The changing medical landscape

L Lo 盧令

HK Pract 2017;39:105-106

The landscape of medical practice is ever changing. And so is general practice and family medicine. Electronic health records, smart phones, universal broad-band internet access, asynchronous communications, electronic visits, telemedicine, team-based care, patient-centred primary care homes are the many changes driven by public expectations.¹

Medical education is like never before. Long gone are the days when medical learning is confined to the four walls - within the boundaries of universities and teaching hospitals. We now see advancements in medicine that were not taught in the “good old days”. For example, the latest recommendation of diagnosing hypertension by ambulatory blood pressure monitoring (ABPM) was unimagined. The wider availability of ABPM enriched our understanding of white coat hypertension (WCH) and white coat effect (WCE). In the excellent review article on benign prostatic hyperplasia (BPH) by Chow et al, we learn about new pharmacological treatments, the use of a validated patient questionnaire to assess symptoms, and the counselling regarding prostate specific antigen (PSA) testing. All these advancements are not just intended to improve health outcomes, but also to enable clinicians to care about the whole person and to better manage patients’ health experience.

Medical curricula are under gradual changes both locally and globally. Professor Amanda Howe, President of WONCA, reviewed the role of family medicine in the future development of medical education. She pointed out that modern medical courses integrate theory and practice, and send students to community and ambulatory settings to gain applied learning from people about people. Medical education has shifted to train doctors for a more person-centered and preventive approach, with emphasis on consultation skills and clinical simulations. These new paradigms are indeed central to the core values of general practice and family medicine.

These changes in medical education and the practice of medicine in the population level are compelled by a recognition of the unsustainable trajectory of health care costs. Extensive evidence has demonstrated that good access to good primary care brings good outcomes: Health care quality and health outcomes improve, problems are diagnosed earlier, self-reported general and mental health goes up, hospital admissions and emergency department utilisation rates decline, and health care costs go down. To thrive and sustain between multiple medical conditions and multiple medications, doctors need expertise and training to help sort out some of the harder and riskier aspects of care.² These are exactly the situations when family medicine training comes in.

Family physicians and general practitioners play an important role in bringing learners, including medical undergraduates, paramedical team members, the general public and even policy makers, into community where the impact and visibility of our discipline are seen. Family physicians and general practitioners also help to underpin how the broader social determinants of health – environment, infrastructure, income, education, employment and political context – influence patients’ well-being and life opportunities.

As Professor Howe has remarked, both societal and scientific factors and assistive technologies are shaping the nature of medical practice and the possibilities for medical education. Over all these years, general practice and family medicine have survived and grown stronger amid the upheaval of health care systems. But according to Dr Donald Li, President Elect of WONCA, challenges are increasingly experienced by family physicians in terms of high level of patient contact, bureaucracy, stringent accreditation processes, escalating medical indemnity cost, cut-throat competition and manpower insufficiency. Family physicians’ workload is steeper than before, as they are now more driven by evidence and regulatory requirements and yet they are more risk averse.

Another hurdle faced by family physicians in the modern time is that the current fee-for-service payment system cannot remunerate the additional resources and activities devoted by family physicians to taking up the care coordinator role. Globally primary care is heading to team-based inter-disciplinary care. These take the form of Primary Care Medical Homes (PCMHs) in the United States³ and Community Health Centres (CHCs) in our local public system. According to a report by White⁴ on the state of family medicine in the United States,an average family doctor spends 34 hours per week on providing face-to-face patient care and 7.4 hours – almost an entire workday – on administrative tasks. While more health care resources are being allocated to the field family medicine and primary health care, financial incentives are still slow to align.

The medical education arena is also poised with challenges. Private medical schools are on the rise and many of them emphasise online and distance learning, which can be contradictory to the socially accountable nature of family medicine. The push to high-tech rather than high-touch medicine drags family physicians further away from their core: whole-person, whole-family and whole-community care.

“The greatest mistake in the treatment of disease is that there are physicians for the body and physicians for the soul, although the two cannot be separated,” Plato, Greek philosopher (428-348 BC).

While resolution or evolution of primary care delivery would not occur without growing pains, primary care practitioners can advance by embracing high-value, patient-centred care, coordinated among providers. Family doctors have to demonstrate to the public their role as health partner for life by providing appropriate preventive care and treatment at early stages. And general practitioners and family physicians should educate the public and decision makers about the value of prevention, rather than relying solely on cure, and empowering and partnering with patients to improve health outcomes and health care experience. Finally a more proactive position should be engaged by family physicians in advocacy and leadership in medicine, leading the way toward its brighter future.