The September 2012 edition of CMPA Perspective provides a sobering reminder to physicians regarding the “New Realities of Medical Care”. The healthcare system has changed significantly even in the last decade, in large part due to fiscal restraints, questions about long-term sustainability, an aging population, alternate models of care, and the impact of technology on care delivery.
In the article, the CMPA highlights a number of areas that I would like to touch upon:
- Technology and Medical Advancements
- There are two aspects to technology advancement that stand out. Diagnostic and treatment modalities that have been enhanced through the addition of new technologies and the informatics based technologies such as electronic health records, personal health records, clinical decision support tools, and a myriad of other advancements that enable new mechanisms to document, diagnose, monitor, and treat patients. Each of these creates significant challenges for clinicians. It is difficult to keep up with medical advancements in a specific specialty area. The addition of new technologies, diagnostic tools, and modalities to collect and share information increase this challenge. In addition, it is not good enough to simply be using these tools. Just as a clinician could be held accountable for not using a stethoscope correctly or missing obvious findings of ischaemia on an EKG, as CMPA states, “Irrespective of the setting, a physician who relies on technology for treatment and care should be knowledgeable and experienced in its use.” As more practices adopt and use Electronic Medical Records, there is clear evidence developing that physicians using EMRs and related technologies will be required to be competent in the use of these tools. This will mean updating and maintaining skills regarding the use of the EMR just as with any other clinical area of competence. Although it is still early days and some functionalities may not yet be common practice in EMRs, the day is coming when it will become a medico-legal imperitive to be competent and aware of the capabilities of the EMR to assist with diagnosis, alerts, recall capabilities, and other decision support tools that are provided as components of the tool.
- Patients as Partners
- Patient-centred care is the new paradigm in care delivery. When healthcare information became widely available through the Internet, it was not uncommon to have patients arrive at the doctor’s office with a stack of printouts (some trustworthy and some not) that would then be deposited on the doctor’s desk with a request to review the information and provide feedback on the most relevant management or diagnostic options. In many cases this was treated as a nuisance by physicians who were time-pressured and did not trust much of the information. This has changed significantly. With the advent of patient portals, personal health records, mobile apps for a wide range of diseases, and better sources of information on the Internet, it is time to leverage the knowledge, expertise, and time that patients have to manage their own health in order to achieve better outcomes. Patients are much more engaged in their health and are willing to seek input from social networks, other disease sufferers, and a wide range of sources in order to ensure that they are receiving the most appropriate care. Using tools that provide an appropriate level of interactivity with their care providers (i.e. not unfettered access), patients can be engaged to research, monitor, and manage their health much more effectively — all supported by new technologies. Because of the shortage of primary care physicians in Canada, there may still be some flexibility to avoid taking on “ePatients” who demand access via the Internet or through a patient portal connected to the EMR; however, the window is narrowing. Soon all physicians will need to use EMRs and other patient-centred tools. Prepare for this and leverage the energy of your patients to help manage them more effectively.
- Fiscal Challenges and Restraint
- When I am asked by students whether they should consider pursuing a career in medicine, this is one of the points that I bring up. It goes something like this, “Get ready to do more with less. Governments are financially strapped and are facing unprecedented challenges to provide care for their growing and aging populations. This means that budgets for healthcare will be stagnant or reduced over time. If you choose an area of medicine that is dependent on resources, for example a surgical specialty, choose carefully. Your ability to practice is not only dependent on your clinical expertise, but also the availability of resources to provide care. If regional authorities are trying to control budgets and close hospital beds and operating rooms, that means your ability to operate will also be restricted. If you are passionate about a specific area of medicine, follow your heart, but be aware of the fiscal realities and plan accordingly.” The fact that fiscal restraint in the healthcare system is highlighted in a CMPA article is clear evidence that the responsibility of physicians to do what is appropriate for patients extends beyond a pure understanding of clinical needs and into a new realm. You must now be aware of the fiscal environment in which you work and balance your code of ethics against the challenges of doing more with less. While the courts will take into account the fiscal environment, you will be measured against your peers in terms of the standard of care and whether what you provided was appropriate and acceptable.