A relic of the past?

At the end of the 19th century, Osler reflected on the rise of specialism: “...the public ... has not been slow to recognize the advantage of a division of labor in the field of medicine. The desire for expert knowledge is... however, now so general that there is a grave danger ... [that] the family doctor should become... a relic of the past.”

In the 21st century, as specialism rules and expands into ever-smaller areas of knowledge and expertise, is the profession even more at risk?

United Kingdom academic Ellen Annandale, in The sociology of health and medicine, argues that “non-physician providers can sometimes deliver a comparable service at lower cost. This is fostered by specialization which permits knowledge to be broken down into smaller tasks which can be undertaken by less skilled workers.” And these workers’ time has come! Task substitution is now touted as a cure for current healthcare woes. We have advanced nurse practitioners, nurse colonoscopists and mental health practitioners, and the list is growing.

At a recent health policy conference, a UK health leader extolled the virtues of a national cancer program involving non-physician “advanced health professionals” who manage treatment protocols and interpret radiological tests, including CT scans. When asked what the role of doctors was in the program, he replied: “Don’t you worry about that! There will always be a place for doctors.” When pressed to explain what precisely that place would be, he answered “diagnostician”, “adviser” and “coordinator of care”.

With task substitution on the health reform agenda, we need to ask: What do doctors do that others don’t, or, indeed, can’t?

The answers may well determine whether doctors as we now know them will become “a relic of the past”.