Whoever is looking for an answer to the question of just what is the responsibility of a doctor in the approach to treatment of the patient of today can easily find it. Just read the Hippocratic Oath, to which every doctor pledges his fidelity.
But it’s more important to ask the right question. A better question is: what are the chief factors in our society regarding treatment and patient care, and what influences them most?
So as not to get bogged down in a purely philosophical debate, I’ll list nine key points that most influence the practice of modern medicine today. In the tenth point I will attempt a brief synthesis. I do so on the basis of my 40 years of practice and teaching on three continents.
- The rise of technology. Without question, the first point is the dramatic increase in medical and research technology on all fronts. Today’s drugs, tests, technology, and especially access to information are at such a level, that possibilities regarding all aspects of the practice of medicine have multiplied in the last 40 years more, than in the previous 400 years.
- Globalization. Related to the first point, medicine has become truly transglobal. To a certain extent, a doctor can try to maintain a ‘personal’ approach to a patient, but if he really wants to know what he has to know, i.e. to ‘keep up’ with everything that is happening in medicine, he’s is now under enormous pressure to constantly and periodically self-educate. In practical terms, he should know English, read multinational journals regularly, and attend national and multinational medical congresses regularly. All of which requires a considerable investment of time and money.
- Uneven knowledge bases. Not all doctors have the above-mentioned opportunities, and not all are forced to do so. This leads to large differences in knowledge between one doctor and another, which are partly determined by the conditions for practicing medicine in a given country. In the United States, for example, it is compulsory for physicians to document a certain number of hours of participation in formal training and self-teaching each year. In addition, all physicians must regularly renew their certification every five to ten years (depending on their specialty). It is not hard to imagine how things would turn out in the Czech Republic if a 62-year-old doctor in the countryside, who did not need to self-educate further after graduating, had to re-master his specialty that he had received before the revolution. As a result, even though there have been significant advances in the level of global medicine, there are huge differences in the knowledge and practice of medicine between one doctor and another based on the standards, requirements and post-graduate training opportunities in place in a given country. In this sense, physicians’ knowledge of the practice of medicine is in many cases still regional or “local”.
- Unequal treatment. Related to the previous point is the approach of a given doctor to diagnosis and treatment. In general, the better and more well-read a doctor is, the more he or she is aware of – or even follows so-called evidence-based medicine. This means that he makes decisions based on clearly documented and proven effective approaches and studies. An example would be the selective use of antibiotics only for certain types or stages of infectious diseases, such as Lyme disease. In contrast to this approach are doctors who treat mainly on the basis of the principle ‘this is how we do it here’. Such an approach may not be harmful, but it may represent a departure of medicine into a certain ‘provincialism’.
- Digitalization. Along with the rise of digitalization and its infiltration into societal thinking, there has automatically been a push to digitalize all information that has any relevance to patient care. As a result, in most modern hospitals you will not find a pencil or a patient chart. Most studies show that digitalizing data in healthcare can be of some benefit, mostly in cases such as telemedicine and data transport, where doctors can more effectively intervene directly and influence healthcare where this has not been possible. Other benefits include the centralization of all data (which brings up additional issues of how to handle data ethically) and better control and insight into prescriptions and therapy. It’s just that when it comes to the overall state of healthcare, which includes the psychological (both from the patient and the doctor), digitalizing healthcare comes at a high price. In addition to the significant investment of money and personnel in implementing and maintaining data systems and technology, digitalization of healthcare distorts the doctor-patient relationship by creating a forced dependency and prioritizing data systems before a doctor can practice at all.
- Choking regulations and administration. On the one hand, due to the ever-increasing digitalization (as mentioned in the previous point) and access to information, and on the other hand, due to the shift in social perception on a whole range of issues around the concept of ‘equality’ and its achievement for all at all costs, modern society is experiencing an unprecedented increase in regulations of all kinds, which are affecting every part of life today. Of all the sectors, this growth is hampering healthcare the most, to the extent that there are countries in the EU that spend up to 10% of their healthcare expenditure on administration alone; in the UK and the US, healthcare administration costs a staggering 20% and 25% respectively of all financial resources devoted to this area. The consequence of this trend is burnout syndrome.
- Burnout syndrome. This is a condition in which a physician is overwhelmed by unnecessary work and regulations that make it increasingly difficult for him or her to practice medicine the way he or she imagines it should be practiced. The syndrome has both physical and psychological symptoms, which mainly include physical and mental fatigue and depression. This syndrome was almost unheard of in the last century; today it is no exception in developed countries, where it effects up to 40% of all doctors. The main reasons for this are the two previous points, namely the digitalization of medicine, which has completely changed the relationship between doctor and patient, and increased regulation, which is affecting every aspect of medical practice. Other reasons include increased complexity of care, the forced reduction in time with patients in the context of an increasing number of patients, and the loss of personal freedom and independent decision-making. Today, there is no modern medical facility that does not offer its physicians both preventive and supportive courses on how to avoid or overcome this common phenomenon.
- A culture of entitlement. This is perhaps the most dominant point of all, which follows from all the previous ones. Postmodern society, stripped of its traditional everyday threats and lulled into a state that increasingly prioritizes commercialism, personal well-being, and has “more” as its main mantra. Related to this is the consequent psycho-cultural position whereby the notion that everyone is not only entitled to everything, but is even entitled to “everything” as part of a natural preference for their own individuality and personal choice. The result is an ever-increasing wave of legal regulation and litigation in which people claim ‘their’ rights over everything else. At the same time, a myriad of movements, ranging from the relevant to the absurd, have sprung up whose mission is to “protect” “everything.” In health care, this applies to all variations of morbid human physiognomies, all manner of gender approaches and transitions, various psychological conditions and diseases, etc., etc. As a result, doctors feel not only confused but increasingly oppressed by being forced to think about whether they can even ask the patient anything specific, and if so, how to wrap it up so that it doesn’t result in a complaint or even a lawsuit. This trend grows more so as one travels west; in the United States (e.g., at my hospital at Yale) there are oversized departments devoted to all manner of “patient relations” disorders, while every doctor, regardless of age or experience, is required to take a course every year on how not to commit sexual harassment. If he fails the course and does not answer the questions on the test correctly, his annual employment contract with the hospital will not be renewed. This requirement applies to all physicians in the state of Connecticut.
- The rise of alternative medicine. For the sake of making a point, I would include under this term everything that does not fit into the so-called evidence-based medicine. This includes branches such as homeopathy, “natural” treatments, all sorts of health “supplements” such as vitamins, etc. The growth in the use of these and other alternative sources far exceeds any other growth in the entire field and history of healthcare. In terms of minerals and vitamins alone, which people do not need unless they have a serious illness, over twenty-four billion ($24,200,000,000) dollars were spent worldwide last year. The reasons for this trend are complex; they are largely due to the points already mentioned, mainly the growth of regulation, the information overload of the overwhelming digital informatics, and the loss of the objective ability to judge. As a result, there is a growing dissatisfaction and distrust of standard treatment approaches by the public, which are often perceived as restrictive, limiting and biased. This is compounded by ever-changing recommendations from health organizations on established treatment approaches. Some are based on studies to achieve ‘better’ care, others change previous recommendations by one hundred and eighty degrees. Examples include the daily dose of aspirin to prevent certain diseases or the composition of dietary fat and cholesterol. It is not surprising that people are looking for other traditional and non-traditional solutions that are easier to navigate.
- Conclusion. Healthcare and the practice of medicine are among the most complex topics of our time. From a slightly different perspective, if you want to learn as much as you can about a given society in the shortest amount of time, look at how its healthcare system works and how its doctors practice. The same factors that are contributing to the transformation of today’s society are contributing to the transformation of medical practice. As a direct result of the advent of digitalization in healthcare, the drowning of society with unnecessary information from all sides, and the shift away from societal priorities to prioritization of one’s own, healthcare has been transformed from a profession in which the doctor’s main focus has shifted to a job in which every patient represents an obligation to, above all, comply with all the standards and protocols and regulations that are now associated with the practice of medicine. This shift has led to the division of the whole notion of ‘treatment’ into two parts: the psychological-human and the empirical-evidential, and the approach to ‘treatment’ has increasingly become one that favors only the latter at the expense of the latter. This has transformed modern medicine into a fundamental imbalance that increasingly distances man from his inner soul and psyche. Almost every patient is taken aback, when I ask him at the end of the first visit, if he is happy. The answer often takes up more time than the entire previous examination. But how many doctors, given personal, time and protocol constraints, can afford to ask that question? And how many patients even want to hear and discuss it?
The author is an assistant clinical professor of neurology at Yale University and director and practicing neurologist at the Polyclinic at Národní in Prague. He also lectures and teaches in Europe, the USA and the Caribbean.
Translated from the Czech original.
published: 28. 3. 2022