Reinventing the Modern Day Physician: Why Every Doctor Needs to Act, Soon…

Dr David KL Quek


Recent developments in our health care scene have cast a shadow of uncertainty over the aspirations and livelihood of more and more Malaysian doctors. Increasingly, we are becoming a disenchanted and frustrated lot.

Large corporations have taken over many private hospitals or set up new ones with such rapidity and sweep that many doctors affected by such manouevres have become so shell-shocked and stunned to disbelief, that they are now still reeling from the reality of it all.

Managed care organizations and other unchecked third party payers have entered the fray of carving out a piece of the health care pie. This is especially so, because there is no straightforward policy, direction or regulation from the government. Ambiguous and yo-yo pronouncements and sideshow manoeuvrings by related industries and quasi-government agencies have only served to spark these outcroppings of companies all scrambling for some piece of the action.

Hospital care especially that of private health care facilities have suddenly become cold-blooded health care business, with businessmen and managers taking increasingly powerful charge of almost all aspects of what has hitherto been a physician-controlled phenomenon. Patient care has become the bottom-line targets of the profit and loss adjudicators.

Doctors have become the easy target for cost-control, and are increasingly squeezed for discounted professional fees or even capitation. Never before has a noble profession been so humiliated by having its potential earnings and livelihood so rudely curbed in a supposedly free economy.

Instead of natural expectations of any citizen to earn an increasingly higher salary, physicians now face the bleak future of having their potential earnings contract, year on year. Are we surprised as to why doctors are now so demoralized and cranky? Should we as health care providers be smiling and gratified that we would now have to share our hard-earned efforts and just rewards with third party interlopers and paper pushers? Perhaps, we have let ourselves become transformed into "hamsters on a treadmill", by our petty in-fighting and inward-looking attitudes thus far. We have to learn to envision something far better and grander if we are to remain relevant in the delivery and practice of medical and health care for the future.

Doctors especially private specialists are now caught in a bind of having to treat patients on a shoestring with many potential decisions being hamstrung and second-guessed by bureaucrats who have been put in place to curb rising healthcare costs. Unfortunately, in the light of dazzling advancements of medical technologies and equipment, expectant patient demands for such tertiary or quaternary care have also multiplied.

Doctors have always been exhorted to improve themselves, and they have, by and large. In their zeal and effort to keep up with these advances in medical care and therapies, many have needless to say, immersed themselves at huge expense and sacrifices, into learning the applications of such new techniques, only to find that invariably, the health care cost has mushroomed in tandem. There is no doubt that, new technologies and new treatment modalities are part of the reason why health care cost has continued to escalate. But as caring physicians we all have to take stock to see if such developments and advancement are truly cost-effective in prolonging survival, and more importantly in improving quality of life. Otherwise, we shall all be caught in the inescapable grasp of the ever-advancing medical-pharmaceutical-industrial juggernaut, where we become mere bit players.

What can we do? Where should we be heading? These and a whole lot of other questions need to be addressed, and very soon. We have to take the leadership to plot our health care future, so that as healthcare providers, we can play a more meaningful and satisfying role. In short we need a momentous paradigm shift to reinvent ourselves to remain relevant in our role as health care players in the future.

In a recent book (Health Care in the New Millennium, 2000, Jossey-Bass Inc., Publishers, San Francisco, USA) health futurist Ian Morrison, describe with excruciating detail why the health care status and industry in the US and in the world, is in such a mess. Regarding health care providers, Mr Morrison has this to say: "Medical practice has impressive new tools but ancient models of organization and delivery of service." He feels strongly that we as practitioners have been languishing in too confined a space for far too long – "we are flailing around inside 1 percent of the possible space. What follows is a start on how to get at the other 99 percent."

In this must-read book, Ian Morrison identifies five key dimensions, which he believes will have profound and serious effects on our medical practice, as we enter the new millennium. These are: new medical technologies, new information technologies, consumerization of health care, reimbursement methods, and organizational forms. This month I shall discuss the first of these imperatives, i.e. coping and changing with the onslaught of new medical technologies.

New Medical Technologies are transforming the way and manner in which we practice medicine. Not only are diagnostic and therapeutic tools multiplying, the imminent exposition of the human genome will radically alter the way some if not most of all ailments will be managed or treated. Genetic and molecular biological methods might be the way to go in the near future, say within 10-15 years. Not only that, there has been tremendous amplification in the field of nanotechnology (microscopic chips or devices—in nano-meters dimension!—that could conceivably act within tiny blood vessels or tubes, in any organ or tissue to clip away or clean up muck or unwanted cells or debris). How then can the physician of the future cope with such changes? He has to adapt and change fast.

Six core functions that physicians will have to perform better in the new medicine are as follows:

  1. Clinical Data Collector: Because physicians have a unique mastery and skills at data collection through sounds, sights and images presented to them – they are likely to continue to play a role in the collection and interpretation of such derived information. Whether or not ever newer technologies such as miniaturized MRI or CT or PET scanners continue to be developed into amazing or extremely sophisticated machinery or otherwise, they can be learnt by physicians who will remain best placed to utilize, interpret and manipulate their results. Our role may be reduced, but they cannot totally vanish. But we cannot allow ourselves to become more and more ignorant.
  2. Shaman: Modern physicians often underestimate the power of their role as healer. Ian Morrison calls this the "shaman factor" which he believes will continue to be important in a world of machines and digital intelligence. He also alludes to the spiritual aspects of birth, illness and death, which he reckons will require the soothing ceremonial role of the physician, or if not them, practitioners of complementary or alternative medicine. We will have to learn to fight the battle for the beliefs, the wills and the hearts of our patients. Or they will find some one or some thing else…
  3. Health Adviser and Wellness Coach: Many if not most people know most of the unhealthy things and risks factors what affect their lives, but they do them regardless. Many patients have great difficulty being compliant with medications, and they need the still persuasive powers of the physician to set them on the right course—albeit through repeated cajoling and reminders. Through the extended use of the Internet, it might be conceivable for each doctor to personally e-mail a reminder message, pose questions or collect data (e.g. body weight, blood glucose or BP, etc. through self-monitoring) daily and interact with the patient on a one to one basis. These may be computer generates, with automatic response analysis made on-line. Periodic voice-mails may help foster gentle reminders and compliance, and the worried can be soothed electronically!
  4. Knowledge Navigator: A recent Harris poll carried out in 1998 showed that some 60 million Americans logged on to the Internet for health information, and that some 91 percent found what they were looking for. Does this imply that we as physicians will soon become obsolete? Not quite yet. Why? Because, like it or not the deluge of such unfettered information obtainable from the World Wide Web is largely unstructured, unfiltered and totally disorganized without any authoritative sieve on what is factual (truly and scientifically ratified or accepted) or pure fad or nonsense. Increasingly it is becoming more plausible that physicians will be called upon to help make sense of all these information largesse—we will be needed to interpret, synthesize, customize and synergize the knowledge for practical use and application by our patients. In other words, our input will become more refined but nevertheless crucial, in harnessing these new age knowledge tools for our patients’ benefit. Individuation of what is important, relevant or beneficial to each singular patient will still be within the realm of the physician’s touch, albeit with less stringent or god-like clout or authority.
  5. Proceduralists: In the near future at least, doctors will still be required to be physically present to perform many procedures—diagnostic or therapeutic. Despite the onslaught of newer technologies such as nanotechologies, robotic or micro- or noninvasive surgeries, or sophisticated pharmacotherapeutic measures, highly trained and re-trained physicians will still be necessary to control or actuate these procedures. True, some of these might be greatly enhanced by robotic refinements, or keyhole visualization techniques. But human input is still for some time mandatory. Cutting, scooping, groping (palpation), ballooning, etc. will still remain within the hands of the physician. Health care decisions however, will have to be tempered with a whole lot more of patient input through their incremental information empowerment, ultimately for the better, as they have to take cognizance of their role in maintaining their own health or condition.
  6. Diagnostician: While it is easy to imagine a future where a Star Trek-like machine (big or small) can be used to scan the human body and make all the diagnoses, this is not the reality in the near future. There are simply just too many variables and intangibles associated with medical decisions and diagnostic examination, which have so far remained within the trained acumen of the physician. Powerful supercomputers in the future can possibly replace our role in this aspect; however, we have yet to cope with the non-specificity or imperfect sensitivity of machine-based approach. As physicians we will have to refine our role in becoming even better at utilizing all these powerful tools to synthesize and diagnosticate even more superlatively. We should become even more expert at collating all such multifarious inputs and make better quality and productivity judgments, by being capable of developing decision-making frameworks for our individual patients.

In this regard, we might have to be more pro-active at re-learning and re-training to keep up with these stupendous changes. Needless to say, those less savvy or laggard will perhaps be edged out in the process. It therefore, behooves the physician to start re-orientating his mindset, now, before these new technologies totally overwhelm him. The time to act is today. Act by being more self-empowered, more interested in the changes, which are swamping us as we speak. I believe we can emerge more involved, more at peace with these paradigm-shifting quakes.

30 April 2000

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