Who needs doctors? Staying fresh in changing times
Abstract
As society changes, doctors must adapt. Despite remarkable advances in medicine, the pace of change–greater now than ever–is challenging doctors to define their role and relevance. Is medicine really facing a crisis? Are claims for a malaise in medicine overstated? Regardless, the profession has been called upon to respond collectively to change. However, clinicians as individuals will need to be equipped with a strategy for embracing and enjoying change. Approaches will vary but one constant should be a steadfast adherence to the scientific basis of medicine as a way of thinking. Engagement with the medical humanities will also help doctors stay fresh and deepen their understanding of what it feels like to be ill. In so doing, clinicians will find inspiration in the ordinary.
Everything has been said before, but since nobody listens we have to keep going back and beginning all over again.
Andre Gide, Le traite du Narcisse (1891)
Doctors have always adapted to change, but as the pace of change escalates, they are being challenged and their role questioned. Despite the achievements of medicine, modern society is more doubtful about the medical profession and, although healthier than ever, is more concerned about health.1 Alternative medicine seems to increase in popularity as the medical profession appears less professionally fulfilled. ‘Who needs doctors?’ shouts the cover of one American news magazine,2 while commentaries in medical journals abound with negative titles: ‘Unhappy doctors’; ‘Modern medicine stuck in a rut’; ‘The failure of medicine as an art’; and ‘Do doctors have a future?’. This is also reflected in the language of a report from the Royal College of Physicians on changing doctors in changing times.3 The report is speckled with adverse terms and references to doctors: ‘medical profession…on the back foot’; ‘malaise’; ‘many doctors seem unhappy’; ‘the doctor…out of time’; and ‘need for clarity in the role of the doctor’.3 Physicians are called upon to take a more active role in shaping the future. Greater commitment to leadership and more emphasis on health maintenance are sensible tactics for a profession seeking to secure its influence on the welfare of society, but the greatest challenge will be ‘partnership’, otherwise known as the doctor–patient relationship.
Over a decade ago, an editorial opinion predicted that of the many drivers of change including super-specialisation, molecular medicine and evidence-based everything, the most radical changes will relate to the doctor–patient relationship.4 This relationship is complex and influenced by trends within society. Analyses in the past tended to focus on how doctors think about the diagnosis, but elusive diagnoses have become rare. The outcome of the relationship for the patient is also dependent on the professional welfare of the doctor, which needs attention. As the profession responds collectively to the challenges of a changing world, individual doctors need to stay fresh and adopt a robust approach that can enable them to embrace and enjoy change. This is not something that can be tackled by some form of ‘up-skilling’ or delegated to continuing medical education (CME) and re-certification. This is a matter of attitude and approach to medicine.
Doctors will adjust to economic, social and demographic trends in society, but some may be challenged by, or miss out on, the promise of advances in science and technology. How much of the malaise that is said to afflict modern medicine is attributable to the influence of information technology on the doctor–patient relationship? The advent of desktop medicine, checklists, guidelines, algorithms and protocol-driven practices raises questions about the role of doctors in certain clinical situations. The vista for some generalists is that of a triage agent. For many non-complex disorders, doctors could be replaced by other healthcare personnel who may be more at ease deploying protocol-driven routines. Doctors may also be unnecessary for many routine diagnostic and therapeutic procedures. The human hand can be removed from surgical interventions by robotics and it is doubtful whether senior clinicians are best suited to interventions that require little more than the hand-eye coordination of youth. Even greater change can be anticipated when disruptive innovations in technology become more accessible to the public. Access to information technology was unimaginable before central mainframe hardware became supplanted by personal desktop equipment. Similarly, biotechnology is moving from the clinic to the home. Nano-diagnostics are opening the way for personalised diagnostics with advances such as capsule endoscopy and rapid throughput kits for biochemical profiling and even genotyping. Armed with such information, patients need a new deal from the doctor–patient relationship. But this is no crisis. This is an opportunity for enhanced not diminished doctor–patient engagement. Clinicians who stay close to science and the scientific basis of medicine will remain relevant, valuable and distinct from other healthcare providers. Science gives us a way of thinking. Those who stray from it are at risk of losing their passion for medicine, are likely to become vague, bored and increasingly irrelevant. Science opens minds, encourages self-questioning, critical thinking, respect for alternative opinions, generates ideas, informs decisions, raises the standard of public debate and promotes tolerance of change. Clinicians who are well grounded in science can embrace the opportunities that come with change and are more likely to influence the future.
Of course medicine is neither science nor art alone; it is, perhaps, a science of an art. Doctors need to be curious about how humans work, but they also need to care about humans. Science can foster interest and enthusiasm, whereas caring requires an understanding of what it feels like to be sick. If doctoring were just a matter of tackling the objective manifestations of disease, doctors would be dispensable. The subjective experience of disease makes illness unique and this requires empathy and understanding. The latter are required not only for professional effectiveness but also for professional fulfillment. Understanding what it feels like to be ill does not flow automatically from texts and other traditional sources of medical information. It can also be eroded when clinical practice becomes repetitive or routine. However, one can find inspiration in the accounts of patients and others, in film, other visual arts and even in fiction.
Doctors should read what their patients read. Most of the great writers and thinkers have had a lot to say about doctors, disease, life and death. Contemporary literature is a valid part of the historical record of society; in contrast to the objectivity and abstract nature of factual reports, literary works are a more memorable and accessible portrayal of the context and impact of disease and what it means to suffer from disease. Narratives and fictional accounts of illness are an effective learning tool that can inspire clinicians to be better listeners and to care more about what their patients say.5
There is opportunity to better equip trainee doctors for change. Medical school curricula no longer need to be bloated with factual content. Rapid access to information means that knowledge has lost some of its value; greater emphasis can be placed on curiosity, critical thinking and the scientific method. This should include more time for critical appraisal of the medical humanities as a means of exploring the impact and context of disease. The limitations, as well as the lessons, of narrative and fictional accounts of disease are open to debate but the debate deserves to be part of the core curriculum, not relegated to elective time. A lot goes into the making of a doctor, but essential ingredients include passion and emotion mixed with science.6 The same blend will work well regardless of the challenges and opportunities that change may bring.
Doctors are privileged in many ways but mainly because of their interactions with patients. Change need not diminish this. Medicine is still wonderful, unpredictable, frustrating, challenging, and marvelous in its contribution to mankind. Doctors can stay fresh in changing times if they steadfastly uphold the scientific basis of medicine as a way of thinking and if they adopt the medical humanities to deepen their understanding of what it feels like to be ill. In so doing, clinicians will find inspiration in the ordinary, and their relationship with patients will be fulfilling and forever valuable.
Acknowledgement
The author is supported in part by Science Foundation Ireland.
- © 2011 Royal College of Physicians
References
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- Porter R
- ↵ Who needs doctors? US News & World Report 31 January–7 February 2005.
- ↵ Royal College of Physicians. Future physician. Changing doctors in changing times. Report of a working party 2010London: RCP
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- Garden R
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