A recent piece by Bruce G Robinson and Peter M Brooks in the Medical Journal of Australia (2012, 1 Suppl 3:3-5) introduces a special issue on the future of the medical workforce in Australia. It struck me as a good reflection not only of the way we are thinking about the future of the medical profession, but also of the issues reshaping the governance of expertise more broadly.
New technology is recognised as a great driver of change. But its impact is occurring on three different fronts:
- Delivery of services. This is often what we hear most about: the ways digital technology is creating new platforms for access to services and information. In the case of medicine this means online and telemedicine offering remote and devolved consultations and prescriptions.
- Nature of what we know. But technology is also reshaping what we know about the world and ourselves. Advances such as genetic testing, imagining techniques, bio-engineering and stem-cell therapy change diagnostic possibilities and treatments and, in the process, the nature of medicine itself, making interdisciplinary collaboration much more important.
- Data collection, management and assessment. And at the same time the mass aggregation of data and the ability to centralise it will shape the way information is kept and assessed. Innovations such as an electronic patient health record have the capacity to reduce many of administrative hurdles, while also requiring new critical skills and safeguards.
But importantly, technology is not the only driver of change. Healthcare will also be shaped by wider geo-political factors, including the changing nature of populations due to immigration, disease implications of the free movement of people, changing weather and biological implications of climate change. Expertise is not isolated from the political economy of its environment; an environment that is shaped by international as well as domestic factors.
How to train doctors and medical professionals for this future is a fundamental question, especially given that careers run for 40 or more years – a stretch of time in which the landscape of expertise is likely to change in ways we can not yet imagine. Robinson and Brooks map out the need ‘to revisit our fairly recent focus on specialism and train more generalist health professionals’. They see skills in critical data analysis as necessary.
The effect this will have on the authority of the expert, is noted. Doctors ‘will not be the all-authoritative figure’ in whom knowledge is centralised, but rather part of teams of professionals ‘providing a range of care in an integrated, evidenced-based way.’
And these shifts to the nature of work and the nature of training, will involve rethinking the way the system is funded – a process that needs to be driven not just by arguments about cost, but also by values and evidence.
Robinson and Brooks are attentive to the aspects of the medical profession that they think will or should remain unchanged. Their main focus is on the relational and embedded aspects of the patients interface with doctors. Doctors will continue to work in communities, the sickest patients will continue to be treated in hospital, personal contact will still be important and relationships that build on the values of compassion, understanding, empathy and ethics will continue to be central.
What Robinson and Brooks do not highlight are the the ethical and technical implications associated with many of these shifts: the security and civil liberty concerns associated with the centralisation of data, for example, or the practical and personal implications for patients of the team-delivery of services. Neither do they address the question of trust. Trust is central to the delivery of all expert services and particularly important in the medical profession. If training, authority and professional association underpinned patient-doctor trust in the twentieth century, how it will be fostered in the future, is less clear.