Governments across the world are facing increasingly complex and demanding problems in delivering health care to their populations. And as they struggle with the solutions, physicians are coming under new pressures that could determine the future role of the medical profession globally.

As the world becomes more of a global village, so the influences and pressures which physicians all over the world are encountering are converging. Whether it is in highly developed countries such as the USA or in western Europe or in the developing or under developed world, these pressures have a common theme.

I have identified five clear global trends now facing individual physicians:

• the inability of public sector health care systems worldwide to cope with demand for health care services and in response to that, the expansion of the private health care sector;

• a movement towards preventive health, where, because physicians are reluctant to take the lead, nurse practitioners and pharmacists are being offered an opportunity to expand their professions;

• a definite shift towards measurable quality. Driven by patient-demand for outcomes-measurement, especially in the USA and UK, there has been an increase in sophisticated systems of professional self-regulation. If doctors do not get their own act together, somebody else will;

• a significant shift from an unmanaged fee-for-service system, where private health care services are provided, to one where costs are managed.

• the increasing role of technology in medical practice.

Unless phyisicians face up to these pressures, I believe that they will begin to lose the battle. The threat to the medical profession and to the patient is that clinical decision-making will eventually be forced into a situation of financial decision-making, which could cause irreparable damage to the patient-physician relationship. My concern is that the medical profession might not be focused enough on its core duties to be able to be effective medical and social leaders.

Physicians will increasingly be more subject to international political influences in health care. Governments will manipulate change with the emphasis on universal access to health care, cross-subsidised funding and the additional emphasis on the preventive and promotional elements of primary health care.

My warning to doctors is to guard against being branded as a self-serving profession. If physicians worldwide do not stay on the high road of being the patient’s best advocate and partner in health, they will suffer.

I believe that in response to the five global trends I have set out, physicians must defend vigorously their fundamental ethical principles in the following ways:

• they should always treat patients as they themselves would like to be treated, and put the patient’s interests above their own. The patient-physician relationship is unique within the health care professions, and I believe it is the single most important competitive advantage our profession has. Patients generally trust us - and we shall literally lose our profession if we lose that trust;

• they should maintain a position of technical and moral independence, so that it is never necessary to make decisions against their conscience and not in the best interest of the patient;

• the patient should always have the right to choose their own physician or change physicians if necessary. This will enhance confidence and trust, not diminish it;

• medical confidentiality should remain a basic principle of medical ethics;

• the physician has a duty to protect the rights and interests of the patient at the level of public health.

I believe that physicians world-wide must re-establish their role as the central leader of the health care team and chief caretaker of our patients by strengthening our knowledge and understanding of the medical art/science, by improving our clinical skills and by paying much more attention to skills of communication. A strong international culture of continuing medical education is a prerequisite for this ideal.

In addition to their role in curative medicine, physicians should expand their clinical horizons by participating much more in the prevention of illness and the promotion of health. This includes areas such as rehabilitation or the care of the handicapped and terminally ill.

To manage change, physicians have the capacity to be both the most knowledgeable specialists and the most gifted generalists, not only in the medical field but also in the socio-economic and management spheres. Apart from sound knowledge and skills, the integrity and ethical nature of our profession are the most important benefit and assurance we can offer our patients.

The most important criteria of a sound health care system are not the number of physicians, nurses or hospitals in a country. Rather it is basic socio-economic indicators such as the per capita level of income and the level of education in a country. Physicians are not involved enough in these political areas, which we can do effectively as individuals or in a collective manner.

If physicians do not speak up and become involved as social leaders, be sure the politicians will plan the system around them.

The autonomy and knowledge of patients have changed significantly over the last few decades. Where in the past the medical profession has acted in a somewhat paternalistic manner, the new patient-physician relationship is much more of a partnership. Again the only threat to the physician is non-adaptation to what I consider a very positive change in the levels of knowledge and choice for our patients.

Across the world, national medical associations are focusing more and more on the issues of patients rights and safety. However, some things never change, especially regarding the core role and function of the physician. Hippocrates, regarded as the father of medicine, lived from 460 to 377 B.C. He taught us to first do no harm when treating patients, to respect and protect life and to maintain the confidentiality and justice of the patient. It is remarkable that most of those ethical principles are still applicable today.

Even the World Medical Association used the Hippocratic oath as the basis to develop the WMA Declaration of Geneva, which is used by some medical schools during the graduation ceremony of their young physicians. Likewise, the WMA Declaration of Helsinki, which is a statement of ethical principles for medical research involving human subjects, contains many principles outlined in the Hippocratic oath.

Without doubt we can say that these principles of the past have not changed.

The WMA, which now represents some seven million physicians of all specialties and sectors from at least 80 countries, has as its main goals for the medical profession the need to attain the highest standards of medical ethics, professional standards, medical education and the best possible treatment of our patients.

The medical profession is approximately 2500 years old. If we wish for a future where our patients have access to high quality health care services and medicine, and where physicians can provide medical leadership and care in an ethical, professional, independent and interdependent manner, physicians urgently need to become involved in managing the good and the bad sides of health care.

September 17, 2002

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