Ian Morrison

Next week the leaders of British doctors will meet to consider the future of medicine. The BMA, the General Medical Council, the royal colleges, and the departments of health will all be represented. This is the first time that these groups have met at such a summit conference since the Christchurch conference of 1961. That conference led to the present system of postgraduate education. Next week’s meeting occurs against a background of falling morale and is a response to a request to doctors from Ken Calman, the chief medical officer of England. He asked us to look beyond the current turmoil in the NHS to consider the core values of medicine, and on p 1140 he sets out his vision of the future. One thing we know about the future is that it will be different from now. Doctors tired of change may long for a period of stability, but this will not happen.

We must applaud this gathering of the clans of British medicine because all the evidence suggests that groups that look to the future do much better than those that look mostly to the past, hankering for a golden age that probably never existed. The simple fact that these groups, which often disagree in public and in private, are trying to speak with one voice is also important (p 1144). It will be important for the clans to consider how the world will change around them, and this editorial looks at changes that are likely to come in medicine, not only in Britain but in all countries. The clans should remember, too, that the common mistake that people make when looking forward is to overestimate the future importance of short term changes and to underestimate the effect of long term change. That is why it will be wise to look beyond the current turmoil in the NHS and not get bogged down in current grievances.

Medicine everywhere is in the midst of profound structural change. No health service is stable, and five key driving forces will continue to transform the practice of medicine well into the next century.

The power of big ugly buyers is the first driving force. Globally, governments, private payers, and individual patients are placing new demands on medical care. The payers in the health care system are demanding cost effectiveness from doctors. Whether they be purchasers in the British NHS or health care coalitions and large employers in the United States, power is shifting – to purchasers. And those purchasers want much better evidence of effectiveness than is currently available for many medical interventions. “Evidence based medicine” is a phrase that is currently familiar to only a few doctors, but all will know it by the millennium.

The rise of sophisticated consumers is the second driving force. No longer patient, these sophisticated consumers and their agents are challenging the unique authority of doctors and insisting on a greater role in clinical decision making. Patients cannot be treated as passive fodder for medical practice. Increasingly patients are as educated as their doctors. Doctors who have treated patients with AIDS have seen this most clearly, but it is spreading across medicine. The doctor-patient relationship, which many see as being at the heart of medicine, will change fundamentally.

New technology is a driving force that has long had an impact on medicine, and the clans will have a session on this force at their meeting. Molecular biology and information technology, both singly and in combination, will transform medicine in the next century. Total exposition of the human genome will raise new insights into disease and may allow effective treatments where none currently exist. The exposition will also allow new methods of diagnosis and deepen our understanding of disease processes: we will be able to predict disease patterns for individual patients. But perhaps more powerful still be the application of computers and communications to the practice of medicine and the coordination of care. Medicine is an information based activity, yet medical practice has lagged behind industry by decades (some say centuries) in the appropriate use of information technology. Reuters, which has already wired together the world’s financial community, has now taken the strategic decision to wire together doctors and hospitals. The most significant transformations will come from the combination of powerful hand held computers – so called PDAs (personal digital assistants) – wireless communications, and large databases on patients. Together these tools will support the mobile nature of medicine and provide a platform for new approaches to clinical practice in the hospital, the clinic, and the home.

Shifts in the boundaries of health and medicine will be the fourth driving force. Health results from a combination of social, economic, and psychological as well as purely biological phenomena. Most doctors now understand this and so increasingly do politicians; this enhances their reluctance to invest heavily in health services when they have only a small effect on health. As science clarifies our understanding of the complex relation between health and the environment of patients, doctors will be drawn into the web of systems around the patients that determine their state of health. New medical disciplines will emerge such as population health informatics, and old disciplines, such as occupational health, will be transformed.

The ethics of controlling human biology will be the final driving force. The mix of new technologies, cost pressures, and sophisticated consumers is a powerful and potentially toxic one. Death and dying will become a major focus of societal debate in the next century as the baby boomers confront their mortality. The legitimacy of rationing – by both public and private payers – on behalf of the patients they serve will come under enormous scrutiny. Debates on the ethics of rationing will not be solved easily by technical analyses; the battles may be ugly, political, and confounded by issues such as race and poverty. Profound questions will be asked about the rights of people to control and shape their own biology and the biology of the unborn. Deep seated beliefs about life, disease, personality, and death will be challenged by the new biology.

It thus makes sense for the British medical clans to concentrate on discussing the core values of medicine. Willard Gaylin, the president of the Hastings Centre, has written: “The most unfortunate thing about the shuttered process [of American health care reform] is that a remarkable opportunity has been missed. What could have been a wide open, far ranging public debate about the deeper issues of health care, our attitudes toward life and death, the goals of medicine, the meaning of “health,” suffering versus survival, who shall live and who shall die (and who shall decide) has been supplanted by relatively narrow quibbles over policy.” Exactly the same could be written about the debate over health care reforms in Britain and most other countries.

Doctors in most countries currently feel beleaguered. But they shouldn’t fear the future. Doctors will be at the centre of the new health system, but not as autocrats. Their dominance as care givers will be eroded by new tools, technology, and systems of care. But doctors have to have a central leadership role in care teams, policymaking, planning, and management. They will increasingly work in teams rather than individually, and they need to understand better how to be effective team players. If doctors do not take up the challenge of leadership in health care but instead retreat to form a selfish artisans’ union they will be letting down the patients and the society they swore to serve.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This article was published October 29, 1994 in the British Medical Journal.