Serving the community is a definition of medicine but will the risks one day outweigh the rewards?
Set against a backdrop of inevitable reform brought on by technology and unsustainable health care costs, the 
discussion at the first Doctors Drum of 2017 took some interesting turns – from work-life balance to artificial intelligence – and how these might impact on the medical profession in the future.
Medicine was a healing profession, said one of the panellists, and as such was a community service. It was also the reason why most doctors entered it in the first place – to make a difference. However, that could take its toll on the health and wellbeing of individual doctors and their families.
Past, Present & Future
The April e-poll shows that about 55% of respondents thought new doctors were not ably trained to tackle problems in the community – so was that a question of training or a generational shift?
One panellist remarked that there seemed to be a sense of complacency amongst junior doctors – rather than exploring routes such as research, they opted for job security and a work-life balance.
“I want to hear people say they want to change the world and improve the lives of others when they go out to their first clinical rotations. We are seeing people who are increasingly focused on a career, lifestyle and income. That is a big generalisation because we as doctors are in a luxurious position of being able to go home knowing we’ve done something bigger (people’s 
health and wellbeing) than simply making money.”
But as another pointed out: “older physicians always seem to say young doctors come out of medical school not knowing anything but knowledge evolved. In looking at the medical education of tomorrow, we have to keep up with society’s expectations.”
Those expectations meant more community medicine.
“We have come a long way with problem-based learning and changing the focus of medical schools towards the patients’ needs and community’s needs but we have to turn the training model to where medicine is practised, which is in the community. That will be intensely uncomfortable for a lot of people but we need to do it.”
Work-Life Balance
The old chestnut in any discussions about ‘then and now’ is the number of hours spent at the coalface. Few if any in the room thought that a return to the bad old days was a good thing. However, while acknowledging that this issue was pendular, some wondered if work-life balance had swung too far into the relaxed and comfortable zone.
One doctor said a good work-life balance meant happier and more productive doctors but if that increased the challenge of meeting ‘demand’, the solution was teamwork. It created a better working environment and better outcomes for patients.
While most agreed the ‘old normal was abnormal’ one doctor suggested that with greater doctor numbers, it should be easier for doctors to look after themselves better and to have longer careers, which meant they could care for their patients better.
Bucking the System
The alarming and tragic incidence of suicide in the profession, particularly among junior doctors, was raised. One doctor said she had run around looking after her community and missed out on her children growing up and she now felt very badly. “That old normal is incredibly abnormal.”
A registrar in the public system spoke out about the demoralising work junior doctors were asked to perform. “Increasingly, interns and RMOs are treated as cogs in this big patient flow machine where a manager tells them what they can or can’t do to a patient. If your job is to put in the cannula, that’s all you do. There is no emphasis on getting to know the patient, to get passionate about the patient’s issues or have time to research because when your shift is over the emphasis is to get you to leave.”
“The community has a very different idea of what doctors should be doing with their patients and that is what medical schools encourage you to do. The reality of being a junior doctor is so different from what they told as when we were students, it’s understandable we get disheartened.”
Another DiT said her time was spent behind a computer screen doing discharge summaries with computer systems that were ‘heinously’ cumbersome.
One doctor who works in the palliative care field said when med students and RMOs came to the service on rotation, they all “absolutely love the experience because they have the time to talk to patients and communicate with them. They find that very satisfying and often say it is what we were trained to do.”
One panellist suggested that while stewardship was essential on issues such as antibiotics use, doctors were losing the ability to act on what they instinctively knew.
While a focus on quality and safety unquestionably resulted in better outcomes, junior doctors were intimidated and some consultants did not give their registrars room to grow and make treatment decisions. It should be about leadership rather than control.
One voice said our system had become very bureaucratic and it did not respect doctors as professionals who were able to make independent decisions. “Evidence comes from the scientific literature but a part of that evidence comes from our patient’s perspectives and what they want out of their life. If we have the freedom to practise like that, then we will be doing good and feeling fulfilled. But if we let generic managers and bureaucrats lead our profession, we will become functionaries. We have to fight against it because we are fighting for what we’ve been trained to do.”
The Robot Will See You Now
The rise of system-based medicine had one senior doctor rueing the loss of self-determination within the profession.
“When the medical profession felt they ran the show in hospitals, they took responsibility for own education, governance – you took pride and you stood out. That has been taken away at the hospital, governance and government levels and young people are told ‘don’t get above yourselves, you’re a worker just like us’. It’s not surprising people stop work at 5pm.”
But this angst could all be for nought.
“We are holding back a dam wall here and the profession has to change. Medicine of the future will be managing computer programs. Kaiser Permanente in the US has data that proves a computer-based algorithm is much more effective in managing patients than a doctor’s brain. The art of medicine is increasingly becoming a thing of the past,” one doctor said
Medicine urgently needed leaders in the profession to take charge of the technologies otherwise tech companies will take over, said another.
“Our inherent conservatism as a profession will be the killer of us all if we don’t take charge. I am heartened though because I do know there are young people like those who are here today who are passionate and committed but you have to be subversive in order to bring the profession forward and we need to stop putting up barriers for them to take us forward.”
So what is the role of the doctor of the future?
“It is the human side we need to promote,” said one. That’s what people are going to want and right now the system is being dictated by a series of metrics, so we have to reassert the human side. Whether you believe it or not, the computers are coming. Patient outcomes will improve but patient satisfaction might be a different story.”
“Medicine has to stay a human, caring profession and we must adapt to preserve our role as something that’s critical in a person’s treatment. Some people will have to put their heads up above the parapet and some may get their heads chopped off but we need to act.”
Patients as Consumers
Along with the rise of the machines, increasingly, patients are asserting their power as consumers.
One panellist said some consumers didn’t want to have a relationship with a doctor. “They want a diagnosis and the right treatment. Perhaps, commonly, in older people with chronic illness, that relationship with their doctor is fundamental in the management of their condition but if machines become so good at mimicking humans, perhaps people won’t know if they are talking to a person or a machine.”
Communication could solve a lot of the problems. One doctor recounted the hospital journey of one of her patients where complex and successful medicine was performed but no one spoke to the patient throughout the process, leaving the patient unhappy.
Another added: “I see a lot of patients at the end of their life who have had months of expensive rounds of chemo and radiotherapy and doctors in the hospitals have not even looked them in the eye to ask them if that is what they wanted. If they had, they would have saved a lot of time and as a result a lot of money.”
The power, said one, resides with the doctor.
“If we don’t start looking our patients in the eye, we will be taken over by celebrities who will freely give their advice. If we are not communicating in the way our patients want us to communicate, we will go down the gurgler because there are plenty of other people who want to do it.”
