronic disease. But medicine is too complex to be managed by simplistic linear systems. Algorithms rarely have a ‘don’t know’ arm, and patients seldom have just one chronic disease. Difficult decisions have to be made and in a show of hands in the (academic, mainly medical) audience in Oxford, most people elected to choose a physician as their first port of call.
Protocols and guidelines have a role and we should be accountable for our actions if we veer off piste, but we also need to be less hierarchical and more team oriented. As one Professor of Medicine put it; ‘I’m always telling students "I don’t know”. Then we go to the computer and try to find the answer. And sometimes it’s still "I don’t know”.’
Unfortunately patients dislike ‘I don’t know’, but they’ll accept anything delivered with emotional intelligence. Nothing can replace the importance of continuity, earned trust, and human relationships in medicine, and our biggest threat is not competition per se (we should be confident enough to see off the polyclinic), but the fracturing of care as patients are bounced from supermarket to pharmacy and to us, each time repeating their story as we still do not have an electronic record to pass between us.
The generalist may be under threat, in both primary and secondary care, but the huge growth in complementary therapies and the ‘happiness industry’2 suggests that no matter how rich people become, and how long they live, what makes them content is to be part of a community where their feelings are acknowledged. Tomorrow’s doctors need to be leaders, communicators, educators, researchers, resource allocators, and navigators through an increasingly complex (and expensive) system. We also need to keep the human touch; if patients don’t feel happier for seeing us, we’re in the wrong job.
- Ashkenazy R, Abrahamson M. Medicare coverage for patients with diabetes. A national plan with individual consequences. J Gen Intern Med 2006; 21 (4): 386–392.
- Layard R. Happiness: Lessons from a New Science. London: Penguin Group, 2005. G
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