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.