Medicine in society

Dr Zen's experience of life as a doctor seems much closer than 2020.* Many of her tribulations are already sapping the morale of clinicians in 2003. It is significant that Dr Zen is a woman. We continue to live in a sexist world, and as the medical workforce, particularly the general practice workforce, becomes more and more female, it is likely to become increasingly subject to exploitative working conditions. Those responsible for recruitment into medical school must ensure that all sectors of society are represented proportionately and that men and women are equally represented. It will then be important to try and ensure that women are given equal opportunities within every branch of medicine and that general practice remains equally rewarding and challenging for men and women. The working conditions within Corporation Enterprise seem unlikely to attract the brightest and best medical graduates of either sex.

The clinical encounter between Dr Zen and her unfortunate patient is an emaciated shadow of a genuine, general practice consultation. The doctor is constrained by her management and financial context and by the technology that she is obliged to use. As medical science develops, clinical practice necessarily becomes more difficult.1 In the future, doctors will need to be more skilful, not less so. As people live longer, more will suffer multiple illnesses, both physical and mental, and will suffer them simultaneously and inseparably. The patient who is overweight, depressed and hypertensive does not have these conditions in separate compartments of his life. He has all three inseparably and he may also be lonely and frightened — all of this is a single condition. The permutations of comorbidity are complex and individual outcomes are always unpredictable.1 Practice based on algorithms pretends that none of this is true and that healthcare is simple. The reductive use of information technology ossifies the processes of care, stifles innovation and fails to realise the potential of computers to model complexity.

Dr Zen works in a context within which the agendas of the pharmaceutical industry and of government leave no room for the needs of the patient or the professional aspirations of the doctor. The result, clearly seen in Dr Zen, is a loss of enthusiasm for education and the disappearance of original research that is inspired and directed by clinicians. Governments, dependent on systems of democratic voting, are driven by the utilitarian imperative of the greatest good for the greatest number. Within healthcare, we are seeing the rise of a new utilitarianism underpinned by modern epidemiology and imposed through systems of healthcare that are supported by information technology and sponsored by pharmaceutical companies. This new utilitarianism treats both doctors and patients as standardised and replaceable units, and would have us believe that a smoker is not an autonomous adult who has chosen to smoke but a patient who has been inadequately treated by their general practitioner. The waning of professional power has been regarded as promoting patient autonomy, but its replacement by corporate power compounded by centralised political control seems likely to be much more destructive of individual patient autonomy, dignity and, ultimately, health.

Current health policy is driven by a view of health defined as the absence of disease and measured by the prolongation of life. This view works to the advantage of the pharmaceutical industry. The interests of corporate profit underpin the trends which are already shifting attention and investment within healthcare from the sick to the well and from the old to the young, and replacing care mediated by touch with a system driven by paper and computers. Only a minority of most populations is acutely ill at any one time, whereas the majority are healthy and can be persuaded of a need to take action to remain so by undergoing screening or taking preventive medication. There is more money to be made from selling healthcare interventions for the healthier, richer majority than for the sicker, poorer minority, both globally and nationally.2 Similar forces drive the widening of health inequalities seen by Dr Zen in a nurse-led service for the poor and a doctor-led service, however attenuated, for the more affluent.

Returning to the not so distant future and confronted by the fear that is enduringly implicit in the human experience of illness, we find that the need for a trusting relationship between doctor and patient is so strong that, by 2025, Australia has witnessed the so-called Taxicab Revolt. More and more people realised that doctors like Dr Zen were being forced to supplement their incomes by driving taxis. Frustrated by the minimal and standardised healthcare offered by commercially sponsored organisations like Corporation Enterprise, worried patients began to seek out GP taxi drivers who gave them time to talk about the real extent of their fears and anxieties, and advice about how to begin to sort them out. An alliance was formed which eventually led to widespread civil unrest and demands for a health service free of commercial interference and offering personal and continuing care of named patients by named doctors.3 The alliance bridged social divides and produced a renewed social solidarity based on the recognition that the need for healthcare is fundamental to human thriving.4 Different services for rich and poor were no longer acceptable. The rest is history.