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Saturday, November 7, 2009

Takeover of the amatuers

In a world in which people's activity is becoming ever more hyper-specialized, our ideas of what we do and how we support ourselves changes rapidly. This trend has tremendous implications within medicine and there is no reason to believe that this trend will impact medicine any more or less than other realms. Ultimately, in an ideal world what any given person does and is rewarded for should have some value to the recipient of that good or service. How this translates to medicine is that patients should be as good or better off after their encounters with us than before.

The question arises "What can I (or anyone) do which is of value to other people and why?" Presumably, the other people I am referring to are those who I am directing my service to. In the realm of medicine it is presumably patients. What is the nature of those value adding activities and what specific expertise or talents do I have which allow me to provide these services better or exclusively?

As I see this, physicians historically have held central positions in health care because they had access to unique information which allowed them make predictions and solve problems, they controlled access to specific diagnostic and therapeutic tools, and they were in a unique position to coordinate human activity to facilitate the care of patients. In order to function in these roles they required substantial training on the background of particular innate talents. The net result of these requirements is that medical management talent was a scarce resource.

This combination of characteristics is not unique in history and is a narrative which describes the existence and evolution of virtually every professional class whether it be priests, scribes, journalists, or professional photographers. In each of these cases, barriers to entry and need for unique tools or expertise limited access to the profession and created a scarcity. However, technological change created rapid displacements. Ultimately, technological change allowed for massive entry of "amateurs" into these respective fields and undermined the role of the professionals.

Much of this historical information is is well described in Clay Shirky's book "Here comes everybody" but some specific observations are well worth repeating. He describes the role of the scribe in the middle ages when the ability to read and write were rare skills and that the scribe was an essential and scarce resource and a key cog in the ability to pass on knowledge from generation to generation. The potential loss of intellectual material which would not occur between generations without the scribe was immense. However, the introduction of the printing press changed all these assumptions and opened the business of replication of the printed word to a much larger number of non-scribe amateurs. Much was actually written lamenting the loss of the scribe profession but interestingly these writings were disseminated using the printing press technology.

In our contemporary world, there are similar trends happening in the world of journalism. Until recently, entry into the world of publishing was limited by the ability to print and disseminate writings. That is not longer the case. A word processor and an internet connection conceivably make everyone into a one man publishing company and this capability is moving toward the loss of the journalist as a professional class. The scarcity associated with previous business model (that is few publishing outlets and few journalists)has vanished. The amateurs have taken over. There is no clear distinction between the professional class and everyone else.

So, what does all this have to do with medicine and health care delivery? The "amateurs" are coming to health care, facilitated by a variety of technological changes, particularly those impacting dissemination of information. Over 45 years ago Kenneth Arrow identified what he believed to be a key and unique element to the health care industry which made it different; information asymmetry between patient and provider. It is remarkable that this concept is still emphasized, as if nothing has changed in the past 45 years.

It is not as if the information asymmetry as evaporated but the calculus as morphed remarkably. As information relating to health care has exploded, physicians have become less and less dependent upon their own brains and rely more and more on information tools which they can access on demand. However, these tools are generally not proprietary and are accessible to patients and other non-physicians. Thus the justification of professional class on the basis of access to and control of information is going away.

Specific technical skills may also serve as a justification for the physician professional class. However, best outcomes in this realm are generally linked to practice, process, and narrow focus. This appears to hardly be a justification for for the broad, extended, and expensive training model now used to train physicians. We perhaps can get better outcomes by focusing on specific technical skills required to do very specific focused tasks.

Finally, the professional class distinction for physicians may be justified on the basis of their ability to synthesize information and coordinate the activities of many people. This skill set is always prized but is not unique to medicine. Entry into the realm may be from many different educational and experience paths. It could be argued that since current medical education has no particular focus on these specific skills and that the current set of financial incentives with traditional medicine has created a culture which is indifferent to this particular need, that these functions should be moved elsewhere.

Where does this leave the medical profession and what is its fate in the future? Perhaps the more important question is how will technological and social change alter our ability to serve the medical needs of our patients? There is little question in my mind that we will cede control to the amateurs in many realms that were traditionally our realms. Innovation brings disruption and our profession will be disrupted. In the end our measure should not be how it affects our particular guild but instead how it affects our patients. It will be a hard pill to swallow.

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