Trends
transforming the futures of General Practice and Practitioners:
Or
is there a doctor in your future(s)?
Sohail Inayatullah
FUTURES
To
begin with, the purpose of futures thinking is only marginally
prediction. More important is opening up the future to alternative
interpretations. This allows a discussion, a debate, of alternative
presents. Basic assumptions of what we believe is most significant,
what we think is the true state of affairs, and how best we desire to
change the world can thus be questioned.
To
understand the future, futurists tend to use a range of methods. These
include:
- Trend
analysis – a quantitative approach to the shape of change
- Emerging
issue analysis– the search for issues that have the promise to
foundationally society. These issues are often irrelevant to
immediate strategic concerns but crucial to map as they can
sidetrack any strategy.
- Scenarios
– stories or pictures,
considered an easy and elegant way to map the future. Scenarios
can be global, operational, convergent or divergent.
- Visioning
– determining the future one desires
- Anticipatory
Action learning – quite the opposite of strategic planning
consisting of creating the future through experiments, and then
following a cycle of reflection, action, reflection, always
questioning and improving the process.
This
said what are the likely futures of general practice in the next ten
to fifteen years? Which trends are opening up the future and which are
constricting what is possible? To
understand the future we must find a balance between our personal and
collective desires as well as with structure -real economic,
political, technological, cultural drivers and forces that are already
creating the future. Indeed, while many claim the future five to ten
years hence requires a crystal ball, the opposite is true. The
short-term future is the known future, forces, giant waves of change,
are already underway. While we can ride these forces, little can be
changed.
Merely
desiring other futures in the short run, while important in setting up
alternative action steps, generally can change very little. Thus the
need for an expanded time horizon in which real change is possible.
TRENDS
TRANSFORMING GP FUTURES
Five
trends are crucial: Globalisation, the internet revolution, the
genetics revolution, the multicultural swing and ageing. The first two
are full blown trends while the latter three are emerging, and will, I
believe, create futures that we are unrecognizable to us today.
Globalisation:
For
the general practitioner what is relevant is that Globalisation leads
to:
1.
More and quicker access to news and technological breakthroughs
elsewhere. This is true for doctors as well as patients. Moreover,
under the pressure of Globalisation, universal definitions of health
are far more difficult to hold on to. [1]
2.
The corporatisation of businesses, partly the buying out of
national business to global players, but as well the adoption of the
corporate business model for all service providers. For small
practices, corporatisation usually means vertical integration. At the
national and global level, it means the merger of giant pharmaceutical
companies. Doctors will have to develop strategies to fend off
vertical integration (through strategic alliances) or through setting
up of their own national corporation or at the very least ensure that
corporatisation occurs on their terms.
3.
Globalisation is also a direct challenge to the welfare state
model, in the health field to the idea of universal cover.[2]
Whether for ideological reasons (privatization or market forces are
more efficient and better meet customers’ needs) or cost reasons
(ageing of population, medicalisation of illnesses) universal health
care, as achieved in advanced OECD nations, is under threat.
4.
While the debate between cradle to grave versus a mix of
private/public or totally private goes back and forth, Australia's
generous model of Medicare is unlikely to continue.
5.
Globalisation also changes the governance context of health
futures. It makes national boundaries far more porous. While not
eliminating the nation-state, it certainly makes action at the very
local level (the shire council), the associative (with local and
transnational non-governmental organisations) and at the very global
(the entire host of UN families, WHO), far more potent.
However the de-evolution of responsibility has generally not
come with concomitant funds, thus changing the local-federal power
relations and expectations. However, this loss of local funding has
been partly solved by an expanding civil society, the gamut of local
and international nongovernmental organisations, from Medicine sans
Frontiers to Amnesty International.
The
Internet Revolution (IR)
Working
in tandem with globalisation, indeed, accelerating this process is the
.com revolution. While
currently this is web-based, very soon this will expand to higher
levels of virtualisation. This will lead to the always on, wearable
computers, or web-bots. These
emergent health bots may take a robotic form or a more virtual form
– either a robodoc or an always- present doctors.com.[3]
In
a rudimentary form, telemedicine is already current underway in
Australia (2000 hours of
consultations are conducted monthly)[4]
and consists of:
·
tele-assistance,
consulting with doctors using email and videoconferencing
·
using
nurses to preform simple procedures supervised by video-linked doctors
(remote supervision)
·
Access
to research data bases as well as potentially a medical records
database
The
justification and goal of telemedicine is to use technology wisely so
that the institutional care costs (21billion dollars of the 46$billion
Australian dollar budget) are reduced.[5]
However,
we should not be lulled into thinking this is a win-win technology.
The internet revolution will take away business for certain GPs.
Individuals are already going to doctors.com sites for general
informational purposes. Overtime this will lead to therapeutic
assistance. Already webmd/Healtheon,
the .com business, is a huge business in the US, currently capitalised
at 8.5 billion. Moreover,
while at a superficial level it appears that the information era means
that economies now enter win-win relations (passing on information to
another does not diminish one’s own information in contrast to
passing on raw materials to others), in reality those who enter the
new economy first create infrastructure monopolies or lock-ins. The
smart get smarter and instead of diminishing returns there are
increasing returns. Earlier
entrants into the internet – digital doctor space – will be able
to capture attention, visual space, one of the most important
characteristics of success in the new economy. They will grow and have
an advantage over traditional practices as well as later cyber med
entrants.
Moreover,
our understanding of cyberspace should not be limited by its current
function. For example, in the near term future, sensors will be
developed that detect health problems through the smell of breath and
alert doctors for early diagnosis.[6]
As
the web develops, we can anticipate health-bots or health coaches,
that is, always-on wearable computers. They will provide
individualized immediate feedback to our behavior, for example,
letting us know caloric intake, the amount of exercise needed to burn
off the pizza we just ate. They will also let us know the make-up of
each product we are considering purchasing, helping us to identify
allergies, for example. [7]These
intelligence computer systems would be reflexive knowledge systems,
learning about us and our preferred and not so preferred external
environment.
Writes
health futurist Clement Bezold:
Future
approaches to heart problems reflect ongoing changes in health care
and biomedical knowledge. In 2010, our DNA profile will be part of our
electronic medical record, and our genetically based proclivity to
major diseases, including heart disease, will be known. There will be
sophisticated, low-cost, noninvasive or minimally invasive
biomonitoring devices; for example, a wristwatch device will provide
very accurate, ongoing information on your health status.
You
will likely have powerful in-home expert systems, probably supplied by
your health-care provider, which will not only aid diagnosis but also
reinforce pursuit of your chosen health goals. These expert systems,
or electronic personal guides, will tailor the information to your own
knowledge level, interest level, and learning style, as well as those
of your family members, each of whom would have a personal electronic
“health coach.” If you are genetically or otherwise inclined to
heart disease, your coach will encourage specific preventive measures[8]
The
assumption here is that 50% of the variance of the causes of
preventable premature death is due to behavior (20% genes, 20%
environment and 10% is related to medical care).[9]
It is this 50% that that the health-bot – the
health professional on a wrist – will help us manage. [10]We
can always take it off unless insurance companies step in and require
their continuous use for cheaper premiums. Of course, geneticists
argue that genes play a much bigger role than 20% and it is genomics
and germ-line engineering that will have a far more profound impact on
our health.
The
questions for gps is: will doctors.com
and health-bots squeeze traditional practitioners or give them
a new way to meet patient's needs? Can GPs help design the content of
these new health tools or will they be passive recipients?
In
the long run, this means that there will be smarter consumers who will
check on research studies and be able to maneuver in a world of
conflicting data and conflicting paradigms. Smarter and more empowered
consumers should make the jobs of GPs easier.
However, as smart cards and health-bots continue to evolve,
their intelligence will certainly reduce doctor's visits, saving money
to the health system but as well forcing GPs to reconsider their role
in the health system. GPs, however, will need to quickly become
net-savvy, seeing it as a way to communicate with patients especially
younger patients raised on the net – the .com generation. [11]
We
know that every year 85% of Australians visit a GP – over 100
million GP consultations. Every year these consultations cost
2.5billion aud.[12]
And every year other costs resulting from visits to GPs, such
as drug prescriptions, tests and investigations, and specialists
visits, add up to more than 7billion aud$. The question is: might
doctors.com reduce these costs?
Or
will health-bots become the new gatekeepers, that is, will the
technology in itself become the new middle-man? And if so, will they
be able to ensure patients rights, one of the key dimensions of the
GPs work. The other dimensions being: business, profession, part of
the health bureaucracy, and community centre.
Indeed,
we can well see how globalisation and the internet revolution further
individualize medicine reducing the probability of the community
health paradigm.
A
question for GPs is: should they have their own websites or should the
Practice have a web kiosk there so that patients can go to doctors.com
and get basic information. Should they recommend particular websites?
Is it ethical to do so? How can they best use the new technologies and
ensure they are not used by them?
They will need to use them, already estimates of e-business are
to go from 61 million in 1997 to 1.3 billion aud in 2001.[13]
The
third revolution is genetics
The
first step in the genetics revolution is identifying what diseases one
is predisposed to. Next is gene therapy (replacing a defective gene
and therefore a disease causing gene with a healthy one). Further
sophisticated and quite likely is body part cloning (growing replica
parts to replace faulty ones). Combined with the information and
technology revolution, we will
have hospitals on our wrists, actually, within our bodies.
Genomics
thus will identify what genes and what physical of behavioral
characteristics (genotypes and phenotypes) are most relevant for
determining how to treat a given condition. This allows for
customization (the claim interestingly of alternative/complimentary
whole person therapies as well).
Will
the GP need to become the genetic counselor as well? Or will the GP
need to ensure that a genetic counselor is on board?
Leroy
Hood, William Gates Professor of
Biomedical Sciences and the founding Chair of the Department of
Molecular Biology at the University of Washington, believes that
overtime we will be able to determine what genes or combination of
genes cause certain types of behavior.[14]
However, the genetics revolution's full potential lies with germ line
engineering, which modified or manipulates the human DNA, for example
by altering the DNA of an unborn child in order to eliminate or
decrease a predisposition towards a given disease. Germ line
engineering can as well pre-select ideal sperm and eggs for
fertilization, thus affecting the germ lines of generations to come.[15]
The
mapping of human genome also transforms the nature of science, making
it global and discovery-based instead of hypothesis-based. It also
changes biology from its historical machine metaphor to an
informational metaphor. There appear at this stage few limits with
science fiction even too timid. Already the first synthetic DNA was
created by scientists at the University of Texas. Researchers are
"planning to create a series of designer bugs, with super
efficient mechanisms for infecting target tissues such as cancer
tumors, and then killing them[16]
And
if nano-technology delivers what it promises than our entire bodies
will become a pharmaceutical factory, reading to detect, diagnose and
react to imbalances, says Bezold.[17]
The
claims of the Foresight Institute headed by Eric Drexler are equally
grand[18]
·
A
mouthwash full of smart nanomachines could do all that brushing and
flossing do and more, and with far less effort—making it more likely
to be used. This
mouthwash would identify and destroy pathogenic bacteria while
allowing the harmless flora of the mouth to flourish in a healthy
ecosystem
·
Medical
nanodevices could augment the immune system by finding and disabling
unwanted bacteria and viruses.
·
medical
nanodevices will be able to stimulate
and guide the body’s own construction and repair mechanisms to
restore healthy tissue
·
Viruses
can be eliminated by molecular-level cellular surgery. The required
devices could be small enough to fit entirely within the cell, if need
be. Greg Fahy, who heads the Organ Cryopreservation Project at the
American Red Cross’s Jerome Holland Transplantation Laboratory,
writes, “Calculations imply that molecular sensors, molecular
computers, and molecular effectors can be combined into a device small
enough to fit easily inside a single cell and powerful enough to
repair molecular and structural defects (or to degrade foreign
structures such as viruses and bacteria) as rapidly as they
accumulate. . . .There is no reason such systems cannot be built and
function as designed.”[19]
MULTICULTURALISM
The
fourth trend can be termed loosely the multicultural trend.
By this I mean (1) the social construction of medicine
movement, for example, mapping how diseases are named, called and
treated variously in different nations. (2) The move toward
alternative medicine or complimentary medicine, primarily drawing on
Chinese and Indian traditions of meditation and acupuncture but as
well less accepted alternatives such as homeopathy (from Germany).
The
data is stunning. In the US, a Harvard Medical School Study reports
that 64% of medical schools offered elective courses in complementary
medicine.[20]
The study also reports that one in every three American adults uses
such alternative treatments such as chiropractic, acupuncture and
homeopathy. They assert that: "patients see conventional medicine
as ineffectual, too expensive or too centered on curing disease rather
than maintaining good health."[21]
In
Australia, the estimate in a 1993 study is 621million aud for
alternative medicine and 309 million for alternative therapists. [22]This
compares with 360 million aud for all classes of pharmaceutical drugs
purchased in Australia in 1992/93.[23]
Users
tended to be female and better educated. But what accounts for this?
Is it the deficiencies in conventional care? And what accounts for
this when one can question the paucity of sound safety and efficacy
data, ask many GPs.
An
article in the Medical Journal
of Australia finds that Victoria over 80% of general practitioners
have referred patients to alternative therapies. 34% are trained in
meditation, 23% acupuncture and 20% herbal medicine. Of particular
interest is that nearly all GPs agreed that acupuncture should be
funded and 91% believe hypnosis should and 77% believe meditation
should and 69% for chiropractic. 93% believe that it should be part of
the undergraduate core curriculum.[24]
Doctors
worry about the professionalism of alternative practitioners as well
as scientific studies supporting them. It is likely that the therapies
supported by doctors are those with strong empirical evidence, for
example, Dean Ornish's focus on life style changes (diet, stress
management, personal growth, reducing social isolation and exercise)
has shown that heart disease can be reversed. A major insurance
company pays for individuals to attend his program.[25]
Data around the world shows interest among GP increasing as
well as by users.
However,
what may account for the interest and use in alternative therapies is
that they empower individuals as alternative therapists tend to spend
greater amounts of time with users and attempt to customize therapy.
This is the suggested by George T Lewith, Honorary Senior Research
Fellow and Honorary Consultant Physician, School of Medicine,
University of Southampton, United Kingdom,
in his review of the literature on complementary medicine.
He
writes: [26]
Disenchantment
with conventional medicine is not necessarily the reason why patients
turn to CAM. One suggestion is that patients are increasingly
knowledgeable about CAM and seek a more egalitarian process within the
consultation. It has been confirmed that patients seek CAM because of
an intuitive feeling that it could offer them a more appropriate
medical model for their illness. Patients may therefore not be seeking
proof of efficacy of particular treatments, but meaning and context
for their illness, thus allowing them the freedom to benefit from
therapeutic consultations within their chosen milieu. Why should we
impose our medical model on patients? Their use of CAM may be their
process of empowerment, which in turn allows them to contain and
manage their chronic illness. It is perhaps difficult for those of us
educated within the conventional medical system to allow our patients
the freedom to make such journeys in a truly egalitarian manner.
Support
for a model more in tune with the Australian population may also come
from the changing demographics of medical students in Australia. There
will be more students from a rural background, more from an Asian
background, but most significantly admissions policies are now being
expanded to include the qualities of communication, tolerance, insight
into others' worldviews, and commitment to patients and their
interests as a priority.[27]
AGEING
There
is a fifth trend that is ageing,
suffice to say it will be dramatic.
While genomics, health-bots and alternative therapies may make
us healthier, the data generally does not look good for the aged.
The
average person is sick or disabled for nearly 80 percent of the extra
years of life he or she gains as life expectancy rises. [28]
Health expenditure for Australians over 65 is already four times
higher than for the rest of the population.
The World Health Organization estimates that by 2020 depression
will be the leading cause of “disability
adjusted life years“ dramatically increasing the demands for
psychiatric health services for young and old. [29]
The aged, particularly those removed from family and community,
will be especially prone to mental illnesses.
In Queensland, Australia the proportion of those over 60 years
will increase from 15% in 1995 to 23% in 2031. Already 25% of those
over 65 demonstrate functional psychiatric disorders.[30]
The
financial implications will be tremendous as well – the retiree to
worker ratio will go from the 3 to 1 to 1.5 to 1. Who will buy the
stocks when baby boomers sell for retirement as there is no age cohort
of that size and income level to follow? [31]How
will society react to the average age going from 20 to 40?[32]
Where will innovation come from?
Moreover
the WHO reports that while ageing is dramatic problem so the global
teenager. By 2025 the teenager cohort will have grown by 252 million
from two thousand million in 2001.[33]
THE
CHOICES AHEAD
Given
these futures what should the GP do. There are a few distinct options:
1.
Multi-door health community centre which has a high tech
component, a genetic counselor and complimentary medicine. While GPs
might remain the gatekeepers, they will have to augment their
understanding of the Net, becoming knowledge navigators. However,
GPs will have to focus as well as on what technology cannot
give – warmth, human understanding and empathy - as well as what
some alternative therapies cannot give either, tough, rigorous
analysis. It is this multiple function in the context of respect and
authority that will GPs ahead of the curve.
The
challenge will be to find the value added, to anticipate the changing
health needs of citizens instead of assuming that patients will be
like yesterday's patients. We already know that generation x is more
aspiration driven concerned about the environment and the community
than previous generations.[34]
Indeed, what shows up consistently in research around the world on
preferred visions of the future is that individuals, especially in the
West, have a great need and desire for community, for interconnection.
[35]Individuals
want to believe and feel that the GP is not far away but part of their
community. GPs that can best develop the multi-door health center in
the context of community medicine will prosper.
2.
Become or remain a mass provider, the bulkbilling scenario.
This in the short run might be the way to go but health-bots and the
internet are likely to reduce the profits on the mass market health
business. The mass market
health care dollars might go to the new technologies. Especially as
the patient-in, patient-out system appears to be what users do not
want. However, it is cheap. The question is: will it retain its value
for money? The answer to this question is partly based on what type of
economy and health system Australia will have? Will it manage to
retain universal care? In any case, for the medicare system to
survive, there will have to be some level of internet technology as
well, clicks and mortar, and the rapidly ageing and not necessarily
healthy (but possibly with genomics and nano-technology around the
corner) age-cohort.
3.
Find specific niches not being met by doctors.com, the
alternative system or genomics. Or excel at one of these niche areas,
that is, become the best possible GP knowledge navigator, It might
also mean finding new partners, expanding beyond the federal or state
levels to international non-governmental health organizations – the
global third sector. Or focus on specific demographic groups – the
global teenager and the aged who will need extra care and find out
what their specific needs are. This also means designing waiting rooms
in practices to reflect their ideals.
The
question is: will these trends impact the three most common reasons
for people going to their GPs (prescriptions, coughs and cardiac
check-ups) Yes or no. What new reasons might they go to GPs for, new
diseases?
What
this means is that GPs will have to reinvent themselves, discerning
what role they desire for themselves in the future. They will need to
ask what level of technology are they familiar with, can they adapt
to? Can they become
knowledge navigators? Can they use the new technologies to increase
their own quality of life, using the Net for seamless administration,
so that their hours can be more flexible? Can they enter into dialogue
with complementary medicine or at least begin to listen carefully to
patient’s concerns about their treatment, that is, about their
body-mind-spirit-environment-community needs?
If
GPs are unable to reinvent themselves and meet the changing needs of
their patients then one future is clear: general practitioners will
come to be considered as quaint alternative medicine practitioners –
the definition of general practice will have changed.
CONCLUSION
If
we go back a century or even 30 years, we know that changes in science
and technology have been tremendous. There is no let up in sight. In
such an environment, trying to forecast the future accurately is a
mistake. Determining alternative futures is a step forward as worst
case and best case scenarios can be developed. Scenarios based on
different drivers – technology, values, economics – can be
explored. But more important than scenario planning is developing
institutional foresight, the capacity to respond to changing needs, to
create a multicultural learning and growing organization, community.
GP organizations, state divisions will need to swiftly embark on
creating health learning organizations that exemplify the type of
future they want.