Medicine in the twenty-first century
Imagine that physicians could multiply their impact on people’s health and improve community health whilst tailoring the delivery of care to each individual patient. The ambit of the present supplement is to say how, with a public health insight into medical practice and physicians’ professionalism.
But clouds obscure the future of the medical profession. Artificial intelligence (AI) threatens to make it obsolete. The commoditisation of care undermines ethics. Bureaucracy is infiltrating practice. Worldwide, cultures are turning materialistic. However, some physicians are resisting these trends. In spite of being well paid, the suicide rate of physicians in the United States is the highest of all occupations, almost twice the national average, and higher than in the military [1]. Taking decisions against one’s intimate convictions partly explains that [2].
To help doctors surmount this existential crisis and resist harsh intangible work conditions, this collection of articles gives them reasons to believe in the survival of medicine as a profession. To do so, the series elaborates on the changes needed in medical culture to keep medical practice as a sacred art, concentrating on what AI does not do or does not do well, especially ethical thinking. With such cultural changes, physicians would impose on AI design the function to support professional endeavour and undermine the opposite process that transforms professionals in technicians. To remain in control, the doctor’s intelligence, emotions, knowledge, communication, ethics, and creativity will have to surpass those of AI, not only in delivering biopsychosocial, ethical care but also in another, insufficiently explored domain that is, in improving collective health with clinical medicine.
Since taxes finance doctors, societies are entitled to demand them to optimise their impact on collective health whilst tailoring healthcare to the patient’s individual needs as much as possible. To meet the practicalities of such a paradoxical norm, the series advocates and delineates the practical and theoretical integration of clinical and public health practice to meet the challenges that medicine faces to survive as a profession, be they financial, political, managerial, or socio-cultural.
In practice, clinicians need to think and act whilst bearing in mind community health stakes - a duty, the importance of which has been clearly demonstrated by the Covid-19 crisis. Conversely, public health physicians must improve clinical healthcare whilst tackling population health risks. Updating the physician’s commitment and medical theory is necessary because dual clinical/public health medical practice is a scientific requirement to optimise the physician’s impacts on individual and collective health.
We adopted the following definitions in collective health.
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According to WHO, “Public health refers to all organised measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole.” (Available: http://www.who.int/trade/glossary/story076/en/) Public health relies on medical, epidemiological, socio-cultural, and environmental techniques. Historically, It has been formed from attempts to control epidemics. Public health addresses “organic” society (such as communities or trade-unions) incidentally, as a disease control resource.
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By contrast, community medicine treats “organic” society as a goal per se, health being one of many issues to improve. Community medicine expands the realm of family medicine to social entities larger than the nuclear or extended family for more effective family medicine, just as family medicine broadens the realm of general practice clinical care for the same reason.
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Preventive medicine aims to improve the health of high-risk groups defined by demographic and epidemiological characteristics (general population, infants, pregnant women, immune-compromised, the elderly, and others) whilst relying on health professionals and a medical, biopsychosocial rationale. Preventive medicine is thus by definition a branch of public health but one tightly connected to community and family medicine because of its reliance on physicians to deliver care.
If such joint practice sounds abstract, consider what doctors can do to potentiate clinical outputs. They can build and lead teamwork, reflect on practice, coach, educate, train, improve health service organisation, coordinate and evaluate health care, improve care accessibility, contribute to disease and health risk control, participate in public health programmes, delegate tasks, improve resource utilisation, do operational research, and lobby for more appropriate health policy design.
Physicians who (inter-)connect all or part of this to their clinical and public health practice could be called “manager physicians”. The term manager is traditionally reserved for persons entrusted with decision-making to achieve their institutions’ predetermined goals most efficiently, but our proposed definition assumes that professional ethics can prevail over institutional missions.
To use her/his knowledge and experience fully, any doctor can adopt the role of “manager physician”, an appealing role when education and research are professionally valued. In fact, any doctor has to adopt this role because the opportunity cost of not adopting it is to be measured in terms of avoidable suffering and mortality [3]. In sum, doctors ought to be “manager physicians” independently of or prior to the adoption of ad hoc institutional policies, thus possibly without being commissioned to be so, for the sake of professional ethics.
To explore the boundaries of medicine and public health, we analysed their (practical, epistemological, ethical, managerial, heuristic, investigative, and political) common facets separately.
The papers are titled as follows:
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A Plea to Merge Clinical and Public Health Practices. Reasons and consequences
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Integrating Medical and Public Health Knowledge – in Support of Joint Medical Practice.
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In Defence of a Single Body of Clinical and Public Health Medical Ethics
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Medical Heuristics and Action-Research. Professionalism versus science
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Objectives, Methods, and Results in Critical Health Systems and Policy Research. Evaluating the healthcare market
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Neo-Hippocratic Health Care Policies. Professional or industrial health care delivery? A choice for doctors, patients, and their organisations