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Response to 'Re-Imagining the Doctor' by Ronald W. Dworkin

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Co-authored by:
• Dr. Katherine Tryon, Vitality Institute, MA (Oxon.) MBBS
• Dennis Schmuland, M.D., F.A.A.F.P., Microsoft Corporation
• Ilene J Klein, M.D., F.A.A.F.P.

In the latest issue of National Affairs, Ronald Dworkin provides a fascinating analysis of the history of the medical profession and the critical need to re-imagine the role of the doctor today (read it here). We support his call for doctors to take on leadership positions and suggest the following critical points be addressed.

Health care is not just about cure
Whilst Dr. Dworkin argues that the Flexner report gave doctors an identity, many have seen Flexner as having some long-term negative impacts on the role of the doctor and on public health. The report solidified a view of science that gives priority to treatments and cures over prevention and long-term care. With the changing nature of health issues in the U.S., this is not a sustainable position. The U.S. already spends more on health care as a percentage of its gross domestic product (GDP) than any other developed country in the world (nearly 18 percent) and yet ranks 17th (for men) and 16th (for women) in terms of life expectancy among 17 high-income countries. Today more than 70 percent of years of life lost in the U.S. are due to non-communicable diseases (NCDs), and the leading causes of life years lost are attributable to preventable risk factors such as tobacco use, physical inactivity, unhealthy diets and alcohol. Health care needs focus on prevention and long-term care, which may or may not involve the doctor. In light of these changes, it is more appropriate that we re-imagine the sum total of interactions that determine health, including engagement, motivation, health behaviours, management and recovery, rather than simply re-imagining the role of the doctor in the curing of disease. The Vitality Institute Commission is currently investigating the necessary changes across U.S. health care system to provide a greater focus on health prevention and promotion.

Extending doctors' reach
The role of technology in health care is accelerating. Dworkin does not fully consider that careful deployment of emerging enabling technologies can extend and expand the doctor's reach and improve patient outcomes. These technologies place doctors in a new role of facilitating consumers to look after their own health, including both prevention as well as long term management of health conditions. The underlying assumption that Dworkin makes regarding the workforce shortage is that there are only three possible solutions to any professional workforce shortage: train more, lose fewer, or find someone else to do the same job (in this case nurses, other health professionals or computers). However, what we are seeing in health care is the ability of technological advances to redesign health care delivery and scale up the ability of doctors to reach a broader audience by engaging and motivating individuals to prevent and manage long-term conditions, and more effectively coordinate care, in order to achieve better patient outcomes. However, the implications of this are that doctors, as well as other health care practitioners, will need to change their method of practice, moving from a focus on one-to-one facility-based encounters to one-to-many relationships that transcend facility boundaries.

Leadership needs to go beyond traditional boundaries
The scope of leadership should not be as narrow as Dworkin defines.

Firstly, he asserts that nurses can "never direct a plan of treatment with the right mix of charisma, authority and decisiveness." Whilst doctors play an extremely important leadership role, this is not exclusively the domain of the doctor. Two examples of nurses taking on powerful leadership roles include Lillian Wald (founder of the Visiting Nurse Service of public health nurses in New York City tenements) and Margaret Sanger (who formed the foundation of Planned Parenthood in response to poor abortion practices). On the reverse side, not all doctors have the skills or native talent to be effective leaders. As a result, while doctor leadership is a critical component, it is also crucial to look across the health profession to find the most effective leaders, regardless of their job role. As health care becomes more team-based, leadership should not be the sole provenance of doctors.

Secondly, Dworkin focusses on the leadership role of a doctor within the care facility setting. As highlighted by Milstein B et al, the greatest cost benefits for the U.S. health care systems will be gained in behavioral and environmental interventions. These are generally beyond the current scope of practice and typical care facility for a doctor, and frequently require the involvement of individuals from a public policy background. However, unlike public health and undergraduate medical education, there is a relative absence health promotion and disease prevention content within public policy education. As a result, doctors are critical in this field. We have many excellent examples of doctors who have effectively taken leadership positions beyond traditional boundaries, including Gro Harlem Brundtland (prior Director General of the World Health Organization), C. Everett Koop (U.S. Surgeon General) and William Frist (powerful voice within and outside Congress for health). These leaders have had significant impact, whilst engaging in the messy political realities of the day, but through basing their advocacy positions on solid science and evidence. However, this science is not the molecular and clinical science that doctors traditionally base their clinical practice on, but rather epidemiological, behavioral and economic aspects alongside such traditional science. We need to ensure that our doctors of the future are trained more broadly to take on such leadership positions.

Thirdly, Dworkin defines leadership as "mediating between people, managing expectations, and inspiring hope," "build[ing] morale," and "put[ting] science in perspective." Critically he does not focus on the role of the doctor as an advocate (beyond mentioning their role in representing small interest groups). Leadership needs to go beyond traditional boundaries and include strong advocacy, whether that is for the person sitting in their office, or the health of the larger groups who doctors will supervise through enabling technologies, or advocating for healthier communities and healthier workplaces, speaking out against perverse incentives in the health care system, and speaking out when single sectors in the system try to capture health care dollars without adding value to improving overall health. Leadership must go beyond leading clinical teams and patients to advocacy for the improvement of the health care system.

Improving long term health
Thus, while we support Dworkin's view on many aspects of re-imagining the role of the doctor, we feel that he has not addressed a number of key issues required to improve the long term health of Americans. The Vitality Institute Commission is currently investigating the necessary changes across U.S. health care system to provide a greater focus on health prevention and promotion, including funding and educational aspects. In addition to this, we would also recommend:

  • A redesign of medical education to emphasise the need for population approaches to health and the use of technology in enabling doctors to extend their reach beyond direct one-on-one interactions within the confines of the care facility.
  • Ensuring multidisciplinary team based training begins in medical school, and incorporates leadership skills not only for doctors but also other health care professionals.
  • Broadening medical education to highlight the role of doctors beyond traditional care facility boundaries, and the need for a solid grounding in epidemiological, behavioral and economic science alongside more traditional clinical science.
  • Incorporating advocacy into medical education, both at the individual and community level

With these in place, doctors of the future will be able to take on effective leadership positions within a health care system that truly improves health in the U.S.

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