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Tuesday December 18 2018

The role of physicians, then and now

Written by Kevin Zhao, Bachelor of Health Sciences (Honours) Class of 2021, Biomedical Sciences Specialization, McMaster University


 
The role of the physician as the authoritative, primary care deliverer has become such a fixture that it is rarely even questioned. Within the medical system of the past century, doctors have played a central role in providing care to patients to such an extent that the British Medical Association has concluded that doctors “alone amongst healthcare professionals must be capable of regularly taking ultimate responsibility.”1 Physicians have been granted immense control over their patients’ care, and can make decisions ranging from drug prescription to hospitalization.2 In more recent years, however, many have expressed concerns that the pre-eminence of physicians is declining in medicine and in society-at-large.3-5

Throughout much of history, the role of a physician was not as centrally prominent nor as unified into a single profession as it is today. Tales of medieval bloodletting, of barber-surgeons blindly butchering their patients, of plague doctors shoving mint in their masks to ward off miasma, paint a picture of the historical medical profession as unglamorous, undignified, and disorganized. And though this view of the history of medicine is simplistic, it bears some elements of truth. For a long time, medicine has adapted to the local conditions of its clients. Rich nobles could afford educated court surgeons while the poor depended on the medicine provided by religious institutions, barber-surgeons, midwives, or travelling caregivers.6 Medical practitioners varied greatly from one to another, and the medical profession was by no means standardized. The word “doctor” was just as likely to invoke images of a travelling dentist as a dignified noble physician.

It was not until the turn of the 18th century that medicine began to be professionalized by the state. The political revolution in Paris at the time also ushered in a medical revolution. In line with the enlightenment values of the French Republic, healthcare began to be rationalized. Scientific principles were introduced with greater emphasis into medical care, as did state involvement. The idea of universal human rights ushered in by the French Revolution permeated into healthcare, and the health of the poor shifted from an individual consequence to a shared societal burden.7 Medical education became standardized to include practical training, slowly taking over the role of surgeons and community medical practitioners.7 Physicians began to gain more confidence in their trade and, in their interactions with their relatively disadvantaged patients, increasingly becoming viewed as distinct authorities.8 Thus, the French Revolution was able to usher in the age of hospital medicine as we know it, featuring standardized and professionally-regulated physicians.

In the 1960s, widespread fears of a shortage of physicians prompted drastic efforts to ensure that the healthcare system was fully-staffed. On the one hand, this perceived deficit was addressed by directly increasing the number of physicians through expanding enrolment into medical education and recruiting foreign doctors.2 On the other hand, many responsibilities traditionally earmarked for physicians were increasingly diverted to other jobs. New jobs were created specifically with this in mind, such as nurse practitioners, physician assistants, and nurse-midwives.9 Though this drive to expand physician supply died down in the 90s, fears have recently been raised about physician undersupply again.10,11 In part to address this, Registered Nurses in Ontario were granted permission to prescribe limited drugs in May of last year as part of the Stronger, Healthier Ontario Act.12 With each wave of fear, the traditional role of primary care physicians has increasingly been supplanted by other professions. In conjunction with the actual oversupply of physicians, this has resulted in a situation where the physician is hardly the only primary care option available to patients anymore.13 In the current situation, more physicians have to share a shrinking slice of the pie —one that they historically had all to themselves.

The increasing emphasis on evidence-based medicine and technology has also heralded a de-emphasis on the experiential physician perspective.14 Automation, an increasingly pressing concern in almost all fields, has not left medicine untouched either.15 In 2011, IBM famously unveiled Watson, their voice recognition AI on the game show Jeopardy! Watson, however, was not designed to merely be a game show contestant.16 Watson was designed to break technological ground in healthcare and, though controversial, Watson has already been implemented in some 230 hospitals worldwide.17 As with automation in any other field, AI and robots have the potential to be cheaper, better informed, and less likely to suffer from overwork than their human counterparts. Though there will always be a role for human physicians in healthcare, the supplanting of primary care by automation can only serve to further increase competition in healthcare.

All this seems to suggest a grim future of medicine that increasingly requires less involvement from its original authority: the physician. Nonetheless, we should keep in mind the four aims of healthcare in judging its quality: improving the work life of providers, elevating population health, enhancing patient experiences with care, and reducing per capita costs. Supporting human physicians with AI decision-making tools can help bring doctors closer, rather than further, from the bedside by automating the menial, time-consuming tasks that currently burden medical practice. Automation is likely to reduce healthcare costs, potentially allowing investment elsewhere. The replacement of physicians in some basic capacities, too, is a cost-saving measure and theoretically allows physicians to put their uniquely extensive training to better use, doing the jobs that others cannot.


References

1. Godlee F. Understanding the role of the doctor. BMJ. 2008;337:a:3035. Available from: doi:10.1136/bmj.a3035.
2. Williams SJ, Nightingale EO, Filner B. Medical Education and Societal Needs: A Planning Report for the Health Professions . United States Institute of Medicine, Division of Health Sciences Policy. Washington: National Academies Press; 1983.
3. Lipworth W, Little M, Markham P, Gordon J, Kerridge I. Doctors on status and respect: A qualitative study. J Bioethical Inquiry. 2013;10(2):205-217. Available from: doi:10.1007/s11673-013-9430-2.
4. Willis E. Doctoring in Australia: A View at the bicentenery. Milbank Quarterly. 1988;66(2):167-181. Available from: doi:10.2307/3349921.
5. Nettleton S, Burrows R, Watt I. Regulating medical bodies? The consequences of the ‘modernisation’ of the NHS and the disembodiment of clinical knowledge. Sociol Health Illn. 2008;30(3):333-348. Available from: doi:10.1111/j.1467-9566.2007.01057.x.
6. Wallis F. Medieval Medicine: A Reader. Toronto: University of Toronto Press;2010.
7. Rochaix, MM. The Long and Rich History of French Hospitals. History of Hospitals – The Evolution of Health Care Facilities – Proceedings of the 11th International Symposium on the Comparative History of Medicine – East and West.
8. Risse GB. Mending Bodies, Saving Souls: A History of Hospitals. New York: Oxford University Press; 1999.
9. Roemer, MI. An Introduction to the U.S. Health Care System. New York: Springer Publishing; 1983.
10. Weiner JP. A shortage of physicians or a surplus of assumptions?. Health Affairs. 2002;21(1). Available from: doi:10.1377/hlthaff.21.1.160.
11. Esmail N. Canada’s doctor shortage will only worsen in the coming decade. Fraser Institute. Available from: https://www.fraserinstitute.org/article/canadas-doctor-shortage-will-only-worsen-in-the-coming-decade.
12. Canada. Stronger, Healthier Ontario Act (Budget Measures): Elizabeth II. Chapter 8. Toronto: Legislative Assembly of Ontario; 2017.
13. Canadian Institute for Health Information. Physicians in Canada, 2016: Summer Report. Ottawa: CIHI; 2017. Available from: https://secure.cihi.ca/free_products/Physicians_in_Canada_2016.pdf.
14. Bradley J. From ‘trust us, we’re doctors’ to the rise of evidence-based medicine. The Conversation. November 15, 2012. Available from: https://theconversation.com/from-trust-us-were-doctors-to-the-rise-of-evidence-based-medicine-10608
15. Majidfar F. Automation of knowledge work in medicine and health care: Future and challenges. Int J Body Mind Culture. 2017;4 (Suppl 1):4-10.
16. IBM. IBM Watson Health [Accessed: November 2, 2018]. Available from: https://www.ibm.com/watson/health/
17. Kelly JE. Watson Health: Setting the Record Straight. Watson Health Perspectives. August 11, 2018. Available from: https://www.ibm.com/blogs/watson-health/setting-the-record-straight/.

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