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Future Practice Alternatives in Medicine, 2d ed.

David Nash, MD, MBA, Editor. Second Edition. New York, N.Y.: Igaku-Shoin, 1993. 406 pages. $24.50 prepaid.

The editor has very ably assembled a "broad spectrum of information that will guide physicians as they make important career and professional decisions." The text is divided into three sections: Social Concerns, Emerging Career Trends, and Future Directions. The intended audience includes medical students, residents, fellows, attending physicians, residency program directors, chiefs of service, hospital directors, and other persons who are interested in the practice of medicine. The editor fulfills his commitment in all respects.

There are many quotable quotes in this book; my only difficulty was in deciding how to write a review without too many quotations! Physicians are exhorted to wear many hats: clinicians, teachers, and managers of resources. Finally, we have a writer who will state (as J. S. Gonnella did in the Foreword) that society's requirements and expectations for the medical profession dwarf the complexities and demands posed by basic and clinical science curricula and postgraduate training.

The book is divided into three sections: Social Concerns, Emerging Career Trends, and Future Directions. There are 13 chapters, each written by one or two authors. The Overview by the editor actually constitutes a fourth section. It sets the tone for the rest of the book by informing some and reminding others of us that modern medical education does not give adequate attention to the medical profession's social responsibility to train physicians for society's most basic health care delivery needs. Attempts are now being made to effect changes in medical school and residency programs to educate the new generation of physicians in ways that will reverse some of the attitudes that worked well in the past but that are not appropriate for the future and, because the future is upon us, for the present as well. Dr. Nash personifies the new approach that is needed by pointing the finger not at the professors or the lecturers but at you, the reader.

The editor takes to task those who predict either a surplus or a shortage of physicians for the next 10 years. He maintains that no methodology exists to make accurate predictions. He approaches the question of young physicians entering the real world by suggesting that the time will come when health care corporations will come to hospitals to recruit physicians in much the same way that "IBM comes to Wharton." Again, I must quote to present the idea as succinctly as the author did: "Physicians should not turn up their...noses at colleagues in other professional schools. One of them may be the reader's future boss in some large HMO or health care conglomerate." The editor refers to several publications to help the reader achieve familiarity with the literature describing the real world. Future trends in medicine include the practice of medicine by protocol (referred to as "cookbook medicine" by its opponents) and continued shift of political power from providers to payers of health care. In other words, we will be dragged into the real world and be subject to the same forces that control the rest of society in the capitalist world.

The first formal section, on Social Concerns, has chapters devoted to physician collectivism, the public-spirited physician, changes in medical education, and the growing influence of women in medicine. There is a lucid discussion of the goals of unions, whether salaried and nonsalaried doctors can join unions, and why unionization should be considered at all by doctors. The prediction is made that, as physicians are forced to join large consortiums to survive, collective action will become more commonplace.

In the chapter on educating physicians for the 21st Century, Dr. Couch looks at health care megatrends, including the changes effected by the institution of Medicare in the 1960s, which created a topsy-turvy world of medical economics that has persisted into the 1990s. Without an apology (there being none needed nowadays), he refers to "the industry" as being ripe for revolutionary change. Any physician who still considers the federal deficit someone else's problem should take a look at this chapter. The author also reviews the need for educational change, to cope with the changes in society and in patients' expectations. He sets out a list of courses to be added to the first- and second-year curricula. If medical students are supplied with computers to enhance their learning rate, there would be ample time for the new courses, which are vital to the transition to the new world. Continuing medical education is covered briefly in this chapter and again in Chapter 12.

The chapter by Dr. Kroser examines the growing influence of women in medicine. It is written in the same clear language that characterizes all of this book. There is a historical review, noting that the first woman was admitted to a U.S. medical school in 1847 and that the first medical college for women was created in 1850. By 1909, Flexner could conclude that separate women's institutions were no longer necessary. There was a lull in the entrance of women into the profession from about 1920 to the mid-1940s. The last school to exclude women did not change its policy until 1960! Career trends for women showed a massive change from 1970 to 1990, when the number quadrupled and the proportion of total physicians more than doubled. The author examines the reasons for women physicians' being different from men in the details of their career choices after they have qualified to be physicians. She suggests that advancement in medicine will depend on being part of the established power structure. That goes as much for men as for women.

Section II deals with emerging career trends as seen by physicians in academia, industry, and the private sector. The six potential pathways are geriatrics, occupational medicine, research, managed care, medical management, and primary care/family practice. Each pathway is presented in a clear, concise fashion that makes the reading of them pleasurable.

Geriatrics is dealt with by a definition and an assessment of its body of knowledge and its art, reviewing the geriatrician's role, or more accurately "roles"; practice settings; and training. The future is seen as being shaped by the same forces that are shaping all of medicine, which is becoming a public industry whose product and producers are being scrutinized in increasing detail.

Occupational medicine is described by someone who unabashedly enjoys it. Dr. Gluck defines the field, provides specifics on programs and functions that make up the field, examines its challenges and gratifications, and then speculates about the future. He sees the roles of occupational physicians expanding, as choices open to private practitioners constrict.

The chapter on research presents the organizational role of physicians in the pharmaceutical industry. It reviews training requirements for industry as well as academia. The philosophic basis of industry is to respond to the demands of the market, while academia responds more to those of society. Other differences between the two disciplines are put forth in detail, most notably in a diagram comparing the academic and industrial hierarchies. The future is seen as holding a shift from academia to industry, as the demand for skilled scientific judgment accelerates the trend of the past 30 years.

The chapter on health maintenance organizations attempts to answer the question that is its subtitle: a new development or the emperor's old clothes? This is not an easy task. The authors review the structure, history, and function of HMOs. Some of the facts are astounding, even to those of us relatively well-versed in health care delivery topics. From 1972 to 1992, for instance, the number of HMOs rose from 40 to 610, and enrollment went from three million to 40 million members. This chapter can serve as a primer for anyone new to the HMO scene and for physicians contemplating becoming staff

members. Staff models, reimbursement mechanisms, HMO look-alikes, and point of service plans, all are dealt with here. Utilization patterns are of major importance in the new world of managed care, and this chapter explores some of the implications. The authors conclude that, as other societies have moved toward socialized medicine, American society has moved toward a capitalist, entrepreneurial style of medical practice.

Chapter 9 presents a personal view of the physician executive world, followed by a detailed discussion of the history and development of medical management. Opportunities and responsibilities are indicated by an exhaustive list of titles held by physician executives and a list of activities within several categories. The discussion on the advantages and disadvantages of having a medical degree before becoming an executive is particularly helpful to anyone contemplating a career in medical management. The components of the ideal curriculum are marketing, finance, accounting, macroeconomics, microeconomics, strategic planning, the decision sciences, and management as it involves conveying a set of values to influence behavior.

The first premise of Chapter 10 is that control of the health care system will move from specialists to providers with the broadest skills, the primary care physicians, who have a new designation as the "integrationists." There is an excellent attempt to define primary care that is well worth the reader's attention. A table in the chapter summarizes the characteristics of primary, secondary, and tertiary care; a lot of effort was put into this section, and the reader is all the better for it.

Section III looks at Future Directions. The three most important new areas for physicians to be involved with and in command of are computers, health care information, and utilization of new technologies. The doctor of the future will have to mix "journals, videotapes, and audiotapes to create the perfect continuing medical education pie." The same doctor will have to manage the explosion of health care information by deciding which conferences to attend, which journals to read, and (not mentioned here) which television programs to watch. In addition, technology assessment will loom with great importance, and the doctor will discover that, without expertise in computers (include both hands-on skills and theory), it will be difficult to make sense out of performance reports, practice analysis, literature search requirements, electronic mail, the electronic medical record with its possibilities of protocol-based reminders, and adverse drug interactions detection. Imagine trying to understand the technique of data encryption if you are not computer literate.

Aspects of computers in hospitals and academic medical centers are also discussed. Computers already have a major role in medical education, patient education in ambulatory settings leading the way. Computers as medical assistants are referred to by the authors as compudocs. They relieve the user of the computational monotony of repeated but relatively automatic tasks. Algorithmic decision systems are defined by a graphic flow diagram. The authors wisely point out that decisions based on the use of algorithms can be uninformed decisions. They reiterate the need for computer literacy on the part of physicians if the computer and its controllers are not to become the controllers of the medical profession. Data-based systems or pattern recognition, clinical database interrogation, Bayesian databases, and knowledge-based systems are all discussed briefly but clearly here. The future is complex when one looks at it from the point of view of computerization; intelligent textbooks will have information encoded to generate patient-specific information. Also, "there will be methods of getting medical information out of the minds of medical experts and into machine-usable form (knowledge engineering) that are better than the brain-picking now commonly in use." The paragraphs on gadgets and toys or hardware innovations make for enlightening reading. Careers in medical computing will develop and physicians will be able to construct "authoring systems" that will allow them to build expert systems without an understanding of the theory of expert systems.

Chapter 12 examines the future of continuing medical education. The author gets down to a basic principle: CME is supposed to change physicians' behavior, specifically to improve patient outcomes. He points out that most studies have not measured these aspects of CME at all. A narrow definition of CME is "any program or experience that was developed to teach physicians and for which credit is given to the participants." A broad definition is "any experience that improves the ability of a physician to be a health care professional." Because of the rapid turnover of medical knowledge, CME is as important to the practicing physician as undergraduate studies are to the medical student. Factors that motivate physicians to seek CME are discussed. They include quality of patient care, peer standing, the threat of malpractice accusations, and marketing. A number of generic issues in planning CME are also discussed, as is the question of the learning environment.

This particular author displays a sense of humor in defining parenthetically a "Wok-Person" as a device made by a company created by the merger of a Japanese food company and an American high-tech firm! This leads into an excellent discussion of electronic technologies and their projected role in future CME: audio- and videotapes, teleconferences, and computer-based learning. Interactive videodisks can store thousands of pages of text, graphics, music, full-motion video, and sound. Each of these modalities of information communication can be accessed in seconds. These programs are being developed so that the learner fully interacts with the program. (Fractal-based programs will likely solve the problem of hardware compatibility. Fractal technology is said to be independent of the particular hardware used to play or display the information.)

A computerized environment can be used to provide the optimal learning experience in CME. The electronic medical record can be searched for diagnoses and their frequency tabulated. CME strategy can then be planned on a quantitative basis. The author reviews the use of CD-ROMs for textbook material, drug-drug interactions, and differential diagnosis, pointing out that the line between practice aids and learning may be blurred. An excellent matrix is displayed, showing such topics as patient experience, journals, home-study programs, and videotapes against diseases, treatments, information systems, business, and sociopolitical. The chapter ends with the profound statement that the reader will either win or lose in the future, depending on the ability to adapt to change and adopt new technologies to reach his or her goals.

The final chapter, on the technologic imperative, takes up where the preceding one left off. Again, we see a clear view of what the medical profession consists of, in that it is seen as a technical trade, requiring mastery of myriad drugs, devices, and procedures with a repertoire of skills that must be constantly updated if the practitioner is to translate knowledge into action. The development of health care technology is reviewed on a grand scale and by example (PTCA procedures being one). The assessment of technology does not keep up with its diffusion throughout the medical world. The risk-benefit tradeoff therefore is difficult to determine. The chapter, and this book, end on a note that cannot be summarized, so I take the liberty of quoting the last paragraph in full: "In the final analysis, however, technology will always remain an adjunct to the doctor-patient interaction--to be applied humanely, precisely and carefully. It should not be allowed to take on a life of its own. Drugs, devices, and procedures are tools to aid in effective health care--they will never be ends in themselves."--Clayton Raeynolds MD, FACPE, Owner, Health Management Medical Center, Lancaster, Calif.
COPYRIGHT 1994 American College of Physician Executives
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Author:Reynolds, Clayton
Publication:Physician Executive
Article Type:Book Review
Date:Jul 1, 1994
Words:2545
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