Where are we going?

The practice of medicine is changing rapidly—or so it seems to me. It may be a characteristic of my own aging that I have this impression, since it seems that hours, days, and weeks are also passing at an accelerating rate.

What changes am I noticing? Well, I hear of newly minted young doctors who intend to practise only 2 days a week. I hear of others who allot 4 minutes per patient. I hear of surgeons who worry that their skills are atrophying because they cannot get enough operating room time. I am told that no one wants to do traditional family practice, that young and not-so-old doctors prefer locum and walk-in work. Is it that no one wants the burden of organizing and managing an office, or is it that the financial burden is too daunting? I am told that one cannot give away an established general practice, let alone sell it.

I am told that specialists really do not need to know any general medicine, that there is always another specialist to look after the bits that are out of one’s field. They tell me that a specialist does not need to take a general history of the patient and that he or she is probably incapable of performing a basic physical examination.

All the various colleges and hospitals and regulatory organizations are demanding proof that we are keeping up with the proliferation of drugs, diagnostic tests, and treatments so that they can certify—for a demanding public and a dominating government—that we are competent. Actually, all that does is certify that we have been exposed to and retained some memory of reports of advances. Since competence is in what one does, not simply not what one knows, this may be false reassurance.

And the public, while we know more and can do more than we ever could before, seem peculiarly ungrateful. Perhaps these changes have coalesced to produce a situation where it is impossible for a patient to have a single practitioner to shepherd him or her, cradle to grave, through life’s tribulations and crises.

So where do we go from here? Walk-in clinics, for the physicians, provide reasonable working hours and remove the worry of managing one’s own practice. For the patient they provide instant access, but they seem unable to provide continuity, in that contact is episodic and that most do not provide any out-of-hours service.

It may be that the way to go will be to a clinic variant, where the patient has walk-in access at all times, but where a full history and physical has been documented, not necessarily by a physician, and which is regularly updated. Where the physicians have access to this data so that a rota of physicians could provide the needed continuity, rather than a single physician having to rely on his or her memory and scribbled notes.

This would provide a bonanza of work for expensive computer programmers. Of course, to be useful, there would have to be experienced medical oversight of how the programmers organize the data.

It sounds like an ideal career opportunity for a clapped-out old surgeon. Is this where we are going?

—PMR