Continuing Education and Continuing Qualityof Life DAVID ALLAN, MD, La Jolla Associate Dean for Continuing Education in the Health Sciences; University of California, San Diego, School of Medicine
ROBERT BRUEGEL, MA, La Jolla
Graduate Student in Sociology; University of California, San Diego
WHILE THE initial contributors to the forum raised important points with regard to the relationship between medicine and the quality of American life, they did not look at this in relation to the enormous explosion of knowledge and technology that has taken place in the past 30 years. One of the roles of continuing medical education is to make this new knowledge and technology available to practicing physicians, and to try to evaluate its effect on the physicians' competence and on patient care. While the effects of new knowledge and technology on patient care have been widely discussed, the equally profound effect of that knowledge and technology on the physicians' role has been largely ignored. At the very least, it has led to an increasing dependence of physicians on technical skills-with the result that failure is now equated with malpractice. Also the technical components of the physicians' role can now be broken down into segments that can be done equally well by other professions. Secondary and tertiary care physicians have become increasingly dependent on technical skills, with all the associated vulnerability that accompanies this. The competency of technical skills can also be monitored and measured by nonphysicians. Computer monitoring of diagnosis and care is only one aspect of this trend. This knowledge explosion has also led to increased medical specialization-with serious problems of fragmentation, organization and communication. It has taken medicine to a stage where the major diseases remaining are those produced by ourselves and our technology. New techniques enable us to palliate more and more chronic diseases in order to maintain our increasingly unhealthy environment and lifestyles. The costs of such palliatives are already prohibitive; as costs continue to increase, national health insurance and more intense utilization review become inevitable. Unfortunately they carry no guarantee of any improvement in the quality of life. Medical specialization with its associated fragmentation has made continuity of care impossible-if a health professional is expected to provide the continuity. It is this situation which generates an insistent demand for new physician and patient roles and relationships. True continuity of care can be maintained only by patients themselves. Patients, however, are not encouraged to take an active responsibility for either their own treatment or their own health. The most important role
396
NOVEMBER 1976
*
125
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change for patients must enable them to provide their own continuity of care. A major new role for primary care physicians must be to provide education and support for that change. It is extremely important that physicians realize that the freedom of both physicians and patients is inextricably linked. The old style of patient dependency has become a trap. As patients who are neither accustomed or encouraged to take responsibility for their own health realize that the old patient role no longer works, they will seek some form of redress. If patients do not move toward more independence, they will transfer more and more responsibility to government. In turn this will mean that physicians and other providers will become increasingly dependent on government. Increasing governmental intervention is the conventional response to the potentials and problems that accompany new technology. The resulting bureaucracy tends to become not accountable; it is also least able to make the kind of continuing and flexible changes that the rapid growth in medical knowledge and technology will require. If physicians thus expect to retain their own independence, they must begin to foster independent patients. This is a major new role-and it entails a new role for continuing medical education. Continuing medical education must provide physicians with the ability to change their own role while providing them with the communication and human management skills to educate their patients to independence. Traditional medical education is inappropriate for this new role and, like the bureaucracy, cannot change rapidly enough to be responsive to new knowledge. United States naval history offers an analogy to this. In the period from 1860 to 1900 the American navy experienced a technological revolution similar in speed and magnitude to that which has occurred in medicine during the past 30 years. Naval leaders, trying to cope with the new rifled gunnery, steel hulls and steam propulsion, attempted to contain all the new potential within the familiar pattern of the British ship of the line. Steam ships were built with sails, simply because it was inconceivable that they could be built any other way. At a time when the effective range of a six-inch gun was three miles, the navy spent most of its time training sailors to repel boarders with pikes and small arms. This is the situation in medical education today. New knowledge and technology made to fit into old familiar patterns has led to the present "crisis" in medical care. Patients are the unutilized resource that the medical system desperately needs. Patients are the basic and most constant link connecting doctor to doctor. The communication and coordinating potential of this link has hardly been explored. The major role of a primary care physician must be to foster the independence of his patients, to enable the patient to be able to provide his own continuity of care and to accept responsibility for his health. The concept of a "consumer" with its overtones of taking and being overfed must be replaced with the new role of a person who is able to use wisely the freedom of making decisions to keep himself healthy and to share the responsibility for decisions made to restore health when he is sick. Such change will not be easy. It does, however, have the potential of organizing a technologically sophisticated health system with minimal use of bureaucracy. As it increases both the freedom and responsibility of physician and patient roles, it stands to improve the quality of life for both. To adopt and accept these new roles, the physician needs new skills; most of all he will need the ability to change. The new role of continuing medical education is to provide the physician with the knowledge and skills to participate actively in change. Refer to: Allan D, Bruegel R: Continuing education and continuing quality of life, In Medicine and the quality of life -A forum. West J Med 125:396, Nov 1976
ROBERT BRUEGEL, MA, La Jolla
Graduate Student in Sociology; University of California, San Diego
WHILE THE initial contributors to the forum raised important points with regard to the relationship between medicine and the quality of American life, they did not look at this in relation to the enormous explosion of knowledge and technology that has taken place in the past 30 years. One of the roles of continuing medical education is to make this new knowledge and technology available to practicing physicians, and to try to evaluate its effect on the physicians' competence and on patient care. While the effects of new knowledge and technology on patient care have been widely discussed, the equally profound effect of that knowledge and technology on the physicians' role has been largely ignored. At the very least, it has led to an increasing dependence of physicians on technical skills-with the result that failure is now equated with malpractice. Also the technical components of the physicians' role can now be broken down into segments that can be done equally well by other professions. Secondary and tertiary care physicians have become increasingly dependent on technical skills, with all the associated vulnerability that accompanies this. The competency of technical skills can also be monitored and measured by nonphysicians. Computer monitoring of diagnosis and care is only one aspect of this trend. This knowledge explosion has also led to increased medical specialization-with serious problems of fragmentation, organization and communication. It has taken medicine to a stage where the major diseases remaining are those produced by ourselves and our technology. New techniques enable us to palliate more and more chronic diseases in order to maintain our increasingly unhealthy environment and lifestyles. The costs of such palliatives are already prohibitive; as costs continue to increase, national health insurance and more intense utilization review become inevitable. Unfortunately they carry no guarantee of any improvement in the quality of life. Medical specialization with its associated fragmentation has made continuity of care impossible-if a health professional is expected to provide the continuity. It is this situation which generates an insistent demand for new physician and patient roles and relationships. True continuity of care can be maintained only by patients themselves. Patients, however, are not encouraged to take an active responsibility for either their own treatment or their own health. The most important role
396
NOVEMBER 1976
*
125
* 5
change for patients must enable them to provide their own continuity of care. A major new role for primary care physicians must be to provide education and support for that change. It is extremely important that physicians realize that the freedom of both physicians and patients is inextricably linked. The old style of patient dependency has become a trap. As patients who are neither accustomed or encouraged to take responsibility for their own health realize that the old patient role no longer works, they will seek some form of redress. If patients do not move toward more independence, they will transfer more and more responsibility to government. In turn this will mean that physicians and other providers will become increasingly dependent on government. Increasing governmental intervention is the conventional response to the potentials and problems that accompany new technology. The resulting bureaucracy tends to become not accountable; it is also least able to make the kind of continuing and flexible changes that the rapid growth in medical knowledge and technology will require. If physicians thus expect to retain their own independence, they must begin to foster independent patients. This is a major new role-and it entails a new role for continuing medical education. Continuing medical education must provide physicians with the ability to change their own role while providing them with the communication and human management skills to educate their patients to independence. Traditional medical education is inappropriate for this new role and, like the bureaucracy, cannot change rapidly enough to be responsive to new knowledge. United States naval history offers an analogy to this. In the period from 1860 to 1900 the American navy experienced a technological revolution similar in speed and magnitude to that which has occurred in medicine during the past 30 years. Naval leaders, trying to cope with the new rifled gunnery, steel hulls and steam propulsion, attempted to contain all the new potential within the familiar pattern of the British ship of the line. Steam ships were built with sails, simply because it was inconceivable that they could be built any other way. At a time when the effective range of a six-inch gun was three miles, the navy spent most of its time training sailors to repel boarders with pikes and small arms. This is the situation in medical education today. New knowledge and technology made to fit into old familiar patterns has led to the present "crisis" in medical care. Patients are the unutilized resource that the medical system desperately needs. Patients are the basic and most constant link connecting doctor to doctor. The communication and coordinating potential of this link has hardly been explored. The major role of a primary care physician must be to foster the independence of his patients, to enable the patient to be able to provide his own continuity of care and to accept responsibility for his health. The concept of a "consumer" with its overtones of taking and being overfed must be replaced with the new role of a person who is able to use wisely the freedom of making decisions to keep himself healthy and to share the responsibility for decisions made to restore health when he is sick. Such change will not be easy. It does, however, have the potential of organizing a technologically sophisticated health system with minimal use of bureaucracy. As it increases both the freedom and responsibility of physician and patient roles, it stands to improve the quality of life for both. To adopt and accept these new roles, the physician needs new skills; most of all he will need the ability to change. The new role of continuing medical education is to provide the physician with the knowledge and skills to participate actively in change. Refer to: Allan D, Bruegel R: Continuing education and continuing quality of life, In Medicine and the quality of life -A forum. West J Med 125:396, Nov 1976
