Presentation to the Queensland Divisions of General Practice, Brisbane, February 11, 2000
By 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:
- 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]
- 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.
- 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.
- 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.
- 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:
- 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.
- 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.
- 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.
[1] See, Which-doctors diagnose us: Medicine still tribal in our high-tech era. The Sunday Star-Bulletin and Advertiser (Honolulu, March 12, 1989), d-2. Noteworthy is: Lynn Payer, Medicine and Culture.
[2] See, Roy Moynihan, Professor warns of Medicare’s ultimate demolition, The Australian Financial Review (February 17, 2000), 5.
[3] For more on this, see bochemist and medical journalist Alexandra Wyke’s 21st Century Miracle Medicine: RoboSurgery, Wonder Cures, and the Quest for Immortality (Plenum, 1997). Writes Wyke: Surgey will depend not on the steady hand and experience of the doctor but on devices such as the recently invented ROBODOC, combined with new imagery technology and computers that essentially make flesh and bone transparent in 3-D images, allowing machines to make cuts or dissolve tumors and blockages in exactly the right place.
[4] See, Call the doctor online, The Sunday Mail (January 2, 2000), 7. Smartcards are already used by the USA army where soldiers carry their medical history on a comuterized dogtag. See: www.coh.uq.edu.au at www.health.qld.gov.au/qtn
[5] ibid.
[6] Sausage Part of World Forum, The AustralianIT, (February 8, 2000) 55.
[7] See, for example, Sohail Inayatullah, Eco-bots in you future, The Age (forthcoming, 2000).
[8] See Clement Bezold, Will heart disease be eliminated in your lifetime? The best of health futures, Futures Research Quarterly (Summer 1995) and The Future of Complementary and Alternative approaches in US Health Care. Institute for Alternative Futures, 1998.
[9] Ibid, Clement Bezold, Will heart disease be eliminated in your lifetime?, 30.
[10] See, for example, Mike Hollinshead, Alternative Futures for Health Care in 2018. Available from Facing the Future. 150003, 56 Avenue, Edmonton, AB, T6H 5B2.
[11] See Heather Gilmore, Younger shoppers opt for the Net. The Courier-Mail (February 21, 2000), 6. Gilmore reports that the number of young people on the Net has tripled in the past year in Australia.
[12] See, press releases and reports from, Australian Institute of Health and Welfare. http://www.aihw.gov.au/
[13] NOIE, E-commerce Beyond 2000. See, Mark Hollands, Internet dreaing drives dot.com fury, The Australian IT (8 February 2000), 51. Also see www.economist.com for the latest data on the new economy.
[14]See: Celebrated biotechnologist Dr. Leroy Hood addresses attendees, Humanity 3000 News (vol. 2, No. 2, 1999), 1 and 7.
[15] See: http://health.upenn.edu/~bioethic/webget/archives.html
[16] The Sunday Times in the Australian, January 25, 2000, pg. 1.
[17] Bezold, Will heart disease be eliminated in your life time, 38.
[18] See the website: Unbounding the Future: the Nanotechnology Revolution – www.forsight.org see, Robert A. Freitas: Respirocytes – A Mechanical Artificial Red Cell: Exploratory Design in Medical Nanotechnology at http://www.foresight.org/Nanomedicine/Respirocytes.html
[19] Ibid, www.forsight.org
[20] Yahoo News, Harvard Medical School Study, September 1, 1998.
[21] Ibid.
[22] Maclenan AH, Wilson, DH, Taylor, AW, Prevalence and cost of alternative medicine in Australia, Lancet, 1996, March 2: 347(9001): 569-73
[23] ibid. Also see, Health Harmony, The Sunday Mail (January 2, 2000), 7.
[24] Marie V. Pirotta, March M Cohen, Vicki Kotsirilos and Sstephen J Farish, Complementary therapies: have they become accepted in general practice? MJA 2000; 172: 105-109.
[25] Clement Bezold, Health Care Faces a Dose of Change, The Futurist (April 1999), 30-33.
[26] See: Complementary and alternative medicine: an educational, attitudinal and research
challenge: We need to understand more about these treatments, why they are being used, and what makes them effective. MJA 2000; 172: 102-103
[27] New breed of doctors on the way – www.aihw.gove.au/releases/1998/csams89-96.html. Accessed January 2000.
[28] Beth J. Soldo and Emily M. Agree quoted from the USA Population Reference Bureau’s bulletin, American’s Elderly in Cheryl Russell, American Demographics, March 1989 v11 n3 p2(1).
[29] www.who.org, See, World Health Organization, The Global Burden of Disease, 1996. http://www.who.int/. See, Caring for Mental Health in the Future. Seminar report commissioned by the Steering Committee on Future Health Scenarios. Kluver Academic Publishers, Dordrecht, 1992, 315. See as well: The Global Movement for Active Ageing. http://www.who.org/ageing/global_movement/index.html.
[30] “To a Queensland Disability Policy and Strategy,” DFFCC, 1997, 12 (Discussion Paper) quoted in Ivana Milojevic, Home and Community Care Services: Generic or Discriminatory, HACC Action Research Project. Report to Catholic Social Response, Auspicing Body, 1999, 35.
[31] See Peter Peterson, Gray Dawn. New York, Random House, 1999.
[32] See Sohail Inayatullah, Ageing Futures: From Overpopulation to World Underpopulation, ” The Australian Business Network Report (Vol. 7, No. 8, October, 1999), 6-10.
[33] www.who.org/hpr/expo/futures11.html. Accessed January 2000. WHO Health Futures – Major trends shaping health.
[34] See www.pophouse.com.au – the work of Rosemary Herceg. See, Future News, GenXers: Quiet Revolutionaries (August, 1999).
[35] See, Sohail Inayatullah,Youth Futures, in Jennifer Gidley and Sohail Inayatullah, Youth Futures. Manuscript in preparation.