As the COVID-19 pandemic continues, seeing the impact on healthcare staff it is timely to consider the future of medicine, and how we support future doctors and adapt our systems to allow them to thrive.
It is hard to make predictions in complex health systems but the work undertaken by Health Education England (HEE) in the Future Doctor Programme1 and pandemic experience highlight the importance of the human side of medicine: doctors’ relationship with patients and others in the team; their confidence in managing complex comorbidity as the norm; and their desire to address health inequalities and the health of populations, as well as that of individuals.
Four themes from the Future Doctor Programme are fundamental to this human element.
THE DOCTOR–PATIENT PARTNERSHIP
HEE’s work showed that most doctors value personal relationships with patients above all. This applies across all healthcare settings including mainly research-based doctors.
Personal interactions enable doctors to absorb innumerable details about individual patients. This allows them to choose the best options for prevention, diagnosis, treatment, or support. It stimulates ‘questioning’ for research, shapes medicine, and develops clinical expertise, allowing experienced clinicians to rapidly assimilate verbal and non-verbal information to produce seemingly intuitive diagnoses.
During COVID-19 we saw the vital importance of human relationships, and human contact, to us all. Doctors want to be able to express empathy and compassion through a human connection with their patients and to treat them holistically, not just treat their disease.
The benefit of investing time to think holistically is known. One long consultation, or many over the years, enable GPs to develop relationships and practise holistically despite seriously constrained time limits. Our target-driven NHS culture often impedes this.
Patients also place great weight on the patient–doctor relationship, enabling trust and ensuring they have the best care as individuals. As they navigate the advances in technology and increased available information, and misinformation, patients need a trusted interpreter to help them find optimal personal solutions. As a patient I value the time and support I am given to understand what different options, research, and risks mean to me personally.
The relationship is changing, as noted by both patients and doctors. The future requires the ‘partnership’ approach, advocated in general practice, across health and social care, which provides effective personalised care, and allows doctors to focus on individuals, with the help of, rather than replacement by, technology.
TEAMWORKING
HEE’s work has also shown that being an effective team member is now a crucial skill for a doctor to develop. Patients, junior healthcare staff, and students understand this and are bemused by unspoken cultural rules that often push clinical practice into professional and specialty silos or create unhealthy tribalism.
COVID-19 created an environment that removed many traditional barriers and required more cross-sector team thinking. Flattened hierarchies demonstrated the power of effective distributed leadership across professional silos, and the shared decision making, involving all grades of staff, gave clinicians a greater sense of shared purpose and boosted morale. The value of all team members was affirmed and appreciated by doctors and patients alike. I was surprised by how much I valued having all the team’s perspectives on what was best for me, in my own experience of care recently.
The need for such teamworking, to effectively provide holistic care for an individual or patient group, extends beyond doctors, individual teams, and any single organisation.
COMPLEXITY, UNCERTAINTY, AND RISK
One of the attributes of a doctor most valued by patients, employers, and other healthcare staff is a doctor’s ability to understand complexity. This manifests in both the internal multisystem interactions of disease and the external complex health, social, and environmental interactions. The ability to hold the uncertainty this creates and balance risks to make the best decisions is respected by all.
Doctors also help others understand this balance of risks so patients and other staff can participate in decision making. Patients value this help to ‘make sense of the world’, when they are vulnerable. However, to understand the possible impact of interventions in individuals with increasing multimorbidity and multiple external influences, the doctor must have a broad general understanding of both society and disease. Kessel described this in general practice in 1960.2 Sixty years later, technology can significantly expand this breadth of understanding of the social and environmental determinants of an individual’s health.
Many recognise the need to enhance holistic generalist skills and develop a universally greater understanding of comorbidity and the wider determinants of health. Chris Whitty stated, ‘if you are not interested in health inequalities, you are not interested in health’.3 Even in the single disease crisis of COVID-19, a holistic approach, considering comorbidity and personal and social health, was required to make the tough interventional decisions. A holistic approach is also now required to manage the service backlog.
THINKING GLOBALLY, ACTING LOCALLY
The current generation of medical trainees and students see doctors’ responsibilities extending beyond individual patients to both local populations and the wider global environment. Many judged an inattention to global issues, including health inequalities and sustainability, as unprofessional. They believe doctors, as leaders with some influence, should act to address the wider determinants of health and they wanted to engage in social activism.
COVID-19 increased the understanding among the public of the importance of social factors, such as isolation, and the health risks associated with multimorbidity, disability, and frailty, although medical teaching has not focused on this. Training could facilitate future doctors to deliver the more positive impacts that they aspire to, for society as well as for individuals.
THE FOCUS FOR TRAINING FOR THE FUTURE
The insight and foresight of today’s trainees should inform education and training for doctors of the future, and five themes emerge when considering what we should be aiming for.
Health
We must attend to doctors’ wellbeing. Wellbeing is a patient safety issue and essential for compassionate care. Exhausted doctors cannot provide truly holistic care.
Doctors in training have a wisdom that previous generations ignored. They recognise the pressures that exist, and the importance of wellbeing, as they see doctors considering leaving all through the career pathways. COVID-19 forced adaptations that supported staff and protected vulnerable healthcare workers, which we must build on.
As we increase the pace of service recovery, we are setting the pattern for the future. Having seen performance decrease when individuals are overstressed, we must look after healthcare staff, so they can deliver good care, and remain motivated to continue working. This is a significant challenge, and important as we invest much time and money in training.
Holistic skills
Despite the increasing comorbidity in the population, as the pressure on the NHS increases, the delivery of care often becomes more single outcome focused. Delivery targets risk the provision of effective complex holistic health care and may inadvertently create a much greater societal cost in readmission, repeated attendance, and social care, as well as the personal cost to individuals. The need for generalist holistic thinking should be reflected in training.
Broader perspectives on training
To enable doctors to take a more holistic view we must allow them to develop broader perspectives than those gained in traditional specialty training. Taking time out to access different specialty or life experiences makes doctors more rounded professionals, as recognised in countries such as Malta where it is required for qualification. By encouraging flexibility initiatives, and challenging thinking about the value of specialist skills without wider experience, we could promote a broader professional approach.
Increased focus on diversity and inclusion
In our NHS culture there are still significant inequality, diversity, and inclusion issues. Trainees still report behaviours that make me deeply ashamed of our profession and we all need to address the issues within our UK medical culture.
We need a more modern construct of medical professionalism viewed through the lens of equality for staff and patients, which embraces personal health insight and an ability to take, and advocate for, an inclusive, broad, holistic, multi-sector approach. My GP career choice was influenced by the respect shown to the Professor of General Practice by professors in medicine and surgery, who included him in their decision making on teaching ward rounds.
During COVID-19, healthcare staff saw a different kind of leadership being role modelled by doctors sharing leadership roles within teams. Rapid decision making and continuous improvements in the approach to COVID-19 were enabled by collaborative working of different multiprofessional groups solving issues, both locally and globally. Wellbeing was considered, both personal and that of the team, and a holistic understanding of the impact of comorbidity on risks was valued.
Professionalism is too important to leave to learn by osmosis. It needs to be emphasised through continuous learning. Education provides the supportive lens for viewing poor behaviour by reframing unprofessional behaviours as ‘insufficient learning’ requiring constructive developmental feedback. But only by talking about professionalism openly and honestly, and being prepared to call out unprofessional behaviours, can we change the NHS culture to enable more respectful and effective teamworking, and to value other and broader perspectives.
Assessing the doctor of the future
In considering how assessment could influence future thinking it is perhaps time for a different approach. Perhaps encouraging trainees to explore the initiatives that they are advocating and self-assess broader holistic development needs is a more professional way to shape career pathways.
Currently there is a huge assessment burden on both doctors learning and those teaching, and although we need to assess learning outcomes, as poor insight often accompanies poor performance, through COVID-19 we have seen that simplified processes may be just as good.
Doctors broadening their learning experiences could do this with minimal assessment. But only senior doctors can encourage the NHS to accept experiences without certification.
When we consider the cost of training doctors, retaining their enthusiasm, broadening their experience, and letting them follow their interests is sensible resource management, especially when their interests are in line with society’s needs. However, any additional burden on trainers should be recognised.
LOOKING FORWARD
There is much to hope for in the future: a healthier workforce with a more balanced working life; a greater understanding of what it means to be a professional, with more inclusivity and a greater respect for others; a more flexible holistic approach across medicine to allow doctors to embrace the inevitable future UK health problems of age and comorbidity, and to address inequalities; and recognition of the wisdom of younger generations in developing our profession and professionalism.
To see that hope realised, more change is needed to support the future professional, with greater flexibility and autonomy in how they train and what they learn, and a greater emphasis on teamworking, professionalism, and holistic perspectives on societal problems.
We all need to consider our professionalism and accept our responsibility for both being, and shaping, the doctors of the future. If it is patient interactions we value most, we need to bring both our expertise and our humanity to work, look holistically at patients, and truly connect with individuals’ hearts and minds.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The author has declared no competing interests.
Footnotes
This text is based on the William Pickles Lecture, given virtually on 25 June 2021. A video of the lecture is available at: https://www.youtube.com/watch?v=RAY3Fovzmws.
- © British Journal of General Practice 2021