Thoughts on future doctors

Every few years, responding perhaps to some deep anxiety, medical organizations think about ‘the role of the doctor’ or ‘the future doctor’. We are in such a phase at the moment – prompted particularly by the disaster of the medical training application service and the subsequent inquiry.¹ The ‘leaders of UK medicine’ (whoever they are) have produced a statement on the role of the doctor,² and the Royal College of Physicians is following up its report on medical professionalism with another on the future doctor.³

For some unknown reason (perhaps random selection), the College of Physicians working party on the future doctor asks me to give evidence. ‘But you're not a practising doctor. What do you know?’ says a doctor friend. Good point, but as the cliché has it, ‘doctoring is too important to be left to doctors’. And besides I'm sort of a doctor, and I know thousands of doctors. I live in a strange but enticing hinterland of doctor, patient, manager, busybody, amateur futurologist and loud mouth. So I'm going.

The first thing that strikes me about the working party is its youth. There are three old guys, but everybody else is young – and mostly women. If the future of the College of Physicians belongs to young women, then it's bright.

‘Things are not right now’

My first point, which they probably agree with otherwise they wouldn't be here, is that things are not right now. Many doctors are unhappy, feeling disempowered, alienated from the system in which they work, hankering after an age gone by and like pawns in a political game they don't like. Meanwhile, doctors are seen by many health managers as part of the problem rather than part of the solution – barriers to change rather than drivers of change. And many of our interactions and those of our family and friends with doctors are in some way unsatisfactory: we feel patronised and more like collections of unsatisfactory parts than human beings. These problems are true everywhere not just in Britain – and must stem in part from a gap between what doctors are trained for and the world they inhabit.

Next, I warn the working party of the dangers of thinking of one kind of future doctor. Doctors do many different things, and the skills needed to be a successful public health physician are quite different from those needed by a neuroradiologist. Peter Richards, one-time dean of St Mary's, used to argue that medical students should be randomly selected from those reaching a minimum (and not too high) academic standard. Then we could be confident of a wide range of skills and attitudes; it would be a much better process than a row of elderly male doctors picking students in their own image.

To prepare for my encounter with the working party I thought that I ought to search for thoughts other than my own on future doctors. The first paper I encountered through Google Scholar was published in 1966, suggesting a lack of enthusiasm for thinking about the future after four decades of failing to foresee major shocks – the oil price rise of the 70s, the Berlin Wall coming down, 9/11 and the credit crunch. But eventually I found two pieces – both, so much for searching, by friends of mine.^4,5

Thoughts of Ian Morrison, futurologist

Ian Morrison, a Glaswegian-turned-Californian, was once president of the Institute for the Future, and says that what you need to think effectively about the future is ‘data and smart people’. I'm not sure if the College of Physicians has the data, but it has the smart people. These are the characteristics that Ian thinks future doctors will need:⁴

• Clinical data collector: increasingly the care of individual patients and of the whole system will be driven by data of all sorts. Doctors, many of whom are currently innumerate, will need to be comfortable with analysis and interpretation of data;

• Shaman: the ‘magical’ part of healing, ‘the doctor as drug’, which was once almost all that doctors had, has been neglected with the rise of effective treatments – but it is important now and will become more so. Currently complementary medicine practitioners do it better;

• Health adviser and wellness coach: a friend who has been the dean of a German medical school argues that the whole model of medicine – using knowledge of the natural sciences to treat people's diseases – is wrong. Rather, he argues, doctors should be experts on change, helping people to live healthier lives and adapt to the chronic disease that will be their lot as they age;

• Knowledge navigator: patients will increasingly use the Internet to access information, and many will be confronted by a maze of conflicting information. Future doctors will not be telling patients what to do but will need the skills to help them navigate through the maze;

• Proceduralist: it is unlikely that in the near future robots will perform procedures alone. Doctors will still be needed to undertake procedures but probably aided by robots;

• Diagnostician: Ken Calman, England's chief medical officer, famously said 15 years ago that the job of doctors is ‘diagnosis, diagnosis, diagnosis’. That will continue to be true, but increasingly it will be a complex diagnosis on multiple levels, again with the help of machines, to synthesize many inputs into a plan of action;

• Physician managers: doctors will be responsible for much more than the care of individual patients;

• Quality assurance specialist: current health systems fall well short of being as good as they might be. Doctors will need to understand quality assurance in order to play a central role in improving systems.

Thoughts of Don Berwick, ‘quality guru’

Perhaps the best thinking I encountered in my search came from Don Berwick, paediatrician, president of the Institute for Healthcare Improvement and ‘quality guru’. In the autumn he gave the John Hunt Lecture to the annual meeting of the Royal College of General Practitioners and received rapturous applause and a standing ovation, no easy thing with GPs, who tend to the ‘seen it all, heard it all’ school.⁵ Although I found Don's lecture in my search, I was there when he gave it, and the way he led his audience was masterful.

He began with a story of a heroic country GP – deeply fulfilled by a lifetime of work with barely a day off, loved by his patients and hugely respected in his community. This was his father, a family doctor in rural Connecticut. But Don was sure that if his father was alive now – beset on all sides by insurance companies, government regulators, the media and lawyers in an age that despises deference – he wouldn't be so happy. Don tried, however, in an imaginary dialogue with his father, to convince him that practising now could be even more fulfilling – because of access to more effective treatments – than it had been in the past. The effective doctor of now and the future needs, however, new competencies.

In describing these competencies Don chose his words as carefully as a poet.

• An embrace of citizenship in the greater whole that is healthcare, even when caring for a single patient. This, in my mind, is the essential competency that many doctors – clinging to the centrality of the doctor and the patient, usually with the doctor as hero – find difficult;

• The skills required for that citizenship: cooperation, teamwork, inquiry, dialogue;

• Skills less to know answers than to find answers, which is of course the only reality in a world of rapid expansion of new learning and the displacement of the old knowledge;

• Embrace the authority and autonomy of patients and families in a wholly new distribution of power and knowledge. Doctors are guests in patients' lives not priests in a cathedral of technology;

• Willingness to trade prerogative for reliability – doing not your best but the world's best. This is the potential pay off to Don's father: he can offer his patients so much more.

My thoughts

Finally, I offered the working party my thoughts, which I've gathered over years and which unsurprisingly overlap with the thoughts of Ian and Don and, indeed, with the thoughts of the College itself reflected in its report on the new professionalism:³

• Healing ability: I chose the phrase ‘healing ability’ because it must include much more than knowledge and a set of technical skills and overlaps with Ian's idea of the shaman;

• Capacity to change: one of the few things we can know with confidence about healthcare 40 years from now, when many current medical students will still be practising, is that it will be very different from now. Future doctors will probably need more than a capacity for change: they will need an enthusiasm for change;

• Understanding of systems: this for me is very important: as Don says, doctors are not lone actors but important players in increasingly complex systems – at many levels from the clinical team to the whole national system. Future doctors need to understand those complex systems and know most importantly how to improve them. A lot of this, probably to the relief of many doctors, is not ‘touch feely stuff’ but a set of technical skills that can be taught;

• Leadership/followership: these can both be taught, and most of us need to be leaders and followers at different times;

• Team work: not dominating teams but being part of them, and understanding of what makes effective teams – because many teams are ineffective;

• Patient-centred: truly, to a point, as Don suggests, that may be uncomfortable. Patients will make choices that seem wrong and even stupid to doctors;

• Communication skills: listening more than telling;

• Comfort with technology: particularly with information technology and a recognition that you plus technology will be much more effective than you alone;

• Understanding of evidence: not just of hierarchies of evidence and randomized controlled trials but of how to combine many different sorts of evidence, weighting them effectively. This is hard, and most doctors will need help, but they will need to understand the questions to ask and that they need help;

• Profound ethical understanding: recognition of the omnipresence of ethical issues and a capacity to think ethically;

• Love of diversity: enjoying working with people from different backgrounds and of different views and skills and recognizing that together we are stronger;

• Enthusiasm for learning: many medical students of my generation were taught at least in part through ‘humiliation’ and that has, I believe, made some of us almost ‘phobic’ about education. But we must not only continue to learn we must love to learn.

By the time I'd finished the working party was glazing over, and I was much too excited by the sound of my own voice. But I'm confident that by taking and weaving together many ideas the working party will produce something of value. The challenge, as always, will be to implement their thoughts – something that depends on understanding systems.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor RS

Contributorship RS is the sole contributor