Created a century
ago, far from perfect and yet the most successful model yet. The model is however now increasingly
inappropriate. It is costly, it is ill adapted to the current environment and
crucially its current practitioners are at best ill at ease and at worst
extremely unhappy.
Why?
A century ago
medicine was largely ineffective. A few innovations which survive had made some
impact - anaesthesia dating from mid 19th century had expanded the
possibilities of surgery including importantly caesarean section. Medicine was
worse off and dominated by a range of unsubstantiated theories and systems.
Flexner's notion was that progress in medicine could only be made by the
application of science. He wanted doctors trained in the methods of science and
in command of the best available knowledge of bodily structure, function and
pathology. He was correct in his
assessment and the last century has seen the fruits of his vision in ways he
may not have imagined. (He died in 1959.)
This was a
reasonable approach given one startling fact - at the time, and for many
decades thereafter there was little or no certainty on what was the best advice
or treatment to give in a wide range of clinical disorders.
The implicit idea
was that the best chance of useful outcomes would come if the doctor, educated and trained and
carrying this knowledge with him would confront a variety of patients' problems
and using a combination of his teachers views, rationale and an ever growing
personal experience and would, by and
large, make helpful suggestions, decisions and interventions. Was that the best
that could have been achieved? Probably. The outcome of this more generally was
the notion of the doctor as we have come to know her - educated, knowledgeable
, skilful, thoughtful, independent, reliable, available and affordable.
Hold on to
"independent" . For as long as there was little systematic evidence
of what was best in any given situation doctors could and did take a variety of
courses and within very broad limits each was as acceptable as the other. The
patient may have had little insight into this variability but it was until
recently the defining feature of medical practice. Doctors were educated and
trained to accept the responsibility this uncertainty placed on them and to
enjoy the status, the respect and the rewards which came with it.
Over the years
scientific research expanded and clinical knowledge grew. As part of this there
was a more concerted focus on establishing precisely what might be the best way
to assist patients in a given situation. The tools needed to do this were also developing
with a growing understanding and application of statistics and the arrival of
the computer to handle the numbers. By the 1980s medicine had increased its
understanding, its options and crucially its costs. Governments and others were
increasingly asking questions on how these costs might be contained and one
conclusion was that if there were a range of ways of dealing with a particular
illness or disease and if there were no differences in the success rate then we
might as well concentrate on the cheapest option. Similarly if there were
differences in the success rate we should ensure that all patients had access
to that best available treatment. One of the main consequences of those
developments was the notion that individual doctors could no longer exercise
wide ranging unquestioned autonomy in making decisions, perhaps denying
patients access to best treatments or incurring costs above those which would
deliver best outcomes. None of this
happened overnight but these last 25 years that has been the direction of
travel and it has had as they say "mixed reviews". Some doctors have
welcomed the change, relishing the notion that for the first time in history we
knew with some confidence what was the best way to help patients with a given
disease or illness. Success of course was gradual and patchy and there remained
plenty of scope for the traditional autonomous doctor to practice. But change
was progressive and irreversible and many traditionally trained doctors,
sensing what was afoot hated the very idea. It must surely be right that any
doctor should be left to come to his own conclusions on what would be best for
"his" patient. There is still talk today of the "sanctity"
of the doctor patient relationship. Along this path there were assorted surveys
of doctors' attitudes to their profession and a recurring theme was -
unhappiness.
So where are we now
and where are we going?
We have seen a
stupendous growth of reliable knowledge on how best to deal with an increasing
number of illnesses. The evidence is well supported, clearly set out,
accessible to all and capable of being enacted by a growing range of clinicians
most of who have not had the extensive, thorough, bioscientific education and
training which Abraham Flexner correctly saw as essential 100 years ago. For an ever
increasing number of clinical consultations we no longer require the presence
of a traditionally conceived doctor and that trend still has a long way to
go. We already have increasing numbers
of patients being seen and managed by a growing range of non medically
qualified professionals from nurses and physician assistants to
physiotherapists and radiographers. We shall see more of this and fewer
consultations with the traditional doctor. We shall of course continue to need some bioscientifically trained doctors at
the front end, seeing patients whose ailments are atypical or unclear,
conceiving and carrying out clinical trials of new approaches,
performing complex physical interventions such as surgery where instant
decision making requires a detailed knowledge of the underlying biology though
even here there is scope for newer types of clinicians who have not had the
extensive detail of the traditional model in their training.
Here we might note
the use of the word training as opposed to education. Education, the developing
of an individual's potential, is of the essence in preparing an autonomous
practitioner capable of safe and effective management of uncertainty. For the
newer model of clinician the organisation wishes her to deliver a structured series of exchanges
with the patient along lines selected and approved by the organisation.
Autonomy is limited and at the margin. Training the individual to do as the
organisation bids is the new imperative.
So the Flexner model
is in decline and though it will not become extinct its passing from
universality will be resisted screaming and kicking by its current adherents.
