Dr. Brett Taylor

Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is at www.thevirtualpediatrician.com.

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"The future is here. It's just not widely distributed yet" Bruce Toganizzi

There have been two dominant memes of the 20th and now early 21st centuries, and they fundamentally oppose each other. On one hand, we have a global techno-euphoria, very pervasive, spurred on by post Second World War optimism, found in Star Trek, the Jetsons, and nearly everything Disney. On the other hand, we have the stubborn persistence of Thomas Robert Malthus, who in the late 18th and early 19th centuries formulated a fundamental rule of socio-economic behaviour that still applies today. Malthus stated that the growth of population, if unfettered, is always faster than the growth of the resources which sustain it. Global appetite, in other words, always exceeds global supply.

Techno-euphoria is about finding better living through technology. Malthus is about limits. In my world, it is clear that how this tension plays out will fundamentally change health care.

While change is an intrinsic part of our society, there are some forces that stand out as dominant. Demographic shift is one; our patient population is getting older, and therefore medically more needy, and so are our caregivers, who are retiring in record numbers. Those that are left don't like working 80-plus hours per week anymore; we are therefore less productive as well. The numbers of doctors in Canada hit a peak in the 1990s, the number of nurses is peaking now, and there is no new baby boom in the pipe to supply our future needs.

'The numbers of doctors in Canada hit a peak in the 1990s, the number of nurses is peaking now, and there is no new baby boom in the pipe to supply our future needs.'

Peak oil is another; health care is entirely dependent upon cheap readily available oil not just to move patients to care, but in the production of supplies and drugs, to light and heat our buildings, cook our food, autoclave our instruments, launder our linens, and to support the society in which health care is embedded.

Many respected mainstream researchers and even senior members of the financial community agree that the end of cheap, readily available oil is at hand, probably before the end of the next decade. Health care, as it exists now, cannot function without cheap oil. As one submission to an Australian senate committee states: "Rather than looking forward breathlessly to … how stem cells will be curing all sorts of ailments … we should really be asking … How will we be able maintain … childhood immunization in 2030 …"

A bit apocalyptic, but even the rosiest of forecasters do not have a ready rebuttal.

The World Health Organization (WHO) anticipates that climate change will in turn change patterns of infectious disease, increase the incidence of weather-related disasters (like New Orleans) and increase, perhaps dramatically, human migration. Effects on industry (farming, transportation, insurance) will result in substantial economic costs for governments. Further, any positive impact we can have may take decades to show results.

Look at these three challenges and you can see three separate categories of impact.

The demographic shift increases patient load, and decreases caregiver supply. Peak oil and other resource shortages compromise patient mobility, day-to-day operations and has significant financial consequences. Global warming has other long-term impacts on government finances, and hence health-care budgets.

Each of the pressures is independent of the others. This isn't a domino effect, where removing one chip stops the process. This is a perfect storm, where, even in the absence of one or two of these factors, it is going to get pretty darned windy.

Dealing with change

So without abandoning advocacy and our passion to change the world, we should begin to visualize the changes implied by these powerful socio-economic forces.

Currently, physician services start locally, in primary care centres and smaller communities, and are usually provided by family doctors. Larger health-care centres, because of increasing population, have more technology (labs, radiology, etc.), and increasing diversity of physician expertise, with the largest having significant access to educational and governmental administration.

Consequently, physician services in Canada are enclosed within a rigid knowledge hierarchy. Patients are distributed, while the health-care system is centralized. Patients are mobile (they have to be to access care) while the system is immobile, and waits for the patient to come to it. We foster a rigid view of the "medical expert," while underutilizing and under appreciating the local generalist.

Information transfer is weak, and generally involves only physicians who end up in the same room as the patient.

Yet, the forces discussed above mean that patient mobility is likely to decrease, perhaps dramatically, while numbers seeking care will increase in the presence of fewer trained caregivers. Local clinicians will have to fill the gap, and patients will have to do more for themselves, while lineups to see specialists will get longer.

'Patient mobility is likely to decrease, perhaps dramatically, while numbers seeking care will increase in the presence of fewer trained caregivers. '

In other words, whether we like it or not, we are moving from a centralized model to one in which health care is distributed.

This is, to some extent, already beginning. Patients are becoming used to educating themselves online, adequately or not. The goal, reliable delivery of sound, believable, and most importantly actionable information online, hasn't been reached. But our patients are telling us that they are seeking a solution to that long wait in the emergency department for the sniffles and diaper rash. And that is a good thing.

'Distributing' healthcare

If the transition to a distributed health-care system is inevitable, we need to ask how to maximize such benefits while minimizing the risks. We need, in short, to get from here to there by the safest route.

For one thing, we need to begin now to enhance the role of peripheral generalists, and accelerate the development of more (for lack of a better term) "clinical technicians." An example is a midwife. Midwives can't diagnose your pneumonia, or set and splint your broken arm. But in a defined role they have substantial expertise, and the profession is a good model for the future. Will we see the development of elder care workers with extended expertise in specific geriatric problems? Greater numbers of nurse practitioners? I think we will.

If patients aren't going to be as mobile and specialists less available, then the onus is on the local primary health-care system to provide, not transport, but information, and on the tertiary care centre to provide, not hands on care, but a workable management plan at a distance.

'In many ways, the move to the distributed health-care model requires a blossoming of technology and health informatics in rural Canada.'

Imagine an emergency physician in Halifax filling the role of trauma team leader in Digby, N.S., for example, with communication occurring via video link, and the local team perhaps entirely composed of paramedics.

We will need to generate detailed knowledge about that patient locally which would mean committing the expensive, but appropriate investment in CT scanners and enhanced lab capabilities for small centres. In many ways, the move to the distributed health-care model requires a blossoming of technology and health informatics in rural Canada.

Another example: Some of you will recall the debate a few months ago about the death of Natasha Richardson following a head injury in Quebec. I don't want to talk about that case directly, but imagine how a similar case might be handled in the future, in a distributed health-care system. An individual with a catastrophic and evolving bleed inside the head often needs a burr hole drilled into the skull to release the blood. This is a terribly intimidating task, but is not that technically complicated. The tools required can be available in any emergency department, but the expertise and experience is often not.

Could this procedure be done by a family physician in a distributed health-care system? I think so, if done with neurosurgeon support through a trusted technological pathway that was familiar through routine consultation.

Physicians, both generalists and specialists, need to change our world view. We need to challenge the meme of "laying on of hands," the idea that sitting in the same room as an expert is required for health care to happen.

We need to enhance and practice distance medicine, with local generalists of all types as partners. The idea of a specialist working through some Jetson-style robot remotely is a bit of a pipe dream; the expense means this simply won't be part of our rural health care anytime soon. And why should it be when a nurse practitioner with infinitely greater capacity can be walked through the subspecialist's examination of a patient over video link.

Critically, we need to know to deliver the right education from the right teacher to the right learner. In many respects, this will be "just-in-time" teaching, and right now we aren't very good at that.

We need to know how to teach effectively when both learner and teacher are under fire (e.g. drilling a burr hole). We need to be less shy about challenging the copious amounts of medical misinformation on the net and other media; we need to teach our population about evidence and risk more effectively. Information is being democratized; it will be a powerful force that shapes our health care and our society. Unfortunately misinformation will have many of the same properties.

Fighting big change is often unreasonable, particularly when that change connotes benefits as well as dangers. It seems more reasonable to try to shape change so that the opportunities can be realized, and risks ameliorated. If we study the move to a distributed health-care system, we can see similarities to what has happened with communication, business, and even personal relationships over the last two decades.

In an increasingly distributed society, should health care really try to buck the trend?