How to make yourselves redundantBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4706 (Published 08 November 2018) Cite this as: BMJ 2018;363:k4706
All rapid responses
I realized a few years ago a self contradicting mindset in our human culture that, even though doctors literally are the most important healthcare workers, everybody, including most doctors and the health secretary, have a deep down habitual mindset that doctors are really responsible for disease (under the mindset of biomedical system developed 400 years ago by Descartes) and that people should look for health elsewhere away from their personal doctor. Doctors really stand for unhealthy. This is a residue of the bipolar categorized thinking for research purposes from the Cartesian mind-body split mentality continuing as health-disease split mindset as quoted by the anthropologist Ashley Montagu, who said that doctors are taught to be interested in disease but not health and the public is taught that health is absence of disease. There was an article in The BMJ in 2002 that it is time to move beyond the mind-body split (https://www.bmj.com/content/325/7378/1433). It s long overdue.
Many patients develop dis-ease from unhealthy but normal social communication skills with the environment leading to the body speaking through illness or as disease. Carol Oates said that "Homo sapiens is the species that invents symbols in which to invest passion and authority, then forgets that symbols are inventions." Our duty assigned from society is to negate labels or make symbol on patients so that we have the authority to ask for money from insurance company or the government to treat them with material intervention. Those who felt ill or unhealthy but were not yet labelled as having an individual organ disease are neglected and they look for homeopathy, etc, elsewhere. In the past 2 decades we have expanded our segmental label to medicalize them under our care. As a society we forget that ultimately doctors should be creators of health for each individual patient in front of them during consultation and that treatment of a disease label is one method.
Almost every patient has general adaptation disorder (GAS) as diagnosed by Dr. Selye 80 years ago. It really is true that every patient is either suffering from hurry sickness asking for quick fix or deep down impatience about their discomfort causing chronic inflammation of their cells leading to organ disease (https://www.sciencedaily.com/releases/2012/04/120402162546.htm). They unconsicously create or catalyse their illness. Apart from material intervention, if this GAS label from doctors can attract rebate from government or the insurance company and doctors then use Dr. Engel’s extended biomedical model mindset (bio-psychosocial medical model 1977) to make patients aware of their ultimate single disease of automatic stress response, add education and training of individual patient to improve their relatively unhealthy but normal communication skills with their environment, doctors can really lead patients to health rather than educating them on the road to disease. Yet actually many of us doctors suffer GAS from our system/culture and we pass it on to patients. There is an old saying in medical culture that doctors “cure sometimes, relieve often, comfort always”. Nowadays we are legally required to add stress to patients as demonstrated in the Montgomery case. Then we comfort patients with more intervention.
As a profession we should ditch our thinking that we only do material intervention, we should educate and train patients to focus their mind to produce endogenous drugs from their own brain (http://rstb.royalsocietypublishing.org/content/366/1572/1790) through developing healthy connections in the brain and supplement it with exogenous drugs when indicated. Only then can patients rely less on tokens and rituals from doctors sometimes in form of placebo surgery to relieve brain pain arising from dis-ease about peripheral imaging.
Sir William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease." In Ancient Chinese wisdom, the great doctor treats the country/system, good doctor treats the person, ordinary doctor treats disease. If we as doctors forget to train a healthy thinking pattern for patients in front of us and delegate the duty to other professions, we end up ourself focusing on disease mindset and disease communication pattern and create more and more chronic patients for life long exogenous drug usage.
Our medical schools adopt the biomedical model and develop disease mindset for doctors and we sell sickness to society for a living. Medical schools should adopt the integrated biopsychosocial medical model which is the ultimate solution to develop a healthy mindset for future doctors so that doctors can sell health to patients for a living (my article - https://www.bmj.com/content/346/bmj.f2809/rapid-responses). Should we as doctors be trained in society to develop a disease mindset or health mindset?
As we struggle to overdiagnose patients to bring them back to us, the sick society responds by telling people to look for health elsewhere away from doctors. Yet only doctors have the proper basic western medicine training to avoid risk of delayed diagnosis by natural therapist and we should make ourselves indispensible for real health in an unhealthy society!
Competing interests: No competing interests
As well as the preventive measures documented surely diet and exercise should be highlighted (in case they were included in 'education' and 'social improvements'). Britains were never healthier than in WW2 with rationing and the need for (increased) physical activity. Glasgow used to hold the dubious record for dental caries due to the ships from the West Indies unloading their sugar with resultant 'sweetie shops'. Today, however, there is an epidemic of obesity and the consequent 'Diseases of Affluence' (hypertension, hyperlipidaemia, cardiovascular diseases, diabetes, arthritis and depression) due to the oversupply of processed foods, better public transport, labour-saving devices including mobile phones and computers, The cost of the drugs to treat these preventable illnesses is absolutely incredible. Yet, in many parts of the civilised world, nutrition and physical education have been lapsed from the school syllabus while TV ads for junk food are designed especially to attract children. The politicians bury reports criticising processed foods as the Fast Food Industry makes incredible donations to their Parties.
It has gone past the point of no-return such that prevention is now up to the motivated, (already) educated individual who are mostly restricted to Socio-economic Classes 1 and 2. As to the rest then, cynically, may I observe the various Governments have adopted the policy of "Let Them Eat Cake (and other Fast Foods)".
Competing interests: No competing interests
After somehow managing to get 2 postgraduate degrees, in addition to my first in Pharmacy, the first 12 successful years of my career were mostly in the Pharmaceutical Industry. Initiated after a relatively short but most rewarding period with the DHSS Medicines Division; now the MHRA, as one of the first three Scientific Officers employed to assist Medical Assessors. Employment was more varied for the following 10 years.
It became rapidly apparent, although I did not realise this until many years later that I had developed skills that set me apart from many of my peers. In particular: organisational; lateral thinking; ability to work on my own without continual guidance and an enduring trait of never being a 'yes man' and prepared to speak my mind to far more senior individuals than myself. As a result I was able to find (or they found me) projects of significance to do, mostly on my own, to initiate and manage change.
The first simple example of these was a new job reviewing preclinical toxicology reports prior to allowing them to be passed to Regulatory Affairs for submission for a Clinical Trials Phase approval, or Product Licence. Given I was female and had never actually worked in an actual industrial toxicology department my many comments for improvement in all aspects of long detailed reports with detail down to individual animal data, were not appreciated. The response was a slow improvement in the quality of the reports received for review such that after two years not only was the role becoming boring, so I had been looking for other 'tasks' to keep me occupied, I essentially became redundant.
Over the years I became an individual 'special projects' resource. Each project that seemed to last around two years and had some endpoint that became clear as it progressed if not obvious from the start. My achievement was the realisation that I had succeeded in what I had been asked to do, or identified as needing to be done. I rarely got any reward or even thanks; this was often taken by the particular boss at the time.
20 years later I had achieved a great deal for companies, but my reward was for the stress and anxiety and far to much working 24/7 that I completely burnt out.
What I have noticed in my local area also is that there seems to have been a direct correlation in the amount of hours put in by clinicians to their huge rises in remuneration over the last 20 - 30 years. The more pay - the less hours, working to contractual hours or many individual arrangements with less days per week, since they probably do not need the money to still have a rewarding out of work lifestyle.
As a result the availability of GP time has decreased at a faster rate to the increase in patient numbers with health problems. (My own analysis, not supported by any reviewed evidence). It is becoming less and less likely that these GPs, Surgeons and Consultants will suffer any 'real' issue with individual overwork; nurses, registrars and support staff in the NHS are not included in this.
They are putting into practice what is 'preached' to the current working population of the UK, but the latter are now working 24/7 more and more, just to survive. On the other hand GPs are becoming more and more difficult to actually see face to face with telephone triageing becoming the norm, sometimes with life threatening misdiagnoses based on these assessments, plus the assumption that a patient is always able to define one problem at a time, when many may be interrelated! Nothing will replace a face to face consultation and these are now to time limited. The growing numbers of elderly will probably find on-line AI questionnaires difficult, if not impossible to complete anyway!
So to agree, in part, with one of the respondents above. The role of a GP, or hospital clinician, may involve ongoing small successes. However, these are replaced on a daily basis by new challenges, some never resulting in making a patient well. The changes in lifestyle and work ethic of the 21st century population is changing at a rate that GPs will find it harder and harder to ever achieve many small successes, let alone become redundant.
Competing interests: No competing interests
In an ideal world the doctor is challenged to make their patients well. Indeed if they were to do so to the fullest extent there would be less demand for their services. We can dream about how every mother would give birth to healthy babies by natural methods of child birth, how we would live healthy lives until the day when we expire, and how we can make people well; however the real world situation is complicated by the growth of the world's population, the steady increase in levels of pollution - today it has been announced that fertility has halved in recent decades. There is a worldwide shortage of doctors moreover the demand for healthcare keeps increasing. In brief there is never going to be a situation when the doctor is made redundant.
The latest announcements re AI technologies which will replace the GP are just marketing hype. The fundamental process means that there is always going to be a limit beyond which the chatbot cannot go beyond - it is limited by the existing state of knowledge (the etiology of most medical conditions remains poorly defined, especially so re complex chronic conditions), and the ability of the patient to relay details about their health to the examining chatbot. Indeed this limited state of knowledge is the reason why there continues to be so much medical research. As stated by Einstein 'if we knew what we are doing it would not be called research'.
You might think I am arguing against a new generation of AI technology which can diagnose the patient's health. No. I am arguing for a new generation of medical technology - based upon a precise and sophisticated understanding of what the brain does and how it does it i.e. a mathematical model of how the brain regulates the autonomic nervous system and the coherent function of the physiological systems - and how this can be applied with diagnostic and therapeutic effect.
Ewing GW, Grakov IG, Mohanlall R, Adams JK. A Clinical Study Report and Evaluation of the Ability of Strannik Virtual Scanning to Screen the Health of a Randomly Selected Cohort of 50 Patients. J Neurophysiol. Neurol. Disord. 2017;4:1-12. DOI:10.17303/jnnd.2017.4.101
Grakov I G, Graham Ewing, Mohanlall R, Adams J K. A summary or meta-analysis of data regarding the use of Strannik Virtual Scanning as a screening modality for healthcare. Asian Journal of Pharmacy, Nursing and Medical Science 2017;5(3):55-71 http://ajouronline.com/index.php/AJPNMS/article/view/4636/2521 .
Ewing GW, Grakov IG (2015). A Comparison of the Aims and Objectives of the Human Brain Project with Grakov’s Mathematical Model of the Autonomic Nervous System (Strannik Technology). Enliven: Neurol Neurotech 2015;1(1): 002.
Competing interests: CEO of Mimex Montague Healthcare, suppliers of Strannik software. Strannik, the first technology to be based upon a mathematical model of how the brain regulates the autonomic nervous system and how this can be applied with diagnostic and/or therapeutic effect.
"Matt Hancock, called for a greater focus on prevention (doi:10.1136/bmj.k4684). If properly funded and implemented over time, this should indeed help more people to keep away from doctors." For a while. Not forever.
It is pleasing to think that good health begets decreased costs. However, all will die and most will do so of a chronic disease preceded by medical treatments. Living longer as healthy people generally does generate additional expenses as well. (1)
(1) van Baal PH, Polder JJ, de Wit GA, et al. Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS Med. 2008;5(2):e29.
Competing interests: No competing interests