Richard Smith: Time to get rid of health professionals?

Richard SmithCan we imagine a world 20 years from now that no longer has health professionals? Instead of regulated health professionals anybody could offer healthcare—and perhaps much of it would be healthcare rather than sickness care. Patients with diabetes might offer care to other patients, and robots with superior technology might  provide round the clock not episodic care. Drug companies might deal directly with patients.

Crazy as this might sound to the 2011 mind, a group of us—all long standing healthcare lags—have been thinking about this question. We were inspired to do so by John Moore, a young doctor who tired of the traditional model of healthcare and moved to the [MIT] Massachusetts Institute of Technology Media Lab to invent a new model. The director of the lab, Frank Moss, says:  “We’re literally looking to break the 500-year-old asymmetry that exists between the high priests of medicine—the clinicians and the physicians—and ordinary people.”

Moore is convinced that the old model isn’t working. It is a “paternalistic and episodic” model of care that only pays lip service to shared decision making and “coproduction” of health. Doctors trying to fix things for passive patients doesn’t work. It may have worked, I reflected, in the brief historical window when doctors had effective treatments like antibiotics and patients had fixable conditions like meningitis, but little of healthcare is like that now. Healthcare is now overwhelmingly about patients with long term conditions, often more than one, and progress depends on the patient taking charge. Half of patients don’t take their drugs as prescribed, and at least in the US, says Moore, half of patients don’t agree with their doctors about what to do. “In healthcare,” says Moore, “we treat people as if they are stupid and assume that those over 75 can’t use technology.” We are wrong on both counts.

The new model of health care proposed by Moore is built on three principles: firstly, patients are a grossly underused resource; secondly, healthcare happens in the real world where patients spend most of their time, not in the surgery or hospital; and, thirdly, simply sharing information is not enough, rather there must be complete transparency for the benefit of education.

Moore has built a range of sophisticated but simple to use tools that allow patients to manage their own conditions, but it’s the philosophical change that is most important. He described how a patient newly diagnosed with diabetes might spend two hours with “experts in diabetes” (perhaps doctors but perhaps not), be given a range of tools to help him or her, and then be told to go away and not come back. Instead of a lifetime of attending a diabetic clinic the patient would be in charge.

And the way to make this change happen is not to mandate it across a system but rather for one centre to try it, get it wrong, try again, and arrive at a workable model. Everything from the number of patients, the floor plan, the technology, and the payments should be open. Others will then begin to copy the model. It’s disruptive change we need, says Moore; incremental change can’t make a difference—and it creates mayhem. There is much risk in the new model, he says, but there are also huge gains.

I must confess that I find all this very encouraging because as I approach the end of my career it takes me back to my beginning. “In my end is my beginning,” wrote T S Eliot, copying Mary Queen of Scots who embroidered the words while in prison. Eliot also wrote: “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.” When I began clinical medicine in Edinburgh I rapidly began to feel that much of what went on was more for the benefit of the doctors than the patients. Then I heard Ivan Illich argue that medicine had expropriated traditional ways of dealing with death, sickness, and pain – the eternals of life, with false promises of defeating all three. Illich, a critic of industrial society, professionals, and coercive institutions, and long dead, is now described as the father of Wikipedia. Perhaps he can also be the father of a new kind of healthcare.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

  • Oliver Francis

    And of course Eliot also said in the same poem, “The whole earth is our hospital / Endowed by the ruined millionaire.”

  • It is human nature to seek explanations for suffering, see
    Job in the Bible or the first two volumes of the ancient history of medicine by
    the great Henry Sigerist for details. We have un-bunged the pill-bottle and
    released the genie of modern medicine and done our damndest to take on the
    ancient roles of priest (or mystic), herbalist, midwife, bone-setter, friend
    and counsellor, and more. It is interesting that in spite of this, and the
    considerable overlap with what we do and other ‘traditional’ keepers of these
    roles, we have done very little to dent the ‘alternative’ health industry. In
    fact there appears to have been a resurgence of interest, perhaps because of
    our focus on the biological rather than the personal or social aspects of
    suffering.

    What seems likely is that people choose the interpretation (and hence the
    ‘healer’) that fits with their belief system and so my initial response to
    Richard’s question, “What would a world without health professionals
    look like?” was, “A world full of health non-professionals’; mystics, misfits and alternative mercenaries.

    But I think distance has alienated him from the sophistication present in
    general practice today. We GPs, whilst not on the whole cognisant of our ancient
    heritage, are the heirs of our mystical forebears, first and foremost here to help
    our patients make sense of their symptoms.

    The largest part of a GPs job is to manage the interface between suffering
    (what the patient presents with), illness and disease. Only for a minority of
    the cases of disease are patients referred to our specialist colleagues. Our job, far more than diagnosing
    disease, is to diagnose or provide an explanation for ‘non-disease’ in other words our job is to help our patients cope
    with illness and suffering without imposing a medical diagnosis. Even for
    patients with established diagnoses such as diabetes or heart disease, most presenting
    symptoms are ‘non-disease’; they are real, somatic symptoms (not imaginary) but symptoms
    nevertheless that can only be managed with the skilled support of a trusted GP; trusted because we are able to recognise when we need start wielding our prescription pads and scapels.
    This part of our job is the most time-consuming, challenging and valuable,
    protecting patients from unnecessary medical intervention, helping them to build on their own strengths and resources, and ensuring that our specialist colleagues, based more firmly in the realm of disease, can work more effectively. This interpretive work we do cannot be measured in terms of productivity; there is no
    product, no measurable difference, no data gathered, no drugs prescribed, blood results
    generated, biometric data tweaked. It is invisible work and the reforms
    threaten this by turning patients and their care into commodities which require
    value adding at every interaction.

    GPs, rightly understood as the intepretive heirs of the ancient ‘medicine-man and woman’ are here for good.

  • A_spurrier

    Agree with these sentiments. A lifetime of nursing has taught me that many individuals 'love' being ill and receiving the attention it generates. I remember the furious reaction of one individual on being informed that their tests had revealed a healthy heart…..'Dont be ridiculous, I've always had a weak heart'. Blimey, of course. no illness, no tea and sympathy.How are we going to get these people to take responsibility for their own health? These ideas will cause a revolution, I'll be out of work homeless and hungary. But, I like it.

  • Joseph

    My father trained as a doctor's helper in the Northern Rhodesia part of the British Empire 1942-44. His foresighted teaches taught him that if patients survived long enough, they would take over the work of doctors. Science only improves if  ectopic eccentric minds pursues their “crazy” ideas. As current cohort of clinicians world slow down to retirement, Max Plancks wisdom will still hold true: “science improves funeral-by-funeral”

  • visiting asthmatic

    True, I have long felt that for my asthma I should deal directly with the pharmacist. The doctors un and ah a bit but generally give me exactly what I ask for, medicine-wise. It's years since I've learnt any tips on asthma management from a doctor, and when I have to change doctors the new ones tend to prescribe conservatively, which has predictable (to me) results, and additionally stresses me out, until it's sorted!

  • Greg Irving

    Illich also claimed: “Medical interventions have not affected total mortality rates, at best they have shifted survival from one segment of population to another.” Was he right?

  • Because it took so long (about 18 hours) for my comments to appear here I assumed they'd been moderated and rejected, so posted a different version on my blog at http://abetternhs.wordpress.co

  • Deborah Verran

    Not yet time to get rid of all health professionals why? Because  the health professionals can become 'the conductor of the orchestra' so to speak particulalry for patients with chronic disease. What is the orchestra-the advice on lifestyle, the advice on prevention, medications, treatments, other professionals/organisations.

    Certainly some patients in the new world[aided by information technology], will have the skills to predominantly self manage their condition. However many people in the community will need more than a few instructions to self manage and this is where the professionals will need to assist

  • hellogoodbye

    I guess it will be good business for the Holiday Inn Express.  Stay there and then you'll be able to operate on yourself, or take care of ICU patients, or administer anesthesia.  Or pick out the appropriate cancer treatment for yourself.

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