Session 4: Fitness to practice in the 21st century What will doctors be doing in the 21st century?

I am not a clinical doctor, therefore it would be highly presumptuous of me to speculate on what doctors will be doing in 20-30 years time. I suspect it would be a difficult task even for a medically qualified speaker. If you think of what has happened over the past 20-30 years, and of how difficult if not impossible it would have been to predict these developments, then you have some measure of the problem in thinking ahead 20-30 years. So, I'm not going to attempt such an exercise. What I aim to do is refocus the question in the title a little and sketch out some of the health policy and health care concerns which are likely to shape the environment and context in which doctors and other health care practitioners will ply their craft.     

... And nursing in the 21st century?

The failure of Descartes' system and the new world-wide context are aspects that point to a crises of current paradigms. This crises triggers the need of reconsidering philosophical and scientific models, as well as the trends guiding the professional practices and relationships. This study reflects about the tendencies that will lead the nursing practices in the twentieth-first century and the consequences of the care practice under new paradigms.     

What is healthy aging in the 21st century?

In the coming years, human aging will be one of the biggest challenges faced by industrialized countries. The average life expectancy is continuously increasing and we may be faced with spending more years in poor health. Because aging is a relatively modern phenomenon, we lack knowledge for a proper understanding of this process. Current biological thinking emphasizes that organisms are encoded for early survival and reproduction, humans not excluded. Aging is not programmed nor is it inevitable. Life span is the result of the interactions between genes and the environment in which we live. In the original habitat, genes encoding early survival and reproduction were optimized in an everlasting attempt to increase fitness and prevent the species from extinction. Aging is best explained as a cost of optimizing fitness because investments in body maintenance and repair cannot be maximized. The environment also determines how a gene influencing life span is expressed over a lifetime. When the conditions in which we live significantly improve, mortality decreases, evolutionary pressures for early survival and reproduction relax, and further resources can be invested in body maintenance and repair, which increases both average life expectancy and maximum life span. Increasing our understanding of the aging process and applying available interventions will help to protect and preserve healthy aging.     

Social inequalities in health: are there gender differences?

Some studies suggest that socio-economic status (SES) inequalities in health are smaller in women than men, but the evidence is inconsistent as to whether this applies across various health measures and life stages. The first aim of this paper was to establish whether the magnitude of social inequality in health differs for men and women during early adulthood, specifically in respect to self rated health, limiting long-standing illness, psychological distress, respiratory symptoms, asthma/wheezing, height and obesity; second, to determine whether explanations for socioeconomic inequality in poor self rated health differ for men and women. Analyses are based on longitudinal data from the British 1958 birth cohort study using information from birth to age 33. When gender differences in inequalities were examined using social class, no significant differences emerged across the seven health measures examined at ages 23 and 33. SES inequalities based on education, however, showed greater inequality among men at age 33 for limiting long-standing illness and respiratory symptoms, but greater inequality among women for poor rated health at age 23 and psychological distress at age 33. Hence, gender differences in the magnitude of health inequality were inconsistent across age and health measures. An analysis of the contribution of explanatory factors to social class differences in self-rated health suggested that causes of inequality were similar for men and women. However, some discrepancies emerged, notably in the greater contribution of job insecurity to class differences for men and in the greater contribution of age at first child for women. The magnitude and explanations for gender differences in SES health inequalities are likely to vary according to life stage and health measure.     

Electronic medical records: are physicians ready?

The use of electronic medical records (EMR) in healthcare organizations will require substantial changes in the way physicians and their staff provide patient care. This study is the first part of a larger study assessing factors that influence successful implementation of EMR in ambulatory care settings. The purposes of this study were to identify specific attitudes or factors that should be targeted before implementating an EMR project, and demonstrate empirical support for a model of perceived usefulness of EMR. We found that computer experience, computer anxiety, and perceptions of organizational support predict the degree to which physicians and mid-level practitioners view the EMR effort positively. Strategies for the successful management of EMR implementation include engaging the physicians and practitioners in computer activities prior to implementation and providing strong organizational support before and during the redesign effort. Acceptance of EMR by physicians and their support staff is essential if computerization is to be successful, yet anecdotal reports of resistance and negative attitudes are frequently reported. Empirical studies indicate that physicians have not yet embraced this technology. As part of strategic planning and deployment of a computerized patient record, attitudes of end-users must be assessed. Using an integrative framework from the job design literature and management information sciences, we propose that multiple factors influence attitudes toward EMR, offer a conceptual model of end-user acceptance, and present findings from an empirical test of our model.     

The great population debates: how relevant are they for the 21st century?

Two great debates--whether population growth is a problem and how to address the problem if one exists--dominated population policy discussions in the 20th century. The debate about whether pitted those who saw rapid population growth as a problem against those who believed the cries of alarm were false. The debate about how was conducted between advocates of the direct delivery of contraceptives through family planning programs and those who counseled a broader, more holistic approach. The debate about how was largely resolved by the 1994 International Conference on Population and Development at Cairo; the debate about whether remains unresolved. Environmentalists, ecologists, and physical scientists generally support the view that rapid population growth is harmful, but economists remain largely unconvinced. Contemporary declines in fertility and the end of the population crisis mentality of the mid- to late 20th century could, ironically, diminish public support for precisely those programs that have been responsible for the rapid fertility decline of the past 3 decades--programs that will be required to complete the "demographic transition" in those parts of the developing world where fertility remains very high.     

Physician use of e-mail: the telephone of the 21st century?

E-mail, as an element of a physician's clinical practice, can provide the means to accomplish a variety of tasks more effectively and more efficiently, increasing patients' involvement in their care and optimizing face-to-face office time. Concerns about billing, improper use, privacy, and confidentiality have complicated its introduction and acceptance. This article discusses guidelines proposed for clinical use of e-mail and barriers that will need to be overcome to move this mode of patient-physician communication into the mainstream.     

The 21st century: the age of family medicine research?

Family medicine has matured as an academic and scientific discipline with its own core concepts, knowledge, skills, and research domains. It has acquired much expertise in studying common illnesses; the integration of medical, psychological, social, and behavioral sciences; patient-centered care; and health services delivery. Many health care challenges in the 21st century will place a great demand on primary care, which can serve its purpose only if it is of high quality and evidence based. Family medicine research can contribute to many areas of primary care, ranging from the early diagnosis to equitable health care. Stakeholders, such as the World Health Organization, governments, and funding agencies, are becoming more supportive to family medicine research because they recognize its key importance in improving the quality of primary care and bridging the gap between biomedical research and clinical practice. Family medicine can play a leading role in shifting the paradigm of medical research from the laboratory to the person. The 21st century should be a golden age of family medicine research because the time is right for the discipline, the health care environment is most suitable, and stakeholders are supportive. Family medicine must prepare for it by building up its research track record and capacity.     

Patient satisfaction in 21st century medicine: revolution or evolution?

The Moment-of-Truth (MOT) patient satisfaction system was created to address each patient's medical care and service needs at the "point-of-care," before the patient leaves the medical facility. The MOT system is patient-centered by actively involving each patient in his or her own healthcare evaluation, planning, and continuous quality improvement. Patient needs are aligned with the required healthcare resources, which simultaneously produce information that can be acted upon "immediately," at the point-of-care, with "a sense of urgency"-addressing patient expectations each and every time the patient encounters the healthcare system. Major changes that occurred in medical service delivery at Hudson Hospital after implementation of the MOT system included a change in the focus of healthcare delivery toward the patient each and every time medical care or service occurred by placing the patient at the center of the care continuum; the ability to capture and react to what the patient needed at the place and time the patient needed it; and the incorporation of patient satisfaction as a way of doing business, throughout the healthcare organization. Results in 2007 to date have averaged 98% among responding patients indicating that they would recommend the Hudson Hospital to family and friends.     

What views and uses of radiation sources in the 21st century?

Considering that in 1899 neither biotechnology nor the electronic revolution were foreseen, some humility might be advisable when one looks into the crystal ball for the future role of radiation sources. In the past 50 years, nuclear medicine, nuclear weapons, and nuclear power have had a huge impact in the world. In the next 50 years, nuclear weapons may be phased out, nuclear power revived, and nuclear medicine may continue, especially for diagnostic purposes. Conflicts between great powers and blocks will no longer be about territorial or ideological domination but about trade, finance, information, and the environment and the weapons used will not be bombs but investments, credits, and control of information. Nuclear power-still based on fission-will be relaunched and get more uses, e.g., to propel ships, to produce heat for industry and for space heating, and perhaps to desalinate water. The public will be more at ease with radiation as it is better educated, as nuclear safety continuously improves and new types of nuclear power plants emerge, as waste sites fail to cause any problems, and as no other energy source is found to deliver so much energy at reasonable cost with negligible impact on climate and environment. One kilogram of oil corresponds to 4 kWh of electricity. One kilogram of uranium fuel corresponds to 50,000 kWh, and 1 kg of plutonium 6,000,000 kWh! In nuclear medicine, radiation may give way to other treatments as the understanding of cancer advances. On the other hand, the extreme ease with which sources of radiation can be identified is unmatched and likely to make them useful tools as tracers and markers in medicine-and other fields-for a long time. For certain uses--perhaps food irradiation--radiation sources, such as cobalt, may be replaced by accelerators which may be switched on and off at will. As more sources are used, registration and control of them must be made very effective around the whole world. Very high natural emissions of radon will continue to call for cautionary measures, but many other nonradiating substances will be identified as hazardous to health and call for vigorous intervention.