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wmj_2_2019_WEB<\/a><\/p>\n

WMA News
\nvol. 65
\nMedical
\nWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 2, September 2019
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t1
\n212th
\nWMA Council Session, 25\u201327 April, 2019, Santiago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t2
\nWorld Health Assembly\u00a0\u2013 Geneva, May 20\u201328 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t13
\nMEDICINA DEL 2030. El Futuro Esta a la Vuelta de la Esquina Prep\u00e1rate! . . . . . . . . . . . . . \t16
\nWFME Conference: Quality Assurance in Medical Education in the 21st
\nCentury . . . . . . . . \t17
\nNow is the Time for Physicians and Medical Associations to Prepare for Augmented
\nIntelligence in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t21
\nIdentifying Training Needs for Heathcare Organisation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t24
\nIn-Flight Medical Events: an Excellent Application to Support Onboard
\nMedical Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t28
\nPrimary Amoebic Meningoencephalitis as a Cause of Headache and Fever \u2013
\na Global Waterborne Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t29
\nStatement by Frank Ulrich Montgomery.
\n\u201cPhysician 2030: the Future is around the corner\u201d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t31
\nPhysician in 30 years from Now\u00a0\u2013 will Technology and Politics Change Physician\u00a0\u2013
\nPatient Relationships or Change Doctor\u2019s Place in Society and Medicine? . . . . . . . . . . . . . . . \t34
\nEditor in Chief
\nDr. P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nMedic\u012bnas apg\u0101ds, Ltd
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr. Leonid EIDELMAN
\nWMA President
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.,
\nP.O. Box 3566
\n52136 Ramat-Gan
\nIsrael
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nDr. Jung Yul PARK
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\nSamgu B\/D 7F 8F 40 Cheongpa-ro,
\nYongsan-gu
\n04373 Seoul
\nKorea, Rep.
\nDr. Miguel Roberto JORGE
\nWMA President-Elect,
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Mari MICHINAGA
\nWMA Vice-Chairperson of Council
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,Tokyo
\nJapan
\nDr. Osahon ENABULELE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nNigerian Medical Association
\n8 Benghazi Street, Off Addis Ababa
\nCrescent Wuse Zone 4, FCT,
\nPO Box 8829 Wuse
\nAbuja
\nNigeria
\nDr. Yoshitake YOKOKURA
\nWMA Immediate Past-President
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,
\nTokyo, Japan
\nDr. Ravindra Sitaram
\nWANKHEDKAR
\nWMA Treasurer
\nIndian Medical Association
\nIndraprastha Marg
\n110 002 New Delhi
\nIndia
\nDr. Joseph HEYMAN
\nWMA Chairperson of the Associate
\nMembers
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nChairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr.\u00a0Andreas RUDKJ\u00d8BING
\nWMA Chairperson of the Medical
\nEthics Committee
\nDanish Medical Association
\nKristianiagade 12
\n2100 Copenhagen 0
\nDenmark
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of The World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nEditorial
\nEditorial
\nMedication non-adherence is one of the worst epidemics of the 21st
\ncentury.
\nOnly one in ten patients buys medicines in a pharmacy. Every sec-
\nond in ten\u00a0\u2013 buys the tablets, but does not open the medicine pack-
\nage. Every third in ten patients takes medicines irregularly, insuffi-
\nciently,forgets about their use.If the patient is prescribed more than
\nsix medicines of different names,it is highly unlikely that he will use
\nall prescribed medicines exactly.
\nThe greatest medication non-adherence is in psychiatric patients.
\nMultimorbid patients with type 2 diabetes, hypercholesterinemia
\nand hypertension should be mentioned among those who do not
\nuse medication and, therefore, more than 150000 such patients die
\neach year on the planet due to not using medicines, from complica-
\ntions of hypertension, most commonly\u00a0\u2013 stroke.\u00a0Non-adherence is
\neven more apparent regarding doctor\u2019s advice on healthy lifestyle.
\nRepeatedly we have to explain to our patient the mantra\u00a0\u2013 eat less,
\nmove more, or\u00a0\u2013 follow a diet, engage in physical activity. It is very
\ndifficult to make your adipose patient go to a physiotherapist and
\nmake them exercise or at least ride a bicycle. A patient-smoker is
\neven more difficult. Specifically, the chronic obstructive pulmonary
\ndisease patient is not ready to drop smoking and start taking medi-
\ncation daily.\u00a0
\nMedication inequality creates transverse pathways for doctors, re-
\nduces treatment results for patients, and yet medication non-adher-
\nence is nothing good or anything bad. Medication non-adherence
\nvaries from full co-management to complete non-inferiority, but
\nmore frequently, it is in the middle.\u00a0 Once an extensive global study
\nrevealed that more than 90% of patients understood the concept
\n\u201cone tablet once a day\u201d. On the other hand, 43% of patients in the
\ndoctor\u2019s office, under conditions of moderate personal stress and ur-
\ngency, misunderstood or mixed \u201cone tablet twice a day\u201d and \u201ctwo
\ntablets once a day\u201d.\u00a0 Research has shown that despite the doctor\u2019s
\nefforts, patients leave the doctor\u2019s office having understood less than
\n50% of the information the doctor had told.\u00a0 Regardless of the pa-
\ntient\u2019s age, culture or education, confusion about drug use, price,
\neffect, side effects cause serious concern and anxiety.\u00a0 Too often, the
\ndoctor does not address the issue of how long the patient should
\ntake the medication. If the disease is acute, the doctor determines
\nexactly\u00a0\u2013 six days. If the disease is chronic, the doctor prescribes the
\nmedication, but admits that the doses and medication will have to
\nbe changed.Often,the doctor prescribes the medicine knowing that
\nthe medicine will have to be administered to the patient for the rest
\nof his life, though the average patient cannot even imagine it to be a
\nfact up to the end of his days.
\nThe issue of the global epidemic of medication non-adherence
\nseems to be actualisable. Medication non-adherence is not an indi-
\nvidual case, but a global phenomenon.The worst of all are activities
\ncarried out by the patient\u2019s relatives, such as parents who do not
\nallow their children vaccination against infectious diseases.
\nDr. med. h. c. Peteris Apinis,
\nEditor-in-Chief of the World Medical Journal
\nBACK TO CONTENTS
\n2
\nWMA News
\nThe 212th
\nWMA Council meeting was held
\nat the Hotel Santiago (Mandarin Oriental)
\nfrom April 25-27. Around 150 delegates
\nfrom 35\u00a0 national medical associations at-
\ntended.
\nTHURSDAY, APRIL 25
\nThe meeting began with the outgoing
\nChair of the Council, Dr. Ardis Hoven,
\nin the chair for the last time, giving a brief
\norientation session for new delegates about
\nthe procedure for the meeting. Dr. Hoven
\nwas stepping down after serving as Chair of
\nCouncil for the past four years.
\nCouncil
\nThe Council session was formally opened by
\nDr. Otmar Kloiber, WMA Secretary Gen-
\neral, with apologies and a welcome for del-
\negates and new Council members.
\nElections
\nThe first item was the election of the chief
\nofficers.
\nDr. Frank Ulrich Montgomery (Germany)
\nwas elected Chair of Council.
\nDr. Mari Michinaga (Japan) was elected
\nVice Chair.
\nDr. Ravindra Sitaram Wankhedkar (India)
\nwas elected Treasurer.
\nAll the elections were unopposed.
\nPresident\u2019s Report
\nDr. Leonid Eidelman, the President, re-
\nported on his activities over the previous six
\nmonths. He referred to the global problem
\nof increasing violence against physicians and
\nhis meeting in Taiwan on Universal Health
\nCoverage (UHC). He talked about one of
\nthe main themes of his presidency, physician
\nwellbeing and burnout among physicians.He
\nhad attended the 12th
\nGeneva Conference
\non Person-Centered Medicine, Promoting
\nWellbeing and Overcoming Burnout, in
\nMarch,where he talked about burnout being
\na global epidemic. It affected both quality of
\nlife and quality of health care.
\n\u2018Physician burnout is one of the most acute
\nchallenges of contemporary medicine and
\nendangers physicians as well as the quality
\nof healthcare. There is a need for studying
\npreventive and treatment solutions\u2019.
\nHe had spoken at the Global Conference on
\nPrimary Health Care, in Astana, Kazakhstan
\nin October 2018.The goal of the meeting was
\nto renew a commitment to primary health
\ncare in order to achieve universal health cover-
\nage and the Sustainable Development Goals
\nwhich were part of the UN\u2019s agenda for 2030.
\nStrengthening of primary health care (PHC)
\nwas essential for Universal Health Coverage.
\nThe role of physicians was crucial in primary
\nhealth care,from education to prevention,and
\nin both acute and chronic care. High quality,
\nevidence-based PHC provided by a trained
\nteam led by a physician was probably the
\nbest foundation of future medicine. However,
\nduring the Astana meeting, it was notice-
\nable that many participants did not think the
\nPHC model should have the physician at the
\nhelm of leadership.The conference focused on
\nother health care providers, traditional ones
\nsuch as nurses, pharmacists and social work-
\ners, and new professions, such as commu-
\nnity health workers and healthcare assistants.
\nHe had also travelled to conferences in To-
\nkyo, Geneva and in Germany, where the
\nNational Association of Statutory Health
\nInsurance Physicians in Germany orga-
\nnized an unveiling ceremony marking the
\nwithdrawal of the medical licenses of Jewish
\nGerman doctors 80 years ago.
\n212th
\nWMA Council Session,
\n25\u201327 April, 2019, Santiago
\nRavindra Sitaram Wankhedkar Leonid Eidelman
\nMari Michinaga
\nBACK TO CONTENTS
\n3
\nWMA News
\nFinally, Dr. Eidelman said he had spoken
\nat a Universal Health Care International
\nConference, in Taipei, Taiwan and at the
\nInternational Conclave on Zero Tolerance
\nto Violence Against Doctors and Hospitals,
\nin Mumbai, India.
\n\u2018Violence against doctors is a global problem.
\nThe speakers described causes of violence
\nand ways to withstand it. I presented the
\nstatement of the WMA on violence against
\nphysicians and stressed that this kind of vio-
\nlence not only has destructive social effects
\nbut impairs the quality of healthcare that
\nis provided to innocent patients as well. In
\naddition, I emphasized the role of physician
\nburnout in this intolerable phenomenon\u2019.
\nSecretary General\u2019s Report
\nDr. Otmar Kloiber also referred to violence
\nin health care and said it was very clear that
\nthis was not an Indian phenomenon but a
\nglobal phenomenon. \u2018We have to do more
\nto address this. It is not an isolated phe-
\nnomenon but rather a general one\u2019.
\nHe reported on the situation in Turkey,
\nwhere the Government was making life
\nharder and harder for physicians. The Turk-
\nish board had been arrested for supporting
\nterrorist activities. They had made a state-
\nment that \u2018War is detrimental to public
\nhealth\u2019, a statement based on WMA policy
\nand one that every clear-thinking person
\nwould agree to. But that was enough to be
\narrested and sent to prison.They were out on
\nbail and Dr. Kloiber urged national medical
\nassociations to talk to their governments to
\nmake them aware of what was happening in
\nTurkey.What was happening was an attempt
\nto crack down on self-government of physi-
\ncians to make them a tool of the government.
\nChair\u2019s Report
\nDr. Ardis Hoven spoke of her incredible ex-
\nperience as Chair of Council.
\n\u2018I now possess a much deeper understand-
\ning of the role of medical ethics and the role
\nthe WMA plays in that field.Thanks to the
\nsecretariat\u2019.
\nShe added:\u2019It has been a great honour to
\nserve, lead and represent the WMA across
\nthe globe. Little did I know when I first
\ncame to the WMA, that I would meet so
\nmany wonderful and caring physicians who
\nwould give freely of their time and intellect
\nto serve their fellow physicians and all pa-
\ntients throughout the world.
\n\u2018I have learned from each and every one
\nof you and have immense respect for your
\ncommitment to excellence in health care.
\nChallenges exist but I am convinced that
\nthe work of the WMA and all of its mem-
\nbers will continue to make credible and pro-
\ngressive improvements on the platforms of
\nchange to which we are committed\u2019.
\nMatters of Urgency
\nThe South African Medical Association
\npresented an emergency resolution on
\nMedical Ethics in Sports Medicine and the
\ncase of the middle-distance runner Caster
\nSemanya.The International Athletics Asso-
\nciation Federation had brought in rules for
\nwomen with differences in sexual develop-
\nment which SAMA believed were contrary
\nto WMA policy. It was appropriate that
\nthe WMA developed statements but also
\nengaged. It was imperative that physicians
\nwere reminded by the WMA of their ethi-
\ncal obligations. These rules would result in
\nsome moral crisis for doctors, as they re-
\nquired the administration of medicine when
\nthere was no pathology.
\nThe Council agreed that the issue should be
\nconsidered by the Medical Ethics Commit-
\ntee. The Chair of Council told the meeting
\nthat a press release had been issued by the
\nWMA that morning.
\nMedical Ethics Committee
\nDr. Andreas Rudkoebing (Denmark) was
\nelected unopposed as Chair of the commit-
\ntee to succeed Dr. Heidi Stensmyren.
\nThe General Secretary reported on new de-
\nvelopments in the field of research ethics.He
\nreferred to CIOMS (The\u00a0Council for Inter-
\nnational Organizations of Medical Sciences)
\nwork groups analyzing aspects of ethics in
\nresearch, one on increased use of healthy
\nvolunteers in clinical research and one on re-
\nsearch in vulnerable groups.Both issues were
\nof relevance to the Declaration of Helsinki,
\nand the WMA as a CIOMS member was
\ncooperating in those work groups.
\nOtmar Kloiber Ardis Hoven
\nBACK TO CONTENTS
\n4
\nWMA News
\nDr. Kloiber also noted that the potential use
\nof artificial intelligence and big data to replace
\ncontrol groups by a virtual control collective,
\nwas an emerging issue.The WMA should ex-
\namine whether this should be reflected in the
\nprinciples of the Declaration of Helsinki. He
\nhighlighted the aspect of patient-centricity
\nin clinical studies and said that that patient
\ngroups had a far bigger influence nowadays
\non how the research was being done.
\nFinally, he suggested that the committee
\nfurther discuss aspects of end-of-life care
\napart from euthanasia and physician assist-
\ned suicide. The WMA regional discussions
\nshowed numerous problems associated with
\nwithholding or withdrawing treatment at
\nthe end of life and problems regarding re-
\nspect for the will of the patient, especially
\nwhen it came to ending curative treatment.
\nGenetics and Medicine
\nThe Chair of the work group gave an oral
\nreport, saying that a year ago it was decid-
\ned a work group should revise the WMA
\nStatement on Genetics and Medicine. The
\nkey aim was to update the Statement re-
\ngarding the increasing clinical use of ge-
\nnetic analyses, including large scale genome
\nsequencing. Genetic testing was a large,
\ncomplicated and rapidly involving area.The
\ngroup had decided to focus its paper around
\nthe key issue of how to facilitate the collec-
\ntion, storage and use of genetic information
\nin the provision of health care.
\nThe committee decided to circulate the
\nwork group\u2019s draft paper to constituent
\nmembers for comment and agreed that
\nProfessor Reynir Arngr\u00edmsson from the
\nIcelandic Medical Association should take
\nover the chairmanship of the work group.
\nInternational Code of Medical Ethics
\nThe committee received an oral report from
\nthe chair of the work group on the work
\ndone in the last months and the future work-
\nplan. The next step was to develop a list of
\npriority issues and possible new headlines.
\nThe work group would decide at a later stage
\nduring the revision process if the scope of the
\nICoME should be broadened and how de-
\ntailed it should be. It proposed to organize
\nregional expert conferences in 2020 as was
\ndone for the Declaration of Helsinki and
\nthe Declaration of Geneva revision process,
\nand which increased the visibility of WMA
\npolicies.The work group was aiming for final
\napproval of a revised Code from the Council
\nin April 2022 and adoption by the General
\nAssembly in October 2022.
\nReproductive Technologies
\nIt was reported that the chair of the work
\ngroup was not able to attend this meeting,
\nbut would report back to the committee at
\nthe next meeting.
\nDocument of Torture
\nThe committee received an oral report from
\nthe rapporteur from the Danish Medical
\nAssociation, regarding the progress of the
\n10-year revision of the WMA Resolution
\non the Responsibility of Physicians in the
\nDocumentation and Denunciation of Acts
\nof Torture and Ill-treatment.
\nThe policy had been reaffirmed with minor
\nedits and had been sent out for comments
\nfrom NMAs and constituent members. But
\nafter receiving the comments, the rappor-
\nteur recommended a major revision. The
\ncommittee recommended to Council that
\na work group be established with the man-
\ndate to work further on the revision of the
\nResolution.
\nFemale Foeticide
\nA proposed revision of the WMA State-
\nment on Female Foeticide was considered
\nby the committee
\nDelegates agreed to one friendly amend-
\nment to the document, making it clear that
\nsex selective abortion for reasons of gender
\npreference was discriminatory where it was
\nsolely due to parental preference and where
\nthere were no health implications for the
\nfoetus or the woman.
\nThe committee agreed to recommend to
\nCouncil that the proposed revision, as
\namended,be approved and forwarded to the
\nGeneral Assembly for adoption.
\nEuthanasia and Physician
\nAssisted Dying
\nThe committee discussed the comments re-
\nceived on the WMA Statement on Eutha-
\nnasia and Physician Assisted Dying.During
\nthe debate it heard from the spokesperson
\nfor the Physicians\u2019 Alliance against Eutha-
\nnasia, representing 1,100 Canadian doctors,
\non why they were opposed to any change in
\nposition by the WMA on euthanasia.\u00a0Oth-
\ner speakers said that it was important to de-
\nfine clearly the relevant terminology.
\nThe committee decided that the policy re-
\nquired further work and recommended to
\nAndreas Rudkoebing
\nBACK TO CONTENTS
\n5
\nWMA News
\nCouncil that the German Medical Associa-
\ntion work further on the proposed Statement.
\nWMA Physician\u2019s Pledge
\nThe proposed amended WMA Statement
\non Action to Stimulate use of the Physi-
\ncians\u2019 Pledge of the Declaration of Geneva
\nwas tabled for discussion.
\nSeveral national medical associations said
\nthey had oaths with different wording.
\nSome speakers disliked the mandatory na-
\nture of the proposed Statement.
\nThe committee agreed to recommend to
\nCouncil that the proposed Statement be cir-
\nculated to constituent members for comments.
\nSolitary Confinement
\nThe committee considered a proposed revi-
\nsion of the WMA Statement on Solitary
\nConfinement setting out new advice to phy-
\nsicians.Delegates were advised of the need to
\nreview policy, and concern was raised about
\nthe mental and physical risks for children
\nand young people from solitary confinement.
\nIt was agreed to recommend to Council that
\nthe document be circulated for comments.
\nThe British Medical Association volun-
\nteered to be the rapporteur.
\nPhysicians Treating
\nRelatives and Friends
\nA proposed Statement on Physicians Treat-
\ning Relatives and Friends was submitted by
\nthe South African Medical Association.This
\nset out new ethical advice to physicians about
\nthe potential moral conflict between their
\nroles as a family member and as a physician.
\nThe committee agreed to recommend to
\nCouncil that the Statement be circulated to
\nconstituent members for comments.
\nThe South African Medical Association
\nagreed to act as rapporteur.
\nPhysician-Patient Relationship
\nThe committee considered a proposed
\nWMA Declaration on the Physician-Pa-
\ntient Relationship introduced by the Span-
\nish Medical Association. This called for
\naction for national medical associations to
\ntake to protect the long-standing physi-
\ncian-patient relationship which it warned
\nwas under threat. During the debate that
\nfollowed, it was suggested that UNESCO
\nshould adopt the relationship as a world
\ncultural heritage.
\nThe committee agreed to recommend to
\nCouncil that the document be circulated
\nto constituent members for comments.
\nThe Spanish and Portuguese Medical As-
\nsociations volunteered to be the joint rap-
\nporteurs.
\nClassification of 2009 Policies
\nThe committee reviewed the recommenda-
\ntions received on revising policies which
\nwere 10 years old and it recommended that
\nthe WMA Statement on Embryonic Stem
\nCell Research undergo a major revision, led
\nby the American Medical Association.
\nHuman Rights
\nMs Clarisse Delorme, WMA Advocacy
\nAdvisor, gave an oral report, highlighting
\nthe invitation by Mr Victor Madrigal-
\nBorloz, the UN Special rapporteur on
\nsexual orientation and gender identity, for
\nthe WMA to take part in a consultation to
\ndevelop human rights guidelines on data
\ncollection about LGBT populations in
\nthe context of violence and discrimination
\nbased on sexual orientation and gender
\nidentity. The first meeting had taken place
\nin February, when the WMA promoted
\nthe Declaration of Taipei on data collec-
\ntion.
\nResolution on Medical Ethics
\nin Sports Medicine
\nThe committee considered the proposed
\nemergency resolution on Medical Ethics in
\nSports Medicine submitted by the South
\nAfrican Medical Association. The resolu-
\ntion urged the WMA to express strong res-
\nervations on the ethical validity of the 2018
\nInternational Association of Athletics Fed-
\nerations Eligibility Regulations for Female
\nClassification to impose an upper hormonal
\nlimit for athletes wishing to compete in the
\nfemale category in international athletics
\ncompetitions.
\nThe committee recommended that the
\nResolution be circulated to constituent
\nmembers for comments.The South African
\nMedical Association volunteered to be the
\nrapporteur.
\nFinance and Planning
\nCommittee
\nDr. Jung Yul Park (Korean Medical Asso-
\nciation) was elected unopposed as Chair of
\nthe Committee.
\nJung Yul Park
\nBACK TO CONTENTS
\n6
\nWMA News
\nMembership Dues and
\nPayments for 2019
\nMr Adolf H\u00e4llmayr, the WMA\u2019s Financial
\nAdviser, presented to the committee the
\nReport on Membership Dues Payments for
\n2019 and Report on Dues Arrears.
\nThe committee recommended that Council
\napprove the Reports.
\nFinancial Statement
\nThe committee then considered the Finan-
\ncial Statement for 2018. Mr H\u00e4llmayr pro-
\nvided an in-depth analysis of the contents
\nof the document. He said the assets of the
\nAssociation were very solid and there was
\nno financial shortfall.
\nThe committee recommended that the
\nStatement be approved by Council.
\nWMA Strategic Plan
\nA draft WMA Strategic Plan for 2020-
\n2025 was introduced. The Chair of Coun-
\ncil reviewed the Plan, which he said would
\nserve as the backbone document to guide
\nthe plans and activities of the WMA. He
\nstressed that this was a living document and
\nthat world events and other factors could
\naffect where the WMA chose to focus its
\nattention. He referred to various priorities,
\nsuch as the Declarations of Helsinki and
\nGeneva, and universal health coverage with
\naccess for every individual to a physician.
\nAfter a brief debate, the committee agreed
\nto recommend to Council that the Plan be
\napproved and forwarded to the General As-
\nsembly for adoption.
\nWMA Statutory Meetings
\nThe committee considered the planning and
\narrangements for future statutory meetings
\nIt recommended that the theme entitled
\n\u2018Transplantation and Donation\/Organ
\nTrafficking: International Scenarios\u2019 be ap-
\nproved by the Council for the Scientific
\nSession of the 71st
\nGeneral Assembly, in
\nCordoba in 2020.
\nIt also recommended several dates and ven-
\nues for future meetings:
\n\u2022\t the 218th
\nCouncil Session to be held from
\n22-24 April 2021 in Seoul, South Korea;
\n\u2022\t the 224th Council session to be held from
\n20-22 April 2023 in Baku, Azerbaijan
\npending clarification of eligibility of all
\nWMA members to attend based on visa
\nrequirements;
\n\u2022\t the 74th
\nGeneral Assembly to be held
\nfrom 4-7 October 2023 in Rwanda;
\nWMA Special Meetings
\nThe committee received an oral report from
\nthe Secretary General on two conferences\u00a0\u2013
\n\u2018Physician 2030\u2019 in Tel Aviv, 13-14 May
\n2019 and \u2018H20 Conference\u2019in Tokyo, 13-14
\nJune 2019.
\nConstituent Membership
\nAn application for constituent membership
\nwas received from Doctors 4 Doctors in the
\nSeychelles.The committee agreed to recom-
\nmend that the application be approved by
\nthe Council and forwarded to the General
\nAssembly for approval.
\nAssociate Membership
\nThe Chair of the Associate Members,
\nDr.\u00a0Joe Heyman, gave an oral report on the
\ngroup\u2019s activities. He said the group had
\n613\u00a0 members from Japan and 505 from
\nelsewhere, including junior doctors and
\nmedical students.
\nIn his report he said that since the General
\nAssembly meeting the group had reviewed
\nthe circulated documents and commented
\non all of them. Its Google group had grown
\nto 230 members and from this group he had
\nreceived more than 100 comments on the
\nissue of physician assisted suicide from both
\nsides of the issue. These had been distrib-
\nuted to the meeting.
\nThe Secretary General congratulated the
\ngroup on its impressive work.
\nJunior Doctors Network
\nThe JDN Chair, Dr.\u00a0Chukwuma Oraegbu-
\nnam, gave an oral report on the Network\u2019s
\nAdolf H\u00e4llmayr
\nJoe Heyman
\nBACK TO CONTENTS
\n7
\nWMA News
\nactivities, including improving the reach of
\nthe Network and increasing the participa-
\ntion of members in its activities. After a re-
\nview of JDN work groups, some groups had
\nbeen closed, while new ones were planned,
\nincluding a one on global surgery.
\nPast Presidents and Chairs
\nof Council Network
\nThe Secretary General, on behalf of the
\nChair of the PPCN Network, Dr. Dana
\nHansen, who could not attend, gave an
\noral report. He said that several past Presi-
\ndents and Chairs had helped in organising a
\nnumber of recent conferences.
\nThe committee received the report.
\nReview Committee
\nThe committee received an oral report from
\nthe Review Committee\u2019s interim Chair.
\nDelegates were told that past and present
\nmembers of the committee believed that the
\nfunction of the committee was very helpful
\nto the organisation and were likely to rec-
\nommend that it became incorporated as a
\nmore permanent body.
\nThe committee received the report.
\nProcedure on WMA
\nCouncil Resolutions
\nThe Committee considered a proposed
\nprocedure for dealing with WMA Council
\nResolutions. With two editorial changes,
\nthe documents were agreed.
\nPolicy Consistency
\nA proposed WMA Statement on Policy
\nFormulation and Consistency among
\nthe World Medical Association and na-
\ntional medical associations was discussed.
\nDr.\u00a0 Kloiber explained that the content of
\nthe proposed statement was procedural,
\nrather than policy-related.There were com-
\nments that the document was too prescrip-
\ntive, which was agreed by Dr. Kloiber.
\nThe committee recommended that the sec-
\nretariat study how the document\u2019s recom-
\nmendations could be implemented.
\nWorld Medical Journal
\nAn oral report was given by the WMJ Edi-
\ntor Dr. Peteris Apinis, who said there had
\nbeen four issues in 2018 and four issues
\nwere planned for 2019 as well.
\nThe WMJ was mainly issued in digital form
\nand was e-mailed to all national medical as-
\nsociations.
\nIn his written report, Dr. Apinis said the
\nJournal was embarking on a new project, to
\nrecord key WMA leaders and global lead-
\ners from national medical associations in a
\ndigital film. The recorded film would then
\nbe preserved for the WMA historical re-
\ncord.
\nPublic Relations
\nThe committee received the Public Rela-
\ntions Report for October 2018\u00a0 \u2013 March
\n2019. Delegates were told that the WMA
\nhad an increasing number of followers on
\nFacebook and twitter and had issued around
\n30 press releases during the past year. This
\nwork should be, and was, complemented by
\nthe work done by Constituent Members.
\nFRIDAY, APRIL 26
\nSocio Medial Affairs
\nCommittee
\nDr. Osahon Enabulele (Nigerian Medi-
\ncal Association) was elected unopposed as
\nChair of the committee.
\nSecretary General\u2019s Report
\nDr. Kloiber spoke about the conference
\nbeing held in Tokyo in June (13-14) in
\nconjunction with the Japan Medical Asso-
\nciation on \u2018The Road to Universal Health
\nCoverage\u2019. This was a preconference to the
\nG20 Summit 2019 in Japan and was pre-
\nparatory to the High-Level United Na-
\ntions meeting in New York in September.
\nThey had to work harder to make politicians
\nunderstand that health was not an expendi-
\nture, it was an investment for their people
\nOsahon Enabulele
\nChukwuma Oraegbunam
\nBACK TO CONTENTS
\n8
\nWMA News
\nand for their nation.The WMA was keen to
\nwork with others to achieve the third of the
\nSustainable Development Goals.
\nSecondly, he spoke about the work the
\nWMA was doing on the issue of a physi-
\ncian-led primary care. There was a growing
\ntrend to replace physicians by nurses and
\ncommunity health workers and the WMA
\nwould like to show examples of successful
\nprimary care models as counter arguments
\nto the big donors. He said there were re-
\ngions in the world where there were no phy-
\nsicians and there would not be physicians
\nin future. So nurses would be needed to fill
\nthese gaps.But this should be first under su-
\npervision and regulated. He invited NMAs
\nto send in examples to assist the WMA\u2019s
\ncase for physician-led primary care.
\nHealth and Environment
\nAn oral report on the Environment Caucus
\nwas given.
\nThe committee was told that the WMA had
\nbeen represented at the 1st
\nWHO Global
\nConference on Air Pollution and Health on
\n30 Oct to 1 Nov 2018 in Geneva and would
\nagain be represented at the next COP meet-
\ning in Santiago on 2\u201313 Dec 2019.
\nThe Associate Members section would con-
\nsider and mark up two papers on chemical
\nexposure in health care\u00a0\u2013 the first on the use
\nof ethylene oxide as a medical sterilant and
\nthe second on reducing the greenhouse gas
\nfootprint of anaesthetic gases.
\nWMA Network on Disaster
\nMedicine
\nA progress report was given by the Japan
\nMedical Association on the Network in
\nthe CMAAO region (Confederation of
\nMedical Associations of Asia and Oceania).
\nTogether with several regional NMAs, the
\nCMAAO with the Asian Medical Doctors
\nAssociation had concluded a Memorandum
\nof Understanding on disaster medicine as-
\nsistance. This was open and mutual assis-
\ntance, a partnership that various different
\norganisations could participate in and a
\nlocal initiative where those who knew the
\nlocality well were best placed to provide
\nmedical assistance. The next task was to
\nlook into ways of collaborating with other
\nregional and local groups and at the next
\nCMAAO General Assembly, in Goa, India
\nin September,medical associations from the
\nregions would work further on the develop-
\nment of the Network.
\nProfessional Autonomy of Physicians
\nThe committee considered a proposed re-
\nvision of the WMA Declaration of Madrid
\non Professionally-led Regulation, reaffirming
\nthe WMA\u2019s view that the medical profes-
\nsion must play a central role in regulating
\nthe conduct and professional activities of
\nits members if public confidence was to be
\nmaintained in standards of care.
\nAfter a brief debate, minor amendments
\nwere agreed and the committee recom-
\nmended that the document be approved by
\nthe Council and forwarded to the General
\nAssembly for adoption.
\nIn a subsequent debate on the wider is-
\nsues, the committee was told by the Brit-
\nish Medical Association that significant
\nchanges had occurred since the Declaration
\nof Madrid was first adopted. This had been
\nhighlighted by the case in the UK of Dr.
\nHadiza Bawa-Garba, who was convicted
\nof gross negligence manslaughter in 2015
\nand convicted of manslaughter over her
\ninvolvement in the death from sepsis of a
\nsix-year-old boy. It was argued that profes-
\nsionally-led regulation could not be seen in
\nisolation involving individual doctors. The
\nsystem and pressures that doctors worked
\nunder should also be considered. There was
\nnow international recognition that where
\nthere was an investigation, the starting
\npoint needed to be the environment. That
\nshould be part of the regulation process.
\nThere was also insufficient attention paid
\nto the training of individuals involved in
\nregulation work, including the problem of
\nracial bias.
\nThe Chair of Council, Dr. Montgomery,
\nsaid these were important issues, and he in-
\nvited the BMA to prepare a paper for fur-
\nther discussion.
\nPseudoscience, Pseudothera-
\npies, Intrusion and Sects in
\nthe Field of Health
\nThe Spanish Medical Association presented
\na new draft of a proposed Declaration on
\nPseudoscience, Pseudotherapies, Intrusion
\nand Sects in the Field of Health, which set
\nout a series of measures to clamp down on
\npseudoscience and pseudotherapies. The
\nchair of the work group reported that more
\nthan 95 amendments and suggestions had
\nbeen made and most of these had been in-
\ncorporated into the new draft.
\nThe committee recommended to Council
\nthat the draft document be recirculated for
\ncomment.
\nAccess to Healthcare
\nA proposed revision of the renamed Reso-
\nlution on Access of Women and Children
\nto Health Care was tabled. The document,
\nwhich sets out to address years of gender
\ninequality between men and woman in
\nhealthcare, was approved, and the commit-
\ntee recommended that it be sent to Council
\nfor forwarding to the General Assembly for
\nadoption.
\nAntimicrobial Resistance
\nAs part of the 10-years revision process, the
\nCouncil in Riga in April 2018 agreed to a
\nBACK TO CONTENTS
\n9
\nWMA News
\nmajor revision of the WMA Statement on
\nAntimicrobial Resistance. The British Medi-
\ncal Association was appointed lead rappor-
\nteur for the revision and presented to the
\ncommittee a draft revision.
\nThe committee was told that this issue was a
\nvery worrying problem and a growing threat
\nto public health in many countries. There
\nwere significant economic and human im-
\nplications involved. This was a crucial time
\nfor advocacy. A lot of decisions and discus-
\nsions were going on at the United Nations
\nand approval for this revision would be very
\nhelpful.
\nAfter a brief debate, the committee agreed
\nto add the statement that the education of
\na sufficient number of clinical infectious
\n\u00ad
\ndiseases specialists in every country was
\na fundamental requirement for tackling
\nAMR and acquired infections.
\nThe committee recommended that the doc-
\nument, as amended, should be sent to the
\nCouncil for forwarding to the General As-
\nsembly for adoption.
\nSodium Intake
\nProposals to reduce excessive salt intake
\nthroughout the world were tabled in a
\nrevision to the WMA Statement on Re-
\nducing Dietary Sodium Intake.The South
\nAfrican Medical Association had acted as
\nrapporteur on the document and spoke
\nabout the need for national and inter-
\nnational action on educating consumers,
\nas well as the labelling of processed food
\nabout salt intake and content. In a brief
\ndebate, the committee agreed to amend
\nthe document by deleting the word \u2018vol-
\nuntary\u2019 in the statement that the WMA
\nshould \u2018support regulatory efforts involv-
\ning voluntary or mandatory targets in
\nfood processing\u2019.
\nThe committee recommended that the doc-
\nument, as amended, should be sent to the
\nCouncil for forwarding to the General As-
\nsembly for adoption.
\nViolence and Health
\nAs part of the 10-year revision process,
\nthe Council had agreed on a major revi-
\nsion of the WMA Statement on Violence
\nand Health. The Nigerian Medical Asso-
\nciation had agreed to act as rapporteur and
\ntabled a revised Statement, warning about
\nthe increasing incidents of violent attacks
\nagainst healthcare professionals and facili-
\nties.
\nDuring the debate, several delegates ex-
\npressed concerns about the document.
\nOne wanted to include the sentence that
\n\u2018violence is often alcohol related. Measures
\nshould be taken to restrict access to alco-
\nhol\u2019. Other delegates wanted specific refer-
\nences included to stalking and to security
\nposts in every health care facility \u2018as neces-
\nsary\u2019.
\nThe committee decided to recommend to
\nCouncil that the document be recirculated
\nto constituent members for comment.
\nAugmented Intelligence
\nThe American Medical Association tabled
\na proposed Statement on Augmented Intel-
\nligence in Medical Care. It was argued that
\nthe terminology should be \u2018augmented in-
\ntelligence\u2019 rather than \u2018artificial intelligence\u2019
\nbecause this was not about replacing the
\nphysician but assisting the physician. Phy-
\nsicians and medical associations needed to
\nbe involved as AI was developed in order to
\nstrengthen the patient-physician relation-
\nship.
\nThe committee agreed to amend the docu-
\nment to recommend \u2018that all healthcare AI
\nsystems be transparent, reproducible, and be
\ntrusted by both health care providers and
\npatients\u2019.
\nThe committee recommended that the doc-
\nument, as amended, should be sent to the
\nCouncil for forwarding to the General As-
\nsembly for adoption.
\nMedical Age Assessment
\nof Unaccompanied Minor
\nAsylum Seekers
\nProposed new policy guidelines on medi-
\ncally assessing the age of unaccompanied
\nminor asylum seekers were presented by
\nthe German Medical Association. A new
\ndraft was proposed, based on discussions
\nat the last Council meeting and comments
\nfrom NMAs. It was argued that child
\nrefugees must have the highest protection
\nthat was their due and potentially harm-
\nful procedures should be avoided. Young
\nasylum seekers had to be given the benefit
\nof doubt in cases where age could not be
\nconfirmed.
\nAfter a debate, the committee recommend-
\ned that the document, as amended, should
\nbe sent to the Council for forwarding to the
\nGeneral Assembly for adoption.
\nFree Sugar Consumption
\nA proposed Statement on Free Sugar Con-
\nsumption from the Kuwait Medical Asso-
\nciation was considered. The committee was
\ntold that its purpose was to highlight the
\nhigh global level of free sugar consumption
\nand sugar-sweetened beverages.
\nAfter a brief debate, the committee recom-
\nmended that the document, as amended,
\nshould be sent to the Council for forward-
\ning to the General Assembly for adoption.
\nHealthcare information for all
\nThe British Medical Association presented
\na revised draft of a proposed Statement
\non Healthcare Information for All. This
\nBACK TO CONTENTS
\n10
\nWMA News
\n\u00ad
\nfocused on the lack of access to healthcare
\ninformation which acted as a major con-
\ntributor to disease and death. The com-
\nmittee was told that access to health care
\ninformation on diseases, treatments, ser-
\nvices and health promotion was crucial for
\npatients and for health personnel. Lack of
\nthis in some countries could lead to some
\nof the fundamental causes of morbidity and
\nmortality.
\nDuring the debate that followed, the com-
\nmittee decided to amend the document
\nto read that \u2018Governments have a moral
\n\u00ad
\nobligation to ensure that the public, pa-
\ntients and health workers have access to the
\nhealthcare information they need to protect
\ntheir own health and the health of those for
\nwhom they are responsible\u2019.
\nThe committee recommended that the doc-
\nument, as amended, should be sent to the
\nCouncil for forwarding to the General As-
\nsembly for adoption.
\nMedical Liability &
\nDefensive Medicine
\nThe Israel Medical Association submitted
\na proposed Statement on Defensive Medi-
\ncine.The Review Committee suggested that
\nthe proposal could be incorporated into the
\nexisting WMA Statement on Medical Liabil-
\nity Reform. It therefore recommended that a
\nrapporteur be appointed to oversee this.
\nThe committee recommended to Council
\nthat a rapporteur from the Israel Medical
\nAssociation be appointed to merge the two
\ndocuments.
\nClassification of 2009 Policies
\nThe committee recommended that the fol-
\nlowing documents undergo a major revi-
\nsion:
\n\u2022\t Declaration of Ottawa on Child Health
\n\u2022\t Statement on Inequalities in Health
\n\u2022\t Statement on Guiding Principles for the
\nUse of Telehealth
\n\u2022\t Resolution Supporting the Rights of Pa-
\ntients and Physicians in the Islamic Re-
\npublic of Iran
\n\u2022\t Emergency Resolution on Legislation
\nAgainst Abortion in Nicaragua
\nThe following documents should under mi-
\nnor revision:
\n\u2022\t Declaration on Guidelines for Continu-
\nous Quality Improvement in Healthcare
\n\u2022\t Statement on Relations Between Physi-
\ncians and Commercial Enterprises
\nTwo policy documents should be reaffirmed:
\n\u2022\t Statement on Patenting Medical Proce-
\ndures
\n\u2022\t Resolution on Task Shifting from the
\nMedical Profession
\nIt was agreed that one document should be
\nrescinded: Improved Investment in Public
\nHealth
\nNuclear Weapons and Health
\nAn oral report was given by the Interna-
\ntional Physicians for the Prevention of
\nNuclear War.
\nDr. Jans Fromow-Guerra, President of
\nIPPNW-Mexico, (International Physi-
\ncians for the Prevention of Nuclear War)
\nexpressed IPPNW\u2019s strong support for the
\nrevised WMA Statement on nuclear weap-
\nons adopted by the General Assembly in
\nReykjavik, which called for the ratification
\nand implementation of the UN Treaty on
\nthe Prohibition of Nuclear Weapons. He
\nspoke about the increasing risks for a global
\nconflagration with nuclear weapons and the
\ndramatic humanitarian consequences. The
\nplanetary health imperative for the eradi-
\ncation of these weapons therefore had even
\ngreater urgency. He said there was an even
\ngreater need to press for the elimination of
\nall nuclear weapons. There had been a gen-
\neral lack of progress among nations on dis-
\narmament and there was now an ongoing
\nescalation from the risks of a new cold war.
\nThese risks included the situation between
\nIndia and Pakistan, the new cold war be-
\ntween Russia and the US and NATO, and
\nthe issue of the Iran deal.
\nThey now faced a world in which there might
\nsoon be no treaty-based limit on the expan-
\nsion of a fully-fledged arms race between the
\nnuclear super powers.As medical profession-
\nals, they had to remind the public and world
\nleaders that they would not have a second
\nchance if even a minor nuclear conflagration
\nin any part of the world took place.
\nDr. Fromow-Guerra urged the WMA and
\nNMAs to move to a period of action to
\ncarry out specific activities to press for the
\nelimination of nuclear weapons. He re-
\nquested the WMA and each of its members
\nindividually to take action to promote the
\nsignature and ratification by all govern-
\nments of the United Nations Treaty on the
\nProhibition of Nuclear Weapons.
\nThey had to consider all nations\u2019health con-
\ncerns, as critical as they were, required a ba-
\nsic condition for their own survival and the
\nsurvival of life on the planet that could be
\nextinguished in a moment of anger or from
\na horrible mistake by a few individuals with
\nthe power to launch nuclear weapons.
\nAs doctors, it was their duty to do all they
\ncould to eliminate this threat.
\nHypertension
\nThe American Medical Association sub-
\nmitted a paper for information on hyper-
\ntension. It described how hypertension was
\nthe most important risk factor for cardio-
\nvascular disease in every region of the world
\nand a major cause of global morbidity and
\nmortality and it was time for the WMA to
\ndevelop policy on the issue.The AMA gave
\nnotice that it would be working on a pro-
\nposed statement for the October meeting.
\nBACK TO CONTENTS
\n11
\nWMA News
\nSATURDAY, APRIL 27
\nCouncil
\nThe Council meeting opened, unusually,
\nwith any other business.
\nVaccination
\nA proposal was submitted to the Council for
\na Resolution on vaccination. The Australian
\nMedical Association said that the WMA
\nhad strong policy on the effectiveness, ap-
\npropriateness and necessity of vaccination as
\nsomething that saved lives.It was time for the
\nAssociation to reaffirm its policy in the light
\nof global reports on the rise of measles.They
\nneeded to ensure that all governments were
\ndoing what they could to ensure vaccination.
\nThis was particularly important because they
\nnow lived in a global village with increased
\nmobilisation.In Australia 35 babies under 12
\nmonths had contracted measles and this was
\nvery concerning. They had had more than
\n200 cases of measles already this year.
\nIn the debate that followed, there was a dis-
\ncussion about whether the motion should
\nrefer specifically to migration and to the
\nanti-vaccination campaign. On balance,
\ndelegates decided against this, but rather to
\ninclude a reference to misconceptions about
\nvaccination.
\nIn a vote, the Council agreed the following
\nmotion:
\n\u2018The WMA is extremely alarmed at the cur-
\nrent increasing reports of measles outbreaks
\nin many parts of the world. It is clear that
\nincreasing global travel by less than appropri-
\nately protected individuals and the miscon-
\nceptions about vaccinations pose a significant
\nchallenge for health authorities of all nations.
\nIt is in this current climate that the WMA
\nstrongly reaffirms its 2012 Statement on the
\nPrioritisation of Immunisation\u2019.
\nThe Council went on to consider reports
\nfrom the committees.
\nMedical Ethics Committee
\nPhysician-Patient Relationship
\nThe Council considered the proposed Dec-
\nlaration on Physician-Patient Relationship
\nand the committee\u2019s recommendation that
\nthis be circulated to constituent members
\nfor comments. The American Medical As-
\nsociation argued that this issue warranted
\nmore attention than simply circulating the
\ndocument. In many parts of the world this
\nrelationship was under attack by govern-
\nments, insurance companies and others who
\nwished to minimise the importance of the
\nrelationship, which the profession regarded
\nas the foundation of medical care.The AMA
\nargued that it merited a work group to be set
\nup to look at all the threats to the relation-
\nship and to produce a document that could
\nbe used as a tool for each NMA to push back
\nagainst these threats. Other delegates agreed
\nthat this was one of the largest threats fac-
\ning the profession. The Council agreed that
\nthe document should be circulated and that a
\nwork group should also be set up.
\nThe Council agreed to forward the follow-
\ning document to the General Assembly for
\nadoption:
\n\u2022\t Statement on Female Foeticide
\nThe Council agreed to circulate the follow-
\ning documents:
\n\u2022\t Declaration of Reykjavik: Ethical Con-
\nsideration Regarding the Use of Genetics
\nin Medicine
\n\u2022\t Statement on Action to Stimulate use of
\nthe Physicians\u2019 Pledge of the Declaration
\nof Geneva
\n\u2022\t Statement on Solitary Confinement
\n\u2022\t Statement on Physicians Treating Rela-
\ntives and Friends
\n\u2022\t Resolution on Medical Ethics in Sports
\nMedicine
\nThe Council agreed to set up a work group
\nto work further on the revision of the Reso-
\nlution on the Responsibility of Physicians
\nin the Documentation and Denunciation of
\nActs of Torture and Ill-treatment.
\nClassification of 2009
\nPolicies
\nThe Council agreed that the Statement on
\nEmbryonic Stem Cell Research should un-
\ndergo a major revision.
\nFinance and Planning
\nCommittee
\nStrategic Plan
\nThe Council agreed to several amendments
\nto the strategic plan. The first was to add to
\nthe list of priorities promoting physician
\nwellbeing, including advocacy to reduce
\nphysician burnout. A second was to include
\nthe promotion of safe and respectful work-
\nplaces, to reduce work related diseases, vio-
\nlence, bullying and harassment. And a third
\nwas to monitor the expanding use of new
\ntechnologies by patients in self-manage-
\nment and how this impacted on the work
\nand role of doctors as well as the doctor-
\npatient relationship.
\nThe Council approved the Strategic Plan, as
\namended, and agreed that it should be for-
\nwarded to the General Assembly for adop-
\ntion
\nThe Council approved the following re-
\nports:
\n\u2022\t Membership Dues Payments for 2019
\n\u2022\t Dues Arrears
\n\u2022\t Interim Financial Statement for 2018
\n\u2022\t Application for constituent membership
\nof Doctors 4 Doctors Seychelles to be
\nforwarded to the General Assembly for
\napproval
\n\u2022\t Planning and arrangements for future
\nstatutory meetings
\n\u2022\t The theme of the Scientific Session of
\nthe 71st
\nGeneral Assembly, in Cordoba in
\n2020 should be Transplantation and Do-
\nnation\/Organ Trafficking: International
\nScenarios
\n\u2022\t Amendments to the Procedure on WMA
\nCouncil Resolutions and Resolutions
\nBACK TO CONTENTS
\n12
\nWMA News
\nSocio Medical Affairs
\nCommittee
\nResolution on Access of Women
\nand Children to Health Care
\nThe Council considered a proposal to
\nchange the Resolution on Access of Wom-
\nen and Children to Health Care to a State-
\nment. It was agreed to change the title of
\nthe document and to forward it to the Gen-
\neral Assembly for adoption.
\nAugmented Intelligence
\nThe Council considered the proposed State-
\nment and agreed it should be made clear in
\nthe text that the document was about \u2018aug-
\nmented\u2019 intelligence rather than \u2018artificial\u2019
\nintelligence\u2019.
\nThis was agreed by the Council and it pro-
\nposed that the document be forwarded to
\nthe General Assembly for adoption.
\nMinor Asylum Seekers
\nThe Council considered the proposed State-
\nment on Medical Age Assessment of Unac-
\ncompanied Minor Asylum Seekers and the
\nsentence \u2018The WMA underscores that any
\nmedical methods that could involve a health
\nrisk for the applicant, e.g. radiological ex-
\naminations without medical indication, or
\nthat infringe upon the dignity or privacy of
\nan already potentially traumatized asylum
\nseeker, e.g. genital examinations, should
\nbe avoided\u2019. The Council agreed that the
\nsentence should be amended to read \u2018must\u2019
\nrather than \u2018should\u2019.
\nThe Council agreed that the proposed
\nStatement, as amended, be forwarded to the
\nGeneral Assembly for adoption.
\nThe Council agreed to forward the follow-
\ning documents to the General Assembly for
\nadoption:
\n\u2022\t Proposed revision of the Declaration of
\nMadrid on Professionally-led Regulation
\n\u2022\t Resolution on Women and Children to
\nHealth Care and the Role of Women in
\nthe Medical Profession
\n\u2022\t Statement on Antimicrobial Resistance
\n\u2022\t Statement on Reducing Dietary Sodium
\nIntake
\n\u2022\t Augmented Intelligence in Medical Care
\n\u2022\t Statement on Medical Age Assessment
\nof Unaccompanied Minor Asylum Seek-
\ners
\n\u2022\t Statement on Free Sugar Consumption
\nand Sugar-sweetened Beverages
\n\u2022\t Statement on Healthcare Information for
\nAll
\nThe Council agreed that the following doc-
\numents be circulated for comment:
\n\u2022\t Declaration on Pseudoscience and Pseu-
\ndotherapies in the Field of Health
\n\u2022\t Statement on Violence and Health
\nThe Council agreed that the proposed
\nStatement on Defensive Medicine be in-
\ncorporated into the Statement on Medical
\nLiability Reform and be renamed Statement
\non Medical Liability Reform and Defensive
\nMedicine and that a rapporteur be appoint-
\ned to undertake the revision.
\nClassification of 2009 Policies
\nThe Council agreed to the classification rec-
\nommendations recommended by the com-
\nmittee.
\nAny Other Business
\nAdvocacy and Communications Panel
\nAn oral report was given from the Advo-
\ncacy Panel. The Chair, Dr. Ashok Paul,
\nhighlighted the need to help smaller NMAs
\nattending these meetings with extended
\nbriefings and more material on the web-
\nsite. It was also important to ensure that
\nmaterial sent to NMAs actually reached
\nthe members. He also referred to the need
\nto see how smaller NMAs might be bet-
\nter represented on the Council. He spoke
\nabout the inability of smaller NMAs to
\nbecome members, particularly from the
\nAsia-Pacific region and the African conti-
\nnent. Other speakers supported his com-
\nments about the membership of Council.
\nThe Chair of Council said these matters
\nwould be discussed in the Executive com-
\nmittee. He also reminded the Council that
\nthe two-year mandate of the Panel had end-
\ned and he would be appointing new mem-
\nbers and a new Chair.
\nWorld Health Assembly
\nOral reports were given to the Council
\nabout this year\u2019s World Health Assembly.
\nAmong the issues to be discussed at the
\nAssembly and in side events were universal
\nhealth coverage and primary health care.
\nThis led to a lengthy debate on the gradual
\nmove and support for using community
\nhealth workers instead of physicians in pri-
\nmary health care.
\nSpeakers expressed concern about the de-
\nveloping trend and the need for the WMA
\nto increase its activities to support a physi-
\ncian-led primary health care system. It was
\nargued that there was a need for more con-
\ncerted lobbying by the WMA. Examples
\nwere given from several countries about
\nother health workers, such as nurses and
\ndentists, taking over from physicians. Some
\ngovernments were supporting this to reduce
\ncosts. But they were not taking into account
\nthe outcome and cost effectiveness of the
\nissue. Using physicians in primary health
\nhelped to reduce the cost of hospitalization.
\nIn a detailed response to the speakers, the
\nSecretary General outlined the history of
\nhow the WHO initially published a good
\nstrategy on physician-led primary care,
\nonly to see the politicians and governments
\nBACK TO CONTENTS
\n13
\nWorld Health Assembly
\nWMA leaders, past and present, were much
\nin evidence at the 72nd
\nWorld Health As-
\nsembly in Geneva from 20 to 28 May.
\nPast President Sir Michael Marmot was
\npresented with a Health Leaders Award
\nby World Health Organisation Secretary
\nGeneral Dr.Tedros Adhanom Ghebreyesus
\nfor his work on the social determinants of
\nhealth and in recognition of his outstanding
\nleadership in global health.
\nSide Event on Primary
\nHealth Care
\nMeanwhile, the current WMA President
\nDr. Leonid Eidelman and WMA Secretary
\nGeneral Dr. Otmar Kloiber hosted with the
\nTaiwan Medical Association a joint side
\nevent on Primary Health Care (PHC).
\nThe well attended seminar at the Intercon-
\ntinental Hotel was a mark of the WMA\u2019s
\nsupport for Taiwan, which for the third
\nconsecutive year was not invited to the
\nWorld Health Assembly.
\nOpening the meeting, Dr.\u00a0Kloiber said he
\nwas fully aware that there were many regions
\nof the world where there were not enough
\nphysicians. He said the WMA valued the
\nwork of other health professions and he
\nstressed the importance of team work. But
\nin arguing for physician led primary care,
\nthe WMA was recognising that diversity
\nrequired different skills and education.
\nDr. Eidelman said that primary health care
\nwas one of the most important issues in the
\nworld of medicine and in the world of uni-
\nversal health coverage (UHC). It was a cor-
\nner stone of health care systems and a major
\ncomponent of UHC. There was an increas-
\ning demand for health care worldwide be-
\ncause the number of people aged 60 years
\nand over was increasing dramatically.People
\nwere suffering from more and more chronic
\ndiseases and they needed more health care.
\nWorld Health Assembly\u00a0\u2013 Geneva, May 20\u201328
\nNigel Duncan
\noverturn this with an alternative health care
\nsystem that was pushed as a cheap option.
\nThe western governments has failed to op-
\npose this approach. Dr. Kloiber said the
\nproblem on physician-led primary care did
\nnot lie with the WHO, but with the large
\ninternational donor organisations, who had
\nhuge financial resources and were making
\ntheir funding conditional on supporting the
\nuse of nurses and community health work-
\ners over doctors.They were setting the scene
\nbecause they had the money. It was they
\nwho were saying that they were not going
\nto invest in doctors because they were too
\nexpensive. He stressed that the WMA ac-
\ncepted community health workers as an ad-
\ndition, but not as substitutes for physicians.
\nFinally, Dr. Kloiber appealed again to
\nNMAs to lobby their governments and to
\nsend in to the WMA arguments and exam-
\nples to back up their case of why physician-
\nled primary care was a very successful mod-
\nel. This would counter the bombardment of
\nstudies they were confronted with, setting
\nout to show that community nurses and
\nhealth workers could do physician work.
\n\u2018Crazy Socks for Docs\u2019
\nDelegates were asked to support an Austra-
\nlian social media campaign, \u2018Crazy Socks
\nfor Docs\u2019,to highlight the issue of physician
\nwellbeing and mental health. This was sup-
\nported in particular by the Indian Medical
\nAssociation. India had a big problem with
\nsuicides among junior doctors and the In-
\ndian Medical Association had started a
\nprogramme on the emotional wellbeing of
\ndoctors and medical students.
\nSudan
\nOn behalf of the Coalition of African
\nMedical Associations, the Nigerian Medi-
\ncal Association thanked the WMA for the
\nstrong statement it had issued on Sudan.
\nThe Coalition was very appreciative of the
\nsolidarity given to physicians who were be-
\ning assaulted, undermined, intimidated and
\nharassed in the course of undertaking their
\nresponsibilities as physicians. The WMA\u2019s
\nefforts had contributed to the stabilization
\nof the situation in Sudan.
\nTribute to Dr. Ardis Hoven
\nThe meeting ended with a video montage
\nof photos of Dr. Hoven during her term as
\nChair of Council.
\nThe Council meeting was then adjourned
\nand the Secretary General thanked all those
\nwho had contributed towards making the
\nmeeting such a success.
\nMr. Nigel Duncan,
\nPublic Relations Consultant,
\nWMA
\nE-mail: nduncan@ndcommunications.co.uk
\nBACK TO CONTENTS
\n14
\nWorld Health Assembly
\nPrimary health care was a fundamental hu-
\nman right and included all kinds of care,
\nincluding prevention, treatment, rehabilita-
\ntion and palliative care. Yet at least half the
\nworld\u2019s people still lacked full coverage of
\nessential health services. A fit for purpose
\nworkforce was essential to deliver PHC.
\nAnd yet there was an estimated shortfall of
\n80 million health workers globally.
\nHe referred to the Declaration of Astana,
\nenvisioning governments and societies that
\nprioritised, promoted and protected peo-
\nple\u2019s health and well-being at both popula-
\ntion and individual levels, through strong
\nhealth systems.
\nHe said person-centred primary care de-
\npended on accessibility, continuity and
\ncomprehensiveness.Team-based care meant
\na strategic redistribution of work among
\nmembers of a practice team, all members
\nplaying an integral role in providing patient
\ncare and the physician and a team of other
\nhealth workers sharing responsibilities for
\nbetter patient care.
\nDr. Eidelman concluded that the future of
\nhealthcare meant a move from hospital to
\ncommunity settings, and a move towards a
\nteam-based model. It also involved techno-
\nlogical development and an urgent need to
\nstrengthen team based PHC under physi-
\ncian leadership. He said the physician was
\nthe most suitable health professional to lead
\nthe healthcare team.
\nA number of speakers from Taiwan, includ-
\ning Taiwan\u2019s Health Minister Chen Shih-
\nChung, spoke about community primary
\ncare in their country and the roles and tasks
\nof primary care physicians promoting ad-
\nvance care planning.
\nAnother speaker, Dr. Lyndah Kemunto, a
\ngeneral practitioner from the Kisii Country
\nGovernment in Kenya, talked about why
\ndoctors needed to be at the centre of pri-
\nmary health care. She said that PHC teams
\nshould be physician-led because of doctors\u2019
\nclinical skills, as well as skills for capacity
\nbuilding,critical thinking and collaboration.
\nThe benefits of physician-led PHC includ-
\ned better health outcomes, cost reduction,
\nincreased efficiency, reduced inequality and
\nintegrated and continuity of care.
\nThe symposium concluded with Dr. Kloiber
\nsaying it was deplorable that Taiwan was again
\nbeing banned from the World Health Assem-
\nbly. It was a very sad situation and he hoped
\nthat next year things would be different.
\nWMA Signs UHC2030
\nThe following evening in a special cer-
\nemony in Geneva Dr. Eidelman signed the
\nUHC2030 Global Compact for a safer,fair-
\ner and healthier world by 2030. In doing so
\nhe committed the world\u2019s 12 million physi-
\ncians to promoting the benefits of universal
\nhealth coverage across the globe.
\nDr.Eidelman said that universal health cov-
\nerage was key to reaching the World Health
\nOrganisation\u2019s \u2018triple billion\u2019 targets\u00a0 – one
\nbillion more people benefitting from uni-
\nversal health coverage, one billion more
\npeople better protected from health emer-
\ngencies and one billion more people enjoy-
\ning better health and well-being.
\n\u2018The World Medical Association embraces
\nthe concept wholeheartedly, and we are
\nkeen to see quality primary care provided
\nby multi-disciplinary teams at the core of
\nstrong and comprehensive health care sys-
\ntems. In our view, UHC is the biggest step
\nforward ever made by WHO, and we are
\nfirmly part of the movement.\u00a0
\n\u2018In parts of the world where health systems
\nare close to UHC we can show that this is
\nfor the benefit of everybody – for our pa-
\ntients, our colleagues and the communities
\nwe serve. UHC is an ideal platform, not
\nonly for providing curative care, but also
\nfor providing prevention, rehabilitation and
\npalliative care\u2019.
\nDr. Eidelman said that investing in univer-
\nsal health coverage was not only a strong
\nhumanitarian move, it was also a sound
\neconomic development to create viable and
\nvalue-adding services for communities.
\nUHC2030, run by the WHO and the
\nWorld Bank, involves building and ex-
\npanding equitable, resilient and sustainable
\nhealth systems, funded primarily by public
\nfinance, and based on primary health care.
\nWMA Interventions
\nThroughout the World Health Assembly
\nmeeting, WMA policy interventions were
\nbeing presented to the Assembly by mem-
\nbers of the Junior Doctors Network. These
\nincluded statements on public health emer-
\ngencies, access to medicines and vaccines,
\nand water, sanitation and hygiene in health
\ncare facilities.
\nOne of the most significant interventions
\nwas on universal health coverage, when the
\nWMA welcomed the WHO\u2019s message that
\nin order to implement UHC, more invest-
\nment in the health workforce was needed.
\nThe WMA argued that this financial com-
\nmitment should prioritize closing the pre-
\ndicted 18 million health workforce gap, by
\nincreasing the number of students, enhanc-
\ning education and specialization as well as
\nimproving working conditions.
\nThe statement added: \u2018The Global Strategy
\non Human resources for health: Workforce
\n2030 recommends that countries should
\nplan for their health workforce as a whole,
\nrather than segmenting planning and re-
\nlated programming and financing efforts
\ninto single occupational groups. The cur-
\nrent international debate focuses mainly
\non prompt ways to meet the HP shortage
\nthrough the replacement of physicians by
\ncommunity health workers (CHW) or
\nnurses. The latest data available shows that
\n76 countries still have less than one physi-
\ncian per thousand population. It is unac-
\nBACK TO CONTENTS
\n15
\nWorld Health Assembly
\nceptable that patients with cancer in some
\ncountries cannot access adequate care be-
\ncause there is no oncologist in the country.
\n\u2018In its report,WHO emphasizes that CHW
\nare not a cheap alternative to close the gap
\nof health professionals and that govern-
\nments should adopt service delivery models
\nin which CHW are assigned general tasks as
\npart of integrated primary health care teams.
\nFor many years, WMA has been advocating
\nfor the need of health care teams with vari-
\nous cadres, including community and social
\nworkers. Each profession has its own scope
\nof practice and clear responsibilities with
\none team member having the overarching
\nresponsibility.This should be reflected in the
\nWHO Global Competency Framework for
\nUniversal Health Coverage. We know there
\nis still a long way to go, but the aim must
\nbe that in the end everybody who needs a
\nphysician will be assisted by physician. If
\nyou give up that aspiration Universal Health
\nCoverage will not come true\u2019.
\nIn its intervention on antimicrobial resistance,
\nthe WMA reiterated the need for the adop-
\ntion of a One Health approach in National
\nAction Plan development, but more impor-
\ntantly in its implementation. And on human
\nresources for health, the WMA noted that in
\nmany countries,including the wealthiest ones,
\nthere was a shortage of physicians. A major
\nreason for this gap was a failure to educate
\nenough physicians to meet the health needs of
\nthe country\u2019s population.As a response to this
\nshortage, many countries encouraged inter-
\nnational recruitment and the WMA empha-
\nsized the need to regulate those recruitments
\nby calling on Member states to implement the
\ninternational code for recruitment of health
\nprofessionals. It urged member states to re-
\nfrain from coercive measures restricting the
\nmobility of health professionals.
\nOn the promotion of health of refugees and
\nmigrants, the WMA said the WHO Glob-
\nal Action Plan failed to address key issues
\nnecessary to ensure proper access to health
\ncare to migrants and refugees in line with
\nhuman rights and medical ethics standards.
\nIt said an explicit reference should be made
\nto the human right to health of refugees
\nand migrants, regardless of their legal, civil
\nor political status. The Plan should also ad-
\ndress the ethical challenge physicians faced
\nand should condemn any practice involving
\ntheir participation to non-medically justified
\nexamination, diagnosis or treatment, such as
\nsedatives to facilitate easy deportation, or
\nbone examination for age assessment.
\nYassen Tcholakov presented the WMA
\nstatement on climate change,welcoming the
\ndraft WHO global strategy, and in particu-
\nlar the proposal to address the wide spec-
\ntrum of climate change impacts on health,
\nthrough cross-sectoral action on determi-
\nnants of health and a health-in-all-policies
\napproach. It supported the recommendation
\nto strengthen the health sector leadership
\nand governance and recommended develop-
\ning further on ways to equip and educate the
\nhealth workforce, including physicians, to
\npromote a better environment, address pa-
\ntients\u2019needs, and transmit health knowledge
\nregarding environmental risks to policy-
\nmakers and communities.
\nBut the WMA also considered that great-
\ner emphasis should be placed on the need
\nfor health impact assessments of new trade
\nagreements being negotiated in multilateral
\nsettings in order to protect,promote and pri-
\noritize public health over commercial inter-
\nests and secure services in the public inter-
\nest,including those impacting on health and
\nenvironment. It suggested that the WHO
\nshould act as a global role model through
\nthe adoption of climate change performance
\nindicators of its own activities, which could
\ninspire the wider UN community.
\nNuclear Weapons
\nThe WMA was also involved in a side event
\non nuclear war. Entitled \u201cNuclear Weap-
\nons Today: An Update of the Humanitar-
\nian Consequences of Nuclear War and the
\nMedical Role in Preventing it\u201d, the event
\nwas organised by the International Physi-
\ncians for the Prevention of Nuclear War,
\nand supported by the WMA and the World
\nFederation of Public Health Associations.
\nWMA Advocacy Advisor Clarisse Delorme
\ngave an update on the humanitarian conse-
\nquences of nuclear war and the role of health
\nprofessionals in preventing it and took part in
\na panel discussion. Speakers said that the use
\nof nuclear weapons brought disproportion-
\nate suffering to vulnerable categories, such as
\nwoman,children and indigenous populations.
\nThere was a need to focus on the health and
\nclimate consequences of nuclear weapons.
\nThe WHO, it was argued, should once again
\nbecome a voice against nuclear weapons.
\nBurnout
\nOn the final day of the Assembly, the
\nWMA issued a press release giving a warm
\nwelcome to the decision by the Assembly to
\nclassify work related burnout as a problem
\nthat influenced health status and to include
\nit in the new version of the international
\ncode of diseases\u00a0
\nWMA President Dr. Eidelman said: \u2018For
\ntoo long burnout among physicians has
\nbeen largely ignored. Emotionally exhaust-
\ned physicians are a danger to patients and a
\ndanger to themselves. The cost in terms of
\nhuman lives and money is appalling.\u00a0
\n\u2018The number of suicides among doctors re-
\nsulting from burnout is a scandal and I\u00a0hope
\nthat the WHO\u2019s new classification will shine
\na spotlight on this disgraceful situation.
\n\u2018I hope that the World Health Assembly\u2019s
\ndecision will lead to a new approach that ad-
\ndresses multiple factors including working
\nconditions for physicians around the world\u2019.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nE-mail: nduncan@ndcommunications.co.uk
\nBACK TO CONTENTS
\n16
\nPhysician 2030
\nProtagoras student of Socrates and Aris-
\ntotle (2,500 BC) said that \u201cMAN IS THE
\nMEASURE OF ALL THINGS\u201d, predict
\nthe future without remembering the prin-
\nciple would lead us to make mistakes, as
\ndoctors understand that there can be noth-
\ning more noble than Protect your health or
\nunderstand your illness.
\nMan is the only being with a known past who
\nlives his present and plans the future,he is the
\none who creates the story and the end of it.
\nIn Mesopotamia medicine was based on
\nmagic to bring out the evil one,in Egypt the
\npriests and fortune tellers treated diseases, it
\nwas Hippocrates who started the scientific
\nmedicine based on experience and carefully
\nobserving the patient.
\nGalen makes dissections of corpses know-
\ning their anatomy and physiology.
\nThe Romans installed the first hospitals to
\ncare for their war wounded and municipal
\nhospitals were born.
\nAlbucasis removes the goiter with crude
\ninstruments, using cautery to treat wounds.
\nMedieval medicine is characterized by
\nplagues, the Catholic Church influences
\ndisease as punishment for sins and con-
\ndemns scientific research, Pasteur talks
\nabout the germs and bacteria that passed
\nfrom one individual to another causing the
\ndisease.
\nR\u00f6ntgen discovers X-rays, the basis for ex-
\nploring the interior of the human body. It
\ntook many centuries for the concept that
\nthe doctor should not only cure diseases,but
\nshould also prevent them.
\nIn the XX and XXI century many drugs
\nthat cure, prevent and control diseases,
\nelectronic devices capable of diagnosing,
\ntransmit important patient information,
\nthese rapid advances allow a better and
\nbetter life for people, increasing their life
\nexpectancy.
\nWhat is the future of
\nMedicine?
\n5 medical technologies
\ncould change the world:
\n\t a)\u2002
\nDrugs and anti-aging treatment (mo-
\nlecular repair to organ replacement),
\n\t b)\u2002
\n3-D and 5-D impressions,
\n\t c)\u2002
\nbionic implants (nanotechnology),
\n\t d)\u2002
\nPrenatal genetic manipulation (avoid-
\ning the development of mutations)
\n\t e)\u2002
\npersonalized medicine, all this accom-
\npanied by Big Data and artificial intel-
\nligence.
\n5 Nobel Prizes in Medicine tell us
\nabout the future of medicine:
\n\t a)\u2002
\nErwin Neher (1991) \u201cthe bugs that
\ninvade us have key (Micro biome) the
\nmissing link, certain bacteria can in-
\nfluence the appearance of diseases.
\n\t b)\u2002
\nRichard J. Roberts (1993). CRISPR
\nsystem (the short genetic stick, modi-
\nfies the genes at your convenience,
\nintroduces changes in the DNA for
\ntreatments of many diseases.
\n\t c)\u2002
\nFerid Murad (1998). The Bio-impres-
\nsion 3-D, the challenge of creating
\nhearts is a present reality, very close
\nto the manufacture of artificial blood
\nand organ culture for transplants using
\nstem cells.
\n\t d)\u2002
\nJules Hoffman (2011). Inverse vac-
\ncinology, 500 diseases will be erased
\nforever, deciphering the genome of
\nbacteria, also particle accelerators to
\nstudy the structure of the virus.
\n\t e)\u2002
\nRandy Schekman (2013). Immuno-
\ntherapy the vaccine against cancer,
\ncombines the genetic profile of the
\ntumor achieving more personalized
\ntherapies. Immunotherapy helps our
\ndefense system detect cancer cells and
\nattack them in a selected way.
\nPersonalized medicine determines that each
\nperson is unique and the same happens with
\ntheir pathology, this allows that the genetic
\nstudy of a person is the ability of genetic ed-
\niting to correct their mutation.
\nThe main reason for this article is:
\n–
\n– to show that the vertiginous advance of
\ntechnology is leaving behind the hu-
\nman part of medicine.
\n\u2022\t We ask ourselves: What about human
\nvalues ? …
\n–
\n– Disease is a bio-psycho, social compo-
\nnent, the disease not only attacks the
\norganism,it also has environmental and
\nsocial factors, influences the family and
\nthe environment, aspects that we must
\nnot neglect from the human point of
\nview.
\n–
\n– 70% of the world population does
\nnot have access to a full health sys-
\ntem, which allows the human right of
\nequal attention without considering
\nMEDICINA DEL 2030. El Futuro Esta
\na la Vuelta de la Esquina Prep\u00e1rate!
\nAnibal Antonio Cruz Senzano
\nBACK TO CONTENTS
\n17
\nWFME News
\neconomic, racial or political factors,
\nthe latter being used by unscrupulous
\ngovernments as a speech to conquer the
\npopulation .
\n\u2022\t We continue with an important poverty
\nmap highlighting:
\n–
\n– poverty, malnutrition, collapsed hospi-
\ntals, limited access to medicines,
\n–
\n– precarious infrastructure, lack of sup-
\nplies and human resources in health,
\ndesolation and death.
\nThis is the true reality with which we will
\nface and is the challenge of the medicine of the
\nfuture.
\nHow should we prepare for the
\nmedicine of the future …?
\nTechnology must not dehumanize medi-
\ncine, on the contrary, it must be accom-
\npanied by ethical and deontological prin-
\nciples.
\nThis is an important responsibility of medi-
\ncal schools where teaching with values \u200b\u200b
\nde-
\ntermines that the main thing is the patient
\nand the resolution of their illness in an inte-
\ngral way. Always trumpet our governments
\nand health administrators, the human right
\nof free and equal access to health according
\nto the basic principles of the Hippocratic
\nOath.
\n\u2022\t We must make a more human medicine!\u00a0…
\n\u2022\t We must make the doctor-patient relation-
\nship intangible heritage of Humanity\u2026!!!
\nFrom the CONFEMEL space, we demand
\nfrom the world and health institutions this
\nright,unconditional commitment to profes-
\nsional competence, altruism and the trust of
\nsociety.
\n\u201cTRUST DEPOSITED IN
\nTHE CONSCIOUSNESS\u201d.
\n\u2022\t Let\u2019s put all our hands together to look
\nat the future and from all the institu-
\ntions: CONFEMEL, ISRAEL MEDI-
\nCAL ASSOCIATION (I.M.A.),
\nWORLD MEDICAL ASSOCIATION
\n(W.M.A.).
\n\u2022\t Propose to the world and UNESCO
\nthat the patient medical relationship
\nshould be the beginning and the end of
\nthe medical act, for that reason and hu-
\nman values \u200b\u200b
\nwe must name the doctor-
\npatient relationship \u201cINTANGIBLE
\nCULTURAL HERITAGE OF HU-
\nMANITY\u201d.
\nWe end this article with the thought of
\nHippocrates 5th
\ncentury BC:
\nLife is short, extensive science, the fleeting occa-
\nsion, the insecure experience, the difficult judg-
\nment. It is necessary not only to prepare to do
\nwhat is due, but also to collaborate: the patient,
\nthose who assist him and the circumstances, ex-
\nternal.
\nDr. Anibal Antonio Cruz Senzano.
\nBolivia
\nE-mail: aacruzs@hotmail.com
\nThe 2019 World Federation for Medical
\nEducation (WFME) Conference, held in
\nSeoul, Korea from April 7-10, hosted more
\nthan 800 participants from 57 countries.
\nThere were 300 presentations that included
\n12 Plenaries, 48 Symposia and 10 Work-
\nshops. 84 Paper presentations and 146
\nPoster presentations in 35 thematic sessions
\nwere all related to the Conference theme
\n\u201cQuality Assurance in Medical Education
\nin the 21st
\nCentury\u201d.
\nIn support of this theme, WFME focused
\non critical activities in the immediate years
\nto come. The three main topic areas were:
\nthe WFME Recognition of Accreditation
\nProgramme,the next edition of the WFME
\nStandards, and quality assessment of Post-
\ngraduate Medical Education.
\nWFME Recognition of
\nAccreditation Programme
\nOne of the aims of the conference was to
\ndiscuss accreditation and to dispel misin-
\nformation that has been circulating in many
\ncountries world-wide about the meaning
\nand process of the WFME Recognition
\nProgramme. WFME does not accredit in-
\ndividual medical schools. Medical schools
\nare accredited by an accrediting agency,
\nwhich can be a government or independent
\norganisation.Through the\u00a0Recognition Pro-
\ngramme,\u00a0WFME evaluates the legal stand-
\ning,accreditation process,post-accreditation
\nmonitoring, and decision-making processes
\nof an accreditation agency for programmes
\nor schools of basic medical education.
\nCurrently, there are 18 agencies with Rec-
\nognition Status, 12 agencies in various
\nstages of the recognition process and more
\nthan 10 additional organisations are in ac-
\ntive communication with WFME regard-
\ning their application.\u00a0
\nWFME often receives enquiries about pos-
\nsible solutions for various countries, agen-
\ncies, or medical schools. Often a school asks
\nwhat to do about the Educational Com-
\nmission for Foreign Medical Graduates
\n(ECFMG) 2023 deadline (see below) when
\nthe agency in their country is not yet recog-
\nnised or when there is no accrediting agency
\nWFME Conference: Quality Assurance in
\nMedical Education in the 21st
\nCentury
\nSeoul, Korea, May 2019
\nBACK TO CONTENTS
\n18
\nWFME News
\noperating in the country. WFME strongly
\ndiscourages schools from pursuing accredi-
\ntation from a recognised agency outside the
\ncountry without verifying that the agency is
\nalso recognised by the relevant authority in
\ntheir country. The agencies with Recogni-
\ntion Status are only recognised by WFME
\nfor operation in countries where they are
\nmandated by the government, or by the rel-
\nevant professional or scientific authority, to
\nperform accreditation of medical education.
\nFor countries where an accrediting system
\nhas not yet been set up, WFME suggests
\nany of the following:
\n\u2022\t Setting up an accrediting system in con-
\nsultation with experts in accreditation, or
\nwith representatives of an already func-
\ntioning agency from a different\u00a0\u2013 yet rea-
\nsonably comparable\u00a0\u2013 country, or
\n\u2022\t Creating a regional accrediting body in
\ncooperation with neighbouring countries,
\nor
\n\u2022\t Reaching out to an already functioning
\nagency in a country that is geographically
\nor culturally close and consider giving
\nthis agency a mandate to perform the ac-
\ncrediting function on behalf of the gov-
\nernment, or on behalf of a relevant pro-
\nfessional or scientific authority, or both.
\nTo avoid any conflict of interest, WFME is
\nnot able to recommend individual experts in
\naccreditation, but can provide a list of pos-
\nsible experts from which anyone working to
\nset up a new agency can choose.The experts
\non this list may also be used to provide in-
\ndependent advice to an agency considering
\nan application in the WFME Recognition
\nProgramme.
\nFor more information on the WFME Rec-
\nognition Programme please visit: wfme.org\/
\naccreditation\/recognition-programme
\nAgencies that wish to apply for Recogni-
\ntion or get more information can contact
\nWFME at accreditation@wfme.org. This
\nemail address also serves for any other en-
\nquiries about WFME Recognition.
\nThe list of agencies with
\nRecognition Status can be
\nfound on the WFME web-
\nsite wfme.org\/accreditation\/
\naccrediting-agencies-status.
\nWFME also announces
\nall newly recognised agen-
\ncies in the News section on
\nthe website and on Twitter
\n(@wfmeorg) and Facebook.
\nCurrently these are the only
\nsources of updated informa-
\ntion about the Recognition
\nProgramme.
\nAccrediting agencies report
\nmany reasons as drivers to
\napply for WFME Recogni-
\ntion. WFME Recognition
\nStatus is seen as a mark of
\nquality \u2013\u00a0 and although it is
\nnot mandatory to go through
\nthe process, accrediting
\nagencies see value in exter-
\nnal evaluation of the core of
\ntheir activity. Almost all ac-
\ncrediting agencies that have
\nachieved Recognition Sta-
\ntus report that their policies
\nBACK TO CONTENTS
\n19
\nWFME News
\nand procedures have benefited from inde-
\npendent appraisal. Recognition Status also
\nacknowledges a globally comparable quality
\nof accreditation while supporting the use of
\ncountry-specific standards that are tailored
\nto the local needs and context.
\nMedical schools, students and graduates are
\nunderstandably primarily interested in the
\nWFME Recognition process because of its
\nconnection to ECFMG policy.
\nBarbora Hrabalov\u00e1
\nWFME\u00a0Head of External Relations
\nPreparing for the ECFMG
\n2023 policy deadline
\nThe World Conference discussed the Edu-
\ncational Commission for Foreign Medical
\nGraduate (ECFMG) policy,that states that,
\nstarting in 2023, individuals applying for
\nECFMG Certification must be a student
\nor graduate of a medical school that is ap-
\npropriately accredited.More specifically,the
\nschool must be accredited by an accrediting
\nagency that is officially recognised by the
\nWFME. ECFMG has planned a 4-phase
\nimplementation process leading up to the
\n2023 deadline (see picture 1).
\nFor continuous update on the progress to-
\nwards 2023, visit ecfmg.org\/accreditation.
\nThe above diagram refers to the World Di-
\nrectory of Medical Schools, which is managed
\njointly by WFME and the Foundation for
\nAdvancement of International Medical
\nEducation and Research (FAIMER). It is
\nimportant to note that listing of a medi-
\ncal school in the World Directory does not
\ndenote recognition or endorsement by
\nWFME or FAIMER, or the eligibility to
\napply for ECFMG licensure. Informa-
\ntion about the eligibility of graduates from
\nany particular medical school to apply for
\nECFMG or Medical Council of Canada li-
\ncensure is currently located in the Sponsor
\nnotes in the school\u2019s page on the World Di-
\nrectory website (wdoms.org). As the 4-phase
\nplan progresses, the World Directory will
\ngradually include information about accred-
\nitation and WFME Recognition, as well.
\nFor information about World Directory of
\nMedical Schools listings, visit the website or
\ncontact info@wdoms.org.
\nWFME Standards: New edition
\nfor basic medical education
\nAs overviewed at the World Conference,
\nsince their first publication in 2003, the
\nWFME standards have regularly been up-
\ndated, reflecting the conditions and chang-
\ning values in medical education. The next
\nedition of the standards for basic medical
\neducation is due for publication in 2020.The
\nnew standards will continue to encompass
\nPicture 1
\nBACK TO CONTENTS
\n20
\nWFME News
\nmission and objectives, educational pro-
\ngrammes, assessment, selection roles and
\nsupport for students, academic staff and re-
\nsources, programme evaluation, governance
\nand administration, and continuous renewal.
\nHowever, the emerging style in development
\nof standards means that standards will move
\naway from detailed specification and toward
\nstreamlined reference frameworks that ask
\nhow institutions make their decisions, rather
\nthan whether they comply with set practices.
\nThis allows the locally-based standards to
\nreflect the diversity of political, professional,
\nhealth,education and social contexts that ex-
\nists among countries and in their correspond-
\ning healthcare and educational resources and
\nvalues. This allows local relevance within a
\nglobal framework that is one of the baseline
\ntenets of the World Health Organisation\u2019s
\ntransformative education policy. It will en-
\nsure local choice and contextual relevance in
\neducational design and action.
\nThe revised standards will guide institutions
\nto take ownership and address the necessary
\ncomponents of curriculum purposes, out-
\ncomes, processes, management, and quality
\nwhile enabling each institution to reach its
\nown contextually appropriate designs and
\nprocesses and enable regulators to make rel-
\nevant and constructive decisions about the
\nquality of medical education offered.
\nProfessor Janet Grant\u00a0
\nSpecial Adviser to the WFME President
\nQuality assessment of
\nPostgraduate Medical Education
\n(PGME): National Examples
\nAnother key element of the World Con-
\nference was a discussion on quality assess-
\nment of Postgraduate Medical Education
\n(\u201cGraduate Medical Education\u201d in North
\nAmerican terminology). PGME training
\nand evaluation varies in different countries
\nand so does the form of oversight and qual-
\nity control. Examples of PGME regulations
\nwere shared at the conference by represen-
\ntatives from three countries:
\n\u2022\t TheanneWalters presented a form where
\nbasic medical education and PGME are
\nmonitored by the same body, the Austra-
\nlian Medical Council (AMC).
\n\u2022\t Jung-Yul Park from Korea discussed a
\ncomplex situation where there the re-
\nsponsibility for regulating PGME is di-
\nvided among several bodies, making it
\ndifficult to provide any unified and con-
\nsistent oversight.
\n\u2022\t T\ufeffhomas Nasca from America presented
\nthe activity of the long-established body
\nthat monitors PGME in the USA, the
\nAccreditation Council for Graduate
\nMedical Education (ACGME).
\nThese three examples show that quality as-
\nsessment of PGME can take varied forms
\nand before striving for any global compari-
\nson and overarching criteria, a comprehen-
\nsive study to map the situation world-wide
\nis needed.
\nT\ufeffhe Junior Doctors Network, serving as the
\ninternational platform for junior doctors to
\nfacilitate an open dialogue of global events
\nand activities that are relevant to their post-
\ngraduate training, is currently organising a
\nsurvey among residents to identify the spe-
\ncifics and needs of PGME training world-
\nwide, and to identify the elements that need
\nto be included in any global PMGE accred-
\nitation criteria.
\nWFME is aiming to coordinate this global
\ndiscussion and will be reaching out to stake-
\nholders world-wide to join in the process.
\nPGME quality assessment will be one of
\nthe main themes in the next World Confer-
\nence which will take place in 2022.
\nProfessor David Gordon
\nWFME President
\nE-mail: admin@wfme.org
\nBACK TO CONTENTS
\n21
\nPhysician 2030
\nNote: This article was adapted from presenta-
\ntions given by Dr. Barbe at the World Medical
\nAssociation\u2019s (WMA) Medical Ethics Confer-
\nence in Reykjavik, Iceland, on October 2, 2018,
\nand at the WMA\/Israeli Medical Association\u2019s
\nPhysician 2030 Conference in Tel Aviv, Israel,
\non May 13, 2019.
\nTechnology and Medicine
\nThroughout the history of medicine, tech-
\nnological innovation has changed the phy-
\nsician practice environment and improved
\npatient care. Think of the thermometer,
\nstethoscope, microscope and the X-ray.
\nThese were all watershed innovations of
\ntheir time and dramatic improvements over
\nwhat had existed before.
\nTransformative changes continue in digital
\nhealth, from big data to wearable devices
\nto telemedicine to artificial intelligence. At
\nthe AMA, we use the term augmented in-
\ntelligence (AI), because we emphasize the
\nfact that this technology is to be designed
\nto enhance human intelligence rather than
\nreplace it. While physicians welcome these
\nadvancements and believe in their potential
\nto improve patient care, at the same time,
\nwe must take care to ensure that technol-
\nogy is thoughtfully designed and deployed
\nso that it enhances instead of undermining
\nthe important patient-physician relation-
\nship.
\nThis means physicians\u00a0\u2013 and medical soci-
\neties\u00a0\u2013 have an important role to play. We
\nmust be knowledgeable about technological
\ntrends and engaged in the ideation, devel-
\nopment, validation, and delivery re-design
\nand integration of new technologies, rather
\nthan responding after the fact.
\nAs a leader in American medicine, the
\nAMA is working to help set priorities for
\nAI, to collaborate with other stakeholders
\nto ensure that the physician perspective is
\nintegrated into the design and implemen-
\ntation of AI, and to facilitate understand-
\ning of the promise and limitations of AI
\nthroughout the medical and health care
\ncommunities.
\nAI in Health Care
\nAI is defined as \u201cthe ability of a computer
\nto complete tasks in a manner typically as-
\nsociated with a rational human being\u00a0\u2013 to
\nfunction appropriately and with foresight in
\nits environment.\u201d
\nThe term AI covers a range of methods,
\ntechniques, and systems. Common ex-
\namples of AI systems include, but are not
\nlimited to, natural language processing,
\ncomputer vision, and machine learning
\nsystems. In health care, as in other sectors,
\nAI solutions may include a combination of
\nthese systems and methods. AI is expected
\nto transform health care by enabling phy-
\nsicians to diagnose and treat patients more
\nquickly and more effectively.
\nAs a research discipline,AI has been around
\nfor 70 years. The underlying techniques,
\nmethods and knowledge are not new. How-
\never, there are two new forces that are fuel-
\ning the rapid advances in AI. First, is the
\ninexpensive and ultra-fast computing pow-
\ner that allows us to supercharge these core
\nmethods to create applications that have the
\npotential to transform the way we deliver
\nhealth care.
\nThe second, market trends indicate that AI
\nwill change health care and the practice of
\nmedicine in significant ways in the next
\n10\u00a0years. This has resulted in an immense
\ninfusion of capital into AI related activi-
\nties. Since 2013, there have been more than
\n570\u00a0health care AI deals worth $4.3 billion,
\naccording to CB Insights.
\nPhysicians may already be familiar with the
\nfollowing examples of AI applications:
\n\u2022\t The Cardiogram app works with heart
\nrate sensor of the Apple Watch to detect
\nhypertension and sleep apnea. In a clini-
\ncal study involving more than 6,000 pa-
\ntients with UCSF, Cardiogram (app on
\nthe Apple Watch) and its machine learn-
\ning system, DeepHeart, detected hyper-
\ntension and sleep apnea with 82 percent
\nand 90 percent accuracy, respectively. The
\nApple Watch Series 4 and later versions
\ninclude an electrical heart rate sensor that
\ncan take an electrocardiogram using an
\nECG app.
\n\u2022\t The Human Diagnosis Project (Hu-
\nman Dx), a nonprofit and public ben-
\nefit corporation, is an online platform
\nthat uses machine learning algorithms
\nto help physicians achieve an accurate
\ndiagnosis and receive specialist consults
\nfor their patients. Human Dx also pro-
\nNow is the Time for Physicians and Medical
\nAssociations to Prepare for Augmented
\nIntelligence in Health Care
\nDavid O. Barbe
\nBACK TO CONTENTS
\n22
\nPhysician 2030
\nvides a platform for medical education
\nthrough its Global Morning Report
\nteaching cases, which are accessed by
\nmedical residents.
\n\u2022\t Advances in the field of surgical robotics
\nallow surgeons to perform surgeries with
\nfine detail and fewer tremors than with
\nthe human hand. AI might one day allow
\nsurgical robots to perform surgical proce-
\ndures autonomously.
\nOpportunities, Challenges
\nand Questions Raised
\nby Health Care AI
\nThe strong momentum behind AI applica-
\ntions brings a number of opportunities and
\nchallenges for physicians and patients, and
\nraises important questions physicians must
\nconfront. These are detailed in a 2018 re-
\nport by the AMA\u2019s Council for Long Range
\nPlanning and Development https:\/\/www.
\nama-assn.org\/sites\/ama-assn.org\/files\/corp\/
\nmedia-browser\/public\/hod\/a18-clrpd-reports.
\npdf
\nOpportunities:
\n\u2022\t AI technology could increase physi-
\ncian productivity by automating office
\nfunctions such as scheduling and order
\nentry.
\n\u2022\t AI could be used for data mining to sur-
\nface the right data at the right time and
\nimprove Electronic Health Records.
\n\u2022\t AI could be used to analyze all the known
\ndata about the patient and produce in-
\nsights helpful to diagnosis.
\n\u2022\t AI could be used to analyze the diagno-
\nsis and all other known data and produce
\nbest-practice treatments.
\n\u2022\t AI could free up time for physicians to
\nspend with patients by automating cer-
\ntain functions.
\n\u2022\t AI could improve patient experience
\nand aid behavioral change and treatment
\ncompliance.
\n\u2022\t AI could assist in medical education by
\nsurfacing needed information, requiring
\nless memorization and continuously as-
\nsessing competencies.
\nChallenges:
\n\u2022\t Data structure, integrity and security;
\n\u2022\t Technological mistrust (why transpar-
\nency is needed);
\n\u2022\t Need to demonstrate that AI can reduce
\ncosts, support the patient-physician rela-
\ntionships, and improve care;
\n\u2022\t Implement and integrate AI into clinical
\npractices and patient care;
\n\u2022\t Uncertain long-term unemployment out-
\nlook for health care professionals;
\n\u2022\t Susceptibility to training bias, malfea-
\nsance, and technical problems;
\n\u2022\t Questions as to who will benefit,and who
\nmay lose? For example, what is best for
\nan individual is not always best for public
\nhealth, especially when limited resources
\nare available.
\nQuestions raised by AI:
\n\u2022\t What evidence is needed to demonstrate
\nvalue, utility, and trust?
\n\u2022\t How does AI intersect with other emerg-
\ning health care capabilities, such as ge-
\nnomic medicine?
\n\u2022\t How will regulatory bodies and profes-
\nsional organizations provide proper over-
\nsight for AI benefits and risks, and com-
\nmunicate these to the public?
\n\u2022\t How can public and systemic expec-
\ntations be managed, and concerns al-
\nlayed?
\n\u2022\t What education and training will health
\ncare professionals need to acquire in order
\nto understand how AI solutions might
\nhelp them, and their patients in clinical
\nsettings?
\n\u2022\t What can health systems considering AI
\nopportunities do now to maximize their
\nchances of success for gaining efficien-
\ncies, improving care, and integrating into
\nclinical workflows?
\n\u2022\t How will risk be allocated, given the
\n\u201cblack box\u201d nature of AI systems?
\n\u2022\t How will legal, policy, and regulatory
\nimplications, including standards for pro-
\nfessional services, intellectual property
\nrights, and FDA oversight be monitored
\nand addressed?
\nHealth Care AI Equity
\nand Access
\nThe use of various AI technologies also
\nraises a number of equity and access consid-
\nerations, as covered by recent articles in the
\nAMA Journal of Ethics.
\nData sets used for health care AI are cre-
\nated by human agents and are imperfect.
\nFor example, data sets based on clinical
\ntrials include or exclude participants based
\non certain characteristics, and the data
\nmay not adequately reflect characteristics
\nof marginalized populations with less ac-
\ncess to care. Biases within the data may
\nunintentionally be reproduced by AI ap-
\nplications.
\nAs noted here https:\/\/journalofethics.ama-
\nassn.org\/article\/can-ai-help-reduce-dispar-
\nities-general-medical-and-mental-health-
\ncare\/2019-02:
\n\u201cAdvances in [AI] and machine learning
\noffer the potential to provide personalized
\ncare by taking into account granular patient
\ndifferences.\u201d
\n\u201cHowever, this same ability to discern
\namong patients brings with it the risk of
\namplifying existing biases, which can be
\nespecially concerning in sensitive areas like
\nhealth care.\u201d
\nThere is also concern that AI is already out-
\npacing the policy and ethics governing its
\ndevelopment and use. As noted here https:\/\/
\njournalofethics.ama-assn.org\/article\/ethical-
\ndimensions-using-artificial-intelligence-
\nhealth-care\/2019-02:
\n\u201cNonetheless, this powerful technology cre-
\nates a novel set of ethical challenges that
\nmust be identified and mitigated since AI
\ntechnology has tremendous capability to
\nBACK TO CONTENTS
\n23
\nPhysician 2030
\nthreaten patient preference, safety, and pri-
\nvacy.\u201d
\n\u201cHowever, current policy and ethical guide-
\nlines for AI technology are lagging behind
\nthe progress AI has made in the health care
\nfield.\u201d
\nThe need for policy and ethical guidelines
\naround AI in health care necessitates the
\ninvolvement of physicians.
\nAMA policy on AI
\nUnderstanding that physicians must be in-
\nvolved in the disruptive technology of AI,
\nthe American Medical Association ad-
\nopted policy directives on AI at its Annual
\nMeeting in June 2018. In the same way, the
\nWorld Medical Association (WMA) is in
\nthe process of developing a Statement on
\nAI. The Statement, approved by the WMA
\nCouncil in Santiago in April 2019, will be
\nconsidered by the WMA Assembly in Oc-
\ntober 2019.
\nOutlined below is a summary of the AMA\u2019s
\npolicy. We believe these are principles that
\nmedical associations should consider as
\nthey address the development of AI in their
\ncountries.
\nUnder our current policy, the AMA will:
\n1.\t Leverage its ongoing engagement in
\ndigital health and other priority areas
\nfor improving patient outcomes and
\nphysicians\u2019 professional satisfaction
\nto help set priorities for health care
\nAI.
\n2.\t Identify opportunities to integrate the
\nperspective of practicing physicians
\ninto the development, design, validation
\nand implementation of health care AI.
\n3.\t Promote development of thoughtfully
\ndesigned, high-quality, clinically vali-
\ndated health care AI that:
\na. is designed and evaluated in keeping
\nwith best practices in user-centered
\ndesign, particularly for physicians and
\nother members of the health care team;
\nb. is transparent;\u00a0
\nc. conforms to leading standards for re-
\nproducibility;
\nd. identifies and takes steps to address
\nbias and avoids introducing or exacer-
\nbating health care disparities including
\nwhen testing or deploying new AI tools
\non vulnerable populations; and
\ne. safeguards patients\u2019and other individu-
\nals\u2019 privacy interests and preserves the
\nsecurity and integrity of\u00a0personal infor-
\nmation.
\n4.\t Encourage education for patients, phy-
\nsicians, medical students, other health
\ncare professionals, and health adminis-
\ntrators to promote greater understand-
\ning of the promise and limitations of
\nhealth care AI.
\n5.\t Explore the legal implications of health
\ncare AI, such as issues of liability or
\nintellectual property, and advocate for
\nappropriate professional and govern-
\nmental oversight for safe, effective, and
\nequitable use of and access to health
\ncare AI.
\nConclusion
\nAs health care technology and AI advances
\ncontinue to transform the physician prac-
\ntice environment, there are two possible fu-
\ntures: One in which health care technology
\nand AI work for physicians and patients\u00a0\u2013
\nand one in which they don\u2019t. The difference
\ndepends on the degree to which physicians
\nare involved in shaping that future. Physi-
\ncians and medical associations must work
\nto shape the new environment rather than
\nsimply react to it\u00a0\u2013 and we must do it . . .
\nright now.
\nAs we do this work, we must remember the
\nmost important relationship in health care:
\nthe physician-patient relationship. We
\nmust continue to work with policymakers,
\nphysician innovators, technology compa-
\nnies and other stakeholders to ensure the
\ndevelopment of clinically sound AI systems
\nthat will enhance the quality of care and
\nsupport the physician-patient relationship,
\nrather than detracting from it.
\nThe American Medical Association has
\nmade involvement in AI development, pol-
\nicy and equity a key priority and encourages
\nother medical associations and interested
\nphysicians to do the same.
\nFor more information about the AMA\u2019s
\nwork on AI, visit: ama-assn.org\/ai.
\nDavid O. Barbe, MD, MHA
\nImmediate Past President
\nAmerican Medical Association
\nBACK TO CONTENTS
\n24
\nTraining Needs
\nIntroduction
\nThe healthcare sector is an ever evolving
\nand changing environment and some of
\nthe key changes are largely driven through
\ntechnology. It is therefore vital for health-
\ncare organisations to continue to invest in
\npeople, by upskilling them in areas that will
\nalso give the company a competitive advan-
\ntage. This includes training on technology
\nand tools that seek to improve business pro-
\ncesses and efficiencies. Knowledge manage-
\nment, training and development are the key
\nattributes to organisational growth and de-
\nvelopment [10]. Most entities develop poli-
\ncies and procedures around this, to ensure
\nthat there is continual training of staff on
\nkey aspects of the business [9].
\nContinued Training
\nand Development
\nOne of the most competitive advantages to a
\nhealth organisation is its workforce, and thus
\ncontinuous training and development is re-
\nquired,with efforts to respond to business de-
\nmands [4]. According to Maimuna, training
\nand development is an instrument that aid
\nhuman capital in exploring their dexterity as a
\nresult training and development is vital to the
\nproductivity of an organization\u2019s workforce
\n[19]. Healthcare companies should continue
\nto view training as a strategic investment,as it
\nenhances and improves customer experience,
\nthroughout the value chain [21].
\nThe identification of training needs at or-
\nganisational level needs to be aligned to key
\nstrategic objectives and goals. Approaches
\nsuch as Gap analysis, SWOT or a Risk As-
\nsessment framework are key in assisting the
\ndevelopment of proactive strategies whereby
\na healthcare organisation can optimise their
\nproduct offering and service delivery model.
\nIt further assists companies, based on needs
\nassessments to identify the resources and
\nthe systems needed.
\nOther methodologies of identifying gaps
\ncouldbethroughconductingsurveys;through
\nusing questionnaires which could comprise
\na series of questions and other prompts, for
\nthe purpose of gathering information from
\nrespondents [25,27]. One typical example
\ncould be that an organisation wants to reduce
\ncosts associated with fraud, waste and abuse
\nor by developing cost containment strategies,
\nwhich could be achieved through proactive
\nidentification of potential culprits. This in-
\nformation could be obtained by conducting
\na survey where key questions are sourced for
\nfraud, waste and abuse, that could be identi-
\nfied through assessing the responses.
\nRespondents could also propose new ap-
\nproaches and provide further pointers to
\nnew sources of fraud in healthcare and
\ncould also provide methods that could be
\nused to pro-actively identify potential inci-
\ndents of fraud.
\nTraining Needs on Health
\nRecord Keeping
\nThe keeping of medical records is a key at-
\ntribute for the efficiency of a health system.
\nIn the main, it provides profiling and trace-
\nability of patients and customers.The keep-
\ning of medical records is also important for
\nensuring that there is adequate care coor-
\ndination when a patient is transferred from
\none provider or facility to another.There are
\nnumerous studies that show that a lack of
\ntraining in patient record keeping is more
\nprevalent in the public healthcare sector
\nwhere there are no systems nor suitable hu-
\nman resources to manage and monitor this
\nfunction. Inadequate training is often stated
\nas one of the reasons that impacts negatively
\non patients\u2019 records processing.
\nThere is also a culture issue, where there
\nneeds to be commitment and support from
\nthe top structure of a healthcare company.
\nMarutha and Ngoepe investigated the role
\nof medical records in the provision of pub-
\nlic healthcare services [15].The study found
\nthat ninety percent (90%) of respondents
\nlacked adequate training on policies, pro-
\ncedures, norms and standards for managing
\nrecords and that only six percent (6%) of the
\nrespondents stated that they had received
\ntraining in those areas. The other key fea-
\nture regarding health records is data secu-
\nrity; particularly where confidential patient
\ninformation is concerned. Healthcare man-
\nagement companies should ensure that they
\nput processes and training programs on data
\nbreaches and the proper guard of patient in-
\nformation in place, as these could negatively
\nimpact an organisation.
\nTraining Needs on Supply
\nChain Management
\nOne of the main strategies to reduce cost
\nand wastage in the healthcare sector is im-
\nproved contracting and supply chain man-
\nagement processes. SCM is also regarded as
\none of the tools when effectively employed
\nIdentifying Training Needs for Heathcare
\nOrganisation
\nMichael Mncedisi Willie
\nBACK TO CONTENTS
\n25
\nTraining Needs
\ncould have a significant impact on reduc-
\ning costs and improving performance in
\nhealth care organizations [18]. A recent ar-
\nticle by Mathew, John and Kumar depicts
\napproaches to optimize costs in healthcare
\nsupply chain operations, which includes the
\nvirtual centralisation of supply chains, sup-
\nply utilisation management practices, the
\nuse of RFID technologies, the use of ana-
\nlytics and streamlining workflow [17].
\nThe author further classifies stakeholders
\ninto three major groups, namely:
\n\u2022\t Producers;
\n\u2022\t Purchaser, and
\n\u2022\t providers.
\nProducers (comprise medical and surgical
\nsupplies, medical devices, and pharmaceu-
\nticals) who distribute these to the purchas-
\ners (wholesalers, distributors and GPOs).
\nPurchasers then distribute them to the pro-
\nviders (hospitals, IDNs, physicians, clinics,
\npharmacies, and nursing homes). Ryan, fur-
\nther elaborates on the addition to the com-
\nplexity of the system,where there is involve-
\nment and participation from governmental
\ninstitutions, regulatory agencies, and insur-
\nance companies [23]. All these key compo-
\nnents of supply chain management need to
\nbe integrated into an effective healthcare
\nmanagement system.
\nTraining Needs of
\nProducts Offered
\nProduct simplicity in healthcare is a very
\ndifficult concept to quantify. There is also
\nthe issue of information asymmetry, where
\nthere is not enough detail about products.
\nHealth\u00a0 generally, is\u00a0 not\u00a0 considered a\u00a0 pub-
\nlic good, because of non-paying individu-
\nals (without\u00a0health insurance, healthy food,
\netc.),\u00a0and this makes it even more complex
\nthan other products. Information in this re-
\ngard is key for choice optimisation by con-
\nsumers,when they purchase health insurance
\nplans. For example, consumers who are of-
\nten not aware of the potential for receiving
\nsubsidies for their premiums and cost shar-
\ning, might choose not to enrol in coverage.
\nSimilarly,consumers who enrol in plans with
\nexpected spending greater than alternative
\nplans could end up spending far more on
\ntheir health care requires, during the year,
\nthan they otherwise would have.
\nIn a medical insurance setting,members en-
\nrol and purchase a product in the form of
\nhealth care plans so to be able to access care.
\nIn the main, these products are often too
\ncomplex for the purchasers to understand.
\nThe level of complexity is also twofold and
\nit affects, both the member and the medical
\nservice provider. Various studies also show
\nthat the purchase of care by citizens who
\nhave low healthcare system literacy may
\nresult in a struggle for them to make key
\ndecisions.The more complex the product is,
\nthe greater the risk is of it not being fully
\nunderstood by the purchasers.
\nDuring 2017, there were two hundred and
\nseventy-eight (278) registered benefit op-
\ntions operating in eighty-one (81) medical
\nschemes in South Africa; thus choosing a
\nbenefit option remains a big challenge, as
\nthere are many benefit options are often
\nnot standardised [3]. Kaplan and Ranchod
\ncontend that the number of benefit options
\navailable in the medical scheme market cre-
\nates complex environment impacting deci-
\nsion making [13]. An annual survey con-
\nducted in 2017 depicted that consumers
\nwere unsure of their own medical scheme
\ndetails and of the benefits that they were
\nentitled to [11].
\nThe complexity of products offered by
\nhealth insurance companies has a positive
\ncorrelation with complaints and customer
\nsatisfaction scores. It is thus critical for
\nhealth insurance and medical schemes to
\ninvest in programmes that will educate and
\ntrain enrolees on the benefits and the prod-
\nucts being offered.
\nTraining Needs of Patient Cen-
\nteredness and Customer Care
\nEffective patient-centred care has become a
\ncentral aim for the nation\u2019s health system,
\nyet patient experience surveys indicate that
\nthe system is far from achieving it [26].
\nBased on interviews with leaders of pa-
\ntient-centred organisations and initiatives,
\nthis report identifies seven key factors for
\nachieving patient-centred care at the organ-
\nisational level [26]:
\n\u2022\t Top leadership engagement;
\n\u2022\t A strategic vision, clearly and constantly
\ncommunicated to every member of the
\norganisation;
\n\u2022\t The involvement of patients and families
\nat multiple levels;
\nOrganization Level
\nLeadership development and training
\nInternal rewards and incentives
\nTrainingin quality improvement
\nPractical tools derived from an expanded
\nevidence base
\nSystem Level
\nPublic education and patient engagement
\nPublic reporting ofstandardized patient-
\ncentered measures
\nAccreditation and certification requirements
\nFigure 1.
\nBACK TO CONTENTS
\n26
\nTraining Needs
\n\u2022\t A supportive work environment for all
\nemployees;
\n\u2022\t Systematic measurement and feedback;
\n\u2022\t The quality of the built environment; and
\n\u2022\t Supportive information technology.
\nThe two main strategies that have been
\nidentified as necessary to overcome barriers
\nand to help leverage widespread implemen-
\ntation of patient-centred care at both the
\norganisation and at system Levels. Figure 1
\ndepicts the characteristics of these.
\nThere is comprehensive theoretical work\u00a0be-
\ning done on customer care,customer service,
\nquality and how these impact on customer
\nfulfilment, organisational performance and
\ncustomer retention. According to Sheahan,
\ncustomer service in health care is not the
\nsame as in other industries,because custom-
\ners are the receivers of the medical services
\nthat are critical to their health [28].As such,
\nhealthcare industries must maintain a good
\ncustomer service relationship with their
\ncustomers [28].
\nMosadeghrad highlighted ten determinants
\nthat could lead to better quality of service,
\nwhich, in turn, will lead to better customer
\ncare [22]:
\n\u2022\t Reliability – consistency of performance
\nand dependability.
\n\u2022\t Responsiveness – the willingness or the
\nreadiness to provide service.
\n\u2022\t Competence – having the required skills
\nand the knowledge to perform the service.
\n\u2022\t Access – approachability and ease of contact.
\n\u2022\t Courtesy – politeness, respect, consider-
\nation,and friendliness of contact personnel.
\n\u2022\t Communication – keeping the customers
\ninformed in a language that they can un-
\nderstand and listening to them.
\n\u2022\t Credibility – trustworthiness, believabil-
\nity, being honest.
\n\u2022\t Security – freedom from danger, risk, or
\ndoubt.
\n\u2022\t Understanding – knowing that the heath
\ncare provider is making the effort to un-
\nderstand the customer\u2019s needs.
\n\u2022\t Tangibles – the physical evidence of the
\nservice.
\nKnowledge Management
\nAccording to Chong, knowledge manage-
\nment is a broad subject with many facets,
\nranging from databases to patents, from the
\nintranet to the mentor, from coldly techni-
\ncal to warmly personal concepts [4]. Differ-
\nent academics and practitioners presented
\na review of the literature, which concluded
\nthat there is no clear definition and con-
\ncept of knowledge management [7]. Salleh
\nand Goh agreed that it is difficult to define
\nknowledge management since various per-
\nspectives and schools can define different
\ndimensions and meanings of knowledge
\nmanagement [24]. A different perspective
\non the concepts of knowledge can lead to
\ndifferent definitions of knowledge manage-
\nment [4].
\nKnowledge management is crucial for en-
\nterprises to determine where they are going
\nand for organisational survival in the long
\nrun; given that knowledge creation is the
\ncore competency of any organisation [4].
\nThe human resources function in organisa-
\ntions needs to drive knowledge manage-
\nment and create an enabling environment,
\nthus by creating a knowledge-sharing cul-
\nture, nurturing and \u201clearning\u2010by\u2010doing\u201dcan
\nyield to competitive advantage [2].
\nFinancial Management
\nin healthcare
\nThe primary role of financial management
\nin healthcare organisations is to manage
\nbudgets and to ensure that financial risk is
\nmitigated. Companies need to be able to
\nhave adequate systems to ensure that there
\nis adequate working capital management,
\nassurance on cost reduction and available
\nfunds, to ensure that the organisation runs
\neffectively [29]. Furthermore, the financial
\nmanagement staff of any healthcare or other
\nform of healthcare organisation should en-
\nsure that the organisation can meet its stra-
\ntegic goals, through proper planning and
\nbudgeting processes. According to Deloof,
\nfinancial management includes evaluation
\nand planning, long-term investment deci-
\nsions, financing decisions, working capital
\nmanagement, contract management, and fi-
\nnancial risk management and risk; in a way
\nthat this helps to achieve the financial goals
\nof the organisation [6]. When a healthcare
\norganisation has strong and organised fi-
\nnancial management plans, which are also
\nmanaged efficiently, they are able to provide
\nefficient healthcare to all their patients.
\nLearning Organisation
\nThe \u2018learning organisation\u2019 is a concept first
\ndescribed as an organisation where people
\ncontinuously learn and enhance their capa-
\nbilities to create the results that they really
\ncare about [1].
\nIt consists of five main disciplines:
\n\u2022\t team learning;
\n\u2022\t shared vision;
\n\u2022\t mental models;
\n\u2022\t personal mastery; and
\n\u2022\t systems thinking.
\nAl-Abri and Al-Hashmi further elaborates
\nthat all five disciplines are dynamic, and
\nthey interact with each other [1]. Further-
\nmore, there are some educational concepts
\nand theoretical models, which are of rel-
\nevance to the learning organisation, and can
\nthus provide a framework for managerial
\ndecisions. The aim of professional health
\ncare education is to educate health care
\npersonnel with up to date knowledge and
\nskills; either by theoretical learning through
\nattending courses or practically, through
\ntraining programmes. The core purpose of
\nhealth care education is to promote quality
\nin health care services by providing compe-
\ntent and safe personnel.Health care manag-
\ners are obligated to acquire and to maintain
\nthe expertise needed to undertake their pro-
\nfessional tasks. Additionally, they are also
\nobligated to undertake only those tasks that
\nare within their competence and to acquire
\ntechnical knowledge in their field of work.
\nBACK TO CONTENTS
\n27
\nTraining Needs
\nGovernance for
\nHealthcare Managers:
\nCorporate governance involves more tradi-
\ntional managerial tasks of finances and bud-
\ngets, procurement and supply-chain man-
\nagement, human resource management, and
\ninfrastructure [16].The principles underpin-
\nning corporate governance include fairness,
\naccountability, responsibility and transpar-
\nency [5]. At a global healthcare ecosystem
\nlevel, healthcare managers ranging from
\npractice managers, policy makers to govern-
\nments, need to ensure that there are enough
\ntwo-way engagements and adequate com-
\nmunication, where corporate governance is
\nconcerned. Furthermore, there needs to be
\nadequate access to information on corporate
\ngovernance policies and continuous training
\nand development in this regard. The ability
\nto understand and to influence corporate
\ngovernance issues in the healthcare space
\nis complex, as most healthcare practitioners
\nare mainly trained more to practise health-
\ncare than in an oversight role. Studies have
\nshown a clear distinction between clinical
\nand corporate governance. Maxwell and
\nCarswell depicts a clear linkage between
\ncorporate governance and clinical gover-
\nnance [20]. The authors further depicts that
\nthe management team should implement
\nclinical governance systems which ultimate-
\nly get reported to the board.The table below
\ndepicts a distinction between corporate and
\nclinical governance [20].
\nConclusion
\nHealthcare management is a complex sector
\nto manage, this is mainly due to the risks
\nassociated with it, ranging from financial
\nmanagement and sustainability, business
\nimprovement processes to the health and
\nthe safety of patients or customer involve-
\nment. The top structure of these organisa-
\ntions operates in a continually changing
\nbusiness environment, ever-evolving tech-
\nnology, complex regulatory requirements
\nand changes in the profile of patients, such
\nas an increasing age profile and the burden
\nof disease.
\nAll these require complex and demanding
\nhealth management; in order to manage
\nhealth organisations in an efficient, cost-ef-
\nfective, competent manner. Health manag-
\ners require various leadership and manage-
\nrial skills and they need to be familiar with
\nthe problems that exist in the health care
\nsystem. Continued identification, analy-
\nsis, and assessment of health management
\ntraining needs are pivotal, for the survival of
\nhealthcare organisations [8].
\nReferences
\n1.\t AL-Abri, R., & Al-Hashmi, S. (2007). Learning
\norganisation and healthcare education.
\n2.\t Beyetlein, M., Collins, R., Jeong, S., Phillips, C.,
\nSunalai, S & Xie, L. (2017). Knowledge sharing
\nand human resource development in innovative
\norganizations.Open access peer-reviewed chapter.
\n3.\t Council for Medical Schemes. CMS Annual
\nReport 2017-2018, 2018, www.medicalschemes.
\ncom\/Publications.aspx
\n4.\t Chong, S.C., & Choi, Y.S.(2005). Critical fac-
\ntors in the successful implementation of knowl-
\nedge management. Journal of Knowledge Man-
\nagement Practice.
\n5.\t Charkham, J. and Ploix, H. (2005). Keeping bet-
\nter company \u2013 Corporate governance ten years
\non. Oxford: Oxford University Press.
\n6.\t Deloof, M. (2003). Does working capital man-
\nagement affect profitability of Belgian firms?
\nJournal of business finance & amp; Accounting,
\nVolume 30, Issue 3 \u2013 4.
\n7.\t Earl, M.J. (1999). Opinion: what is a chief
\nknowledge officer?\u00a0Sloan Management Review.
\n8.\t Gaspard, J., & Yang, C.M. (2016). Training
\nneeds assessment of health care professionals in
\na developing country. US National Library of
\nMedicine National Institutes of Health.
\n9.\t Gesme, D.H., Towle, E.L., & Wiseman, M.
\n(2010). Essentials of staff development and why
\nyou should care. Journal of oncology practice.
\n10.\tGould, D., Kelly, D., & White, I. (2004). Train-
\ning needs analysis: an evaluation framework.
\n2004 Jan 28 \u2013 Feb 3; 18(20): 33-6.
\n11.\tGTC (formerly Grant Thornton Capital). The
\nGTC Medical Aid Survey. Benet and cost com-
\nparisons 2018. The Wanderers Office Park,52
\nCorlett Drive, Illovo, 2196, 2018, http:\/\/www.
\ngtc.co.za. [Accessed February 2019].
\n12.\tJacobs, S., Rouse, P., & Parsons, M. (2016).
\nLeading change within health services.
\nTable 1.\u2002 Difference between corporate and clinical governance
\nClinical governance: Role of the Board Corporate Governance: Role of the Board
\n\u2022\u2002
\nendorse policies and clarify\u00a0expecta-
\ntions. regarding the desired outcomes
\nfor the CEO and the management
\nteam, with respect to patient safety
\nand quality.
\n\u2022\u2002
\nreceive, review and react to regular
\nreports on clinical performance from
\nthe CEO and the management team.
\n\u2022\u2002
\nexpect that such reports should be
\nsufficiently detailed so that the board
\ncan assure itself that the organisa-
\ntion is performing in accordance with
\nformally recorded expectations, but
\nnot be so exhaustive that potential
\nproblem areas are lost or disguised in
\nthe detail.
\n\u2022\u2002
\nAssure themselves that appropriate
\nremediation steps are activated for
\nproblematic areas.
\n\u2022\u2002
\nappointment and evaluation of the CEO.
\n\u2022\u2002
\nengagement with the CEO and senior
\nmanagement in setting-up the strategy of
\nthe organization.
\n\u2022\u2002
\nidentification and management of any real
\nor perceived conflicts of interest among
\ndirectors and\/or officers.
\n\u2022\u2002
\nassessment of the contributions of each
\nindividual board member, as well as the col-
\nlective performance of the board.
\n\u2022\u2002
\nenabling the chairman to effectively dis-
\ncharge this\/her special responsibilities as a
\n\u201cfirst among equals\u201d.
\n\u2022\u2002
\nensuring that new board members are thor-
\noughly oriented to the organization and the
\noperations of the board.
\n\u2022\u2002
\nunderscoring that the interests of the
\nstakeholders are paramount (in the case of a
\nhealthcare entity, this is the community the
\ninstitution serves).
\nSource: King IV compliance supplementary report [14]
\nBACK TO CONTENTS
\n28
\nIn-Flight Medical Events
\nIn 2017 I had the pleasure to write an infor-
\nmation paper on in-flight medical events at
\nthe request of your association. Since then
\nthe subject has remained and will continue
\nto remain an important and often misun-
\nderstood issue. One of the issues I raised
\nin the article was the lack of familiarity of
\nmost physicians with the details of the flight
\nenvironment. I mentioned that the Aero-
\nspace Medical Association (AsMA) has
\nproduced a document called \u2018Managing in-
\nflight medical events\u2019to provide guidance to
\nhealth professionals that are called to help
\nduring an in-flight medical event. While
\nI\u00a0also wrote that an application for Android
\nand Apple (iOS) had also been created to
\nprovide guidance on how to deal with the
\nin-flight medical events, I feel I did not in-
\nsist enough on this relatively new product
\nthat can now be downloaded totally free
\nof charge on Apple Store or Google Play.
\nThe app is updated regularly.It has been de-
\nsigned by medical professionals knowledge-
\nable in medical emergencies and aerospace
\nmedicine under a non-profit organization.
\nInformation can be found on the follow-
\ning web site: http:\/\/airrxmedical.com\/index.
\nhtml. AirRX provides quick guides for the
\n23 most common medical emergencies, in-
\nformation regarding the legal right to treat
\npatients, lists of available equipment and
\nmedications, and much more. Once down-
\nloaded on the mobile phone,the application
\ndoes not require internet access to operate
\nit, which is clearly an advantage when on
\nan airplane. As can be seen on the web site,
\nthat application has already been down-
\nloaded in over 87 countries,but it is felt that
\nit could help a lot more physicians around
\nthe world if it was better known, hence this
\nnote so your association and its members
\ncould spread the good news.
\nClaude Thibeault MD Consultant,
\nM\u00e9decine A\u00e9ronautique et Sant\u00e9
\nau Travail Consultant,
\nAerospace Medicine and
\nOccupational Health President,
\nConsultants Aeromed Inc.
\n13.\tKaplan, J. & Ranchod, S. (2015). Analysing the
\nstructure and nature of medical scheme ben-
\nefit design in South Africa. In: South African
\nHealth Review.Eds.Padarath A,King J,English
\nR, 2015, Health Systems Trust, Durban.
\n14.\tKing IV compliance supplementary report,
\n(2017).
\n15.\tMarutha, N.S. & Ngoepe, M. (2017). The role
\nof medical records in the provision of public
\nhealthcare services in the Limpopo province of
\nSouth Africa,South African Journal of Informa-
\ntion Management 19(1).
\n16.\tMash, R., Blitz, J., Malan, Z., & Von Pressentin,
\nK. (2016). Leadership and governance: learn-
\ning outcomes and competencies required of the
\nfamily physician in the district health system.
\nSouth African Family Practice.
\n17.\tMathew, J., John, J., and Kumar, S. (2013). New
\ntrends in healthcare supply chain.Paper present-
\ned at the International Annual Conference, Pro-
\nduction and Operations Management Society,
\nDenver, Colorodo.
\n18.\tRotimi A.Gbadeyan,Rotimi A.Gbadeyan ,Fran-
\ncis O. Boachie-Mensah , Olubunmi F. Osemene
\n, Francis O. Boachie-Mensah , Olubunmi F. Os-
\nemene (2017).EFFECT OF SUPPLY CHAIN
\nMANAGEMENT ON PERFORMANCE IN
\nSELECTED PRIVATE HOSPITALS IN IL-
\nORIN,NIGERIA .International Journal of Eco-
\nnomic Behavior, vol. 7, n. 1, pp. 99-116.
\n19.\tMaimuna, Muhammad & , Nda & Yazdani-
\nfard, Assc. Prof. Dr. Rashad. (2013). THE IM-
\nPACT OF EMPLOYEE TRAINING AND
\nDEVELOPMENT ON EMPLOYEE PRO-
\nDUCTIVITY. 2. 91-93.
\n20.\tMaxwell, D. & Carswell, P. (2011). Corporate
\nand clinical governance in the public health sec-
\ntor context: definitions and issues arising. AN-
\nZAM 2011.
\n21.\tMondy, R.W., Noe, R.M., & Premeaux, S.R.
\n(2002). Human resources management, 8th ed.
\n22.\tMosadeghrad AM. (2014). Factors influencing
\nhealthcare service quality. Int J Health Policy
\nManag. 3(2):77\u201389.
\n23.\tRyan, K. Jennifer. (2005). Systems Engineering:
\nOpportunities for Health Care, Building a Bet-
\nter Delivery System: A New Engineering\/ Health
\nCare Partnership. National Academy Press.
\n24.\tSalleh, Y. & Goh, W. (2002). Managing human
\nresources toward achieving knowledge manage-
\nment. Journal of knowledge management.
\n25.\tSaunders, M., Lewis, P. & Thornhill, A. (2016).
\n7th edn. Harlow: Pearson education.
\n26.\tShaller, Dale & Consulting, Shaller. (2007).
\nPatient-Centered Care: What Does It Take?.
\nCommonw. Fund. 68.
\n27.\tShaw, E. (1999). A guide to the qualitative re-
\nsearch process: evidence from a small firm study.
\nQualitative market Research.
\n28.\tSheahan, K. (2017). Definition of customer ser-
\nvice in the health field.
\n29.\tUhlers, N., Weimer-Elder, B., & Lee, J.G.
\n(2008). Simulation game provides financial
\nmanagement training: all health care leaders
\nshould grasp the essentials of financial manage-
\nment. Health Finance management, 2008 Jan;
\n62(1): 82-8.
\nMichael Mncedisi Willie,
\nGeneral Manager Research & Monitoring,
\nCouncil for Medical Schemes, South Africa
\nE-mail: m.willie@medicalschemes.com
\nIn-Flight Medical Events: an Excellent
\nApplication to Support Onboard Medical
\nVolunteers
\nClaude Thibeault
\nBACK TO CONTENTS
\n29
\nNaegleria infection
\nIntroduction
\nNaegleria fowleri, also known as Primary
\nAmoebic meningoencephalitis, is a deadly
\nglobal waterborne disease, which infects the
\nbrain of young children or adults,and which
\nrequires immediate diagnosis and treatment
\nfor successful outcomes.
\nEarly recognition in Australia led to
\nnaming of the organism attributed for
\nDr.\u00a0Malcolm Fowler from Adelaide Chil-
\ndren\u2019s Hospital in Australia [1]. Overland
\nwarm water pipes in Australia were a factor
\nin producing the infection there and the
\nUSA southwest.
\nGlobal cases
\nMedscape has reviewed this deadly brain
\ninfection in 2019 [1]. Globally, over 310
\ncases had occurred by 2012 [2]. Recent
\ncases from China and Pakistan are also il-
\nlustrative of its global nature [3, 4]. Paki-
\nstan currently has an outbreak of 11 cases
\nat Karachi alone\u00a0 [4]. Indeed cases have
\nbeen seen on the six major continents of
\nthe world.
\nPresentation
\nIf patients present with a headache and fe-
\nver, particularly in warmer months, physi-
\ncians globally should consider the diagnosis
\nof primary amoebic meningoencephalitis
\n(PAM). Careful history, special laboratory
\ntesting, and special treatment may be ur-
\ngently needed to save the lives of these pa-
\ntients [1, 5, 6, 7]. The authors are including
\nelements of a summary letter published re-
\ncently in the American Family Physician by
\nSherin, Linam and Jett [5].
\nRisk factors for
\nNaegleria infection
\nPAM is caused by Naegleria fowleri, a ther-
\nmophilic free-living ameba that occurs nat-
\nurally in warm freshwater. The trophozoite
\nform is believed to be the most infective.
\nRisk factors for infection include participa-
\ntion in freshwater-related activities such as
\nswimming underwater, diving, and head-
\ndunking; other similar activities that could
\ncause water to go up the nose; and nasal
\nirrigation for medical or religious pur-
\nposes\u00a0[1, 5]. Wakeboarding is another risk
\nsport. The organism is believed to cross the
\nnasal cribriform plate and enter the olfac-
\ntory bulb and frontal lobe region to cause
\nthe disease.
\nTap water and
\nfreshwater supplies
\nN. fowleri has also been detected in pub-
\nlic drinking water supplies. Even garden
\nhoses, water splash parks and artificial wa-
\nter rafting activities have been implicated.
\nIrrigation of the nose other than with dis-
\ntilled or saline water carries substantial
\nrisks.
\nTrends in the Geographic
\nRange
\nRecently, the geographic range of PAM has
\nexpanded, with cases identified as far north
\nas Minnesota and Indiana since 2010\u00a0[5].
\nClimate change may be a factor in this
\ndisease being reported in more temperate
\nzones. Widespread use of nasal ablution
\nor rinsing is a factor without proper dis-
\ntillation. Tap water or river water are both
\nSwanie Jett Steve Smelski
\nMichael J Muszynski
\nPrimary Amoebic Meningoencephalitis as a Cause of Headache and
\nFever \u2013 a Global Waterborne Disease
\nKevin Sherin
\nBACK TO CONTENTS
\n30
\nNaegleria infection
\ngrossly insufficient for safety for this nasal
\nprocedure. These nasal techniques are often
\ndone with Neti pots.
\nRapid diagnosis is essential
\nEffective treatment and cure is however
\npossible without residual sequelae, rapid
\ndiagnosis is therefore essential\u00a0 [1, 6, 7].
\nThe first step is identifying at-risk patients:
\nthose presenting with fever, headache, and
\nrecent freshwater exposure. A preliminary
\ndiagnosis can be made by observing mo-
\ntile amoebae in a wet mount of cerebro-
\nspinal fluid (CSF) or visualization of the
\norganisms on CSF Wright or Giemsa stain.
\nN\u00a0multiplex tests can add Naegleria antigen
\nto a CSF antigen panel.
\nImmediate treatment
\nTreatment requires immediate administra-
\ntion of a combination of systemic and in-
\ntrathecal antibiotics such as Amphotericin
\nB and including oral miltefosine, which
\nis available commercially, and by contact
\nfor guidance from the Centers for Disease
\nControl and Prevention (CDC) [7]. If you
\nhave a patient with a suspected infection,
\nyou can call call the CDC\u2019s 24\/7 emergency
\nconsultation telephone to: 001-770-488-
\n7100 for diagnostic and treatment recom-
\nmendations. Laboratory confirmation is not
\nnecessary before consultation or treatment.
\nThe CDC can confirm the organism from a
\nCSF sample or N multiplex Naegleria anti-
\ngen assay. Equally important is the manage-
\nment of cerebral edema, which is typically
\nsevere and requires critical care manage-
\nment. Strategies to reduce intracranial pres-
\nsure include: steroids, CSF drainage, hyper-
\nventilation,hyperosmolar therapy,mannitol,
\nand hypothermia [1, 6]. The Medscape 2019
\nreference provides an excellent overview of
\nthese points [1].
\nFuture directions
\nCurrently,only three USA states specifically
\nrequire reporting of PAM cases (Florida,
\nLouisiana, and Texas). No nations yet re-
\nquire reporting of PAM.
\nReaders of The World Medical Journal are
\nurged to learn more about this deadly
\nbut highly treatable disease and promote
\nprompt effective treatment. WHO could
\nset up a passive case reporting system as a
\nnext step. We urge considerations of global
\nsurveillance, active reporting of cases, and
\nsharing of treatment enhancements. Warn-
\ning labels on Neti pots for nasal ablution or
\nrinsing are also suggested along with post-
\ning health warnings at warm water swim-
\nming points in lakes or rivers for bathers or
\nreligious worshippers.
\nA summit on Naegleria is being streamed
\nfrom Orlando FL USA on September 13,
\n2019 and will have an ongoing link. The
\nlinks are here:
\nhttp:\/\/hospitalchurch.org\/sermons\/watch-live\/
\nafter the Summit the recordings will be here:
\nhttp:\/\/hospitalchurch.org\/sermon\/
\njust look for Amoeba Summit 2019.
\nThis conference is supported by the Jordan
\nSmelski Foundation and named in Jordan\u2019s
\nhonor. Jordan Smelski, a young healthy
\nboy, died of Naegleria in 2014 after a fam-
\nily vacation to Central America. No cases
\nof Naegleria had ever been reported in that
\nregion before.
\nReferences
\n1.\t Subhash Chandra Parija; Chief Editor: Mark R
\nWallace.Naegleria Infection and Primary Amoe-
\nbic Meningoencephalitis (PAM). Medscape.
\nMay 22, 2019. Accessed 08-27-2019. URL htt-
\nps:\/\/emedicine.medscape.com\/article\/223910-
\noverview
\n2.\t Naegleriasis Global Impact. Published in the
\nwebsite of CPIPD (The Center for Parasitic and
\nInfectious Diseases at the University of Cali-
\nfornia, San Diego, California, USA). Accessed
\n08-27-2019. URL http:\/\/www.cdipd.org\/index.
\nphp\/naegleriasis-global-
\n3.\t A case of Naegleria fowleri related primary
\namoebic meningoencephalitis in China diag-
\nnosed by next-generation sequencing. Qiang
\nWang, Jianming Li, [\u2026]Yingxia Liu ; BMC In-
\nfectious Diseases Vol 18 (349); 2018
\n4.\t Karachi: 11 Naegleria fowleri deaths in 2019
\nthrough July according to Pakistan media.
\nOutbreak News Today. outbreaknewstoday.
\ncom Published 08-13-2019;. Published news
\ndesk by @infectiousdidesenews. Accessed 08-
\n27-2019. URL https:\/\/www.google.com\/amp\/
\noutbreaknewstoday.com\/karachi-11-naeg-
\nleria-fowleri-deaths-in-2019-through-july-
\naccording-to-pakistan-media-15269\/amp\/
\n5.\t Sherin KM, Jett S, Linam M. Letters to the
\nEditor. Primary Amoebic Meningoencephali-
\ntis as Cause of Headache and Fever. American
\nFamily Physician. 2016 Apr 15; 93(8):644. Ac-
\ncessed 08-27-2019. URL https:\/\/www.aafp.org\/
\nafp\/2016\/0415\/p644.html
\n6.\t Liman WM, Ahmed M, Cope JR, Chu C, Vis-
\nvesvara GS, da Silva AJ, et al. Successful treat-
\nment of an adolescent with Naegleria fowleri
\nprimary amoebic meningoencephalitis. Pediat-
\nrics. 2015; 135(3):e744\u2013e748
\n7.\t Parasites: Naegleria fowleri. Primary Amoebic
\nmeningoencephalitis PAM. Treatment. Pub-
\nlished online by The Centers for Disease Control
\nand Prevention, Atlanta GA, USA. Accessed
\n08-23-2019. URL https:\/\/www.cdc.gov\/para-
\nsites\/naegleria\/treatment-hcp.html
\n*British spelling of Amoeba is used throughout.
\nAmeba and Amebic is also correct.
\nKevin Sherin, MD, MPH, FAAFP,
\nFACPM Orlando, Fla.
\nE-mail: Sherinkmj@gmail.com
\nSwanie Jett,
\nDrPH, MSC Brookline MA
\nMichael Muszynski MD, MS,
\nFAAFP. Orlando, FL pielikum\u0101
\nSteven Smelski
\nBA. Orlando FL
\nBACK TO CONTENTS
\n31
\nPhysician 2030
\nWhen the German Emperor, Kaiser Wil-
\nhelm II, saw a motor vehicle for the first
\ntime, he said that he was sure that \u201c…the
\nhorse would prevail over the motorcar\u2026\u201d.
\nAnd when the world\u2019s first train crawled
\nfrom Nuremberg to F\u00fcrth, the medical
\nsociety of Bavaria published a sharp warn-
\ning that there was scientific evidence that
\nspeeds over 25 kilometers per hour were ex-
\ntremely dangerous to humans.
\nAnd Dr. Watson, the first CEO of a firm
\nnamed Integrated Business Machines\u00a0\u2013 better
\nknown as IBM\u00a0\u2013 risked the prognosis that no
\nmore than 5 \u201csupercomputers\u201dof the post-war
\nperiod would ever be built or needed.
\nHumans have always been reluctant to eas-
\nily accept progress.On the other hand,there
\nwere visionaries\u2026
\nIn 1925, just over a century before the year
\nwe have been asked to envision today, in-
\nventor and futurist Hugo Gernsback was
\nalready dreaming about a device that would
\nallow physicians to treat their patients from
\nafar at the touch of a button.
\nThis contraption, which he called the Tele-
\ndactyl, would allow the \u201cdoctor of the fu-
\nture\u2026to be able to feel his patient, as it
\nwere, at a distance\u201d. The instrument he de-
\nscribed would have both visual and haptic
\nelements. Doctors would see their patients
\non a screen, while also physically examining
\nand reacting to the patient using remote-
\ncontrolled arms.
\nWhat would Kaiser Wilhelm or Hugo
\nGernsback say when they looked at our so-
\nciety and our situation today?
\nThey didn\u2019t know the words, but they were
\nfaced with the three key issues of todays
\nmeeting.
\nDigitalization, Migration and Globaliza-
\ntion.
\nGernsback\u2019s vision, it turns out, was not
\nthat far off from what we are technically
\ncapable of doing now. While modern vir-
\ntual communication as we know it today
\nand the implementation of robotics and
\naugmented intelligence in medicine were
\nmore or less the stuff of science fiction
\nin 1925, the germ of an idea of what the
\nfuture of medicine could look like had al-
\nready begun to form. Nowadays DaVinci
\nrobot techniques and teleconsultations
\nhave become unspectacular normality of
\nmedical practice. Digitalization is already
\nover our doorstep!
\nAnd the future is closer than ever. Today
\nwe have been asked to look not 100 years
\ninto the future, but rather just over a de-
\ncade, to the year 2030. As a point of com-
\nparison, ten years ago Google wasn\u2019t yet a
\nteenager. Dr. Google hadn\u2019t even applied
\nfor medical school. The iPhone was but a
\ntoddler and a fledgling messaging service
\ncalled WhatsApp had 250,000 active us-
\ners (that number, by the way, is now 1.5
\nbillion). The world, and the way we com-
\nmunicate, is changing at lightning speed.
\nThere has been a fundamental shift in the
\nway we interact with each other, and the
\nmedical profession is, of course, not im-
\nmune to that fact.
\nIn ancient Greek this was called \u201cpanta rhei\u201d
\neverything flows.This was always the case\u00a0\u2013
\nonly the speed of change has altered!
\nThe developments we have seen in the med-
\nical profession in recent decades extend far
\nbeyond communication, which is an issue
\nI\u2019ll return to later. To understand what the
\nfuture might hold for the patient-physician
\nrelationship, it is important to first take
\nstock of where we are today and how we got
\nhere.
\nAdvancements in medicine, state-of-the-
\nart medical devices and modern treat-
\nment options mean that certain diseases
\nthat were once more or less considered
\na death sentence for patients have now
\nbeen transformed into manageable, treat-
\nable chronic conditions. Just look at cancer
\nand HIV. And many patients are surviv-
\ning long enough to have the \u201cchance\u201d to
\nbe diagnosed with a second formerly fatal
\ndisease. In the past they would have died
\nof the first and not lived to the diagnosis
\nof the second.
\nDemographic changes in the form of aging
\npopulations are a fact that cannot be ig-
\nnored in any country of the world. The de-
\nmographic shift has an impact on society as
\nFrank Ulrich Montgomery
\nStatement by Frank Ulrich Montgomery.
\n\u201cPhysician 2030: the Future is around the corner\u201d
\nBACK TO CONTENTS
\n32
\nPhysician 2030
\na whole, the healthcare system and the way
\nit is organized and financed. And it has an
\nimpact on migration. You don\u2019t find skilled
\nhealth care professionals in Sub-Saharan
\nAfrica but you do find them in richer so-
\ncieties.
\nAnd by the way, demography doesn\u2019t ex-
\nclude our profession: Just as our patients
\nare aging, physicians in the more affluent
\ncountries of this world have been getting
\nolder, too, and the number of physicians is
\ngrowing too slowly to compensate for the
\nchallenges that lie ahead for our healthcare
\nsystem.
\nAnd governments are hesitant to react to
\nthis shortage in a sensible manner: instead
\nof increasing the number of students in uni-
\nversities and the number of training posts
\nfor specialization, they opt for cheaper al-
\nternatives instead.
\nOne approach which is often touted by na-
\ntional governments and other authorities
\nas a solution to personnel shortages in the
\nmedical profession is that of task shifting.
\nThe World Health Organization defines
\ntask shifting as
\n\u201cA process of delegation whereby tasks are
\nmoved, where appropriate, to less special-
\nized health workers. By reorganizing the
\nworkforce in this way, task shifting can
\nmake more efficient use of the human re-
\nsources currently available.\u201d
\nBut in the eyes of the medical community,
\nthis is a fallacy. Patients deserve physicians.
\nQuality of medical care and the right of ac-
\ncess to a fully trained doctor are basic hu-
\nman rights.Of course\u00a0\u2013 in cases where there
\nis no physician\u00a0\u2013 it is helpful to have a nurse
\non hand. And of course, where there is a
\nlack of nurses, community health workers
\nmight come in handy. No one denies that\u00a0\u2013
\nnot even us. But we cannot accept that gov-
\nernments or international organizations like
\nthe WHO or the World Bank promote the
\ntraining of nurses and community health
\nworkers rather than fully trained physicians.
\nThis is equivalent to denying patients ac-
\ncess to quality health care.We must be clear
\nand firm that under a concept of Universal
\nHealth Coverage, health care must involve
\nphysician-led teamwork and this must be
\nthoroughly financed.
\nAnd let\u2019s be very clear: a patient-physician
\nrelationship demands a physician\u00a0 \u2013 not a
\nsubstitute or surrogate.
\nPhysician shortages are not a problem fac-
\ning lower-income countries alone. One
\nchange I continue to campaign for in Ger-
\nmany is at least a 10% increase in the num-
\nber of slots available for students to study
\nmedicine. And I mean thorough training of
\nstudents at Universities.
\nThis is not without pitfalls: As Richard Ri-
\nley, Secretary of Education under Bill Clin-
\nton once said: \u201c\u2026we are currently prepar-
\ning students for jobs that don\u2019t yet exist, using
\ntechnologies that haven\u2019t yet been invented, in
\norder to solve problems we don\u2019t even know are
\nproblems yet\u201d.
\nAnd this is where our approach to global-
\nization comes in. We have to maintain and
\ndevelop standards we do not even know of
\n(yet)\u2026.
\nBut the overarching issue however is the
\nhuman relationship between a patient and
\nhis or her physician. All these modern tech-
\nniques that we talk of, are only tools in this
\nrelationship,they cannot be substitutes.And
\nwe have to recognize this as well in medi-
\ncal training. The trend to blended learning
\ninstitutions of training with \u201chome studies\u201d
\nat your own computer and some practical
\ntraining in local hospitals, is not equivalent
\nto a decent University or Medical School
\ntraining curriculum. Our students need
\nmore practical experience; we need more
\ndirect contact between student and teacher
\nand we definitely do not need more elec-
\ntronic \u201cOpen Universities\u201d in medicine.
\nI firmly believe that if we do not actively
\naddress physician shortages now, the situa-
\ntion for patients will deteriorate in the years
\nahead.
\nIn addition, efforts must be made to in-
\ncrease the attraction of going into general
\npractice, since this is precisely where we are
\nfalling short. Models in which rural hospi-
\ntals cover tuition and, in exchange, medical
\nstudents must agree to work at said hospital
\nfor a certain number of years\u00a0\u2013 could help
\ninsure that the patient-physician remains
\nbalanced and robust despite challenging de-
\nmographic changes.
\nWhat we must avoid at all costs, however,
\nis the impracticable expectation for over-
\nworked physicians to add more consultation
\nhours to their schedules.
\nAs I mentioned at the very top of my ad-
\ndress, technological advancements have not
\nonly had a positive impact on the types of
\nmedical treatments available and, by exten-
\nsion, patient outcomes, but also on how pa-
\ntients access this treatment and how doctors
\nand patients communicate with each other.
\nDigitization is ubiquitous.
\nIt is changing how we read, how we order
\nproducts and how we consume media con-
\ntent. And now it is changing how health
\nservices are delivered, how patients book
\ndoctor\u2019s appointments, follow up on medi-
\ncal exams and order medicine.
\nIn the best cases, technology improves ef-
\nficiency and reduces the burden of admin-
\nistrative work for physicians and their col-
\nleagues\u00a0\u2013 all while ensuring quality of care
\nand maintaining the highest standards of
\nmedical excellence.
\nIn the worst case it substitutes human em-
\npathy with \u201cartificial intelligence\u201d.
\nWhen Hugo Gernsback conjured up the
\nTeledactyl more than a century ago, it was
\nBACK TO CONTENTS
\n33
\nPhysician 2030
\nas if he had foreseen modern-day telemedi-
\ncine. The World Medical Association de-
\nfines telemedicine as \u201cthe practice of medi-
\ncine over a distance, in which interventions,
\ndiagnostics and treatment decisions and
\nrecommendations are based on data,includ-
\ning voice and images, documents and other
\ninformation transmitted through telecom-
\nmunication systems.\u201d
\nThe digital tools we now have at our dis-
\nposal\u00a0\u2013 from medical apps to wearables to
\nonline portals for making appointments\u00a0\u2013
\noffer tremendous opportunities to enhance
\nthe healthcare experience for our patients.
\nBut we have to keep in mind: they are only
\ntools, not substitutes.
\nAnd whether we wanted it or not\u00a0 \u2013 they
\nhave become a reality. And whether we like
\nit or not, younger generations use them
\ntoday like we used Walkmans and cassette
\nplayers when they were the latest invention,
\nleading our parents to shake their heads
\nover all these new\u00a0\u2013 in their eyes totally use-
\nless – modern gadgets\u2026
\nBut what impact do these new techniques
\nhave on the patient-physician relationship?
\nIn an ideal world, physicians should always
\nprovide medical consultation and treatment
\nto patients through direct, personal contact.
\nThat is the \u201cGold Standard\u201d.
\nHowever, as we saw earlier, this is not always
\nas simple as it sounds, particularly in remote
\nareas where physician shortages are and will
\nlikely continue to be an issue going forward.
\nAnd we also have to accept a generational
\nchange in our societies.The smartphone has
\nbecome a constant companion of our days.
\nIt has become an extension of our senses.
\nAnd digital natives don\u2019t understand why
\nwe conventional, old-fashioned grufties
\nprefer a look in the eyes, a touch on the skin
\nor physical examination.
\nQuestion is: WHO has to change? I believe:
\nWe have to adapt. We have to learn.
\nFor years it has been permissible in Ger-
\nmany for physicians to use communications
\nmedia only to supplement, but not replace
\nin-person patient care. Last year\u2019s German
\nMedical Assembly, however, paved the way
\nfor physicians, at least in individual, medi-
\ncally justifiable cases, to provide medical
\nconsultation or treatment exclusively via
\ncommunications media. Generally speak-
\ning,there is no difference in the responsibil-
\nity for the medical act of a physician. He or
\nshe must know what they are doing\u00a0\u2013 and
\nthis applies to electronic consultation just as
\nmuch as to conventional physical contact.
\nVirtual treatment raises important ethical
\nquestions which we must continue to ad-
\ndress in the years ahead. And we have to be
\naware that there are still impediments asso-
\nciated with this type of contact, which place
\nmore responsibility on doctors\u2019 shoulders.
\nIn addition to concerns about data privacy,
\nit could, if used incorrectly, undermine the
\nrelationship of trust or at the very end de-
\npersonalize the relationship between physi-
\ncians and their patients.
\nSome might argue that some forms of tech-
\nnology\u00a0\u2013 for example, the use of robotics in
\nsurgery and AI, could render doctors obso-
\nlete in the future.
\nHere\u2019s why I think that will not happen:
\nThe physician-patient relationship has been
\nevolving for generations from a paternalistic
\nmodel, in which the patient was essentially
\nexpected to do what the physician said, no
\nquestions asked, to a model of shared, par-
\nticipative decision making.
\nDigital technology has increased patients\u2019
\naccess to\u00a0\u2013 and hunger for\u00a0\u2013 information. It
\nhas made them more informed and empow-
\nered participants in their medical destiny
\nand contributed to symmetry of communi-
\ncation between patients and physicians.
\nHowever,there is a downside to the flood of
\ninformation patients have at their disposal.
\nAs we see on a daily basis, social media\u00a0\u2013 for
\nall its positive aspects\u00a0\u2013 can also be used as a
\nbreeding ground for misinformation.
\nA prime example of this is anti-vaccination
\ndiscourse, which is having a serious detri-
\nmental impact on public health.
\nPatients will always need physicians to be
\na source of professional expertise and em-
\npathy\u00a0 \u2013 perhaps even more so as sources
\nof dubious online health content are called
\ninto question.
\nAnd we have to maintain and fight for our
\nposition as serious information brokers to
\nour patients.
\nWe will not win this battle by simply calling
\nelectronic evidence from Dr. Google, Wat-
\nson or whatever \u201cpoppycock\u201d.
\nWe have to seriously engage as reliable
\ntranslators of a lot of nonsense to discrimi-
\nnate good from bad for our patients. They
\nneed\u00a0\u2013 and mostly want\u00a0\u2013 our help!
\nAnd of course, every disruptive change in a
\nhealthcare system brings with it the poten-
\ntial for failure of mutual trust and respect
\nbetween physicians and patients. This is
\nsomething we must always keep in mind
\nand actively resist.
\nFor this reason, it is essential that we con-
\ntinue to adhere to\u00a0\u2013 and update where nec-
\nessary\u00a0\u2013 the key ethical guidelines that unite
\nour profession, like the WMA\u2019s Declaration
\nof Geneva and the WMA International
\nCode of Medical Ethics. For example, the
\nnewest version of the DoG incorporates
\ngreater emphasis on the autonomy and self-
\ndetermination of the patient.
\nA positive patient-physician relationship
\nbased on mutual trust is good for patient
\nhealth outcomes and it is good for physi-
\ncians, too. Physician well-being is another
\nBACK TO CONTENTS
\n34
\nPhysician 2030
\nissue that was integrated into the revised
\nversion of the DoG, as there is a direct cor-
\nrelation between self-care of physicians and
\ntheir ability to provide care of the highest
\nstandards.
\nModern technologies, new techniques of
\ncommunication and robotics tend to fright-
\nen us and the public, when they are brand-
\nnew.That\u2019s a fact\u00a0\u2013 and that is normal.
\nBut the key ingredients of the patient-phy-
\nsician relationship have not changed. And
\nthey must not change. After some time we
\noften realize that what once frightened us
\nhas become a useful, sometimes inevitable
\ntool of our profession. It became part of
\npatient-physician partnership.
\nThat\u2019s why I am not afraid of the future.
\nAnd I am sure the future will be bright\u00a0\u2013
\nactually it has to be, because looking at my
\nown age I will in the future definitely have
\nmore physician-patient encounters from the
\nother side of this relationship.
\nIt sometimes opens your eyes when you
\nchange sides.
\nAnd medicine is extremely successful.
\nAnd it will stay to be.
\nIn the most affluent countries of the world
\nthe average life-expectancy of the people
\nwill increase by four years over the next two
\ndecades. So having listened to me at this
\nconference has increased your personal life-
\nexpectancy for at least ten minutes. I hope
\nit was worth ist.
\nFor centuries, our profession has under-
\nstood the importance of adhering to ethical
\ncodes\u00a0\u2013 from the Hippocratic Oath to our
\nmodern-day WMA policies. And this will
\nstill be the case in 2030 and beyond, so long
\nas we safeguard professional autonomy, re-
\nspect patient self-determination and remain
\nfocused on the primacy of patient health and
\nwell-being as the cornerstone of our profes-
\nsion.
\nProf. Dr. Frank Ulrich Montgomery
\nChairperson of the WMA
\nCouncil, at the conference
\nOne of two WMA conferences this year
\nwas dedicated to the future of medicine,
\nnamely, medicine round the corner. The
\nconference took place in Israel, Herzley, in
\nMay 2019, and was organised by WMA
\nPresident, Professor Leonid Eidelman,
\ntogether with the Israel Medicine Asso-
\nciation. Fantastic lecturers were welcomed
\nwho considered future medicine from very
\ndifferent viewpoints, both geographic (Ja-
\npan, Brazil, Kenya, Israel, USA, Germany,
\netc.) and medical (primary care, prevention,
\nradiology, functional diagnostics, etc.). I re-
\nquested a number of lecturers to share their
\nviews in WMJ.
\nInspired by conference reports and articles
\nin different medical journals of the world
\non medical futurology, I have outlined some
\nvision of where to medicine and health care
\nwill develop in the next 10-30 years. Un-
\nlike clinical medicine or molecular biology,
\nmedical futurology approaches vary from
\ncountry to country. Writing this article, to
\na large extent, is due to impressions I have
\nfrom the lectures and publications by the
\nPresident of the CPME, Chairman of the
\nCouncil of the World Medical Association
\nFrank Ulrich Montgomery and the Secre-
\ntary General of the World Medical Associ-
\nation Otmar Kloiber, representing the views
\nof the world leading medical organisation.
\nThere are many people talking and writing
\nabout where medicine is going to develop.
\nEveryone, who writes about the future,
\nlooks into the past, and their assumptions
\nare based on different axioms and theories.
\nDiscussions and conferences on the future
\ndirections of medicine are dominated by
\nprecision or personalized medicine, genome
\nresearch and gene therapy, modern technol-
\nogies (diagnostic geeks) and artificial intel-
\nligence, new drugs and personalized drugs.
\nFor a physician to make any forecasts for
\nthe future is a dangerous project. On De-
\ncember 7, 1835, after the first train in the
\nworld crashed on its way from Nuremberg
\nto F\u00fcrth, the Bavarian Society of Doctors
\nPhysician in 30 years from Now\u00a0\u2013 will Technology and Politics
\nChange Physician\u00a0\u2013 Patient Relationships or Change Doctor\u2019s Place
\nin Society and Medicine?
\nPeteris Apinis
\nBACK TO CONTENTS
\n35
\nPhysician 2050
\npublished a sharp warning of scientific
\nevidence that speed exceeding 25 kilome-
\nters per hour is extremely dangerous to
\nhuman health. Dr. Watson, the first head
\nof the company Integrated Business Ma-
\nchine, once forecasted that no more than
\n5 supercomputers will ever be built in the
\nworld because nobody will need it. The
\ncompany\u2019s name was shortened to IBM,
\nbut computerization has taken over the
\nentire world.
\nDescribing future medicine (a view in the
\n30-year future\u00a0\u2013 2049), the key words are:
\n(i) biochemistry and biology;
\n(ii) business;
\n(iii) chemistry;
\n(iv) mathematics and computer science;
\n(v) engineering and nanotechnology;
\n(vi) genomics.
\nIn 2049, medicine will be personalised, pre-
\ndictable, preventive, co-sustainable, with
\nhigh technology, high data processing,
\ninformatics and artificial intelligence in-
\nvolved.The three major discoveries that will
\nrapidly advance medical development over
\nthe next 30 years will include:
\n(i) artificial lungs (or rather artificial gills):
\nvery close supersensitive membranes, blood
\nflowing between them and oxygen-rich air
\nor liquid on the other side;
\n(ii) artificial blood, a fluid that will be able
\nto flow through the blood vessels and to at-
\ntract and return oxygen to tissues;
\n(iii) stem cell studies, gene engineering and
\n3D printing or in vivo breeding abilities in
\nanother organism will certainly allow the
\ndevelopment of such important structures
\nas kidneys, liver, and I believe, even lungs.
\nCertainly, in 2049 you won\u2019t be able to print
\nor grow new brains.
\nIt is essential that among basic medical em-
\nployments\u00a0 \u2013 diagnostics, treatment, reha-
\nbilitation, prevention, the emphasis in the
\nfuture will shift to rehabilitation (currently
\nthe emphasis is placed on diagnosis, often
\npaying more attention to diagnosis than
\ntreatment or rehabilitation facilities).
\nA Modern Doctor\u2019s Viewpoint
\non Medicine in 2049. A 2049
\nDoctor\u2019s Viewpoint on Medicine
\nand Healthcare in 2019
\nFor those reading this article, I suggest imag-
\nining oneself in 2049. Let us agree that all
\nthose doctors, who now are 50-55 year old,
\nwill work as doctors also in 2049 because not
\nonly society, but medicine, too, will grow old
\nglobally, and working life will be long. But
\nall those, who are over the age of 55, should
\nimagine that in the doctor-patient dialogue
\nthey will take the patient\u2019s part. It is essential
\nthat life expectancy has increased significantly,
\nand according to social determinants of health,
\na retired doctor will live in good conditions,in
\na good urban area,will move a lot,eat healthily,
\nbe well diagnosed and treated, so will live for
\nover 100 years. For all those, who have adopt-
\ned these rules, I would add that they will also
\nhave to experience the demographic global
\nmegatrends: the ageing of the planet\u2019s people,
\nurbanisation and an increase of total wealth,
\nwhich will lead to three global pandemics: de-
\nmentia, depression and diabetes affecting ev-
\neryone\u00a0\u2013 all three together or one by one.
\nI recommend to everyone today, in 2019,
\nto remember medicine in 1989, it means
\n30\u00a0years back:
\n(i) even though single use tools and equip-
\nment had already entered the world,most of
\nthe world\u2019s blood transfusion systems,injec-
\ntion syringes, surgical needles, endotracheal
\ntubes were sterilized and used many times;
\n(ii) the world had learned something about
\nHIV\/AIDS, but knew nothing about hepa-
\ntitis C;
\n(iii) penicillin was administered to muscular
\ninjections for 2 million six times a day;
\n(iv) invasive cardiology and invasive angio-
\nlogical diagnostics took first steps and was
\nultimately not available daily;
\n(v) resection in the event of gastric bleeding;
\n(vi) there were no ventilation units on emer-
\ngency ambulance cars;
\n(vii) had to look in the arthroscope and en-
\ndoscope instead of looking at the screen;
\n(viii) a lot of small hospitals with a very long
\nhospital treatment time. Hospital as a social
\nassistance institution.
\nEach of us has our own memories of 1989,
\nbut more than half of the drugs that were
\navailable and used in medicine at the time
\nare not manufactured and used today, but
\nsome have been found to be harmful and
\ndangerous.
\nNow let us imagine ourselves living in
\n2049. How would we remember the 2019
\nmedicine? What will we think of the public
\nhealth of 2019?
\n(i) The majority of the diseases for which
\nwe treated our patients were chronic non-
\ncommunicable diseases, but health care had
\nremained the one created in the early 20th
\ncentury to treat injuries and acute diseases;
\n(ii) Treatment was determined not by the
\ndoctor\u2019s knowledge and patient participa-
\ntion, but by hospital, a large unfriendly
\nbuilding. The patient had occasionally to
\nstay in hospital only for one non-essential
\ndiagnostic or medical manipulation;
\n(iii) Occasionally you couldn\u2019t see a doc-
\ntor immediately once you were in hospital.
\nThere were waiting lines for medical treat-
\nment and diagnostics.There were practically
\nno options for talking to a doctor in a digital
\nenvironment;
\n(iv) The digitalisation of health data was so
\ndifferent that the majority of data in medi-
\ncine was not available in other countries,
\nbut often\u00a0\u2013 in another medical institution
\nof one country;
\n(v) Medical hardware and devices were huge
\nand scary, patients had to travel to perform
\na CT or MRI;
\n(vi) The drugs were produced by BigPharma
\ncompanies,which for decades were preparing
\nthe same drugs and trying to sell the same
\ndoses to millions of people.Everyone got the
\nsame pills\u00a0\u2013 no personalised medicines;
\n(vii) Inventing of new treatments and
\nhealth-care techniques, but mainly regis-
\ntering them, took a lifetime. Patients died
\nwaiting for a new treatment because of the
\nlack of officials to register methods and
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\n36
\nPhysician 2050
\nmedicines. Clinical trials\u00a0\u2013 long and incred-
\nibly expensive. The medicinal product was
\ntested on real patients;
\n(viii) The patient was not only treated while
\nin hospital, but also got new infections in
\nhospital;
\n(ix) In hospital, professionals often made
\nmistakes because of the lack of algorithms,
\ndepletion of physical resources, fault of the
\nmedical organisation. In 2019, medical er-
\nrors were the third or fourth most frequent
\ncause of death;
\n(x) Epidemiological studies were slow and
\nmany were completely redundant;
\n(xi) Cancer was considered a dramatic life
\nevent, not a chronic disease.
\nYou have the opportunity to supplement this
\nreflection from the perspective of your spe-
\ncialty and the ability to look into the future.
\nKey Factors Determining
\nMedicine and Public Health
\nOver the Next 30 years
\nIn terms of the future of medicine, many
\nknown and unknown factors have to be tak-
\nen into account. I have chosen 10 essential
\nfactors that will determine medicine and
\npopulation health over the next 30 years,
\nand ranked them by personal sense:
\n(i) climate change. It is climate change that
\nwill cause a very significant humanitarian
\ncrisis in Subsaharan and North Africa and
\npossibly South Asia over the next 15-20
\nyears. This humanitarian crisis will cause
\nmigration of more than 200 million people,
\nwith very high pressure on health systems of
\nthe migration target countries;
\n(ii) planet pollution. Household chemicals
\nas poison, excessive armament and military
\nactions as planet degradation factors. En-
\ndocrine disruptors will be a birth limiting
\nfactor further affecting the loss of flora and
\nfauna global biodiversity. Excessive use of
\nchemical substances will also result in an
\nincrease in hereditary pathologies and in-
\nherited defects;
\n(iii) overuse of pesticides, fungicides, herbi-
\ncides as well as antimicrobial therapies used
\nin medicine and veterinary medicine will
\naffect the characteristics and resistance of
\nbacteria. Pathogenic bacteria resistant to all
\nantibiotics will develop. Antimicrobial re-
\nsistance will lead to very serious morbidity
\nand mortality. The control of infections will
\nbe based on vaccination against antibiotic-
\nresistant micro-organisms.Over the next 30
\nyears, one or more global epidemics caused
\nby viruses will spread around the world.
\nPeople will start avoiding hospitalization
\nafraid of contagion risk;
\n(iv) the overpopulation of the planet and
\ndemographic changes, a significant increase
\nin life expectancy (in both rich and poor
\ncountries). This will lead to a number of
\nconsequences:
\n\u2022\t medical treatment,provided it has sufficient
\nresources,might ensure extending the life of
\neach individual very significantly;
\n\u2022\t eachindividualwillclaimaverylargeamount
\nof the money resources to extend their indi-
\nvidual life and, regardless of the country\u2019s
\neconomic wealth, medicine will start to run
\nout of funds in a catastrophic way;
\n\u2022\t any resource (medical knowledge, intu-
\nition, experience, working time, premises,
\nhardware, medicines, money) that will be
\ninvested in health care, specific preven-
\ntion, diagnosis, medicine and rehabilita-
\ntion will extend the human lifespan and
\nimprove the quality of life;
\n\u2022\t the fundamental paradox of medicine will
\ncome true: if greater sums are invested in
\nhealth care,the longer people will live and
\nmore resources will be needed for health
\ncare. Consequently, there will be public
\ndiscontent in all countries with the health
\ncare system and its financing;
\n(v) an ever greater role of social determi-
\nnants between the rich and the poor,educat-
\ned and uneducated\u00a0\u2013 the predictable length
\nof human life will be more determined by
\nthe ZIP code than the genetic code (in any
\ncountry in the world, a wealthy and edu-
\ncated person lives on average a significantly
\nlonger life than poor and uneducated);
\n(vi) the ageing of the population\u00a0 \u2013 both
\npatients and doctors. Epidemics of chronic
\ndiseases, multimorbidity (patients with
\nmultiple diseases) and polypragmasia (a
\npatient taking many different drugs at the
\nsame time);
\n(vii) lack of doctors and medical profession-
\nals;
\n(viii) digital technologies, particularly in di-
\nagnostics; artificial intelligence as a key ele-
\nment of diagnostic and screening;
\n(ix) rehabilitation as the leading medical
\nsector;
\n(x) healthcare, medicine and pharmaceuti-
\ncal market (together) as the main economic
\nsector of any country with a share of at least
\n25% of gross national product.
\nRanking all this in different order, remov-
\ning one piece of the puzzle and replacing
\nit by another, anyway, the conclusion is that
\nthe worst that may characterise medicine in
\nthe 21st
\ncentury is the following: overpopu-
\nlation, new deadly global fast-spreading
\nviruses, antimicrobial resistance, medical er-
\nrors and lack of clinicians, but demographi-
\ncally: a senior patient with chronic diseases,
\nmultimorbidity and polypragmasia.
\nThe positive scenario rests upon the fact
\nthat medical development, state-of-the-art
\ndiagnostic equipment and modern medi-
\ncal treatment will translate diseases previ-
\nously considered a death sentence for pa-
\ntients into treatable chronic diseases such as
\ncancer or HIV\/AIDS. Many patients with
\nthese diseases will survive long enough to
\nawait the diagnosis of another deadly dis-
\nease. In the past, they would have died from
\ntheir first diagnosis and would not have
\nlived long enough to learn about another
\nfatal diagnosis. In the past, it was easier to
\ncreate mortality statistics, but thirty years
\nlater, the pataloganatomist will find it dif-
\nficult to state clearly from which disease the
\npatient died.
\nThirty years later, immortality would not be
\nachieved. Everyone who will be born will
\ndie sooner or later. Human organs from
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\n37
\nPhysician 2050
\none\u2019s own cells and genes will be \u201cgrown\u201daf-
\nter some 15-20 years, but not all body cells
\nand organs will be replaced.
\nIn the next thirty years, the main vector in
\nmedicine will be doctor-patient relation-
\nship. Politicians, officials and journalists use
\ntwo expressions\u00a0\u2013 \u201cteam work\u201dand \u201cpatient-
\ncentered\u201d in this situation. The concept of
\n\u201cteam work\u201d is synonymous with \u201cI\u00a0 don\u2019t
\nknow what to say, but I want to pretend
\nto be smart\u201d. The concept of \u201cpatient-cen-
\ntered\u201d means the personal experience of a
\npolitician or an official in hospital, dental
\nchair, pharmacy or ambulance, which is
\ngeneralized and based on a complete lack
\nof knowledge. This lack of knowledge is ac-
\ncompanied by an inability to believe that
\nthe doctor has undergone training for many
\nyears and therefore understands human
\nanatomy, physiology, health, disease, drug
\nuse, motion, thinking, brain activity and in-
\nternal secretion, immunology, cell symbio-
\nsis, microbiome and many other things at
\na completely different level and in a com-
\npletely different context. Therefore, a poli-
\ntician and an official responsible for global
\nhealth quickly is exposed to the disease of
\na second year medical student, caused by
\nthinking about money, magnetic resonance,
\nibumetin and hospital repair. The igno-
\nrance of both\u00a0\u2013 the average politician and
\nthe average official\u00a0 \u2013 will increase in the
\nnext 30 years, with only a negative impact
\nupon medicine. Any disruptive change in
\nthe health system (usually referred to as re-
\nforms) undermines mutual trust and respect
\nbetween doctors and patients.
\nOn Remote Communication
\nBetween the Doctor
\nand the Patient, Called
\nTelemedicine (WhatsApp,
\nApps, Skype and e-Health)
\nLet\u2019s return in the past to look at the future.
\nIn 1925, namely, nearly a century ago, the
\nGerman inventor and futurist Hugo Gern-
\nsback described a device of the future that
\nwould allow doctors to treat their patients
\nfrom a distance, and the doctor would do
\nso by touching the button. Gernsbak called
\nhis futurological prediction a teledactyl that
\nwould allow the future doctor not only to
\nsee, but also to feel his patient from a dis-
\ntance, using long\u2013distance hands. Gerns-
\nbak\u2019s vision is pretty close to modern tele-
\nmedicine and da-Vinci\u2019s surgical robot.
\nWMA defines telemedicine as a medical
\npractice from a distance where interven-
\ntional, diagnostic and medical decisions
\nand recommendations are based on voice
\ncommunication, data, images, documents
\nand other information transmitted through
\ntelecommunication systems.
\nDigitization is ubiquitous. Changes affect
\nthe extent healthcare services are provided
\nand the way patients reserve or apply for
\ntheir visit to a doctor, how doctors and pa-
\ntients follow medical examinations and orga-
\nnise the medical treatment process. At best,
\ntechnology improves efficiency and reduces
\nthe burden of administrative work for physi-
\ncians, while ensuring the quality of care for
\nall patients and maintaining high medical
\nstandards.At worst,it replaces human empa-
\nthy with notional artificial intelligence.Med-
\nical politicians\u2019 fascination with the digitiza-
\ntion of medicine often puts the computer in
\nthe centre of health care, but the patient and
\ndoctor are expelled from the centre.
\nRemote communication is an instrument,not
\nreplacement of a doctor. Avoiding doctor-pa-
\ntient communication is impossible, and com-
\nmunication via computer or mobile phone
\nwill become a commonplace way of commu-
\nnicating between a doctor and a patient.
\nHow do the new communication methods
\naffect patient\u2013doctor relationships? In an
\nideal world, the gold standard means that
\na doctor should always provide medical ad-
\nvice and treatment to patients through di-
\nrect, personal contact. At the same time, for
\npatients a visit to a doctor means spending a
\nlot of time and financial resources.The doc-
\ntor\u2019s workload is heavy enough and to save
\ntime short advice provided on the internet
\nmight be preferred.
\nThe smartphone has become a constant
\nguide in our daily life. Digital oriented
\nyoung generation does not understand why
\ndoctors due to old-fashioned traditions
\nshould prefer looking into eyes, touching
\nskin, conversation in a low-pitched voice
\nabout individual health history, ausculta-
\ntion, percussion or physical testing rather
\nthan conversation in WhatsApp or Skype.
\nDifferent types of remote communication
\nbetween a doctor and a patient will become
\ncommonplace worldwide, developing con-
\ntinuously together with the technological
\ndevelopments. The world and the way we
\ncommunicate are changing very quickly.
\nThe fundamental change takes place in the
\nway we interact one with another, and the
\nmedical profession is certainly not immune
\nto general trends.
\nVirtual conversation between a doctor and
\na patient, virtual diagnostics and treatments
\ncreate new ethical challenges. The biggest
\nconcern is data privacy. Virtual diagnostics
\nand treatments, used incorrectly, can un-
\ndermine confidence in the doctor-patient
\nrelationship or even depersonalize relation-
\nships between the doctor and the patient.
\nIn addition to the benefits of communica-
\ntion between the doctor and the patient in
\nthe internet environment, there is a concern
\nthat the computer will be fully positioned
\nbetween the doctor and the patient. The
\ndigitalisation and remoteness of diagnostics
\nfrom the treating physician, and particularly
\nthe direct transfer of the examination data
\nto the patient, leads to leaving the patient
\nalone with their health problems, com-
\nplaints and numerous worries.
\nIn this situation, artificial intelligence
\ncomes in, or in a simple case an algorithm,
\nwhich allows data to be analyzed: there is
\nsomething too much here, too little here,
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\n38
\nPhysician 2050
\nsome sort of formation in the picture, etc.
\nIt is important\u00a0\u2013 who has sent the patient
\nto a diagnostic test\u00a0\u2013 a GP or a specialist.
\nUnfortunately, a CT or MRI study, as a law,
\nhas been performed a few weeks or even
\nmonths after administration, the examina-
\ntion result is ready in a few more days, and
\nnow is stored somewhere in the depths of
\nDataMed. The patient hopes that someone
\nis following what happens with this study,
\nbut the GP does not even know about the
\nexistence of any other test appointed by a
\nnarrow-sector specialist. If the patient on
\nhis own initiative finds and receives the
\nanswer of the radiologist or laboratory, the
\nexamination and diagnostics will continue
\nor the treatment started. If a patient has
\nbeen referred for testing by a narrow-sector
\nspecialist, there are concerns whether the
\nindications in the study\u2019s response to pa-
\nthology under the responsibility of another
\nnarrow-sector specialist will be evaluated.
\nIn this case, the only one capable of help-
\ning, directing diagnostics and treatment is a
\ndoctor of general practice\u00a0\u2013 a GP.
\nIn addition to supporting the system of gen-
\neral practitioners,its development,the devel-
\nopment of expertise,and for the search of op-
\ntimal organisational forms no effort should
\nbe spared both in professional organisations
\nand in national ministries, and parliaments.
\nSupporting family doctors means additional
\nfunding,additional support of municipalities,
\nadditional training, serious red tape reduc-
\ntion. A doctor of primary care or a GP will
\nbe needed and will be a key stage in medicine
\neven after thirty years, regardless of how the
\nprofession will be called.
\nDigital technology has increased patient
\naccess to information. Digital technology
\nhas made patients more informed and em-
\npowered over their health and health care
\nand promoted symmetric communication
\nbetween patients and doctors. The claim
\nthat a patient can be as informed as a doc-
\ntor is exaggerated because it is more difficult
\nfor a patient without medical knowledge to
\ndistinguish between honest, modern medi-
\ncal information on social networks and in-
\nternet portals from erroneous messages or
\nfake news.
\nOver the next thirty years, patients will
\nneed doctors as a source of professional
\nexperience and empathy, particularly when
\na patient sees highly questionable online
\nhealth content. The doctor will have to be
\na middleman for information between the
\ndigital information platform and the pa-
\ntient in the future.
\nThe biggest lie is replacing a doctor with
\nan app. Every day, an average of 100 new
\nmedical or health applications are created in
\nthe world, while on average one person uses
\n10 to 20 applications on his mobile phone,
\neven if he has installed a hundred. The cre-
\nation of apps is synonymous with the extor-
\ntion of money.
\nRegardless of enjoyment or trouble, data
\nstorage and analysis will play a huge role in
\nthe future. The digitisation of health data
\nwill open the possibility of legally, semi-le-
\ngally or illegally manipulating a huge array
\nof health data, both for marketing purposes
\nand in optimising insurance issues, more or
\nless ethically questionable,acceptable or un-
\nacceptable research, etc.
\nAs well as attempts to digitize everything\u00a0\u2013
\nfrom a doctor\u2019s and patient\u2019s direct or imag-
\ninative recording and a full MRI study in
\ndigital form to self-sensing and temperature
\nreadings, the need to hide the information
\nwill appear. Sooner or later, the doctor will
\nneed not to provide the whole world with
\ninformation on decision-making, reason-
\ning, risks.The problem of keeping a doctor\u2019s
\nsecret separate from the huge global data
\ncemetery will have to be addressed.
\nThis will be the matter of significant differ-
\nence between the European and Chinese
\napproaches: in China, all medical docu-
\nmentation will be available for research, in-
\ncluding the gene map of each citizen. Due
\nto legislative differences, China\u2019s medical
\nscience will have great breakthrough op-
\nportunities in the near future. And there is
\nno envy or regret: Europeans and Ameri-
\ncans prefer to take care of their data security
\nrather than global achievements.
\nTask Shifting\u00a0\u2013 Attempts of
\nthe World Politicians and
\nFinanciers to Replace a Doctor
\nWith a Nurse or Public Health
\nWorker as Preparing Physicians
\nSeems too Expensive
\nArtificial intelligence will not replace the
\ndoctor, but will slowly push the human fac-
\ntor out of digital diagnostics and medicine.
\nThe world health care is not driven by mon-
\ney and new technologies, but by the doctor-
\npatient relationship.The eternal question in
\nmedicine is about the main decision maker:
\nwho is it\u00a0\u2013 the doctor, patient, doctor and
\npatient (and relative), payer?
\nDemographic changes and population age-
\ning are some of the essential factors to be
\ntaken into account for distant and not too
\ndistant future, visualizing national or even
\nworld development scenarios.Demographic
\nchange\u00a0\u2013 population ageing, drain of work-
\ning population to cities or global megalo-
\npoli\u00a0\u2013 have an impact on society as a whole,
\nthe health system and the way healthcare is
\norganised and funded.
\nThe demographic impact is equally felt on
\nthe whole of society, including the age of
\nmedical specialists. Doctors in the rich-
\nest countries of the world are aging, but
\nthe number of doctors increases too slowly,
\nand this increase does not compensate for
\nthe growing health care problems. At Eu-
\nropean level, governments are hesitant to
\nreact sensibly to this situation, namely, to
\naddress the lack of medical staff by increas-
\ning the number of students and residents in
\nuniversities, but supports the redeployment
\nof the workforce from (slightly or signifi-
\ncantly) poorer countries. The other solu-
\nBACK TO CONTENTS
\n39
\nPhysician 2050
\ntion, included in their strategy by national
\ngovernments and politicians, is the change
\nof tasks or task shifting. The World Health
\nOrganisation defines the task shifting as a
\ndelegation process, where appropriate, the
\ntasks and functions of medical treatment
\nare delegated to less specialised healthcare
\nworkers.This redeployment of workforce al-
\nlows task shifting using the currently avail-
\nable human resources more efficienly.
\nTask shifting means delegation of a function
\nto someone else. For example, at the begin-
\nning of the 20th
\ncentury it was hard to imag-
\nine that a doctor might not perform an in-
\njection. At the beginning of the 21th
\ncentury,
\nthis function is entirely delegated to a nurse,
\nwhose training is shorter and cheaper. Ini-
\ntially,only the doctor was entitled to measure
\nblood pressure, do cupping and apply leech-
\nes, make incisions and perform other similar
\nmanipulations. Later these functions were
\nassigned to nurses, paramedics or nursing
\nassistants with some training. Governments
\nare interested in making task shifting their
\nstrategy. There is the illusion that funds will
\nbe economised in this way.As a rule,govern-
\nments take over from one another only the
\nnegative experience. A\u00a0 variant of the task
\nshifting are efforts to reduce the professional
\nautonomy of physicians and pharmacists.
\nThere are attempts to allow physicians to sell
\ndrugs or pharmacists to prescribe drugs.
\nTo a large extent, task shifting is also pro-
\nmoted by a global document such as the
\n2018 WHO Declaration of Astana (now
\nNursultan), which directs universal and
\nglobal medical coverage.The Astana confer-
\nence was dedicated to the 40th
\nanniversary
\nof the AlmaAta conference.
\nSince the AlmaAta conference in 1978, the
\nWorld Health Organization has set the task
\nof providing primary care for every citizen
\nof the planet. It is known as universal cover-
\nage and it became the basis of the Astana
\ndeclaration. This document is carefully pre-
\npared, but the feeling still remains that its
\ncreators did not know or did not want to
\nknow about social determinants, the docu-
\nment reminds of a debut in a global race.
\nThe document was produced by many
\ngovernments and financial donors, but the
\nresult goes against the intent of the docu-
\nment: Instead of building stable health sys-
\ntems with high-quality primary care at the
\ncentre, the document looks like an excuse
\nfor a minimalist approach.
\nPatients around the world deserve physi-
\ncians care. The quality of medical care and
\nthe right to access a fully trained doctor is
\na fundamental human right. Of course, in
\ncases where there is no doctor (e.g.in certain
\nAfrican countries), it is helpful if there is at
\nleast a nurse in the village. And, of course,
\nwhere there are no nurses (in the poor-
\nest countries of Africa or small islands), it
\nmight seem good if there is a public health
\nworker trained for at least three months.
\nStates should forget their pipe dreams that
\noverloaded and burnout doctors will add
\neven more working hours to their schedules.
\nStates should make every effort to increase
\nthe attractiveness of the GP service because
\nit is this area that provides universal cover-
\nage and it is in this area that there are many
\nopportunities for medicine to develop in ev-
\nery country of the world.
\nFuture Medicine Means
\nHigh-Quality Training of
\nStudents and Residents
\nThose, who after thirty years will be pro-
\nfessors, specialty leaders in clinics and top
\nspecialists are finishing medical faculty or
\nresidency right now. In the world\u2019s richest
\ncountries, the average lifespan of people
\nwill increase by 6-10 years over the next
\nthirty years, and in developing countries
\nby 12\u00a0years. Advanced technologies in di-
\nagnostics and treatment, new communica-
\ntion techniques in medicine, but especially
\nrobotics tend to frighten both doctors and
\nsociety only as long as they are completely
\nnew. After a while, we often realize that
\nwhat frightened us has become a useful tool
\nin our profession. Science is increasingly
\ndistancing from everyday practices. There is
\nno much difference for a general practitio-
\nner whether or not a particular patient has
\na certain genotype. Even if a doctor knows
\nfrom the gene analysis that a particular
\npatient is likely to develop obesity and hy-
\npercholesterolemia, he would suggest more
\nmoving around and sticking to a diet, just
\nlike he advises all other patients.
\nThe more we will know and acquire knowl-
\nedge via computer, the less we will under-
\nstand what to do with this knowledge: we
\nwill diagnose a rare disease or a rare virus,
\nbut we will treat with bed rest and addi-
\ntional fluid intake, or we will ask permission
\nand genotype every person on the planet,
\nbut 99.9% will not be able to use this in-
\nformation. Therefore, empathy and medi-
\ncal ethics should also be at the heart of the
\ntraining process for future doctors. There is
\nno reason to think that thirty years later de-
\nvices like mobile phones and computers will
\nhave taken a full fledged place between a
\ndoctor and a patient.The main components
\nof the doctor-patient relationship have not
\nchanged. They must not change, and it is
\nunlikely to change in the next thirty years.
\nA positive relationship between a doctor
\nand a patient based on mutual trust is and
\nwill be an important factor for the patient
\nhealth outcomes, and will always be good
\nfor doctors. For centuries, doctors in their
\nprofession have understood the importance
\nof the code of ethics\u00a0\u2013 from the Hippocrat-
\nic Oath to the political documents of the
\nWorld Medical Association. They define
\nthe professional autonomy of doctors as a
\ncornerstone of the profession for ensuring
\npatient health and well-being.
\nPhysician autonomy and\/or professional
\nfreedom are integral to ethics, empathy
\nand deontology. A key prerequisite for this
\nis high-level education, intelligence, integ-
\nrity, courage and other virtues of the doc-
\ntor himself. Artificial intelligence will also
\nBACK TO CONTENTS
\n40
\nPhysician 2050
\ncome into post-graduate training and pro-
\nfessional evaluation of doctors and it will be
\nassessed not only by the number of confer-
\nences and lectures visited, but also based on
\nsuch criteria as education, empathy, courage
\nand integrity. On the other hand, the doc-
\ntor\u2019s own well-being and attending to his
\nhealth are finally included in the Declara-
\ntion of Geneva because there is a direct cor-
\nrelation between the doctor\u2019s state of health,
\nwell-being and the ability to provide high
\nstandards of health care.
\nFuture Hospitalisation\u00a0\u2013
\nChange of the Direction from
\nthe Patient\u00a0\u2013 the Medical
\nDevice to the Medical
\nDevice\u00a0\u2013 the Patient
\nToday\u2019s hospital largely rests on the para-
\ndigm\u00a0\u2013 devices are big and expensive, so the
\npatient should go to hospital for examina-
\ntion or treatment. The future hospital will
\nbe a hospital at home:
\n(i) future hospitals will be designed around
\nthe patient, not around the diagnostic de-
\nvices. So, a hospital at home;
\n(iv) a large part of the investigations will
\nmove from hospital to outpatient institu-
\ntion or, rather, home hospital;
\n(iii) hospitals will be intended only for the
\ncritically ill;
\n(iv) hospitals will be smaller than they are
\nnow, and there will be many intensive ther-
\napy beds, but very few other beds. Hospitals
\nwill look more like a hotel.
\nFuture Pharmaceuticals\u00a0\u2013
\nMore Personalised Medicines,
\nDigitized Administration and
\nComputer Virus as a Real Threat
\nof a Global Deadly Epidemic
\nFuture medicine will largely advance to per-
\nsonalized medicine; a genome reader will
\nenter medicine that will be able to read a
\nhuman genetic code within minutes. This
\ninformation will play a key role in determin-
\ning specific doses of medicines and choosing
\nalternative medicines. Medicines prepared
\nfor an individual patient with a specified
\ndosage and administration time will be com-
\nmon practice as commerce will be involved.
\nIn richer countries, drug dosing will be fully
\nautomated. The types of administration will
\nchange, but in any case, the share of oral
\nmedicinal products will be proportionally
\ngreater than that of parenteral products.New
\nways of medicine administration will appear.
\nThe increase of polypragmasia will be at-
\ntempted to be put on brakes by the prepara-
\ntion of individual polydrug capsules.If people
\nmonitor smart devices,and they will not only
\nreport health problems but also administer
\nmedicines,these sensors,devices and systems
\nwill be networked, then the computer virus
\nwill be much more dangerous because it can
\nactually kill someone. Cyber security will be
\nmuch more significant.
\nFuture Medical Triad:
\nDoctor-Device-Patient
\nA future rank-and-file doctor is most eas-
\nily to be imagined with expensive, small
\nsize and sophisticated tools. The following
\nmedical and diagnostic technology can be
\npredicted with the highest probability:
\n(i) miniature portable laboratories;
\n(ii) substantially increased use of ultrasound
\nin diagnostic and visualization, miniature
\nultrasound machines;
\n(iii) dermatoscopes for each doctor,but with
\na high resolution image and immediately
\ntransmittable on the internet;
\n(iv) a computer-like object used increasing-
\nly in daily diagnostics collecting a variety of
\ndata (genetic, laboratory, clinical);
\n(v) the genome sequencing so cheap that it
\nwill allow the detection of disease-causing
\ngenes at a very low cost; it may be assumed
\nthat the genome will be determined at birth.
\nMedical and diagnostic patient technologies
\nwill be worn (clothes, glasses, footwear with
\nsensors), implanted or installed at home or
\nworkplace. It will be the internet of things
\nin combination with fee-based intelligence
\nin the sense that the flow of information will
\nbe exposed to artificial intelligence analy-
\nsis, turning a stream of raw data into a thin,
\nhighly personalized knowledge beam. Digi-
\ntal companies with phenotyping (an Amazon
\nphenotype that already knows everything
\nabout your shopping habits today) will trans-
\nfer skills to digital medicines, but they will
\nalso let someone know what medicines the
\npatient needs, how the body responds to
\nmedicines and specifies digital medicines. As
\na result, the data will become more specific,
\naccurate and usable instead of general, vari-
\nable and entertaining. Focusing on the reli-
\nability of data in health care will make it pos-
\nsible to focus on data compatibility arising
\nfrom many different signals about the con-
\nsumer life flow, which is much more impor-
\ntant information for health-care knowledge
\nthan the payer\u2019s cash flow, a digital record
\nwith a doctor or a doctor\u2019s schedule.
\nTechnology will therefore continuously mea-
\nsure patients\u2019 physiological and biochemical
\nparameters by observing their behaviour,
\neating, breathing, elimination and living
\nspace. A patient will visit his GP with an
\neven greater amount of data, especially about
\nbiochemistry and genetics. And it is still go-
\ning to be screened with artificial intelligence.
\nThe data amount that will be provided by a
\nuniversal coverage of patients and their en-
\nvironmental sensors, combined with genome
\nand microbioma information, will be much
\ngreater than the ability of the human (doc-
\ntor) to understand and summarize. Most
\nof the futurological articles admire smart
\ncomputer like small objects that will diag-
\nnose, monitor, report problems to the doc-
\ntor today and in the future. It will indeed be
\na reminder of the need for tablets or other
\nmedicines, healthy lifestyle and proper eat-
\ning, but following advice of the gadgets, like
\nthat given by medical practitioners of today,
\nwill be mostly determined by the patient co-
\noperation,the ability to listen to the views on
\nregular drug use, \u00ad
\nrecommended sports ac-
\nBACK TO CONTENTS
\nPhysician 2050
\ntivities and non-smoking. It can be assumed
\nthat smart computer like small objects would
\nserve more as an indulgence for not doing
\nanything for the benefit of one\u2019s own health.
\nTherefore, even after 30 years, talking with
\na doctor (both a family doctor and a spe-
\ncialist) will be a \u201cgold standard\u201d, but virtual
\nreality will come into this discussion (prob-
\nably not more than 10 years left for mobile
\nphones).GPS 6 will replace avatars.30 years
\nlater, there will be already expanded reality.
\nThe main megatrend that will transform
\nmedicine is digital technology.
\nTheAnswertotheHeadlineQues-
\ntion:willTechnologyandPolicy
\nChangetheDoctor-PatientRela-
\ntionshiporChangetheDoctor\u2019s
\nPlaceinSocietyandMedicine?
\nTechnology will affect physician-patient
\nrelationships, they will become increas-
\ningly remote, and a computer or a simi-
\nlar smart object in different forms will
\nbe increasingly in the middle. Artificial
\nintelligence will enter diagnostics, show
\npotential diagnoses in radiological exami-
\nnations, laboratory parameters, but deci-
\nsion-making and further treatment will
\nremain between doctors and patients. In
\nmedicine, if not through the door, global
\ndigital technology and programming will
\ncome through the window to analyse the
\npatient\u2019s genome, viruses, drug effective-
\nness, risks and treatment scenarios by tak-
\ning a large part of the funding. But here
\ntoo, for at least the next thirty years, the
\ndecision will be taken and upon action de-
\ncided between the physician and the pa-
\ntient during their conversation.
\nWith the population ageing, the proportion
\nof chronic patients increasing, combined
\nwith multimorbidity and polypragmasia,
\nthe number of doctors will grow globally,
\nat both absolute and relative rates, and after
\n30\u00a0years on average doctors will be signifi-
\ncantly older than today. Unfortunately, the
\nrole of each particular doctor in society will
\nbe reduced, while the overall share of medi-
\ncine in national economy will grow: health-
\ncare,medicine and pharmaceuticals together
\nwill be the main economic sector exceeding
\n25% of gross national product. Today, the
\nglobal health care industry is estimated at
\nseven trillion. Half of the earnings, with the
\nlargest share of the profit, are in the USA.
\nBy 2049, globally, there will be forty trillion
\ndollars worth of vodsel hardware, tools and
\npharmaceutical industry,and more than half
\nof that, with most of its profits in Asia and
\nmore than 15% in Africa.Global megatrend
\nis the globalization of the free market and
\ncapitalism; health care and medicine will
\nmove toward population growth over the
\nnext 30 years.
\nDr. med. h. c. Peteris Apinis,
\nEditor-in-Chief
\nof the World Medical Journal
\nBACK TO CONTENTS
\nIV
\nWMA News
\nWMA General Assembly
\nThe participians of the 212th
\nWMA Council Session, April, 2019, Santiago, Chile
\nBACK TO CONTENTS<\/p>\n"},"caption":{"rendered":"

wmj_2_2019_WEB WMA News vol. 65 Medical World Journal Official Journal of The World Medical Association, Inc. ISSN 2256-0580 Nr. 2, September 2019 Contents Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2019\/09\/wmj_2_2019_WEB.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/13219"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=13219"}]}}