Medical practice: where next?

Advances in technological and medical understanding in the past half century have brought substantial improvement in health. It is ironic that, at a time when potential returns from medical interventions are higher than ever before, the satisfaction levels of both doctors¹ and the public² seem particularly low. In this article we examine the external forces that are driving change and creating huge tensions within medicine; and, looking to the future, we broaden our discussion and ask what medicine really is and how its various components will fit into a broader concept of the organization of healthcare.

THE PAST: HOW WE GOT HERE

The rise of consumerism in medicine

The social environment in which medicine is practised has been particularly affected by the growth of consumerism, both in medicine and in society. Behind this lie wider social changes, such as a growing demand for civil liberties. Rises in civil litigation and criminal prosecution, along with other forms of official complaint, are quantifiable manifestations of a more critical culture. The very word patient has become contested, ‘consumer’ or ‘service user’ being preferred by some.

The increasingly corporate nature of medical practice

There is another less widely recognized but more pervasive change in healthcare. Even twenty years ago, the (admittedly implicit) contract between patient and doctor was entirely personal. When the first author came to this country in 1979, hospital administrators were loath to remonstrate with consultants over the length of their waiting lists. Indeed, when an administrator suggested that an established consultant should offer patients who had been waiting for more than two years the opportunity to have their operation under the care of a newly appointed colleague, he received a very dusty answer. Today, waiting lists are seen as a corporate responsibility, and managers' intervention in long waits is part of their performance review function. In many countries, most notably the United States, the increasing costs of medical care (driven largely by technology and subspecialization) have also required concerted ‘organizational’ responses—for example, the introduction of diagnostic related groups and the rise in health maintenance organizations. Along with an increase in corporatism there has been a fragmentation of the medical function, creating important tension within the system.

THE PRESENT: CONFLICT AND PAIN

The doctor—patient relationship

Thus the forces of increased public expectations and increasing fragmentation of care continue to affect the nature of the doctor—patient relationship in a fundamental way. Care is no longer an entirely private/personal matter between two human beings. When a patient enters intensive care, becomes mentally ill or embarks on pregnancy, the quality of care, its cost and its nature are increasingly determined at the organizational level. Organizations, under societal and commercial pressure to respond, accept responsibility for quality of care. Thus, healthcare organizations such as hospitals are no longer simply a ‘platform’ providing various technical and hotel services, but are now required to be managerially responsible for clinical services. Doctors are a resource, along with nurses, physiotherapists, laboratory staff and hotel services, which must be deployed to maximum effect. Doctors may still be the most important actors in the care of illness in that they make the most critical decisions in human and resource terms, but in their capacity as doctors they no longer direct the play.

Interprofessional relationships

New tensions have been created not only at the interface between professional and client but also between professions. As care becomes more fractured, so more professions have come to play decision-making and technologically sophisticated roles in patient care. Nurses, for example, perform lifesaving interventions such as defibrillation and diagnostic techniques such as endoscopy. Their increased responsibility and role in decision-making is reflected in nurse prescribing and nurse-led clinics. At the same time, many professions have sought to challenge the dominant status of medicine and argued that they are equipped to give certain aspects of care in better or more cost-effective ways. The maternity services, for example, have seen a reawakening of old tensions between obstetricians and midwives.

Why are doctors unhappy?

It is easy to think that problems are unique to our times, but the morale of doctors does seem exceptionally low and we argue that their unhappiness is linked with loss of power both at the level of the individual patient and at the level of service organization. A large body of research shows that unhappiness, stress and consequent ill-health are associated with a feeling of loss of control over work for which the employee will nevertheless be held to account. This discovery—of the harmful effects of ‘responsibility without power’—was a principal finding of the Whitehall II study³. Doctors are increasingly the targets of complaints and rhetorical abuse, while exercising progressively less control over the source of criticism. To make matters worse, medical technology has outgrown the capacity of even the most generous funders, and doctors often find themselves at the sharp end of rationing decisions. Issues of the funding of care have increasingly been dealt with in settings distant from most doctors, and their opportunities to influence these decisions have declined.

THE FUTURE: SEEING AROUND CORNERS

Medicine will lose its hegemony

Although one response to threats to power is to adopt strategies to regain and increase power, we would argue that this will not happen in the case of doctors. On the contrary we maintain that medicine as a professional identity, defined from an early stage in the development of a career rather than by the work performed, will change fundamentally. What we are arguing is that the link between the work of a health professional and specific ‘professional background’ will become increasingly tenuous. This happened some twenty years ago in chemical pathology and more recently in public health, and the trend is now apparent in subjects as diverse as anaesthesia, primary care and ophthalmology. It is increasingly difficult to define ‘doctor’ in such a way as to distinguish the practitioner unambiguously from other clinicians in the healthcare team who have decision-making responsibility and/or who administer critical interventions.

The ‘consultation’ as central component of health practice

It would be wrong to think that, as medicine loses its professional hegemony, the whole of healthcare will dissolve into amorphous and harmonious islands of multidisciplinary practice floating in an egalitarian sea. Some aspects of practice simply demand more expertise than others and responsibility tends to rest here. Such expertise may be technical or intellectual, and while technical expertise is currently on something of a pedestal (think of heart surgery or interventional radiology), it is intellectual and communication skills which will become the most crucial competency in healthcare. Intellectual skills are ‘primary’ in the sense that they determine the need for any interventions that may follow. These intellectual skills consist of systems thinking (by which we mean integration of many bits of disparate knowledge to reach a diagnosis or form a plan of action). Communication skills are exhibited par excellence in the consultation. In our opinion, the consultation will reassert itself as the central encounter of health practice, and special education (see below) will be needed for those who consult. The consultation is the intellectually and emotionally most demanding part of clinical practice. It is here that the most value turns—in both human and financial terms. Hence, it is also the aspect of practice which encapsulates the greatest risk to patient and doctor; we regard it as the apotheosis of responsibility. It is the most enduring feature of healthcare, with roots that go back to the origin of human life itself.

We predict that in the future, those who consult, while bearing the greatest responsibility, will receive commensurate rewards. Call those who consult ‘doctor’, if you like; the point is that the routes by which this position is attained will be multifarious. The links between what kind of initial undergraduate training a person has had and the kind of work he or she finally does, will be increasingly eroded.

In-built quality control

At the moment, doctors work in complex systems of care but feel inadequately supported by their employing organizations—which, as we have seen, are increasingly charged with responsibilities of clinical governance. As care has become more complex and fractured, so the opportunities for errors of commission and omission have risen. Furthermore, they do so exponentially. If a patient's care consists of a hundred components with an error rate of only 1% for each component, the probability of experiencing no error is 0.99¹⁰⁰. In other words, most patients will be the victims of at least one error. Preliminary empirical investigations have not only confirmed a high error rate but have also shown that about 5% of patients experience an adverse but avoidable iatrogenic problem⁴. Third-party payers are responding to this threat and designing better systems. Training incorporates drill and practice in ‘skills laboratories’. For example, obstetricians and midwives are taught how to deal with shoulder dystocia on models, not just on those rare patients who encounter this potential catastrophe. The idea of compulsory near-miss reporting has gained currency, but this is unlikely to succeed in an atmosphere of fear and a culture of blame. Increasingly it is recognized that human beings are not perfect—no matter how much training they are given—and that systems have to be created to reduce errors.

Improved information systems, with an intelligence function to act as a medical ‘co-pilot’, could revolutionize clinical practice and reduce demands on consulting clinicians. Systematic reviews of such on-line action suggestions and reminders have shown them to be effective in improving quality of care⁵. Prescribing systems which warn of drug interactions and inappropriate doses must already have saved thousands of lives. However, systems that follow patients over time and integrate clinical, prescribing and laboratory information are long overdue. The construction of such systems is an enormous task—akin to a major space operation. The great majority of developers who have attempted to implement such systems have grossly underestimated the difficulties. However, this has to be the right way in the long-term and millions in investment will repay billions in dividend. We will realize in the next decade or so that developing algorithms to track patients through care pathways, by an appropriate mix of manual and electronic methods, will save far more lives and prevent more morbidity than all the advances emanating from molecular genetics.

Primary care and hospitals versus systems of care

Earlier, we described how the basic contract of healthcare had changed from a private matter between doctors and patients to a more public one, between healthcare providers—epitomized by hospitals—and patients. However, increasingly hospitals are becoming places which you go to only when you are very sick, and the balance of care is given in the community where prevention is getting welldeserved emphasis. All this leads to a prescription for healthcare arranged around client groups or disease entities, rather than geography. As a result, we are already seeing the development of networks straddling home, community facilities or hospitals and providing systems of seamless care for diseases, such as cancer⁶, or client groups, such as those with mental illness⁷. This means that governance—both financial and clinical—is no longer properly located in any one particular place. Managerial oversight of clinical practice will therefore move away from being organized in units of hospitals and towards organization in service units, such as the mental health or maternity services. Hospitals can take on a simpler and more manageable role, of providing facilities for consortia of healthcare providers. The Private Finance Initiative will go some way towards separating the construction and maintenance of buildings from the management of clinical teams which will straddle facilities of different types. Prevention of acute illness will be seen less and less as a ‘medical’ problem and will involve a wider variety of actors.

Education

Education and training will, we predict, change utterly. Medical schools will become part of broad schools of health. They will train people to consult in contexts where complex (systems-based) thinking is required. These trainees will all be graduates. Some will come from a direct-care training programme (somewhat analogous to nursing training) and others will have done a degree course in a generic academic discipline. They will do a core life-sciences degree which will be modular and flexible (according to previous educational experiences). People who have done the direct-care package could specialize in some aspect of non-consultant care if they do not wish to take this route. However, those who have done the core life-sciences degree will be eligible for advanced life-sciences courses, leading to a technical or scientific career. Those who want to become ‘consultant’, however, would undergo a further training emphasizing systems thinking, clinical examination, ethics, communication and social dimensions of healthcare. This group of people would also get an enhanced package of mentoring/pastoral care. Consulting work has been shown to make huge psychological demands on individuals and the caring professions are commonly seen as failing, especially in their duty of communication. The new course for a ‘consultant’, therefore, should concentrate as much on the psychological as on the intellectual development of this crucial corps of healthcare workers. A scheme of how the whole framework could look is shown in Figure 1. Our thinking builds on the ideas proposed by Conroy⁸. She argued for a restructuring of the NHS workforce in which traditional roles would be replaced by ‘generic health practitioners’. We argue for an extension of this concept, so that the consulting function is specified and trained for, to complement the activities of practitioners who fulfil a more traditional nursing role or whose tasks are governed largely by algorithms rather than complex analytic and consulting approaches. Such changes in the structure of training would not lead to the abolition of those workers with more specialist skills, but would simply allow for the best use of all skills. Such a framework could allow for greater flexibility in training and career pathways for NHS professionals, a point emphasized in a recent Department of Health document⁹. Adoption of such a model is, we argue, the best way to develop a workforce that is suited to delivering the best healthcare in the future.

Figure 1.

Scheme of health education