Dean Cairns on the future of medicine

The transformation of medicine in BC over the past 100 years and the breakneck pace of change we now find routine ensure that pre-dictions are hazardous, particularly about the future (to paraphrase a famous social commentator). Nevertheless I will make a few predictions for the next quarter century in BC.

Our approaches to individual patients will be revolutionized by the completion of the Human Genome Project and further progress with delineation of gene function. Accurate prediction of risk, even in utero, will create the possibility of a range of interventions to prevent or mitigate discomfort, disability, and premature death. The enhanced ability to predict will lead to moral dilemmas in regard to pressure to terminate pregnancies because of definite evidence or simply increased risk of late disease or disability. In later life we will be faced by the personal and family impact of accurate predictions in the absence of effective therapies.

Some of the mysteries of varied responsiveness to drug therapies among individuals will be resolved, and genetic profiling will allow more rational choices of therapies to maximize efficacy and minimize side effects. The avalanche of new medications emerging from genetic engineering will accelerate as human- and animal-derived biological products are increasingly generated by genetic engineering techniques. There will be increasingly sophisticated rational drug design and synthesis. Organ replacement will be revolutionized by advances in sophisticated artificial prostheses and devices, xenotransplantation, and the culture of human tissues and organs from stem cells. Damaged heart muscle and other tissues are likely to be reparable with the transfer and in situ growth of replacement human tissue using genetic and growth factor techniques.

The provision of health care will occur in the setting of more planned and all-encompassing models exemplified best by BC’s current cancer-care system. The full spectrum of prevention, early detection, evidence-based management, complete follow-up, and palliative care within a system of integrated education and research will be deployed in other major diseases.

The complexity of health care, the need for comprehensive approaches from prevention to palliative care, and the huge costs borne by the taxpaying public will demand more system-wide planning and service delivery. Physicians will rarely be independent contractors working as individuals or in small groups. Instead they will be increasingly compensated by capitated or time-based systems, within increasingly planned and managed practice settings.

They will use sophisticated patient information storage systems that will ensure immediate availability of patient records wherever care has been delivered in the country, rapid access to test bookings and results, and facilitated prescription writing with appropriate safety checks. Interactive desktop computer systems will provide immediate data and appropriate prompts on allergies, drug reactions, potential drug interactions, evidence-based preventive, diagnostic, and management schedules, and access to consultative support on a more immediate and readily accessible manner. Patients’ personal data may be encoded on a chip embedded in their health-care cards.

Increasingly, other health professionals will assume some of the tasks traditionally performed by physicians, allowing us to concentrate on activities only we can perform. Just as physicians will work in teams within large organizations, so too will other health professionals, ensuring that the current trend to proliferation of independent and insufficiently accountable health professions will be modified.

It is clear that patients prefer to have an ongoing professional relationship with their own doctor, and the creation of a true system of health care, the formalization of multidisciplinary practice settings allowing patients one-stop-shopping for prevention, diagnosis, and treatment under the guidance of a range of health professionals, and the availability of sophisticated practice management techniques will work to strengthen the traditional doctor-patient relationship.

We will face a growing epidemic of cancer, renal failure, diabetes mellitus and its complications, degenerative joint disease, and Alzheimer’s and other degenerative neurological diseases as our successes with heart disease, stroke, and infectious disease increase life expectancy and diseases of aging become more dominant. Increasingly we will face the health ravages of mental illness, poverty, social disorganization, addiction, violence, and environmental degradation. Our earlier triumphs over infectious disease may be seen as only a temporary respite as antibiotic resistant bacteria, tuberculosis, and HIV/AIDS threaten the health not only of those in the developing world, but in the wealthiest of nations.

Medical education in BC will change dramatically in the next quarter century as the province reaches maturity and takes increased responsibility for the education of its own physicians. Since 1980, BC’s population has grown by 50%, but the output of physicians has remained fixed at 120 per year. BC has fewer medical students and fewer postgraduate trainees (residents) in relation to population than in any other province in Canada and is able to satisfy only 25% of the annual need for new physicians in BC.

The emerging shortages in remote and rural regions and in many specialties—even in the population centres—will be addressed by rational physician resource planning, and medical education activities will be linked more closely to provincial needs. The expanded medical education endeavor is likely to be centred in Vancouver, but the current network of centres including Victoria, Prince George, Chilliwack, Kelowna, Nanaimo, and 80 affiliated hospitals and practices around BC will be substantially expanded, with medical students and residents spending major components of their clinical education and training in hospitals and practices around the province. This will ensure that their experiences are relevant to eventual practice and that they build strong relationships with the communities where they will live and work.

The current trend to somewhat older students entering medical school following broader academic and life experiences will be sustained, but it is unlikely that the duration of medical training will be extended beyond the current length. With the explosion of medical knowledge, however, there will be greater pressure to select subspecialty directions earlier, with extensive generalist training confined to those who will be pursuing careers as generalists and primary care specialists.

We will move away from the paradigm that suggests that medical training is considered complete with entry to practice, and begin to put greater emphasis on the growth in skills, judgement, and knowledge that continues in the first few years of practice and may need to be recognized in the organization of medical practice and approaches to physician compensation. The trend to mandatory maintenance of competence and recertification will intensify, and a formal curriculum of continuing medical education will become available in family practice and all specialties throughout the province.

The increasing focus on non-medical determinants of health, knowledge of the health-care system, preventive and behavioral strategies, critical appraisal of evidence, and practice guidelines will continue, and it is likely that medical students will increasingly be expected to have accumulated significant life experiences and education in the humanities before entering medical school.

The declining provincial support for medical research will be sharply reversed as BC’s citizens recognize the successes of learning-based economies in other parts of North America and Europe. An appreciation of the direct contributions of research to the quality and advances in our provincial health-care system and an increasing understanding of the positive impacts of research will encourage BC citizens to demand that the province invest as do other Canadian provinces.

Basic research across Canada will increase, as the nation joins other Western countries in making an appropriate investment in the curiosity driven research that builds a future strong economy. Applied research into the etiology and pathogenesis of disease will capitalize on the huge advances in knowledge that will come from delineation of the human genome and functional genetic insights to follow. Scientists will devote increased energy to the really difficult determinants of human health including poverty, social disorganization, addiction, violence, and environmental degradation.

Efforts will be expended to adapt to social sciences and behavioral research, the experimental techniques that have worked so well in the biomedical realm. Resources must be directed to these problems if we are to benefit optimally from the cascade of advances in our understanding and modification of the biological determinants of disease and disability. The energy and resources directed to health-care-system research will also increase as we seek to ensure optimal and cost- effective application of the knowledge we have already gained from the basic and clinical trial laboratories. Evidence-based approaches to health-care delivery will become pervasive.

Medicine in British Columbia will change enormously in the next 25 years. The management and the evolution of our health-care system will require joint engagement by politicians, civil servants, administrators, lay boards, the public, and members of the health-care professions. It is critical that physicians remain at the forefront not only in the delivery of medical care, but also in taking responsibility for the medical components of the health-care system to ensure that the advantages of increasingly optimal physician care, advances in medical education, and the avalanche of new knowledge from research are made available to British Columbians in an equitable, up-to-date, and cost-effective manner.

This engagement will also help to ensure their own satisfactions in the practise of their profession. Physicians have a huge responsibility to take an active role in shaping the future of medical care in BC—as they have throughout the history of our province. I believe they will continue to fulfill this responsibility, and that British Columbians will benefit from a health-care system that is constantly evolving for the better.

Dr Cairns is the dean of the Faculty of Medicine at UBC.