Wednesday, September 20, 2006

Are Doctors Society's Dinosaurs?

Tanveer Ahmed from Sydney wrote in today's Age suggesting that changes in medical education have not kept pace with other changes in the wider community, and that it is "one of the last bastions of the Old World left in our economy and requires a genuine shake-up... It is the East Germany of our society, waiting for its wall to fall."

Dr Ahmed (I don't know whether to refer to Tanveer as he or she) challenges the role of "systems, through colleges and apprentice-style training, that have effectively been unchanged for decades."

Let me tell you, Dr Ahmed, decades are not a long time. Our political system has not changed for over a century - is it time for a "radical shake-up"? Human anatomy has not been re-defined for at least several hundred years. Is it time to revamp the textbooks? Should we ditch the apprenticeship model that trains your plumber, electrician, painter or mechanic because it is not keeping pace with modern society?

There are a number of reasons that medical education and health systems have not been torn asunder and rebuilt every few years (despite what the ACCC may want).

Firstly, it is because small, incremental changes are happening all the time. This is how change is managed. Minor changes and improvements are introduced. They are assessed. If they work out they are kept, and if they don't they are reversed (let us hope the dilution of anatomy teaching will be reversed). We are not fighter pilots. We are doctors. The training produces flexible doctors who can make use of new technology, new information, new health system structures, and adapt to suit community requirements as they arise. If you knew that you needed fifteen left-handed dynamic hip-screw inserters in five years time you could train for that, but in five years time the DHS might be obsolete. And so will be your specialist DHS inserters.

Secondly, you may recall the Latin phrase "Primum non nocere" (First do no harm). Tearing down the public health system and medical education in one fell swoop would cause a lot of harm, long before it did any good, especially when no adequate replacement is conceived or planned for.

Thirdly, my favourite saying: "If it ain't broke, don't fix it". As you say, the current arrangement of "cheap labour in underfunded public hospitals... suits many people in authority, both within the profession and in government". Well, let me tell you, it also suits the common citizen holding their Medicare card, who gets first-world health-care for 1% of their gross taxable income each year. As doctors we may grumble and bitch about our lack of pay, long working hours, lack of recognition, long training periods, and no social life, but aren't you the least bit proud that you are providing the majority of your patients with health care that is the envy of many countries around the world?

If anything, the most frustrating part about being a doctor in Australia is that given state and federal funding constraints we can only provide some of the services to some of the people some of the time, but of what we do deliver it is still top quality care. Yes, my pay after 16 years of training is paltry compared to my younger cousin who reprograms the ATM system for a major bank, or my recently-graduated friend who advises semi-private health insurance companies how to waste the wads of cash they make every second. But I have the satisfaction of a patient coming up to me and saying "Thankyou for improving or saving my life" every now and again, and that makes me proud of what I do, despite the fact that the public health system uses and abuses me.

My concern is that if Tanveer's opinion translates to a general perception that doctors are over-trained, then we are looking at the inevitable extinction of the traditional doctor. No longer will we have a health professional who is expected to deal with anything and everything that could possibly come through the door, and to have a good grasp of all the other facets of health care and medicine that affect their patients - we will have a workflow-oriented, productivity-driven, multidisciplinary team-based system with cannulation technicians, specialist nurse practitioners, phlebotomists, reporting radiographers, analytic biochemistry technicians, and diagnostic hygiene specialists who will hold a committee meeting every half hour to discuss why the patient in Cubicle 21 is deviating from the ingrown toenail clinical pathway. There will not be a doctor to be seen because they will be unnecessary. Is this what the Productivity Commission wants?

I might as well retire today. Perhaps we should not be reforming our health-care system or medical training, just our expectations of what it should deliver.


Borneo Breezes said...

Great post. I'm not sure I agreed with you but I feel informed and reasoned with--not bad, and it suggests you have put a great side of the debate together. I think sometimes incremental works and sometimes more is needed. And I feel stimulated just to have read your post.

Sheepish said...

Thanks for your comments, Borneo Breezes. I hope that more people find what I have to say worth reading. I may or may not be right, but I feel it is a reasoned point of view.