A forensic psychiatrist. A radiation physicist. A clinical perfusionist. A speech-language pathologist for the developmentally disabled. A systems navigator at a Community Health Centre. A tobacco enforcement officer at a local public health agency. A Manager of Procurement for Drugs and Devices at the Ministry of Health. A death midwife. What must these people all have in common in order for the health care system to function?
Nothing. Which is kind of the point.
In fact, the odds are good that any one of them wouldn't have a clue as to what any of the others does in the run of a day, much less the others' incomes or qualifications (apart from the psychiatrist being an MD).
There's a tendency in health care, and in other parts of public life, to think that we need to go back to the Way Things Were in order to the Make Things Better. Moreover, there's also the tendency to think that somehow, in a system of ever-expanding complexity and increasing detail and interconnection, we're only One Change Away - user fees, putting doctors on salary, government reorganization - from Things Being Perfect. I'm not a psychologist, so I can't rhyme off the cognitive biases at work here. Nevertheless, these are notions we all intuitively grasp as being erroneous, yet continue to indulge.
It doesn't take much searching on social media to find doctors lamenting the slow and steady demise of a "generalist" medical practice. Family doctors bear most of the blame here - they choose non-office work like the ER or hospital medicine; they don't deliver babies; or they become pseudo-specialists in pain management, palliative care, or sports medicine. That being said, specialists get it as well - OB/Gyns get called out for opening fertility clinics instead of delivering babies in rural areas; or surgeons limit the scope of who they'll see and what operations they'll perform routinely.
Underlying the critique are assertions that these doctors (or any specialized professional, really) are somehow in violation of an unspoken social contract, or flouting the principles laid out in their training, by following their professional interests or meeting a perceived need. In the more toxic corners of social media, following that logic leads to circular arguments, gang mentality, and personal sniping. But when those assertions reach the heights of policy makers, we end up with everything from academic medicine's government edicts on where and how MDs can practice.
The bottom line is that the ever-increasing specialization in health care isn't a bad thing and isn't a good thing...it's just reality. Moreover, it's a reality that won't and can't be reversed.
Don't believe me? This is how medicine in the 21st century works:
A medical oncologist in Kingston treats prostate, breast, and testicular cancer. Her colleague, who treats lung, colon, and kidney cancer, is moving to another city. The oncologist staying around picks up kidney as one of her tumor sites. She spends the next season immersing in the science, evidence, and practical experience of treating kidney cancer, attending conferences and other workshops, yet still finds herself asking colleagues for advice. We're talking about an experienced oncologist who underwent the same nine(!) years of medical pelatihan as her colleague, needing months of time to understand the nuances of a single type of cancer, a category of disease she ostensibly treats full-time.
A family doctor in rural Nova Scotia has been working as a hospitalist for fifteen years. He sits on a plethora of hospital committees, is a valuable liaison with local home-care agencies, has spearheaded a wide range of quality improvement projects, and is regarded as indispensable by his local colleagues. The provincial government has decided, as a cost-saving measure (insert punch line here), to have nurse practitioners fill the role of hospitalist in place of doctors, and advise the MD that his position will no longer be funded. When asked what he's supposed to do for work if he wants to stay local, the MD is advised that, as a licensed family doctor, he should have no duduk kasus opening or joining a private practice. Except that not once in fifteen years has he: supervised a pregnancy; delivered a baby; treated childhood illnesses; counseled a patient with depression; prescribed stimulant medications; prescribed birth control; or evaluated a patient's diet plan.
A year or two into my job at a Community Health Centre, I was mainly practicing pain medicine and primary care psychiatry. Before the CHC, I'd worked in private practice for nine years. By the time I left the CHC at the end of 2015, I was no longer up to date on anti-clot medications for atrial fibrillation, nor two classes of drugs used to treat diabetes. It didn't take me long to catch up on the evidence, but we're talking about two of the most ubiquitous conditions in medicine. Was I less of a doctor for using my conference time and medical reading to get a better handle on PTSD and addictions? How am I serving the patients in front of me by keeping abreast of treatments for conditions they don't have?
And how would I react if the government decided to conscript me for the ER? I haven't worked a shift in over a decade. Sure, I can still cast a fracture and suture a wound, if sloppily. But even if I updated all my resuscitation certificates, would I trust myself to competently manage a heart attack? A car accident victim? A child with a life-threatening infection?
There's a case to be made that doctors "owe something" to the community, both for subsidizing their education and according them the status of a high-earning and self-regulated profession (much as that's been greatly undermined of late). And the idea of a new graduate setting up a focused practice in a busy city, while rural areas are getting desperate to provide even emergency health care services, doesn't seem right.
But turning back the clock on medicine - or all of health care, for that matter - and thinking we can go back to a world of jack-of-all-trades generalists is wishful thinking. Maybe generalist work can be foisted on new grads for a few years, but that comes with the necessary acceptance of real risk to patient safety in high-acuity situations. We've simply come too far, spread too far, and learned too much to go back to any Good Old Days, that almost certainly weren't all that good to begin with. The sooner everyone accepts the reality of the times, the sooner we can find a sensible way to move forward.
Ditulis
Unknown
—
Sunday, November 19, 2017
—
Add Comment
—
education,
Family Medicine,
health care,
health policy
Belum ada tanggapan untuk "No Going Back"
Post a Comment