Status of the doctor—present and future

Abstract

Until his retirement in 1994, Arend J Dunning was professor of Cardiology at the University of Amsterdam, Netherlands, and chief of the Department of Cardiology, Academic Medical Centre, Amsterdam. During 1983–95, he was also editor of the Nederlands Tijdschrift voor Geneeskunde. At the beginning of the 20th century, in the preface to his play The Doctor's Dilemma, George Bernard Shaw wrote that all professions are a conspiracy against the laity. The medical profession conceals its own shortcomings, but is less suspect than others. 100 years ago, doctors were held in high regard by their patients, although the patients' expectations of their doctors' performance were low. Today, medicine has become a powerful and complex part of our society, but its practitioners are being held to account for sins of commission and omission, for their attitude towards their patients, and for their belief in the miracles of medical technology. The professional's autonomy is severely restricted by budgets, bureaucracy, guidelines, and peer review. Doctors may well prove to be competent technicians, but society continues to expect more. Better interpersonal communication, and respect for patients' rights including self-determination, informed consent, and protection of privacy, have become the doctor's plight. A better-informed community is asking for accountability, transparency, and sound professional standards. Speaking in 1903, Sir William Osier observed that “half of us are blind, few of us feel, and we are all deaf”. Of all the complaints levelled against medical practice, our often insensitive behaviour is the main one. As a body of practitioners, we have earned respect for what can be achieved, for example, in surgery, cardiology, or pharmacotherapy. In the space of two generations, major and chronic diseases have been prevented, postponed, or treated effectively, and life expectancy has been prolonged, albeit not liberating people from illness and doctors. Where expectations fall short of actual performance, as with cancer, diabetes, schizophrenia, or dementia, the patient, in the absence of a cure, hopes at least for a caring doctor. The medical curriculum does not provide for these skills. Our 60 to 80-hour working week is devoted to doing, and not to sitting and listening. Cloistered in our practices and in our hospitals, we are unable to find the time or to summon up the incentive to reflect on what we do, and we shy away from suffering and death, regarding them as medical failures. The doctor as a father figure has vanished. His paternalism in today's adult, informed, and autonomous population of patients is no longer desired, but it does not suffice to substitute him with a competent plumber. The patient's autonomy is lost in the face of severe illness and the process of dying, and people are looking for comfort and care. A previous and famous editor of The Lancet, Sir Theodore Fox, wrote that lack of time made us all bad doctors. This lack of time is selective, since, in Western Europe, one in 500 citizens has a medical diploma. In the near future, women will constitute half of this medical workforce. There will be increasing pressure to harmonise working hours with those of the population at large, for paid absence for family care, for retraining, and for part-time work employment. Finally, there will come an end to the exploitation of junior doctors. Tomorrow's doctors will be more equal to their patients, they will have a greater understanding of the real world, and female hands may prove to be gentler and more caring. Feminisation will alter the status of the medical profession, as it has already done in Eastern Europe and in Israel. The nature of medical education as a quasi-medieval guild, with its pyramid-like structure of fame, recognition, and remuneration, will be irretrievably transformed as we seek to compress the burden of illness into the final decade of a long and, on average, healthy lifespan. Who knows, we might even need fewer doctors but more nurses, fewer hospitals but more homes for the disabled and disoriented. Medicine is not a commodity for the marketplace. In the USA, one seventh of the gross national product is devoted to health care, but one in seven Americans is not covered by medical insurance. Nor is it governmental property, as state medicine in Eastern Europe, with its increasing mortality, has clearly shown. The profession's sole legitimacy is the interest of its patients. The provision of this service has to be done competently, adequately, and with care, and has to accord with the society's needs and not its demands. Therein lies our future status, which would be immeasurably enhanced if we could succeed in exporting it, even in part, to the much poorer and sicker wider world surrounding us.