I have witnessed many changes within medicine over the last 20 years – one of which has been the increasing fragmentation of medicine despite the introduction of the importance of holistic medicine. This fragmentation is across the board and exists on many levels.
Fragmentation by Specialising
As our knowledge of anatomy, physiology, biochemistry, pathology, pathophysiology, pharmacology and the many varieties of illness and disease has expanded, it was recognised that it was not feasible for all doctors to be expert and up-to-date in every area of medicine and thus increasingly doctors have focused on one area or speciality. This has the advantage of doctors being able to concentrate on an area in which they can become expert, but the disadvantage that they lose skills and knowledge that apply to other specialities. Apart from those who work in remote locations and who may, because of their work location, have to be true generalists, the numbers of doctors to whom that name could apply are increasingly few. We tend to focus on parts or on a particular body system or age of patient – eg the heart in cardiology, the skin in dermatology, the blood vessels in vascular surgery, the large bowel and rectum in colorectal surgery, the mind in psychiatry, the gastrointestinal system in gastroenterology, care of the elderly or paediatrics – and on and on the list could go.
Whilst I see and understand the advantages for both patients and doctors of specialising, I wonder if the pendulum has swung too far? By dividing medicine into its many parts and focusing on them, have we lost sight of the whole of medicine and the whole of the patient? By concentrating in one or two areas, we become less comfortable addressing issues or conditions that are outside those areas and so we refer to other doctors in the relevant speciality. In an age when the multi-symptomatic man is increasing, such a patient can end up being seen by many doctors focusing on the parts, with no one doctor addressing the whole of the patient and their needs. This occurs despite there supposedly being a greater awareness of the importance of holistic medicine – which in truth is a term that is often bandied around as a good thing to do, but in practice is rarely applied, where all aspects of the patient are considered in illness and disease manifestation and treatment. Whilst sub-specialising was developed with good intentions of having experts that could offer the best care for patients and to make the practice of medicine more manageable for the doctors, is it possible that in doing so we have in fact moved further away than ever before in providing true holistic care?
Fragmentation of Relationships by Ways of Working
In addition to the increasing fragmentation of medicine by systems/organs etc we also have had more fragmented ways of working. When I was in training, we worked in teams for periods of occasionally 3 but usually 6 months, and some later and more specialised training positions could be for 12 months. As a house officer (the most junior level of doctor, just after graduation), there was a good sense of camaraderie in the team, with everyone playing their part and when all the parts worked well together the team as a whole functioned well. We worked an on call system that could be onerous, but facilitated working as a team, as we were present every day together on the ward. The introduction of the European working time directive and reduction in hours of work for junior doctors has led to shift working, which has crucified team working with different doctors coming and going and a lack of consistency and continuity in team working. This has many detrimental effects where junior staff have a lack of ownership of patients and a reduced sense of responsibility and accountability.
We all lose out on the interpersonal relationships that can be established by consistent team working. Consultants become frustrated by the constant turnover of new faces and having junior doctors who do not know the patients and who are just covering for a day or two. This is a situation that adds more stress to both the consultant and the junior doctor. Most junior doctors want to do a good job and it is also not easy for them to be continually passed from team to team and to have to get to know the vagaries of working of each consultant and to get to know a fresh set of patients to care for every few days. Of course all of this impacts on the quality of patient care and so patients too are definitely affected by the increasing fragmentation of working patterns of doctors. I am not suggesting that we go back to working onerous hours – just highlighting that in attempting to solve one problem (onerous hours of work) is it possible we have created many more, all of which impact the quality of care for patients?
The Fragmentation of Self
We have a tendency in medicine to blame the current systems of working for the high levels of burnout, stress, addiction and suicide experienced by the medical profession currently. The fragmentation of medicine is a contributing factor. The systems have been designed and emerged from people – the problem is that those systems were not designed with true care of the human being foremost. Thus it is not necessarily systems per se, but the fact that they have emerged without a focus on true care for the human being – be that human being the patient or the doctor. We cannot hope to have a caring medical system if it only focuses on care for the patient without care for the doctor. Medicine as a whole, contains both patients and doctors and to care for only a part is detrimental to the whole. Perhaps if we shift our focus away from ‘patient’ or ‘doctor’ and make it about the human being, irrespective of the role being played then perhaps we may make some in-roads to designing and having systems that are caring for the whole and not just a part.
However, this change has to first start within ourselves and will not come from expecting or demanding that managers and politicians do it differently and come up with better systems. As doctors we need to realise that medicine is something that we do, but it is not who we are – we are human beings. As human beings we take on the role of a doctor who is recognised to be someone with a set of skills and knowledge about the human body, health, illness and disease. In the same way a lawyer is a human being who knows about the laws of the land, or a farmer is a human being who knows about crop rotation and animal management and on and on the list could go. We must not conflate what we do with who we are.
I used to think that what I did in my private life and what I did in my professional life were two separate things that did not impact on each other. So long as I was professional at work, then I could do what I liked outside of work and it would not impact work. I had different hats I put on depending on where I was and what I was doing. My surgeon hat went on during the day and my party hat went on during the evening/night. I thought at the time this was ok but I now know that it is not. Many others may also have their work hat and their home hat – thinking that we have different parts to play according to what we are doing. This is also a key part of the fragmentation of medicine – the fragmentation of ourselves according to what we do rather than just living who we are all of the time. The doctor and the human being must become one and not exist as separate parts. In so doing it is obvious that how we live outside of work also impacts how we are inside work.
The microcosm reflects the macrocosm – if we are divided in how we see ourselves and separate the doctor and the human being, then it is no surprise that this fragmentation is reflected throughout medicine in many different ways.
If we are to have a truly holistic medical system rather than the medicine of many parts, then we must start with ourselves and end the separation of being a doctor and a human being. We only need to be who we are no matter what we are doing – just be a human being and make that the focus of deep care.
How would this play out in life?
Well it would mean that if someone chooses to learn the practice of medicine and to work as a doctor, then it would be important to realise that choice comes with a certain level of intensity and pressure of work, that it is a stressful occupation and thus that intensity means we need to adjust our lifestyle accordingly. How we live every day impacts our ability to cope with that stress and is affected by every day simple things like what we eat, how we exercise, our emotional state of being, what we drink and so on. Instead of burning the candle at both ends as I did, it would bring a degree of care and responsibility that before going in to do a long operation we would make sure we had a good night’s sleep beforehand. We would structure our holidays throughout the year to ensure we had sufficient breaks from the intensity so we did not become overwhelmed. The ways are myriad in terms of changes we can make to our lifestyle in order to support the level of intensity and work required as a doctor.
Focus on the Human Being.
Furthermore, if we made the focus about the human being and not what we do as a profession, this would go someway to dissolving the arrogance of the medical profession that holds itself superior or in some way special to other healthcare professionals. There would be a much greater acceptance of the parts played by other healthcare professionals that go to make up the whole of medicine and thus they would be afforded the respect they deserve as equal human beings who have a skill set that is a necessary part of delivering whole healthcare. This would lead to more harmonious and respectful working relationships with human beings relating to other human beings rather than ‘doctors’ and ‘nurses’ for example. Of course this arrogance doesn’t just exist between different professions but occurs within the profession also – whereby surgeons will consider themselves more important than physicians and even within surgery there will be subspecialist arrogance to contend with as well.
Thus we have plenty of work to do to break down these false ideals and barriers to true collaborative and harmonious working relationships. As long as we continue to give focus to the medicine of many parts and practices that perpetuate the fragmentation of medicine in whatever form that comes, then we cannot expect to deliver whole medicine or whole patient care. If we continue to believe that doctors are in any way special or different to other human beings and that we can as doctors wear different hats at work and at home then we will pay the price for perpetuating that separation both personally and professionally.
We are human beings first and foremost – working as a doctor is what we do but it is not who we are. By making the focus of care the human being and applying true care to both our working and home lives (as we are a human being in both places), we will be more ably placed to provide that same quality of care to those human beings we call patients and to change toxic systems and ways of working from within by knowing what it is to care for the human being first and foremost irrespective of the role adopted.