This book comprises reflections from medical practitioners, academics and educationalists, on factors which they deem to be affecting the evolution of the role of doctors. These include, among others, the changing working environment, regulation and revalidation and the changing demographics of the profession.
As one of the guinea pig doctors who took on District General Manager posts in the wake of the Griffiths Report of 1983 I was particularly interested in the chapter on doctors in management. I have no doubt that people with clinical experience make more effective managers than those from a purely administrative background and that more doctors, nurses and paramedical staff should be actively encouraged to take on management roles after appropriate training of course – I had the great good fortune to be sent to Harvard for health systems management training. I do wonder however whether it is sensible for clinicians to retain a clinical responsibility after they have taken up a management role. It seems to me that the potential conflict in interest between the greater good of the institution in question and its patients and that of the particular clinician’s patients is just too great. In my own case a public health background and perspective meshed in very well with my management role. This being so it rather surprised me that only a handful of my fellow public health doctors chose to become managers.
Having witnessed what has happened to doctors and medical practice over my own 50 year medical career, to me the key influences have been the development and implementation of evidence based practice, the empowerment of patients through the information revolution, the expanding role of other healthcare professions and the increasing salience of management in trying to control spiralling costs. The effect of these influences has been the transformation of medicine from a judgement based profession to an evidence based, checklist/computer aided technology with increasingly blurred boundaries in relation to other healthcare professions, particularly nurses.
It is significant I believe that my own speciality of public health has opened its doors to non-medical graduates. Is this, I wonder, a harbinger of things to come in the clinical specialities? As a budding obstetrician I had no doubt that midwives with suitable training could do all the things I did; and I recall a general surgeon contemporary of mine telling me in all seriousness that training as a seamstress would have been a good basis for his surgical technique. The position of the medical specialities may be different, but I doubt it.
This is not to say that there is not a place for a cadre of medical scientists and epidemiologists to develop the healthcare evidence base. But the future of healthcare delivery surely must lie with a cadre of generic healthcare practitioners applying the knowledge base developed by the scientists with the help of appropriate checklists and computer programs.
Looking more strategically at the country’s needs in an increasingly competitive global environment, one has to wonder whether we can continue to divert so much of our academic/intellectual capital into healthcare rather than into science and technology. It is the case, I am told, that one of the medical schools in Israel rejects applicants with good exam results for this very reason.
If I could turn back the clock would I choose medicine as a career now? The profession has changed out of recognition since I decided to become a doctor at the age of 10 years. The idea of being a professional with all that this meant in terms of status and independence appealed greatly then. But medicine is no longer a profession and today it would be the challenge of being an entrepreneur, living on one’s wits and hard work, that would attract.
So an important book with interesting contents that has also stimulated some thinking about where medicine is going. Billed as being aimed at doctors and medical students seeking new strategies for understanding and managing change; and at sociologists and policy makers, it fulfils, I believe, a useful purpose.
Paul Walker, June 2013
Publisher Radcliffe. ISBN – 1 3: 978 184619 991 2