The Greatest Challenge Facing Doctors and Clinicians
1. Introduction
Healthcare today is delivered in a complex environment with a diversity of settings. The system involves many different sectors and is faced with a rising cost, technological advances, and increasing consumer demands. The healthcare industry is a series of different systems in which people and tools work in a coordinated fashion to deliver care that enables people to stay healthy and productive. While the accomplishments of healthcare are to be envied, the industry now finds itself with a series of new challenges—challenges so pervasive and urgent that they can no longer be addressed effectively within the existing paradigms. The challenges jeopardize the very core of what healthcare delivery is all about. It is these challenges that need to be addressed in the near future.
Healthcare is defined as the prevention, treatment, and management of illness and preservation of mental and physical well-being through the services offered by the medical and allied health professions. The World Health Organization expanded the definition of health to “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Health remains a universal concern for every country; as a result, every nation has its own healthcare system designed to meet the needs of its people. It is widely accepted that good health is a basic human right and is vital for the growth and prosperity of any community. In view of the above statement, healthcare is an important and basic necessity for every person, and therefore it is important that healthcare services are made available to everyone on a consistent basis.
1.1 Background of the healthcare industry
Rising cost is the first and foremost challenge in the current healthcare delivery system. Developed countries spend more than 15% of their GDP on healthcare. It is projected that this cost will continue to increase due to an increase in the elderly population and ready access to new and expensive treatments. The cost will not only be in terms of money, as patients will need to spend more time accessing health services and waiting longer for elective procedures. High-quality care will become less accessible to many and will be a preserve of a few. High cost may also lead to more inequality in the care received by different races and social classes.
Traditional healthcare delivery system has now passed its peak of youth and is entering into old age. The current system has been marred by deficiencies such as increased cost, fragmented care, and inefficient delivery. The United States of America came up with the Affordable Care Act in 2010 to address some of these issues. However, the challenges still lie ahead with increased cost, demand, and the need to improve care coordination and provide patient-centric care.
1.2 Importance of addressing challenges in healthcare
Occupational related illness is also highly prevalent in the healthcare industry. In the Netherlands, it is estimated that 6% of workers compensation claims are for employees in the healthcare sector. This statistic is quite alarming considering that the size of the sector is only about 10% of the total working population. High levels of sick leave, often related to mental health disorders such as burnout and depression are also a major concern for the healthcare industry in many countries. It has been reported by the UK Health and Safety Executive that there are over one million workers who are suffering from a work-related illness. These injuries and illnesses not only affect an employee’s health, but can also have a significant effect on the quality of patient care and overall effectiveness of a healthcare organization. High levels of staff absence due to factors related to ill health can result in decreased patient safety and service quality.
Effective operation of a healthcare institution, which brings us to the issue of addressing healthcare challenges, depends a lot on good health of its employees. Employees in the healthcare industry are not only exposed to the traditional occupational risks, but are also prone to increased risk of injury and illness. Work in the healthcare sector is demanding and often has a major impact on a person’s health. The Dutch healthcare sector employs a workforce of approximately 1.2 million people, who in 2007 reported almost 160,000 occupational injuries. This is equivalent to an average annual incidence rate of 13.4%, which is high when compared to other sectors.
1.3 Purpose of the dissertation
Secondly, this research aims to address methodological issues in the evaluation of complex interventions. Many of the improvement strategies used in healthcare today are multifaceted and tailored to the local needs of a particular setting. Nevertheless, the randomized controlled trial (RCT) is commonly cited as the gold standard for the evaluation of interventions because it provides the most unbiased estimate of an intervention’s effect. The pragmatic RCT is designed to evaluate health service interventions and compares the outcomes of alternative strategies for diagnosing, treating, or preventing a clinical condition or the provision of care. However, RCTs are often poorly suited to the evaluation of complex interventions because they are designed to test a single variable and are unable to mimic the real-life multifaceted conditions in which complex interventions take place. The Medical Research Council has highlighted the need for alternative approaches to the RCT in the evaluation of complex interventions, but to date, little work has been done in this area. By using a range of methodologies including an RCT and ethnographic case studies, it is hoped that this research will generate useful insights into new approaches for the evaluation of complex interventions.
This research has several purposes. Firstly, it aims to review the rising literature surrounding quality improvement in healthcare. Although there is a wealth of literature in this area, it is not systematic and is therefore of limited use to policy makers, clinicians, and managers who wish to make evidence-based decisions. There is also a lack of a shared understanding about which improvement strategies are effective in changing the quality of care and uneven dissemination of evidence into practice. By examining the effectiveness of different strategies in a range of settings, it is hoped that this research will go some way to providing a better understanding of how to improve the quality of care.
2. Literature Review
This literature review will critically analyze the challenges currently facing healthcare professionals and its impact on the healthcare industry over the next decade. The types of challenges that will be looked at in this review will be in terms of its complexity in the context in which healthcare delivery is being provided. The major issue is that of a rapidly aging population. In 2006, 11.1% of the population were aged 65 or over, set against a government target of 20% by 2010. With this increase in the elderly comes a higher probability of illnesses, chronic conditions, and diseases. This places a higher demand on healthcare services that will need to be addressed. Providing healthcare that is deemed to be of high quality is another challenge. This is in terms of wants from the public, an increase in chronic disease and multimorbidity, and a need for evidence-based practice, all within a tight financial constraint. An international context will also be considered, as global health is becoming increasingly relevant in the successful healthcare delivery in the UK. This is with the increase in travel, migration, and the interconnectedness of health with other societal and environmental factors. The final challenge is that of using information effectively to improve the quality of care. This can be complex with the vast types of primary and secondary care settings and providers. However, it is believed that improvements in this area can have a significant and positive impact on the future healthcare delivery.
2.1 Overview of challenges faced by doctors and clinicians
There are numerous challenges faced by the doctors and clinicians in the present healthcare service delivery system. Some of the primary and most critical challenges are the changing disease patterns, the changing expectations in the patients, and the technological advancements. The doctors are often unable to diagnose the new disease patterns because they are usually well-versed with the old disease patterns. The changing expectations in the patients have increased the pressure on the doctors to prescribe medications, even for illnesses that do not require medications. Often, patients expect more from the doctors than the doctors can provide. They may expect an x-ray to diagnose a common cold or an MRI or CT scan to diagnose headaches. This would cause a monetary burden on the patient and, in turn, pressure on the doctor to concede to the patient’s requests. Technologies in the near future would likely be even more effective in facilitating early and accurate diagnosis and treatment monitoring. It may shift more diagnostic and treatment responsibilities to the patients themselves. For example, genetic testing, developing medical and surgical treatments customized to the needs of each individual, and even predicting the likelihood of the treatment’s success, with the patient taking a greater role in selecting treatments. They are aware of the technology involved in clinical medicine and have high expectations. Healthcare would be ‘self-centered’ around the patient. Information on the patient (and how to provide the best care for the patient) would be more accessible. Patients would like access and help in interpretation of all the information on diagnosis and treatment available from the doctor. The patient would want to participate in decisions that affect their health and thus change the conventional patient-practitioner relationship. This patient-driven approach has a multitude of effects on the doctors. While its advantages are undeniable, there may be aspects of it that would impede the optimal delivery of healthcare. The doctors would face increasing pressure from the patients to conform to the latest expected standard of care. This is especially true where there is direct-to-consumer advertising for healthcare.
The doctors are facing more complaints from their patients. Japan Medical Association data shows that compared with 1996, the number of complaints has increased almost four times in the year 2003. In the UK, 69% of the doctors have faced a complaint at least once in their professional careers. The major reasons for these are the increasing education and awareness in the patients of their right to proper medicine and the government policies to protect patient’s rights. The doctors have been burdened with longer-lasting trials, some going even up to ten years after the incidence, and therefore the fear of legal problems and litigations would be a challenge many doctors face. This has forced many clinicians to spend an increased amount of time conforming to various documentation and regulation requirements. The age of evidence-based medicine and modern technology has contributed to a deluge of information, creating a greater need for doctors to quickly access information to make the best decisions on the patient’s treatment and increasing the complexity and duration of the task.
2.2 Impact of technological advancements on healthcare
In the past, one of the key challenges may have been to spur development of the appropriate technology. At present, the challenge lies in its diffusion into healthcare delivery. The transformation of medical records from paper to digital formats is an example of how technology is changing the healthcare sector. Digital health solutions have also proven to be extremely popular with patients as they offer better access to health information and services. The use of telemedicine via video and smartphones simplifies the process for both patients and clinicians. However, lack of a clear regulatory framework hinders wider adoption of such technologies. Another common and growing implementation of technology is in robotics. The Da Vinci Surgical System is one example which is widely used in urology and prostate surgery. On the pharmaceutical front, drug design and development is an area which is given much importance by policymakers and the implementation of artificial intelligence in this field is showing significant progress. While these advancements are pivotal to addressing some of the greatest health challenges of our time (e.g. the development of more targeted therapies for diseases), the cost of development and relative effectiveness of these technologies in healthcare delivery is not clear. This, in turn, opens up its own set of challenges with the possible creation of a ‘two-tiered’ system, faster progression of the efficacy to effectiveness gap, and increased medical pluralism.
2.3 Role of government policies in shaping healthcare challenges
Arguably, the most important health care policy of the last decade has been the decision to increase the number of medical school places and subsequently the number of medical graduates, with a target of 23,400 homegrown doctors by 2006. This policy was enacted with little thought given to future consultant posts or the attempt to decrease the number of hours junior doctors work. The result has been an increase in unemployment of medical graduates, and one that many of them did not foresee. In an era of high tuition fees and education debts, these graduates may well feel aggrieved that the government has reneged on the “deal” they were promised when applying to medical school. This policy will undoubtedly have long-term implications on the medical workforce in the UK.
Government policies play a large role in the provision of health care in the UK. It follows that changes in these policies may affect how health care is provided. Primary care has been the main focus of recent health care policy in the UK. General practitioners have seen many changes in their contractual arrangements since 1990, and it has been argued that health care policy has failed to take secondary care into account. Increasingly, the direction of health care policy has been towards that of the private sector with an emphasis on targets and incentive payments.
2.4 Analysis of scholarly research on the topic
The systematic review had gathered comprehensive qualitative and quantitative articles and reports on all three countries in order to make this paper as well-rounded as possible. However, the sheer number of theoretical ways to approach the topic, in conjunction with finding reliable sources through the UM library databases, meant that the articles chosen generated an overall analysis using hospitals in Singapore with a few comparisons and models from other developed countries due to the wealth of literature available for this small country. Data and statistical representation of the problems occurring in hospitals in Malaysia and the impact of the fragile state of medical practice in a highly politicized environment in Malaysia were limited to more recent reports or singular qualitative reports. It is safe to say that there are too few studies on the latency and efficiency of cost-effective measures to make healthcare improvement changes realizable within the time frame of a decade for a developed nation undertaking economical evaluations in healthcare. The transparency, ethnography, and focus group/individual interviews of qualitative reports reveal an in-depth analysis of the situation and problems on a smaller scale, by individual level healthcare personnel. It provides an excellent understanding of the illness career and medical history of the patient seeking care in general practice and the means and referral to hospital care.
2.5 Identification of research gaps and unanswered questions
It is often easy to be caught up in reviewing the facts and fall into the trap of uncritical acceptance. Analyzing and critiquing the data is important as often it raises more questions than answers, new theories and new ways of interpreting data emerge and point to the need for further research. Authors from the various studies of the aforementioned issues are in agreement that more research is needed in the quest to understand how to retain the art of medicine in the face of increasing technocratic and economic rationalist influences. The most comprehensive research on the subject has been a study on GPs in Australia and UK dealing with job satisfaction.
The reader is led to infer that the drop in satisfaction is due to the changing work environment and the increase in medical litigation rather than direct changes in population health needs or patient interactions. However, this is an issue that affects all doctors and research in this area would be beneficial in understanding what has changed and how it can be maintained. A Canadian paper raises the potentially troubling issue of a division in quality of care between the rich, who will seek the latest and most technologically advanced treatments, and the rest of the population. The implications of the steadily increasing proportion of the bureaucratic healthcare system on patient health are understudied as is the effectiveness of various policies in achieving their aims for the population’s health.
3. The Greatest Challenge: [Specific Challenge]
A UK publication defined this new care model as the attempt to base care on what matters to the patients, to obtain a comprehensive understanding of what an illness means to the patient, discerning the patient’s patterns of living with the illness, and bringing care that is sympathetic to the patient’s illness experience. These sentiments were echoed by a moving article in the British Medical Journal, where the author uses her experiences as a cancer patient to illustrate the failings of the healthcare system in being unable to meaningfully address the needs of those it is trying to help.
The case for patient-centered care is being proclaimed throughout the healthcare system. The Institute of Medicine’s report on the quality of healthcare delivered in the United States documented that the care provided is not of consistently high quality and many patients are receiving suboptimal care. As a result, the report has called for a complete overhaul in the approach to quality assessment and improvement in the US healthcare system.
Patient-centered care is the relative newcomer to the challenge for doctors on how to practice the art of medicine in the modern era. Traditionally, the illness has been in the forefront with the physician being the one in charge of its diagnosis and treatment. This disease-oriented approach to medicine is rapidly being replaced by a patient-centered model. This new approach is defined as care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
3.1 Definition and explanation of the specific challenge
Faced with providing more health care to more people at a lower cost, society has an ever-increasing need for science to play a larger role in providing answers to health care problems. Clinical research is one of the most important means of improving the effectiveness and quality of health care. However, there is a danger that the scientific enterprise in its entirety becomes skewed toward the interests of commercial partners rather than the interests of the public and patients; this could result in a net loss of scientific knowledge and harm to the public [3]. To understand how this could happen, one must first recognize changes in the nature of the clinical research workforce. Ideally, the clinical research workforce should be composed of highly trained experts who work to translate the best scientific knowledge into health improving interventions. Unfortunately, this is no longer the case as the majority of the clinical research tasks are actually carried out by workers in the health care sector trying to generate additional income for their institutions, supplement their own clinical incomes, or compete for industry funding directed at their institutions [4]. This situation places a heavy burden on these clinicians without research training and increases the probability that the research will be focused on questions of interest to industry rather than questions arising from the expertise of the investigator. Yet, the most significant change to the clinical research workforce has been the increase of scientists working directly for industry. This group often conducts research that never enters the public domain and the generation of scientific knowledge is not the primary focus of their work. Instead, the main objective is to gain regulatory approval for a product or to increase market share for a company. While these scientists may possess the expertise to conduct valid research, it is an inefficient use of resources to have two parallel research workforces and the net result may well be that the public is ill served by both. Clinical research conducted by medical students, residents and fellows is the final group that deserves mention. With debt from education and increasing competition in the job market, many students and clinicians in training view industry funded research as an opportunity to improve their financial standing and ease the transition to an independent career. While there is nothing inherently wrong with this, it becomes problematic when industry funded research becomes the most viable career option for these individuals and their numbers increase to the point where they hinder the progress of clinical research and erode the infrastructure for the next generation of independent investigator.
3.2 Factors contributing to the challenge
Doctors and clinicians often face challenges more complex than the usual ailments and injuries that are presented to cure. Lazarus and Folkman say, “Most people think of health as of cured disease or a prescribed ideal. Few understand that their health often depends on what goes on in their minds.” This is particularly poignant for the chronically ill patients, who often struggle with psychological issues and pain that is difficult to define and measure. Yet, many would argue that the greatest challenge facing doctors and clinicians in trying to provide the best care for their patients. There is no single ‘right’ way to care for a patient, and determining the most appropriate care for a specific patient often entails sifting through a large number of options and making decisions about what is best for the patient. This requires good communication between patient and doctor, exploring the patient’s preferences and making decisions together. The rapidly advancing science and plethora of treatment options available means that this task is becoming increasingly difficult. This decision making process can often take a long time and be quite frustrating for the patient if they feel that their doctor is using a ‘trial and error’ approach. Frustration can also arise for the doctor if the patient’s health does not improve or deteriorates, as they may feel that they have failed to provide effective treatment for the patient. This frustration can strain the patient-doctor relationship and has the potential to lead to doctors trying to ‘offload’ complex patients to other clinicians, making a decision that the patient would be best managed by someone else. This is not in the best interest of the patient, and often results in wasted healthcare resources and further dissatisfaction for the patient.
3.3 Case studies and examples illustrating the challenge
Doctors and clinicians are faced with many challenges daily, and one of the most significant, yet often overlooked, is abstaining from causing harm to patients. Sir Liam Donaldson, Chief Medical Officer of England, describes patient safety as the prevention of “avoidable adverse outcomes or injuries sustained during healthcare.” This definition is broad and includes intentional and unintentional acts, but the most obvious evidence of this failure in safety is in the form of error.
Medicine is an inherently uncertain activity, which carries a degree of risk and probability of failure. Despite the high stakes, doctors are still human and are fallible to the same influences as anyone else. Historically, errors have been perceived as being due to personal negligence or recklessness, and the individual responsible would be subjected to some form of punishment. However, this approach is outdated and unfair. It does not take into account the complexity of the healthcare system and the defenses that individuals develop in order to prevent error, nor does it help to identify the root cause of errors in order to prevent repetition. Nowadays, with an understanding of the hole that error can lead to and its potential effects, there is a great sense of personal responsibility and a burden of guilt when a mistake is made. This is the case when considering the example of Dr. Al, a senior house officer in a district general hospital.
3.4 Current strategies and approaches to address the challenge
3.4.1 Drawing of strategies to overcome the current challenges.
The most important development in solving the current problems has been the formation of a campaign, five years ago by the Department of Health funding £45m for mental health staff to provide dedicated care for depressed heart disease patients. That money has funded nearly 500 workers, from August 2004 nearly 3593 patients have been referred to or seen by workers this equates to 12,000 patient mental health contacts.
The principal investigator of a study to be published in Circulation: Cardiovascular Quality and Outcomes described as one of the most efficient methods comes from a trial called UPBEAT-UK a large randomized controlled trial which will specifically address the problem of depression for patients with coronary heart disease. The trial is designed to test the efficacy and cost effectiveness of a Home Based Intervention using a cognitive behavioural approach augmented by exercise is a potential low risk/high gain option in an era of limited health care resources, if successful it could be rolled out over the NHS as a model of care for patients with CHD and depressive symptoms. Measures of health outcome and resource use will be taken from 700 patients over two year’s duration.
Counting the cost is a new report which is arguing that for every patient with long term conditions to have access to psychological therapy across the UK it cost £1.45 per head of population per year. It’s claimed that this will benefit the patients by improving their quality of life and the cost offsets from reduced physical healthcare usage and improved employment.
The British Heart Foundation have part funded a programme called Beating the Blues and this has been tested through a pilot of 25 patients. Initial feedback has suggested that patients like it and find it quite stimulating. A further small study with 40 patients informs of an online computerised CBT for the treatment of depression in patients with CHD. This has shown clear potential for the future way of treating these patients and abolishes the capacity or living in an area considered to access traditional psychological therapies. However there is a need to ensure that allocation of patients to any of these specified interventions or treatments are both smooth and safe. A balance of using self-referral and identification through a primary carer or health professional method would be best.
3.4.2 Shortcomings of strategies available today.
There are however many handicaps in actioning these strategies. The current provision of mental health services continues to be weak with an immense gap in providing the right type of care. As a result the overloading of available services tend to overburden defined or trial treatments and subsequently lead to an unclear patient allocation and randomization. This might put the patient at risk of missing appointments, delayed information retrieval and right away disqualification from any treatment due to change in his/her health status. This can be particularly in the case of patients with severe medical conditions and has been shown to happen in an UK example of an online computerised CBT trail which failed to recruit or simply lost track all intended patients. An evident deficiency of patient access to therapy service is despite
Increased research on depression has still left the cause and effects still poorly understood. Mentioned treatments are based upon the premise that psychological or biological interventions will improve mechanisms and mitigate symptoms where it is known to cause harm in cardiac patients. It is essential to confirm and identify such treatments with real patient symptoms and prognosis with precise identification of a depression related cause or effect on cardiac disease and abstracting possibly harmful treatments in dangerous or unsure situations of patient health.
3.5 Evaluation of the effectiveness of existing solutions
The function and purpose of evaluation in health care is to investigate the effectiveness of interventions in achieving their aims and to consider alternative approaches to achieve better outcomes. In this context, evaluation means the systematic application of scientific and statistical procedures to assess whether the intervention achieved the intended outcomes. It may be a small scale investigation of the care of an individual patient or a large scale, multi-centre trial of a new treatment. With both examples, the simple question is whether the intervention made any difference to the patient’s health. Answering that question is often more complex than it first appears. The background, intervention and outcomes are frequently confounded with factors that influence the course of the patient’s illness. Separating the impact of the intervention from these confounding factors requires a rigorous and robust research design. Cost effectiveness analysis is an important part of the evaluation of an intervention, that assesses whether the health gains from the intervention represent value for money, compared to the best alternative use of the resources. This type of analysis is essential in our current healthcare environment, where treatments compete for a limited budget and health and social care. An intervention may be highly effective but poor value for money, in which case resources may be better directed elsewhere. Step by step guidance for the evaluation of complex interventions is available from the Medical Research Council.
4. Recommendations and Future Directions
4.1 Proposed strategies to overcome the challenge
The challenges faced in the medical workforce and the medical education system are complex and gradual to change, hence it is crucial to develop and implement careful pre-emptive and responsive strategies to combat these issues. The strategies must be well supported, sustained, and evaluated for there to be functional change in the delivery and management of medical education in the competency of preparing tomorrow’s doctors.
According to the current literature and evidence, the challenges identified all have a significant negative impact on today’s medical workforce that is required to provide leadership, cope with uncertainty, and equip future doctors with the necessary knowledge and skills to manage a rapidly changing health industry towards more patient-centered care. This essay has also revealed that the greatest challenges have substantial adverse effects on delivering optimal patient care and patient outcomes. The limitation of this essay is that it has not provided an extensive coverage of all the issues and possible strategies facing medical educators and has not employed a wide consultation process among all stakeholders in medical education, such as doctors, students, patients, and professional groups. However, the preliminary work has provided a baseline for the future identification and management of these issues with further extensive research. As a pre-emptive measure of coping with the identified workforce preparedness issues, developing doctors and sustaining change in the delivery and role of medical education, it is vital to reform medical education, with the overarching aim of improving the quality of patient care and safety.
4.1 Proposed strategies to overcome the challenge
Developing and implementing strategies to address these challenges is crucial for the future of medicine. This will require the cooperation and support of governments, health and research funding bodies, and the medical and public health community. A greater understanding of the risk factors for depression in doctors and how it impacts their medical practice will provide the medical community with the knowledge to develop prevention and early intervention strategies. This will require further longitudinal and qualitative research involving doctors at different career stages and specializations. In addition, mental health literacy in the medical community needs to be improved, and the stigma associated with doctors seeking help for mental health problems must be addressed. This will allow depressed doctors to seek help with confidence and without fear of discrimination.
Research and preventive interventions focusing on doctors’ physical health needs to be extended to the psychological and cognitive effects of stress and fatigue on medical performance. Integrating concepts from occupational and organizational psychology into medical education and training is vital to promote self-care and the development of coping strategies for doctors during their medical careers. This will require curriculum review and the provision of resources and support for medical students and doctors at both individual and organizational levels. Optimizing work organization, including hours of work, job control, job demands, and social support at work, are methods outlined in the broader job stress and prevention literature, which have been shown to be effective for preventing psychological distress and job-related health conditions. Similar studies involving doctors and medical workforce trials are needed to determine the most effective strategies for maintaining a healthy medical workforce.
4.2 Consideration of ethical implications and patient-centered care
An ethical analysis of patient-centered care must begin by clarifying whose interests are being served. It is argued that patient-centered care is consistent with medicine’s primordial commitment to the patient’s welfare because it provides opportunities for patients to express their values and concerns and have them guide decisions about looking for or applying new medical treatments. However, as doctors have been acculturated to a role of strong paternalistic decision-making, some may feel that patient-centered care is a guise for abandoning patients to make uninformed decisions or to make decisions that the clinician feels are not in the patient’s best interests. This can raise much inner conflict for doctors about what it means to act in their patient’s best interests.
A complex web of professional, business, and biomedical ethics frames the challenge of delivering patients more involving roles in making decisions about their healthcare. The shift towards patient-centered care has been widely advocated as a means to improve the quality of healthcare and to better meet the needs and preferences of healthcare consumers. Despite the lack of consensus on its definition, the essential elements are the involvement of patients in decision making about their treatment and an adjustment of the delivery of care to account for the individual patient’s priorities, preferences, and decision making.
4.3 Potential impact of future developments in healthcare
Overall, future developments in healthcare have the potential to alleviate the greatest challenge both in the United States and globally. These recommendations have the potential to affect change over a long period of time and may not necessarily be directed at the immediate future. The great challenge facing clinicians and practitioners, as it has been discussed, may be overcome through both specifying and responding to the needs of vulnerable populations with evidence-based interventions. This approach is in stark contrast to the recent trends of global health initiatives to bring change in low and middle-income countries through partnered relationships between wealthier and poorer nations. While at times these relationships appear altruistic in nature, often the needs of the targeted populations are undefined and interventions are unproven. Whether it is caring for an individual patient or implementing global health policy, collective knowledge regarding which interventions are effective and understanding the social determinants of health are what enable meaningful improvements in health outcomes. In the end, the successful implementation of these strategies should enable equal access and quality of care for vulnerable populations. This would be a successful outcome for all stakeholders involved, including the patients themselves, those who provide their care, and the myriad individuals and organizations that are invested in the health of their communities.
4.4 Areas for further research and exploration
A related issue is that of how to provide best care for an ageing population. It is widely known that the populations of developed countries are getting older, and that older people are the major consumers of healthcare resources. This represents a huge challenge in terms of increased demand on the healthcare system, but also a great opportunity. Older people suffer more from chronic and disabling diseases, and so the shift to preventive treatments for these conditions could greatly benefit them. With increasing age there is also a greater relative burden of diseases such as cancer and cardiovascular diseases, so research into effective preventive treatments will be highly relevant. On the other hand, older people are often excluded from clinical trials, and little is known about how to best treat many conditions in this population. An increased focus on improving the evidence base for treatments specific to older people, and greater integration of clinical and social care are other strategies that could greatly benefit this growing section of the population.
One potential area for further research is to explore the possibility of preventive treatment. Much of the current research is focused on improving treatment of diseases, and relatively little on preventing them. This is particularly relevant to cancer, cardiovascular diseases, mental illness, and conditions such as obesity and diabetes. It is these chronic diseases, and the disabilities arising from them, that represent the greatest burden on the healthcare system. A shift in focus from treatment to prevention has the potential to not only make a lot of people healthier and happier, but also save a great deal of money. This will involve research that goes beyond the traditional bounds of medical science. For example, the causes of many diseases are as much social and environmental as they are biological. Effective preventive treatments for these diseases will involve social and political, as well as medical, strategies. An understanding of the complex causal pathways of diseases, and the factors that can interrupt these pathways and prevent a disease developing, is another area where medical science could do much better. For too many diseases we simply do not know enough about how to prevent them. Preventive treatments do offer a great challenge for medical science, but are potentially the most cost-effective ways of improving public health.

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