wmj_2_2019_WEB2

WMA News
vol. 65
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 2, September 2019
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
212th
WMA Council Session, 25–27 April, 2019, Santiago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
World Health Assembly – Geneva, May 20–28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
MEDICINA DEL 2030. El Futuro Esta a la Vuelta de la Esquina Prepárate! . . . . . . . . . . . . . 16
WFME Conference: Quality Assurance in Medical Education in the 21st
Century . . . . . . . . 17
Now is the Time for Physicians and Medical Associations to Prepare for Augmented
Intelligence in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Identifying Training Needs for Healthcare Organisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
In-Flight Medical Events: an Excellent Application to Support Onboard
Medical Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Primary Amoebic Meningoencephalitis as a Cause of Headache and Fever –
a Global Waterborne Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Statement by Frank Ulrich Montgomery.
“Physician 2030: the Future is around the corner” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Physician in 30 years from Now – will Technology and Politics Change Physician –
Patient Relationships or Change Doctor’s Place in Society and Medicine? . . . . . . . . . . . . . . . 34
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Leonid EIDELMAN
WMA President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
Dr. Miguel Roberto JORGE
WMA President-Elect,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Mari MICHINAGA
WMA Vice-Chairperson of Council
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Yoshitake YOKOKURA
WMA Immediate Past-President
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Andreas RUDKJØBING
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
Kristianiagade 12
2100 Copenhagen 0
Denmark
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Editorial
Editorial
Medication non-adherence is one of the worst epidemics of the 21st
century.
Only one in ten patients buys medicines in a pharmacy. Every sec-
ond in ten – buys the tablets, but does not open the medicine pack-
age. Every third in ten patients takes medicines irregularly, insuffi-
ciently,forgets about their use.If the patient is prescribed more than
six medicines of different names,it is highly unlikely that he will use
all prescribed medicines exactly.
The greatest medication non-adherence is in psychiatric patients.
Multimorbid patients with type 2 diabetes, hypercholesterinemia
and hypertension should be mentioned among those who do not
use medication and, therefore, more than 150000 such patients die
each year on the planet due to not using medicines, from complica-
tions of hypertension, most commonly – stroke. Non-adherence is
even more apparent regarding doctor’s advice on healthy lifestyle.
Repeatedly we have to explain to our patient the mantra – eat less,
move more, or – follow a diet, engage in physical activity. It is very
difficult to make your adipose patient go to a physiotherapist and
make them exercise or at least ride a bicycle. A patient-smoker is
even more difficult. Specifically, the chronic obstructive pulmonary
disease patient is not ready to drop smoking and start taking medi-
cation daily. 
Medication inequality creates transverse pathways for doctors, re-
duces treatment results for patients, and yet medication non-adher-
ence is nothing good or anything bad. Medication non-adherence
varies from full co-management to complete non-inferiority, but
more frequently, it is in the middle.  Once an extensive global study
revealed that more than 90% of patients understood the concept
“one tablet once a day”. On the other hand, 43% of patients in the
doctor’s office, under conditions of moderate personal stress and ur-
gency, misunderstood or mixed “one tablet twice a day” and “two
tablets once a day”.  Research has shown that despite the doctor’s
efforts, patients leave the doctor’s office having understood less than
50% of the information the doctor had told.  Regardless of the pa-
tient’s age, culture or education, confusion about drug use, price,
effect, side effects cause serious concern and anxiety.  Too often, the
doctor does not address the issue of how long the patient should
take the medication. If the disease is acute, the doctor determines
exactly – six days. If the disease is chronic, the doctor prescribes the
medication, but admits that the doses and medication will have to
be changed.Often,the doctor prescribes the medicine knowing that
the medicine will have to be administered to the patient for the rest
of his life, though the average patient cannot even imagine it to be a
fact up to the end of his days.
The issue of the global epidemic of medication non-adherence
seems to be actualisable. Medication non-adherence is not an indi-
vidual case, but a global phenomenon.The worst of all are activities
carried out by the patient’s relatives, such as parents who do not
allow their children vaccination against infectious diseases.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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2
WMA News
The 212th
WMA Council meeting was held
at the Hotel Santiago (Mandarin Oriental)
from April 25-27. Around 150 delegates
from 35  national medical associations at-
tended.
THURSDAY, APRIL 25
The meeting began with the outgoing
Chair of the Council, Dr. Ardis Hoven,
in the chair for the last time, giving a brief
orientation session for new delegates about
the procedure for the meeting. Dr. Hoven
was stepping down after serving as Chair of
Council for the past four years.
Council
The Council session was formally opened by
Dr. Otmar Kloiber, WMA Secretary Gen-
eral, with apologies and a welcome for del-
egates and new Council members.
Elections
The first item was the election of the chief
officers.
Dr. Frank Ulrich Montgomery (Germany)
was elected Chair of Council.
Dr. Mari Michinaga (Japan) was elected
Vice Chair.
Dr. Ravindra Sitaram Wankhedkar (India)
was elected Treasurer.
All the elections were unopposed.
President’s Report
Dr. Leonid Eidelman, the President, re-
ported on his activities over the previous six
months. He referred to the global problem
of increasing violence against physicians and
his meeting in Taiwan on Universal Health
Coverage (UHC). He talked about one of
the main themes of his presidency, physician
wellbeing and burnout among physicians.He
had attended the 12th
Geneva Conference
on Person-Centered Medicine, Promoting
Wellbeing and Overcoming Burnout, in
March,where he talked about burnout being
a global epidemic. It affected both quality of
life and quality of health care.
‘Physician burnout is one of the most acute
challenges of contemporary medicine and
endangers physicians as well as the quality
of healthcare. There is a need for studying
preventive and treatment solutions’.
He had spoken at the Global Conference on
Primary Health Care, in Astana, Kazakhstan
in October 2018.The goal of the meeting was
to renew a commitment to primary health
care in order to achieve universal health cover-
age and the Sustainable Development Goals
which were part of the UN’s agenda for 2030.
Strengthening of primary health care (PHC)
was essential for Universal Health Coverage.
The role of physicians was crucial in primary
health care,from education to prevention,and
in both acute and chronic care. High quality,
evidence-based PHC provided by a trained
team led by a physician was probably the
best foundation of future medicine. However,
during the Astana meeting, it was notice-
able that many participants did not think the
PHC model should have the physician at the
helm of leadership.The conference focused on
other health care providers, traditional ones
such as nurses, pharmacists and social work-
ers, and new professions, such as commu-
nity health workers and healthcare assistants.
He had also travelled to conferences in To-
kyo, Geneva and in Germany, where the
National Association of Statutory Health
Insurance Physicians in Germany orga-
nized an unveiling ceremony marking the
withdrawal of the medical licenses of Jewish
German doctors 80 years ago.
212th
WMA Council Session,
25–27 April, 2019, Santiago
Ravindra Sitaram Wankhedkar Leonid Eidelman
Mari Michinaga
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WMA News
Finally, Dr. Eidelman said he had spoken
at a Universal Health Care International
Conference, in Taipei, Taiwan and at the
International Conclave on Zero Tolerance
to Violence Against Doctors and Hospitals,
in Mumbai, India.
‘Violence against doctors is a global problem.
The speakers described causes of violence
and ways to withstand it. I presented the
statement of the WMA on violence against
physicians and stressed that this kind of vio-
lence not only has destructive social effects
but impairs the quality of healthcare that
is provided to innocent patients as well. In
addition, I emphasized the role of physician
burnout in this intolerable phenomenon’.
Secretary General’s Report
Dr. Otmar Kloiber also referred to violence
in health care and said it was very clear that
this was not an Indian phenomenon but a
global phenomenon. ‘We have to do more
to address this. It is not an isolated phe-
nomenon but rather a general one’.
He reported on the situation in Turkey,
where the Government was making life
harder and harder for physicians. The Turk-
ish board had been arrested for supporting
terrorist activities. They had made a state-
ment that ‘War is detrimental to public
health’, a statement based on WMA policy
and one that every clear-thinking person
would agree to. But that was enough to be
arrested and sent to prison.They were out on
bail and Dr. Kloiber urged national medical
associations to talk to their governments to
make them aware of what was happening in
Turkey.What was happening was an attempt
to crack down on self-government of physi-
cians to make them a tool of the government.
Chair’s Report
Dr. Ardis Hoven spoke of her incredible ex-
perience as Chair of Council.
‘I now possess a much deeper understand-
ing of the role of medical ethics and the role
the WMA plays in that field.Thanks to the
secretariat’.
She added:’It has been a great honour to
serve, lead and represent the WMA across
the globe. Little did I know when I first
came to the WMA, that I would meet so
many wonderful and caring physicians who
would give freely of their time and intellect
to serve their fellow physicians and all pa-
tients throughout the world.
‘I have learned from each and every one
of you and have immense respect for your
commitment to excellence in health care.
Challenges exist but I am convinced that
the work of the WMA and all of its mem-
bers will continue to make credible and pro-
gressive improvements on the platforms of
change to which we are committed’.
Matters of Urgency
The South African Medical Association
presented an emergency resolution on
Medical Ethics in Sports Medicine and the
case of the middle-distance runner Caster
Semanya.The International Athletics Asso-
ciation Federation had brought in rules for
women with differences in sexual develop-
ment which SAMA believed were contrary
to WMA policy. It was appropriate that
the WMA developed statements but also
engaged. It was imperative that physicians
were reminded by the WMA of their ethi-
cal obligations. These rules would result in
some moral crisis for doctors, as they re-
quired the administration of medicine when
there was no pathology.
The Council agreed that the issue should be
considered by the Medical Ethics Commit-
tee. The Chair of Council told the meeting
that a press release had been issued by the
WMA that morning.
Medical Ethics Committee
Dr. Andreas Rudkoebing (Denmark) was
elected unopposed as Chair of the commit-
tee to succeed Dr. Heidi Stensmyren.
The General Secretary reported on new de-
velopments in the field of research ethics.He
referred to CIOMS (The Council for Inter-
national Organizations of Medical Sciences)
work groups analyzing aspects of ethics in
research, one on increased use of healthy
volunteers in clinical research and one on re-
search in vulnerable groups.Both issues were
of relevance to the Declaration of Helsinki,
and the WMA as a CIOMS member was
cooperating in those work groups.
Otmar Kloiber Ardis Hoven
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4
WMA News
Dr. Kloiber also noted that the potential use
of artificial intelligence and big data to replace
control groups by a virtual control collective,
was an emerging issue.The WMA should ex-
amine whether this should be reflected in the
principles of the Declaration of Helsinki. He
highlighted the aspect of patient-centricity
in clinical studies and said that that patient
groups had a far bigger influence nowadays
on how the research was being done.
Finally, he suggested that the committee
further discuss aspects of end-of-life care
apart from euthanasia and physician assist-
ed suicide. The WMA regional discussions
showed numerous problems associated with
withholding or withdrawing treatment at
the end of life and problems regarding re-
spect for the will of the patient, especially
when it came to ending curative treatment.
Genetics and Medicine
The Chair of the work group gave an oral
report, saying that a year ago it was decid-
ed a work group should revise the WMA
Statement on Genetics and Medicine. The
key aim was to update the Statement re-
garding the increasing clinical use of ge-
netic analyses, including large scale genome
sequencing. Genetic testing was a large,
complicated and rapidly involving area.The
group had decided to focus its paper around
the key issue of how to facilitate the collec-
tion, storage and use of genetic information
in the provision of health care.
The committee decided to circulate the
work group’s draft paper to constituent
members for comment and agreed that
Professor Reynir Arngrímsson from the
Icelandic Medical Association should take
over the chairmanship of the work group.
International Code of Medical Ethics
The committee received an oral report from
the chair of the work group on the work
done in the last months and the future work-
plan. The next step was to develop a list of
priority issues and possible new headlines.
The work group would decide at a later stage
during the revision process if the scope of the
ICoME should be broadened and how de-
tailed it should be. It proposed to organize
regional expert conferences in 2020 as was
done for the Declaration of Helsinki and
the Declaration of Geneva revision process,
and which increased the visibility of WMA
policies.The work group was aiming for final
approval of a revised Code from the Council
in April 2022 and adoption by the General
Assembly in October 2022.
Reproductive Technologies
It was reported that the chair of the work
group was not able to attend this meeting,
but would report back to the committee at
the next meeting.
Document of Torture
The committee received an oral report from
the rapporteur from the Danish Medical
Association, regarding the progress of the
10-year revision of the WMA Resolution
on the Responsibility of Physicians in the
Documentation and Denunciation of Acts
of Torture and Ill-treatment.
The policy had been reaffirmed with minor
edits and had been sent out for comments
from NMAs and constituent members. But
after receiving the comments, the rappor-
teur recommended a major revision. The
committee recommended to Council that
a work group be established with the man-
date to work further on the revision of the
Resolution.
Female Foeticide
A proposed revision of the WMA State-
ment on Female Foeticide was considered
by the committee
Delegates agreed to one friendly amend-
ment to the document, making it clear that
sex selective abortion for reasons of gender
preference was discriminatory where it was
solely due to parental preference and where
there were no health implications for the
foetus or the woman.
The committee agreed to recommend to
Council that the proposed revision, as
amended,be approved and forwarded to the
General Assembly for adoption.
Euthanasia and Physician
Assisted Dying
The committee discussed the comments re-
ceived on the WMA Statement on Eutha-
nasia and Physician Assisted Dying.During
the debate it heard from the spokesperson
for the Physicians’ Alliance against Eutha-
nasia, representing 1,100 Canadian doctors,
on why they were opposed to any change in
position by the WMA on euthanasia. Oth-
er speakers said that it was important to de-
fine clearly the relevant terminology.
The committee decided that the policy re-
quired further work and recommended to
Andreas Rudkoebing
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5
WMA News
Council that the German Medical Associa-
tion work further on the proposed Statement.
WMA Physician’s Pledge
The proposed amended WMA Statement
on Action to Stimulate use of the Physi-
cians’ Pledge of the Declaration of Geneva
was tabled for discussion.
Several national medical associations said
they had oaths with different wording.
Some speakers disliked the mandatory na-
ture of the proposed Statement.
The committee agreed to recommend to
Council that the proposed Statement be cir-
culated to constituent members for comments.
Solitary Confinement
The committee considered a proposed revi-
sion of the WMA Statement on Solitary
Confinement setting out new advice to phy-
sicians.Delegates were advised of the need to
review policy, and concern was raised about
the mental and physical risks for children
and young people from solitary confinement.
It was agreed to recommend to Council that
the document be circulated for comments.
The British Medical Association volun-
teered to be the rapporteur.
Physicians Treating
Relatives and Friends
A proposed Statement on Physicians Treat-
ing Relatives and Friends was submitted by
the South African Medical Association.This
set out new ethical advice to physicians about
the potential moral conflict between their
roles as a family member and as a physician.
The committee agreed to recommend to
Council that the Statement be circulated to
constituent members for comments.
The South African Medical Association
agreed to act as rapporteur.
Physician-Patient Relationship
The committee considered a proposed
WMA Declaration on the Physician-Pa-
tient Relationship introduced by the Span-
ish Medical Association. This called for
action for national medical associations to
take to protect the long-standing physi-
cian-patient relationship which it warned
was under threat. During the debate that
followed, it was suggested that UNESCO
should adopt the relationship as a world
cultural heritage.
The committee agreed to recommend to
Council that the document be circulated
to constituent members for comments.
The Spanish and Portuguese Medical As-
sociations volunteered to be the joint rap-
porteurs.
Classification of 2009 Policies
The committee reviewed the recommenda-
tions received on revising policies which
were 10 years old and it recommended that
the WMA Statement on Embryonic Stem
Cell Research undergo a major revision, led
by the American Medical Association.
Human Rights
Ms Clarisse Delorme, WMA Advocacy
Advisor, gave an oral report, highlighting
the invitation by Mr Victor Madrigal-
Borloz, the UN Special rapporteur on
sexual orientation and gender identity, for
the WMA to take part in a consultation to
develop human rights guidelines on data
collection about LGBT populations in
the context of violence and discrimination
based on sexual orientation and gender
identity. The first meeting had taken place
in February, when the WMA promoted
the Declaration of Taipei on data collec-
tion.
Resolution on Medical Ethics
in Sports Medicine
The committee considered the proposed
emergency resolution on Medical Ethics in
Sports Medicine submitted by the South
African Medical Association. The resolu-
tion urged the WMA to express strong res-
ervations on the ethical validity of the 2018
International Association of Athletics Fed-
erations Eligibility Regulations for Female
Classification to impose an upper hormonal
limit for athletes wishing to compete in the
female category in international athletics
competitions.
The committee recommended that the
Resolution be circulated to constituent
members for comments.The South African
Medical Association volunteered to be the
rapporteur.
Finance and Planning
Committee
Dr. Jung Yul Park (Korean Medical Asso-
ciation) was elected unopposed as Chair of
the Committee.
Jung Yul Park
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WMA News
Membership Dues and
Payments for 2019
Mr Adolf Hällmayr, the WMA’s Financial
Adviser, presented to the committee the
Report on Membership Dues Payments for
2019 and Report on Dues Arrears.
The committee recommended that Council
approve the Reports.
Financial Statement
The committee then considered the Finan-
cial Statement for 2018. Mr Hällmayr pro-
vided an in-depth analysis of the contents
of the document. He said the assets of the
Association were very solid and there was
no financial shortfall.
The committee recommended that the
Statement be approved by Council.
WMA Strategic Plan
A draft WMA Strategic Plan for 2020-
2025 was introduced. The Chair of Coun-
cil reviewed the Plan, which he said would
serve as the backbone document to guide
the plans and activities of the WMA. He
stressed that this was a living document and
that world events and other factors could
affect where the WMA chose to focus its
attention. He referred to various priorities,
such as the Declarations of Helsinki and
Geneva, and universal health coverage with
access for every individual to a physician.
After a brief debate, the committee agreed
to recommend to Council that the Plan be
approved and forwarded to the General As-
sembly for adoption.
WMA Statutory Meetings
The committee considered the planning and
arrangements for future statutory meetings
It recommended that the theme entitled
‘Transplantation and Donation/Organ
Trafficking: International Scenarios’ be ap-
proved by the Council for the Scientific
Session of the 71st
General Assembly, in
Cordoba in 2020.
It also recommended several dates and ven-
ues for future meetings:
• the 218th
Council Session to be held from
22-24 April 2021 in Seoul, South Korea;
• the 224th Council session to be held from
20-22 April 2023 in Baku, Azerbaijan
pending clarification of eligibility of all
WMA members to attend based on visa
requirements;
• the 74th
General Assembly to be held
from 4-7 October 2023 in Rwanda;
WMA Special Meetings
The committee received an oral report from
the Secretary General on two conferences –
‘Physician 2030’ in Tel Aviv, 13-14 May
2019 and ‘H20 Conference’in Tokyo, 13-14
June 2019.
Constituent Membership
An application for constituent membership
was received from Doctors 4 Doctors in the
Seychelles.The committee agreed to recom-
mend that the application be approved by
the Council and forwarded to the General
Assembly for approval.
Associate Membership
The Chair of the Associate Members,
Dr. Joe Heyman, gave an oral report on the
group’s activities. He said the group had
613  members from Japan and 505 from
elsewhere, including junior doctors and
medical students.
In his report he said that since the General
Assembly meeting the group had reviewed
the circulated documents and commented
on all of them. Its Google group had grown
to 230 members and from this group he had
received more than 100 comments on the
issue of physician assisted suicide from both
sides of the issue. These had been distrib-
uted to the meeting.
The Secretary General congratulated the
group on its impressive work.
Junior Doctors Network
The JDN Chair, Dr. Chukwuma Oraegbu-
nam, gave an oral report on the Network’s
Adolf Hällmayr
Joe Heyman
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WMA News
activities, including improving the reach of
the Network and increasing the participa-
tion of members in its activities. After a re-
view of JDN work groups, some groups had
been closed, while new ones were planned,
including a one on global surgery.
Past Presidents and Chairs
of Council Network
The Secretary General, on behalf of the
Chair of the PPCN Network, Dr. Dana
Hansen, who could not attend, gave an
oral report. He said that several past Presi-
dents and Chairs had helped in organising a
number of recent conferences.
The committee received the report.
Review Committee
The committee received an oral report from
the Review Committee’s interim Chair.
Delegates were told that past and present
members of the committee believed that the
function of the committee was very helpful
to the organisation and were likely to rec-
ommend that it became incorporated as a
more permanent body.
The committee received the report.
Procedure on WMA
Council Resolutions
The Committee considered a proposed
procedure for dealing with WMA Council
Resolutions. With two editorial changes,
the documents were agreed.
Policy Consistency
A proposed WMA Statement on Policy
Formulation and Consistency among
the World Medical Association and na-
tional medical associations was discussed.
Dr.  Kloiber explained that the content of
the proposed statement was procedural,
rather than policy-related.There were com-
ments that the document was too prescrip-
tive, which was agreed by Dr. Kloiber.
The committee recommended that the sec-
retariat study how the document’s recom-
mendations could be implemented.
World Medical Journal
An oral report was given by the WMJ Edi-
tor Dr. Peteris Apinis, who said there had
been four issues in 2018 and four issues
were planned for 2019 as well.
The WMJ was mainly issued in digital form
and was e-mailed to all national medical as-
sociations.
In his written report, Dr. Apinis said the
Journal was embarking on a new project, to
record key WMA leaders and global lead-
ers from national medical associations in a
digital film. The recorded film would then
be preserved for the WMA historical re-
cord.
Public Relations
The committee received the Public Rela-
tions Report for October 2018  – March
2019. Delegates were told that the WMA
had an increasing number of followers on
Facebook and twitter and had issued around
30 press releases during the past year. This
work should be, and was, complemented by
the work done by Constituent Members.
FRIDAY, APRIL 26
Socio Medial Affairs
Committee
Dr. Osahon Enabulele (Nigerian Medi-
cal Association) was elected unopposed as
Chair of the committee.
Secretary General’s Report
Dr. Kloiber spoke about the conference
being held in Tokyo in June (13-14) in
conjunction with the Japan Medical Asso-
ciation on ‘The Road to Universal Health
Coverage’. This was a preconference to the
G20 Summit 2019 in Japan and was pre-
paratory to the High-Level United Na-
tions meeting in New York in September.
They had to work harder to make politicians
understand that health was not an expendi-
ture, it was an investment for their people
Osahon Enabulele
Chukwuma Oraegbunam
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8
WMA News
and for their nation.The WMA was keen to
work with others to achieve the third of the
Sustainable Development Goals.
Secondly, he spoke about the work the
WMA was doing on the issue of a physi-
cian-led primary care. There was a growing
trend to replace physicians by nurses and
community health workers and the WMA
would like to show examples of successful
primary care models as counter arguments
to the big donors. He said there were re-
gions in the world where there were no phy-
sicians and there would not be physicians
in future. So nurses would be needed to fill
these gaps.But this should be first under su-
pervision and regulated. He invited NMAs
to send in examples to assist the WMA’s
case for physician-led primary care.
Health and Environment
An oral report on the Environment Caucus
was given.
The committee was told that the WMA had
been represented at the 1st
WHO Global
Conference on Air Pollution and Health on
30 Oct to 1 Nov 2018 in Geneva and would
again be represented at the next COP meet-
ing in Santiago on 2–13 Dec 2019.
The Associate Members section would con-
sider and mark up two papers on chemical
exposure in health care – the first on the use
of ethylene oxide as a medical sterilant and
the second on reducing the greenhouse gas
footprint of anaesthetic gases.
WMA Network on Disaster
Medicine
A progress report was given by the Japan
Medical Association on the Network in
the CMAAO region (Confederation of
Medical Associations of Asia and Oceania).
Together with several regional NMAs, the
CMAAO with the Asian Medical Doctors
Association had concluded a Memorandum
of Understanding on disaster medicine as-
sistance. This was open and mutual assis-
tance, a partnership that various different
organisations could participate in and a
local initiative where those who knew the
locality well were best placed to provide
medical assistance. The next task was to
look into ways of collaborating with other
regional and local groups and at the next
CMAAO General Assembly, in Goa, India
in September,medical associations from the
regions would work further on the develop-
ment of the Network.
Professional Autonomy of Physicians
The committee considered a proposed re-
vision of the WMA Declaration of Madrid
on Professionally-led Regulation, reaffirming
the WMA’s view that the medical profes-
sion must play a central role in regulating
the conduct and professional activities of
its members if public confidence was to be
maintained in standards of care.
After a brief debate, minor amendments
were agreed and the committee recom-
mended that the document be approved by
the Council and forwarded to the General
Assembly for adoption.
In a subsequent debate on the wider is-
sues, the committee was told by the Brit-
ish Medical Association that significant
changes had occurred since the Declaration
of Madrid was first adopted. This had been
highlighted by the case in the UK of Dr.
Hadiza Bawa-Garba, who was convicted
of gross negligence manslaughter in 2015
and convicted of manslaughter over her
involvement in the death from sepsis of a
six-year-old boy. It was argued that profes-
sionally-led regulation could not be seen in
isolation involving individual doctors. The
system and pressures that doctors worked
under should also be considered. There was
now international recognition that where
there was an investigation, the starting
point needed to be the environment. That
should be part of the regulation process.
There was also insufficient attention paid
to the training of individuals involved in
regulation work, including the problem of
racial bias.
The Chair of Council, Dr. Montgomery,
said these were important issues, and he in-
vited the BMA to prepare a paper for fur-
ther discussion.
Pseudoscience, Pseudothera-
pies, Intrusion and Sects in
the Field of Health
The Spanish Medical Association presented
a new draft of a proposed Declaration on
Pseudoscience, Pseudotherapies, Intrusion
and Sects in the Field of Health, which set
out a series of measures to clamp down on
pseudoscience and pseudotherapies. The
chair of the work group reported that more
than 95 amendments and suggestions had
been made and most of these had been in-
corporated into the new draft.
The committee recommended to Council
that the draft document be recirculated for
comment.
Access to Healthcare
A proposed revision of the renamed Reso-
lution on Access of Women and Children
to Health Care was tabled. The document,
which sets out to address years of gender
inequality between men and woman in
healthcare, was approved, and the commit-
tee recommended that it be sent to Council
for forwarding to the General Assembly for
adoption.
Antimicrobial Resistance
As part of the 10-years revision process, the
Council in Riga in April 2018 agreed to a
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9
WMA News
major revision of the WMA Statement on
Antimicrobial Resistance. The British Medi-
cal Association was appointed lead rappor-
teur for the revision and presented to the
committee a draft revision.
The committee was told that this issue was a
very worrying problem and a growing threat
to public health in many countries. There
were significant economic and human im-
plications involved. This was a crucial time
for advocacy. A lot of decisions and discus-
sions were going on at the United Nations
and approval for this revision would be very
helpful.
After a brief debate, the committee agreed
to add the statement that the education of
a sufficient number of clinical infectious
­
diseases specialists in every country was
a fundamental requirement for tackling
AMR and acquired infections.
The committee recommended that the doc-
ument, as amended, should be sent to the
Council for forwarding to the General As-
sembly for adoption.
Sodium Intake
Proposals to reduce excessive salt intake
throughout the world were tabled in a
revision to the WMA Statement on Re-
ducing Dietary Sodium Intake.The South
African Medical Association had acted as
rapporteur on the document and spoke
about the need for national and inter-
national action on educating consumers,
as well as the labelling of processed food
about salt intake and content. In a brief
debate, the committee agreed to amend
the document by deleting the word ‘vol-
untary’ in the statement that the WMA
should ‘support regulatory efforts involv-
ing voluntary or mandatory targets in
food processing’.
The committee recommended that the doc-
ument, as amended, should be sent to the
Council for forwarding to the General As-
sembly for adoption.
Violence and Health
As part of the 10-year revision process,
the Council had agreed on a major revi-
sion of the WMA Statement on Violence
and Health. The Nigerian Medical Asso-
ciation had agreed to act as rapporteur and
tabled a revised Statement, warning about
the increasing incidents of violent attacks
against healthcare professionals and facili-
ties.
During the debate, several delegates ex-
pressed concerns about the document.
One wanted to include the sentence that
‘violence is often alcohol related. Measures
should be taken to restrict access to alco-
hol’. Other delegates wanted specific refer-
ences included to stalking and to security
posts in every health care facility ‘as neces-
sary’.
The committee decided to recommend to
Council that the document be recirculated
to constituent members for comment.
Augmented Intelligence
The American Medical Association tabled
a proposed Statement on Augmented Intel-
ligence in Medical Care. It was argued that
the terminology should be ‘augmented in-
telligence’ rather than ‘artificial intelligence’
because this was not about replacing the
physician but assisting the physician. Phy-
sicians and medical associations needed to
be involved as AI was developed in order to
strengthen the patient-physician relation-
ship.
The committee agreed to amend the docu-
ment to recommend ‘that all healthcare AI
systems be transparent, reproducible, and be
trusted by both health care providers and
patients’.
The committee recommended that the doc-
ument, as amended, should be sent to the
Council for forwarding to the General As-
sembly for adoption.
Medical Age Assessment
of Unaccompanied Minor
Asylum Seekers
Proposed new policy guidelines on medi-
cally assessing the age of unaccompanied
minor asylum seekers were presented by
the German Medical Association. A new
draft was proposed, based on discussions
at the last Council meeting and comments
from NMAs. It was argued that child
refugees must have the highest protection
that was their due and potentially harm-
ful procedures should be avoided. Young
asylum seekers had to be given the benefit
of doubt in cases where age could not be
confirmed.
After a debate, the committee recommend-
ed that the document, as amended, should
be sent to the Council for forwarding to the
General Assembly for adoption.
Free Sugar Consumption
A proposed Statement on Free Sugar Con-
sumption from the Kuwait Medical Asso-
ciation was considered. The committee was
told that its purpose was to highlight the
high global level of free sugar consumption
and sugar-sweetened beverages.
After a brief debate, the committee recom-
mended that the document, as amended,
should be sent to the Council for forward-
ing to the General Assembly for adoption.
Healthcare information for all
The British Medical Association presented
a revised draft of a proposed Statement
on Healthcare Information for All. This
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10
WMA News
­
focused on the lack of access to healthcare
information which acted as a major con-
tributor to disease and death. The com-
mittee was told that access to health care
information on diseases, treatments, ser-
vices and health promotion was crucial for
patients and for health personnel. Lack of
this in some countries could lead to some
of the fundamental causes of morbidity and
mortality.
During the debate that followed, the com-
mittee decided to amend the document
to read that ‘Governments have a moral
­
obligation to ensure that the public, pa-
tients and health workers have access to the
healthcare information they need to protect
their own health and the health of those for
whom they are responsible’.
The committee recommended that the doc-
ument, as amended, should be sent to the
Council for forwarding to the General As-
sembly for adoption.
Medical Liability &
Defensive Medicine
The Israel Medical Association submitted
a proposed Statement on Defensive Medi-
cine.The Review Committee suggested that
the proposal could be incorporated into the
existing WMA Statement on Medical Liabil-
ity Reform. It therefore recommended that a
rapporteur be appointed to oversee this.
The committee recommended to Council
that a rapporteur from the Israel Medical
Association be appointed to merge the two
documents.
Classification of 2009 Policies
The committee recommended that the fol-
lowing documents undergo a major revi-
sion:
• Declaration of Ottawa on Child Health
• Statement on Inequalities in Health
• Statement on Guiding Principles for the
Use of Telehealth
• Resolution Supporting the Rights of Pa-
tients and Physicians in the Islamic Re-
public of Iran
• Emergency Resolution on Legislation
Against Abortion in Nicaragua
The following documents should under mi-
nor revision:
• Declaration on Guidelines for Continu-
ous Quality Improvement in Healthcare
• Statement on Relations Between Physi-
cians and Commercial Enterprises
Two policy documents should be reaffirmed:
• Statement on Patenting Medical Proce-
dures
• Resolution on Task Shifting from the
Medical Profession
It was agreed that one document should be
rescinded: Improved Investment in Public
Health
Nuclear Weapons and Health
An oral report was given by the Interna-
tional Physicians for the Prevention of
Nuclear War.
Dr. Jans Fromow-Guerra, President of
IPPNW-Mexico, (International Physi-
cians for the Prevention of Nuclear War)
expressed IPPNW’s strong support for the
revised WMA Statement on nuclear weap-
ons adopted by the General Assembly in
Reykjavik, which called for the ratification
and implementation of the UN Treaty on
the Prohibition of Nuclear Weapons. He
spoke about the increasing risks for a global
conflagration with nuclear weapons and the
dramatic humanitarian consequences. The
planetary health imperative for the eradi-
cation of these weapons therefore had even
greater urgency. He said there was an even
greater need to press for the elimination of
all nuclear weapons. There had been a gen-
eral lack of progress among nations on dis-
armament and there was now an ongoing
escalation from the risks of a new cold war.
These risks included the situation between
India and Pakistan, the new cold war be-
tween Russia and the US and NATO, and
the issue of the Iran deal.
They now faced a world in which there might
soon be no treaty-based limit on the expan-
sion of a fully-fledged arms race between the
nuclear super powers.As medical profession-
als, they had to remind the public and world
leaders that they would not have a second
chance if even a minor nuclear conflagration
in any part of the world took place.
Dr. Fromow-Guerra urged the WMA and
NMAs to move to a period of action to
carry out specific activities to press for the
elimination of nuclear weapons. He re-
quested the WMA and each of its members
individually to take action to promote the
signature and ratification by all govern-
ments of the United Nations Treaty on the
Prohibition of Nuclear Weapons.
They had to consider all nations’health con-
cerns, as critical as they were, required a ba-
sic condition for their own survival and the
survival of life on the planet that could be
extinguished in a moment of anger or from
a horrible mistake by a few individuals with
the power to launch nuclear weapons.
As doctors, it was their duty to do all they
could to eliminate this threat.
Hypertension
The American Medical Association sub-
mitted a paper for information on hyper-
tension. It described how hypertension was
the most important risk factor for cardio-
vascular disease in every region of the world
and a major cause of global morbidity and
mortality and it was time for the WMA to
develop policy on the issue.The AMA gave
notice that it would be working on a pro-
posed statement for the October meeting.
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11
WMA News
SATURDAY, APRIL 27
Council
The Council meeting opened, unusually,
with any other business.
Vaccination
A proposal was submitted to the Council for
a Resolution on vaccination. The Australian
Medical Association said that the WMA
had strong policy on the effectiveness, ap-
propriateness and necessity of vaccination as
something that saved lives.It was time for the
Association to reaffirm its policy in the light
of global reports on the rise of measles.They
needed to ensure that all governments were
doing what they could to ensure vaccination.
This was particularly important because they
now lived in a global village with increased
mobilisation.In Australia 35 babies under 12
months had contracted measles and this was
very concerning. They had had more than
200 cases of measles already this year.
In the debate that followed, there was a dis-
cussion about whether the motion should
refer specifically to migration and to the
anti-vaccination campaign. On balance,
delegates decided against this, but rather to
include a reference to misconceptions about
vaccination.
In a vote, the Council agreed the following
motion:
‘The WMA is extremely alarmed at the cur-
rent increasing reports of measles outbreaks
in many parts of the world. It is clear that
increasing global travel by less than appropri-
ately protected individuals and the miscon-
ceptions about vaccinations pose a significant
challenge for health authorities of all nations.
It is in this current climate that the WMA
strongly reaffirms its 2012 Statement on the
Prioritisation of Immunisation’.
The Council went on to consider reports
from the committees.
Medical Ethics Committee
Physician-Patient Relationship
The Council considered the proposed Dec-
laration on Physician-Patient Relationship
and the committee’s recommendation that
this be circulated to constituent members
for comments. The American Medical As-
sociation argued that this issue warranted
more attention than simply circulating the
document. In many parts of the world this
relationship was under attack by govern-
ments, insurance companies and others who
wished to minimise the importance of the
relationship, which the profession regarded
as the foundation of medical care.The AMA
argued that it merited a work group to be set
up to look at all the threats to the relation-
ship and to produce a document that could
be used as a tool for each NMA to push back
against these threats. Other delegates agreed
that this was one of the largest threats fac-
ing the profession. The Council agreed that
the document should be circulated and that a
work group should also be set up.
The Council agreed to forward the follow-
ing document to the General Assembly for
adoption:
• Statement on Female Foeticide
The Council agreed to circulate the follow-
ing documents:
• Declaration of Reykjavik: Ethical Con-
sideration Regarding the Use of Genetics
in Medicine
• Statement on Action to Stimulate use of
the Physicians’ Pledge of the Declaration
of Geneva
• Statement on Solitary Confinement
• Statement on Physicians Treating Rela-
tives and Friends
• Resolution on Medical Ethics in Sports
Medicine
The Council agreed to set up a work group
to work further on the revision of the Reso-
lution on the Responsibility of Physicians
in the Documentation and Denunciation of
Acts of Torture and Ill-treatment.
Classification of 2009
Policies
The Council agreed that the Statement on
Embryonic Stem Cell Research should un-
dergo a major revision.
Finance and Planning
Committee
Strategic Plan
The Council agreed to several amendments
to the strategic plan. The first was to add to
the list of priorities promoting physician
wellbeing, including advocacy to reduce
physician burnout. A second was to include
the promotion of safe and respectful work-
places, to reduce work related diseases, vio-
lence, bullying and harassment. And a third
was to monitor the expanding use of new
technologies by patients in self-manage-
ment and how this impacted on the work
and role of doctors as well as the doctor-
patient relationship.
The Council approved the Strategic Plan, as
amended, and agreed that it should be for-
warded to the General Assembly for adop-
tion
The Council approved the following re-
ports:
• Membership Dues Payments for 2019
• Dues Arrears
• Interim Financial Statement for 2018
• Application for constituent membership
of Doctors 4 Doctors Seychelles to be
forwarded to the General Assembly for
approval
• Planning and arrangements for future
statutory meetings
• The theme of the Scientific Session of
the 71st
General Assembly, in Cordoba in
2020 should be Transplantation and Do-
nation/Organ Trafficking: International
Scenarios
• Amendments to the Procedure on WMA
Council Resolutions and Resolutions
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12
WMA News
Socio Medical Affairs
Committee
Resolution on Access of Women
and Children to Health Care
The Council considered a proposal to
change the Resolution on Access of Wom-
en and Children to Health Care to a State-
ment. It was agreed to change the title of
the document and to forward it to the Gen-
eral Assembly for adoption.
Augmented Intelligence
The Council considered the proposed State-
ment and agreed it should be made clear in
the text that the document was about ‘aug-
mented’ intelligence rather than ‘artificial’
intelligence’.
This was agreed by the Council and it pro-
posed that the document be forwarded to
the General Assembly for adoption.
Minor Asylum Seekers
The Council considered the proposed State-
ment on Medical Age Assessment of Unac-
companied Minor Asylum Seekers and the
sentence ‘The WMA underscores that any
medical methods that could involve a health
risk for the applicant, e.g. radiological ex-
aminations without medical indication, or
that infringe upon the dignity or privacy of
an already potentially traumatized asylum
seeker, e.g. genital examinations, should
be avoided’. The Council agreed that the
sentence should be amended to read ‘must’
rather than ‘should’.
The Council agreed that the proposed
Statement, as amended, be forwarded to the
General Assembly for adoption.
The Council agreed to forward the follow-
ing documents to the General Assembly for
adoption:
• Proposed revision of the Declaration of
Madrid on Professionally-led Regulation
• Resolution on Women and Children to
Health Care and the Role of Women in
the Medical Profession
• Statement on Antimicrobial Resistance
• Statement on Reducing Dietary Sodium
Intake
• Augmented Intelligence in Medical Care
• Statement on Medical Age Assessment
of Unaccompanied Minor Asylum Seek-
ers
• Statement on Free Sugar Consumption
and Sugar-sweetened Beverages
• Statement on Healthcare Information for
All
The Council agreed that the following doc-
uments be circulated for comment:
• Declaration on Pseudoscience and Pseu-
dotherapies in the Field of Health
• Statement on Violence and Health
The Council agreed that the proposed
Statement on Defensive Medicine be in-
corporated into the Statement on Medical
Liability Reform and be renamed Statement
on Medical Liability Reform and Defensive
Medicine and that a rapporteur be appoint-
ed to undertake the revision.
Classification of 2009 Policies
The Council agreed to the classification rec-
ommendations recommended by the com-
mittee.
Any Other Business
Advocacy and Communications Panel
An oral report was given from the Advo-
cacy Panel. The Chair, Dr. Ashok Paul,
highlighted the need to help smaller NMAs
attending these meetings with extended
briefings and more material on the web-
site. It was also important to ensure that
material sent to NMAs actually reached
the members. He also referred to the need
to see how smaller NMAs might be bet-
ter represented on the Council. He spoke
about the inability of smaller NMAs to
become members, particularly from the
Asia-Pacific region and the African conti-
nent. Other speakers supported his com-
ments about the membership of Council.
The Chair of Council said these matters
would be discussed in the Executive com-
mittee. He also reminded the Council that
the two-year mandate of the Panel had end-
ed and he would be appointing new mem-
bers and a new Chair.
World Health Assembly
Oral reports were given to the Council
about this year’s World Health Assembly.
Among the issues to be discussed at the
Assembly and in side events were universal
health coverage and primary health care.
This led to a lengthy debate on the gradual
move and support for using community
health workers instead of physicians in pri-
mary health care.
Speakers expressed concern about the de-
veloping trend and the need for the WMA
to increase its activities to support a physi-
cian-led primary health care system. It was
argued that there was a need for more con-
certed lobbying by the WMA. Examples
were given from several countries about
other health workers, such as nurses and
dentists, taking over from physicians. Some
governments were supporting this to reduce
costs. But they were not taking into account
the outcome and cost effectiveness of the
issue. Using physicians in primary health
helped to reduce the cost of hospitalization.
In a detailed response to the speakers, the
Secretary General outlined the history of
how the WHO initially published a good
strategy on physician-led primary care,
only to see the politicians and governments
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13
World Health Assembly
WMA leaders, past and present, were much
in evidence at the 72nd
World Health As-
sembly in Geneva from 20 to 28 May.
Past President Sir Michael Marmot was
presented with a Health Leaders Award
by World Health Organisation Secretary
General Dr.Tedros Adhanom Ghebreyesus
for his work on the social determinants of
health and in recognition of his outstanding
leadership in global health.
Side Event on Primary
Health Care
Meanwhile, the current WMA President
Dr. Leonid Eidelman and WMA Secretary
General Dr. Otmar Kloiber hosted with the
Taiwan Medical Association a joint side
event on Primary Health Care (PHC).
The well attended seminar at the Intercon-
tinental Hotel was a mark of the WMA’s
support for Taiwan, which for the third
consecutive year was not invited to the
World Health Assembly.
Opening the meeting, Dr. Kloiber said he
was fully aware that there were many regions
of the world where there were not enough
physicians. He said the WMA valued the
work of other health professions and he
stressed the importance of team work. But
in arguing for physician led primary care,
the WMA was recognising that diversity
required different skills and education.
Dr. Eidelman said that primary health care
was one of the most important issues in the
world of medicine and in the world of uni-
versal health coverage (UHC). It was a cor-
ner stone of health care systems and a major
component of UHC. There was an increas-
ing demand for health care worldwide be-
cause the number of people aged 60 years
and over was increasing dramatically.People
were suffering from more and more chronic
diseases and they needed more health care.
World Health Assembly – Geneva, May 20–28
Nigel Duncan
overturn this with an alternative health care
system that was pushed as a cheap option.
The western governments has failed to op-
pose this approach. Dr. Kloiber said the
problem on physician-led primary care did
not lie with the WHO, but with the large
international donor organisations, who had
huge financial resources and were making
their funding conditional on supporting the
use of nurses and community health work-
ers over doctors.They were setting the scene
because they had the money. It was they
who were saying that they were not going
to invest in doctors because they were too
expensive. He stressed that the WMA ac-
cepted community health workers as an ad-
dition, but not as substitutes for physicians.
Finally, Dr. Kloiber appealed again to
NMAs to lobby their governments and to
send in to the WMA arguments and exam-
ples to back up their case of why physician-
led primary care was a very successful mod-
el. This would counter the bombardment of
studies they were confronted with, setting
out to show that community nurses and
health workers could do physician work.
‘Crazy Socks for Docs’
Delegates were asked to support an Austra-
lian social media campaign, ‘Crazy Socks
for Docs’,to highlight the issue of physician
wellbeing and mental health. This was sup-
ported in particular by the Indian Medical
Association. India had a big problem with
suicides among junior doctors and the In-
dian Medical Association had started a
programme on the emotional wellbeing of
doctors and medical students.
Sudan
On behalf of the Coalition of African
Medical Associations, the Nigerian Medi-
cal Association thanked the WMA for the
strong statement it had issued on Sudan.
The Coalition was very appreciative of the
solidarity given to physicians who were be-
ing assaulted, undermined, intimidated and
harassed in the course of undertaking their
responsibilities as physicians. The WMA’s
efforts had contributed to the stabilization
of the situation in Sudan.
Tribute to Dr. Ardis Hoven
The meeting ended with a video montage
of photos of Dr. Hoven during her term as
Chair of Council.
The Council meeting was then adjourned
and the Secretary General thanked all those
who had contributed towards making the
meeting such a success.
Mr. Nigel Duncan,
Public Relations Consultant,
WMA
E-mail: nduncan@ndcommunications.co.uk
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14
World Health Assembly
Primary health care was a fundamental hu-
man right and included all kinds of care,
including prevention, treatment, rehabilita-
tion and palliative care. Yet at least half the
world’s people still lacked full coverage of
essential health services. A fit for purpose
workforce was essential to deliver PHC.
And yet there was an estimated shortfall of
80 million health workers globally.
He referred to the Declaration of Astana,
envisioning governments and societies that
prioritised, promoted and protected peo-
ple’s health and well-being at both popula-
tion and individual levels, through strong
health systems.
He said person-centred primary care de-
pended on accessibility, continuity and
comprehensiveness.Team-based care meant
a strategic redistribution of work among
members of a practice team, all members
playing an integral role in providing patient
care and the physician and a team of other
health workers sharing responsibilities for
better patient care.
Dr. Eidelman concluded that the future of
healthcare meant a move from hospital to
community settings, and a move towards a
team-based model. It also involved techno-
logical development and an urgent need to
strengthen team based PHC under physi-
cian leadership. He said the physician was
the most suitable health professional to lead
the healthcare team.
A number of speakers from Taiwan, includ-
ing Taiwan’s Health Minister Chen Shih-
Chung, spoke about community primary
care in their country and the roles and tasks
of primary care physicians promoting ad-
vance care planning.
Another speaker, Dr. Lyndah Kemunto, a
general practitioner from the Kisii Country
Government in Kenya, talked about why
doctors needed to be at the centre of pri-
mary health care. She said that PHC teams
should be physician-led because of doctors’
clinical skills, as well as skills for capacity
building,critical thinking and collaboration.
The benefits of physician-led PHC includ-
ed better health outcomes, cost reduction,
increased efficiency, reduced inequality and
integrated and continuity of care.
The symposium concluded with Dr. Kloiber
saying it was deplorable that Taiwan was again
being banned from the World Health Assem-
bly. It was a very sad situation and he hoped
that next year things would be different.
WMA Signs UHC2030
The following evening in a special cer-
emony in Geneva Dr. Eidelman signed the
UHC2030 Global Compact for a safer,fair-
er and healthier world by 2030. In doing so
he committed the world’s 12 million physi-
cians to promoting the benefits of universal
health coverage across the globe.
Dr.Eidelman said that universal health cov-
erage was key to reaching the World Health
Organisation’s ‘triple billion’ targets  – one
billion more people benefitting from uni-
versal health coverage, one billion more
people better protected from health emer-
gencies and one billion more people enjoy-
ing better health and well-being.
‘The World Medical Association embraces
the concept wholeheartedly, and we are
keen to see quality primary care provided
by multi-disciplinary teams at the core of
strong and comprehensive health care sys-
tems. In our view, UHC is the biggest step
forward ever made by WHO, and we are
firmly part of the movement. 
‘In parts of the world where health systems
are close to UHC we can show that this is
for the benefit of everybody – for our pa-
tients, our colleagues and the communities
we serve. UHC is an ideal platform, not
only for providing curative care, but also
for providing prevention, rehabilitation and
palliative care’.
Dr. Eidelman said that investing in univer-
sal health coverage was not only a strong
humanitarian move, it was also a sound
economic development to create viable and
value-adding services for communities.
UHC2030, run by the WHO and the
World Bank, involves building and ex-
panding equitable, resilient and sustainable
health systems, funded primarily by public
finance, and based on primary health care.
WMA Interventions
Throughout the World Health Assembly
meeting, WMA policy interventions were
being presented to the Assembly by mem-
bers of the Junior Doctors Network. These
included statements on public health emer-
gencies, access to medicines and vaccines,
and water, sanitation and hygiene in health
care facilities.
One of the most significant interventions
was on universal health coverage, when the
WMA welcomed the WHO’s message that
in order to implement UHC, more invest-
ment in the health workforce was needed.
The WMA argued that this financial com-
mitment should prioritize closing the pre-
dicted 18 million health workforce gap, by
increasing the number of students, enhanc-
ing education and specialization as well as
improving working conditions.
The statement added: ‘The Global Strategy
on Human resources for health: Workforce
2030 recommends that countries should
plan for their health workforce as a whole,
rather than segmenting planning and re-
lated programming and financing efforts
into single occupational groups. The cur-
rent international debate focuses mainly
on prompt ways to meet the HP shortage
through the replacement of physicians by
community health workers (CHW) or
nurses. The latest data available shows that
76 countries still have less than one physi-
cian per thousand population. It is unac-
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15
World Health Assembly
ceptable that patients with cancer in some
countries cannot access adequate care be-
cause there is no oncologist in the country.
‘In its report,WHO emphasizes that CHW
are not a cheap alternative to close the gap
of health professionals and that govern-
ments should adopt service delivery models
in which CHW are assigned general tasks as
part of integrated primary health care teams.
For many years, WMA has been advocating
for the need of health care teams with vari-
ous cadres, including community and social
workers. Each profession has its own scope
of practice and clear responsibilities with
one team member having the overarching
responsibility.This should be reflected in the
WHO Global Competency Framework for
Universal Health Coverage. We know there
is still a long way to go, but the aim must
be that in the end everybody who needs a
physician will be assisted by physician. If
you give up that aspiration Universal Health
Coverage will not come true’.
In its intervention on antimicrobial resistance,
the WMA reiterated the need for the adop-
tion of a One Health approach in National
Action Plan development, but more impor-
tantly in its implementation. And on human
resources for health, the WMA noted that in
many countries,including the wealthiest ones,
there was a shortage of physicians. A major
reason for this gap was a failure to educate
enough physicians to meet the health needs of
the country’s population.As a response to this
shortage, many countries encouraged inter-
national recruitment and the WMA empha-
sized the need to regulate those recruitments
by calling on Member states to implement the
international code for recruitment of health
professionals. It urged member states to re-
frain from coercive measures restricting the
mobility of health professionals.
On the promotion of health of refugees and
migrants, the WMA said the WHO Glob-
al Action Plan failed to address key issues
necessary to ensure proper access to health
care to migrants and refugees in line with
human rights and medical ethics standards.
It said an explicit reference should be made
to the human right to health of refugees
and migrants, regardless of their legal, civil
or political status. The Plan should also ad-
dress the ethical challenge physicians faced
and should condemn any practice involving
their participation to non-medically justified
examination, diagnosis or treatment, such as
sedatives to facilitate easy deportation, or
bone examination for age assessment.
Yassen Tcholakov presented the WMA
statement on climate change,welcoming the
draft WHO global strategy, and in particu-
lar the proposal to address the wide spec-
trum of climate change impacts on health,
through cross-sectoral action on determi-
nants of health and a health-in-all-policies
approach. It supported the recommendation
to strengthen the health sector leadership
and governance and recommended develop-
ing further on ways to equip and educate the
health workforce, including physicians, to
promote a better environment, address pa-
tients’needs, and transmit health knowledge
regarding environmental risks to policy-
makers and communities.
But the WMA also considered that great-
er emphasis should be placed on the need
for health impact assessments of new trade
agreements being negotiated in multilateral
settings in order to protect,promote and pri-
oritize public health over commercial inter-
ests and secure services in the public inter-
est,including those impacting on health and
environment. It suggested that the WHO
should act as a global role model through
the adoption of climate change performance
indicators of its own activities, which could
inspire the wider UN community.
Nuclear Weapons
The WMA was also involved in a side event
on nuclear war. Entitled “Nuclear Weap-
ons Today: An Update of the Humanitar-
ian Consequences of Nuclear War and the
Medical Role in Preventing it”, the event
was organised by the International Physi-
cians for the Prevention of Nuclear War,
and supported by the WMA and the World
Federation of Public Health Associations.
WMA Advocacy Advisor Clarisse Delorme
gave an update on the humanitarian conse-
quences of nuclear war and the role of health
professionals in preventing it and took part in
a panel discussion. Speakers said that the use
of nuclear weapons brought disproportion-
ate suffering to vulnerable categories, such as
woman,children and indigenous populations.
There was a need to focus on the health and
climate consequences of nuclear weapons.
The WHO, it was argued, should once again
become a voice against nuclear weapons.
Burnout
On the final day of the Assembly, the
WMA issued a press release giving a warm
welcome to the decision by the Assembly to
classify work related burnout as a problem
that influenced health status and to include
it in the new version of the international
code of diseases 
WMA President Dr. Eidelman said: ‘For
too long burnout among physicians has
been largely ignored. Emotionally exhaust-
ed physicians are a danger to patients and a
danger to themselves. The cost in terms of
human lives and money is appalling. 
‘The number of suicides among doctors re-
sulting from burnout is a scandal and I hope
that the WHO’s new classification will shine
a spotlight on this disgraceful situation.
‘I hope that the World Health Assembly’s
decision will lead to a new approach that ad-
dresses multiple factors including working
conditions for physicians around the world’.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
E-mail: nduncan@ndcommunications.co.uk
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16
Physician 2030
Protagoras student of Socrates and Aris-
totle (2,500 BC) said that “MAN IS THE
MEASURE OF ALL THINGS”, predict
the future without remembering the prin-
ciple would lead us to make mistakes, as
doctors understand that there can be noth-
ing more noble than Protect your health or
understand your illness.
Man is the only being with a known past who
lives his present and plans the future,he is the
one who creates the story and the end of it.
In Mesopotamia medicine was based on
magic to bring out the evil one,in Egypt the
priests and fortune tellers treated diseases, it
was Hippocrates who started the scientific
medicine based on experience and carefully
observing the patient.
Galen makes dissections of corpses know-
ing their anatomy and physiology.
The Romans installed the first hospitals to
care for their war wounded and municipal
hospitals were born.
Albucasis removes the goiter with crude
instruments, using cautery to treat wounds.
Medieval medicine is characterized by
plagues, the Catholic Church influences
disease as punishment for sins and con-
demns scientific research, Pasteur talks
about the germs and bacteria that passed
from one individual to another causing the
disease.
Röntgen discovers X-rays, the basis for ex-
ploring the interior of the human body. It
took many centuries for the concept that
the doctor should not only cure diseases,but
should also prevent them.
In the XX and XXI century many drugs
that cure, prevent and control diseases,
electronic devices capable of diagnosing,
transmit important patient information,
these rapid advances allow a better and
better life for people, increasing their life
expectancy.
What is the future of
Medicine?
5 medical technologies
could change the world:
a) 
Drugs and anti-aging treatment (mo-
lecular repair to organ replacement),
b) 
3-D and 5-D impressions,
c) 
bionic implants (nanotechnology),
d) 
Prenatal genetic manipulation (avoid-
ing the development of mutations)
e) 
personalized medicine, all this accom-
panied by Big Data and artificial intel-
ligence.
5 Nobel Prizes in Medicine tell us
about the future of medicine:
a) 
Erwin Neher (1991) “the bugs that
invade us have key (Micro biome) the
missing link, certain bacteria can in-
fluence the appearance of diseases.
b) 
Richard J. Roberts (1993). CRISPR
system (the short genetic stick, modi-
fies the genes at your convenience,
introduces changes in the DNA for
treatments of many diseases.
c) 
Ferid Murad (1998). The Bio-impres-
sion 3-D, the challenge of creating
hearts is a present reality, very close
to the manufacture of artificial blood
and organ culture for transplants using
stem cells.
d) 
Jules Hoffman (2011). Inverse vac-
cinology, 500 diseases will be erased
forever, deciphering the genome of
bacteria, also particle accelerators to
study the structure of the virus.
e) 
Randy Schekman (2013). Immuno-
therapy the vaccine against cancer,
combines the genetic profile of the
tumor achieving more personalized
therapies. Immunotherapy helps our
defense system detect cancer cells and
attack them in a selected way.
Personalized medicine determines that each
person is unique and the same happens with
their pathology, this allows that the genetic
study of a person is the ability of genetic ed-
iting to correct their mutation.
The main reason for this article is:
–
– to show that the vertiginous advance of
technology is leaving behind the hu-
man part of medicine.
• We ask ourselves: What about human
values ? …
–
– Disease is a bio-psycho, social compo-
nent, the disease not only attacks the
organism,it also has environmental and
social factors, influences the family and
the environment, aspects that we must
not neglect from the human point of
view.
–
– 70% of the world population does
not have access to a full health sys-
tem, which allows the human right of
equal attention without considering
MEDICINA DEL 2030. El Futuro Esta
a la Vuelta de la Esquina Prepárate!
Anibal Antonio Cruz Senzano
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17
WFME News
economic, racial or political factors,
the latter being used by unscrupulous
governments as a speech to conquer the
population .
• We continue with an important poverty
map highlighting:
–
– poverty, malnutrition, collapsed hospi-
tals, limited access to medicines,
–
– precarious infrastructure, lack of sup-
plies and human resources in health,
desolation and death.
This is the true reality with which we will
face and is the challenge of the medicine of the
future.
How should we prepare for the
medicine of the future …?
Technology must not dehumanize medi-
cine, on the contrary, it must be accom-
panied by ethical and deontological prin-
ciples.
This is an important responsibility of medi-
cal schools where teaching with values ​​
de-
termines that the main thing is the patient
and the resolution of their illness in an inte-
gral way. Always trumpet our governments
and health administrators, the human right
of free and equal access to health according
to the basic principles of the Hippocratic
Oath.
• We must make a more human medicine! …
• We must make the doctor-patient relation-
ship intangible heritage of Humanity…!!!
From the CONFEMEL space, we demand
from the world and health institutions this
right,unconditional commitment to profes-
sional competence, altruism and the trust of
society.
“TRUST DEPOSITED IN
THE CONSCIOUSNESS”.
• Let’s put all our hands together to look
at the future and from all the institu-
tions: CONFEMEL, ISRAEL MEDI-
CAL ASSOCIATION (I.M.A.),
WORLD MEDICAL ASSOCIATION
(W.M.A.).
• Propose to the world and UNESCO
that the patient medical relationship
should be the beginning and the end of
the medical act, for that reason and hu-
man values ​​
we must name the doctor-
patient relationship “INTANGIBLE
CULTURAL HERITAGE OF HU-
MANITY”.
We end this article with the thought of
Hippocrates 5th
century BC:
Life is short, extensive science, the fleeting occa-
sion, the insecure experience, the difficult judg-
ment. It is necessary not only to prepare to do
what is due, but also to collaborate: the patient,
those who assist him and the circumstances, ex-
ternal.
Dr. Anibal Antonio Cruz Senzano.
Bolivia
E-mail: aacruzs@hotmail.com
The 2019 World Federation for Medical
Education (WFME) Conference, held in
Seoul, Korea from April 7-10, hosted more
than 800 participants from 57 countries.
There were 300 presentations that included
12 Plenaries, 48 Symposia and 10 Work-
shops. 84 Paper presentations and 146
Poster presentations in 35 thematic sessions
were all related to the Conference theme
“Quality Assurance in Medical Education
in the 21st
Century”.
In support of this theme, WFME focused
on critical activities in the immediate years
to come. The three main topic areas were:
the WFME Recognition of Accreditation
Programme,the next edition of the WFME
Standards, and quality assessment of Post-
graduate Medical Education.
WFME Recognition of
Accreditation Programme
One of the aims of the conference was to
discuss accreditation and to dispel misin-
formation that has been circulating in many
countries world-wide about the meaning
and process of the WFME Recognition
Programme. WFME does not accredit in-
dividual medical schools. Medical schools
are accredited by an accrediting agency,
which can be a government or independent
organisation.Through the Recognition Pro-
gramme, WFME evaluates the legal stand-
ing,accreditation process,post-accreditation
monitoring, and decision-making processes
of an accreditation agency for programmes
or schools of basic medical education.
Currently, there are 18 agencies with Rec-
ognition Status, 12 agencies in various
stages of the recognition process and more
than 10 additional organisations are in ac-
tive communication with WFME regard-
ing their application. 
WFME often receives enquiries about pos-
sible solutions for various countries, agen-
cies, or medical schools. Often a school asks
what to do about the Educational Com-
mission for Foreign Medical Graduates
(ECFMG) 2023 deadline (see below) when
the agency in their country is not yet recog-
nised or when there is no accrediting agency
WFME Conference: Quality Assurance in
Medical Education in the 21st
Century
Seoul, Korea, May 2019
BACK TO CONTENTS
18
WFME News
operating in the country. WFME strongly
discourages schools from pursuing accredi-
tation from a recognised agency outside the
country without verifying that the agency is
also recognised by the relevant authority in
their country. The agencies with Recogni-
tion Status are only recognised by WFME
for operation in countries where they are
mandated by the government, or by the rel-
evant professional or scientific authority, to
perform accreditation of medical education.
For countries where an accrediting system
has not yet been set up, WFME suggests
any of the following:
• Setting up an accrediting system in con-
sultation with experts in accreditation, or
with representatives of an already func-
tioning agency from a different – yet rea-
sonably comparable – country, or
• Creating a regional accrediting body in
cooperation with neighbouring countries,
or
• Reaching out to an already functioning
agency in a country that is geographically
or culturally close and consider giving
this agency a mandate to perform the ac-
crediting function on behalf of the gov-
ernment, or on behalf of a relevant pro-
fessional or scientific authority, or both.
To avoid any conflict of interest, WFME is
not able to recommend individual experts in
accreditation, but can provide a list of pos-
sible experts from which anyone working to
set up a new agency can choose.The experts
on this list may also be used to provide in-
dependent advice to an agency considering
an application in the WFME Recognition
Programme.
For more information on the WFME Rec-
ognition Programme please visit: wfme.org/
accreditation/recognition-programme
Agencies that wish to apply for Recogni-
tion or get more information can contact
WFME at accreditation@wfme.org. This
email address also serves for any other en-
quiries about WFME Recognition.
The list of agencies with
Recognition Status can be
found on the WFME web-
site wfme.org/accreditation/
accrediting-agencies-status.
WFME also announces
all newly recognised agen-
cies in the News section on
the website and on Twitter
(@wfmeorg) and Facebook.
Currently these are the only
sources of updated informa-
tion about the Recognition
Programme.
Accrediting agencies report
many reasons as drivers to
apply for WFME Recogni-
tion. WFME Recognition
Status is seen as a mark of
quality –  and although it is
not mandatory to go through
the process, accrediting
agencies see value in exter-
nal evaluation of the core of
their activity. Almost all ac-
crediting agencies that have
achieved Recognition Sta-
tus report that their policies
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19
WFME News
and procedures have benefited from inde-
pendent appraisal. Recognition Status also
acknowledges a globally comparable quality
of accreditation while supporting the use of
country-specific standards that are tailored
to the local needs and context.
Medical schools, students and graduates are
understandably primarily interested in the
WFME Recognition process because of its
connection to ECFMG policy.
Barbora Hrabalová
WFME Head of External Relations
Preparing for the ECFMG
2023 policy deadline
The World Conference discussed the Edu-
cational Commission for Foreign Medical
Graduate (ECFMG) policy,that states that,
starting in 2023, individuals applying for
ECFMG Certification must be a student
or graduate of a medical school that is ap-
propriately accredited.More specifically,the
school must be accredited by an accrediting
agency that is officially recognised by the
WFME. ECFMG has planned a 4-phase
implementation process leading up to the
2023 deadline (see picture 1).
For continuous update on the progress to-
wards 2023, visit ecfmg.org/accreditation.
The above diagram refers to the World Di-
rectory of Medical Schools, which is managed
jointly by WFME and the Foundation for
Advancement of International Medical
Education and Research (FAIMER). It is
important to note that listing of a medi-
cal school in the World Directory does not
denote recognition or endorsement by
WFME or FAIMER, or the eligibility to
apply for ECFMG licensure. Informa-
tion about the eligibility of graduates from
any particular medical school to apply for
ECFMG or Medical Council of Canada li-
censure is currently located in the Sponsor
notes in the school’s page on the World Di-
rectory website (wdoms.org). As the 4-phase
plan progresses, the World Directory will
gradually include information about accred-
itation and WFME Recognition, as well.
For information about World Directory of
Medical Schools listings, visit the website or
contact info@wdoms.org.
WFME Standards: New edition
for basic medical education
As overviewed at the World Conference,
since their first publication in 2003, the
WFME standards have regularly been up-
dated, reflecting the conditions and chang-
ing values in medical education. The next
edition of the standards for basic medical
education is due for publication in 2020.The
new standards will continue to encompass
Picture 1
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20
WFME News
mission and objectives, educational pro-
grammes, assessment, selection roles and
support for students, academic staff and re-
sources, programme evaluation, governance
and administration, and continuous renewal.
However, the emerging style in development
of standards means that standards will move
away from detailed specification and toward
streamlined reference frameworks that ask
how institutions make their decisions, rather
than whether they comply with set practices.
This allows the locally-based standards to
reflect the diversity of political, professional,
health,education and social contexts that ex-
ists among countries and in their correspond-
ing healthcare and educational resources and
values. This allows local relevance within a
global framework that is one of the baseline
tenets of the World Health Organisation’s
transformative education policy. It will en-
sure local choice and contextual relevance in
educational design and action.
The revised standards will guide institutions
to take ownership and address the necessary
components of curriculum purposes, out-
comes, processes, management, and quality
while enabling each institution to reach its
own contextually appropriate designs and
processes and enable regulators to make rel-
evant and constructive decisions about the
quality of medical education offered.
Professor Janet Grant 
Special Adviser to the WFME President
Quality assessment of
Postgraduate Medical Education
(PGME): National Examples
Another key element of the World Con-
ference was a discussion on quality assess-
ment of Postgraduate Medical Education
(“Graduate Medical Education” in North
American terminology). PGME training
and evaluation varies in different countries
and so does the form of oversight and qual-
ity control. Examples of PGME regulations
were shared at the conference by represen-
tatives from three countries:
• TheanneWalters presented a form where
basic medical education and PGME are
monitored by the same body, the Austra-
lian Medical Council (AMC).
• Jung-Yul Park from Korea discussed a
complex situation where there the re-
sponsibility for regulating PGME is di-
vided among several bodies, making it
difficult to provide any unified and con-
sistent oversight.
• Thomas Nasca from America presented
the activity of the long-established body
that monitors PGME in the USA, the
Accreditation Council for Graduate
Medical Education (ACGME).
These three examples show that quality as-
sessment of PGME can take varied forms
and before striving for any global compari-
son and overarching criteria, a comprehen-
sive study to map the situation world-wide
is needed.
The Junior Doctors Network, serving as the
international platform for junior doctors to
facilitate an open dialogue of global events
and activities that are relevant to their post-
graduate training, is currently organising a
survey among residents to identify the spe-
cifics and needs of PGME training world-
wide, and to identify the elements that need
to be included in any global PMGE accred-
itation criteria.
WFME is aiming to coordinate this global
discussion and will be reaching out to stake-
holders world-wide to join in the process.
PGME quality assessment will be one of
the main themes in the next World Confer-
ence which will take place in 2022.
Professor David Gordon
WFME President
E-mail: admin@wfme.org
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21
Physician 2030
Note: This article was adapted from presenta-
tions given by Dr. Barbe at the World Medical
Association’s (WMA) Medical Ethics Confer-
ence in Reykjavik, Iceland, on October 2, 2018,
and at the WMA/Israeli Medical Association’s
Physician 2030 Conference in Tel Aviv, Israel,
on May 13, 2019.
Technology and Medicine
Throughout the history of medicine, tech-
nological innovation has changed the phy-
sician practice environment and improved
patient care. Think of the thermometer,
stethoscope, microscope and the X-ray.
These were all watershed innovations of
their time and dramatic improvements over
what had existed before.
Transformative changes continue in digital
health, from big data to wearable devices
to telemedicine to artificial intelligence. At
the AMA, we use the term augmented in-
telligence (AI), because we emphasize the
fact that this technology is to be designed
to enhance human intelligence rather than
replace it. While physicians welcome these
advancements and believe in their potential
to improve patient care, at the same time,
we must take care to ensure that technol-
ogy is thoughtfully designed and deployed
so that it enhances instead of undermining
the important patient-physician relation-
ship.
This means physicians – and medical soci-
eties – have an important role to play. We
must be knowledgeable about technological
trends and engaged in the ideation, devel-
opment, validation, and delivery re-design
and integration of new technologies, rather
than responding after the fact.
As a leader in American medicine, the
AMA is working to help set priorities for
AI, to collaborate with other stakeholders
to ensure that the physician perspective is
integrated into the design and implemen-
tation of AI, and to facilitate understand-
ing of the promise and limitations of AI
throughout the medical and health care
communities.
AI in Health Care
AI is defined as “the ability of a computer
to complete tasks in a manner typically as-
sociated with a rational human being – to
function appropriately and with foresight in
its environment.”
The term AI covers a range of methods,
techniques, and systems. Common ex-
amples of AI systems include, but are not
limited to, natural language processing,
computer vision, and machine learning
systems. In health care, as in other sectors,
AI solutions may include a combination of
these systems and methods. AI is expected
to transform health care by enabling phy-
sicians to diagnose and treat patients more
quickly and more effectively.
As a research discipline,AI has been around
for 70 years. The underlying techniques,
methods and knowledge are not new. How-
ever, there are two new forces that are fuel-
ing the rapid advances in AI. First, is the
inexpensive and ultra-fast computing pow-
er that allows us to supercharge these core
methods to create applications that have the
potential to transform the way we deliver
health care.
The second, market trends indicate that AI
will change health care and the practice of
medicine in significant ways in the next
10 years. This has resulted in an immense
infusion of capital into AI related activi-
ties. Since 2013, there have been more than
570 health care AI deals worth $4.3 billion,
according to CB Insights.
Physicians may already be familiar with the
following examples of AI applications:
• The Cardiogram app works with heart
rate sensor of the Apple Watch to detect
hypertension and sleep apnea. In a clini-
cal study involving more than 6,000 pa-
tients with UCSF, Cardiogram (app on
the Apple Watch) and its machine learn-
ing system, DeepHeart, detected hyper-
tension and sleep apnea with 82 percent
and 90 percent accuracy, respectively. The
Apple Watch Series 4 and later versions
include an electrical heart rate sensor that
can take an electrocardiogram using an
ECG app.
• The Human Diagnosis Project (Hu-
man Dx), a nonprofit and public ben-
efit corporation, is an online platform
that uses machine learning algorithms
to help physicians achieve an accurate
diagnosis and receive specialist consults
for their patients. Human Dx also pro-
Now is the Time for Physicians and Medical
Associations to Prepare for Augmented
Intelligence in Health Care
David O. Barbe
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22
Physician 2030
vides a platform for medical education
through its Global Morning Report
teaching cases, which are accessed by
medical residents.
• Advances in the field of surgical robotics
allow surgeons to perform surgeries with
fine detail and fewer tremors than with
the human hand. AI might one day allow
surgical robots to perform surgical proce-
dures autonomously.
Opportunities, Challenges
and Questions Raised
by Health Care AI
The strong momentum behind AI applica-
tions brings a number of opportunities and
challenges for physicians and patients, and
raises important questions physicians must
confront. These are detailed in a 2018 re-
port by the AMA’s Council for Long Range
Planning and Development https://www.
ama-assn.org/sites/ama-assn.org/files/corp/
media-browser/public/hod/a18-clrpd-reports.
pdf
Opportunities:
• AI technology could increase physi-
cian productivity by automating office
functions such as scheduling and order
entry.
• AI could be used for data mining to sur-
face the right data at the right time and
improve Electronic Health Records.
• AI could be used to analyze all the known
data about the patient and produce in-
sights helpful to diagnosis.
• AI could be used to analyze the diagno-
sis and all other known data and produce
best-practice treatments.
• AI could free up time for physicians to
spend with patients by automating cer-
tain functions.
• AI could improve patient experience
and aid behavioral change and treatment
compliance.
• AI could assist in medical education by
surfacing needed information, requiring
less memorization and continuously as-
sessing competencies.
Challenges:
• Data structure, integrity and security;
• Technological mistrust (why transpar-
ency is needed);
• Need to demonstrate that AI can reduce
costs, support the patient-physician rela-
tionships, and improve care;
• Implement and integrate AI into clinical
practices and patient care;
• Uncertain long-term unemployment out-
look for health care professionals;
• Susceptibility to training bias, malfea-
sance, and technical problems;
• Questions as to who will benefit,and who
may lose? For example, what is best for
an individual is not always best for public
health, especially when limited resources
are available.
Questions raised by AI:
• What evidence is needed to demonstrate
value, utility, and trust?
• How does AI intersect with other emerg-
ing health care capabilities, such as ge-
nomic medicine?
• How will regulatory bodies and profes-
sional organizations provide proper over-
sight for AI benefits and risks, and com-
municate these to the public?
• How can public and systemic expec-
tations be managed, and concerns al-
layed?
• What education and training will health
care professionals need to acquire in order
to understand how AI solutions might
help them, and their patients in clinical
settings?
• What can health systems considering AI
opportunities do now to maximize their
chances of success for gaining efficien-
cies, improving care, and integrating into
clinical workflows?
• How will risk be allocated, given the
“black box” nature of AI systems?
• How will legal, policy, and regulatory
implications, including standards for pro-
fessional services, intellectual property
rights, and FDA oversight be monitored
and addressed?
Health Care AI Equity
and Access
The use of various AI technologies also
raises a number of equity and access consid-
erations, as covered by recent articles in the
AMA Journal of Ethics.
Data sets used for health care AI are cre-
ated by human agents and are imperfect.
For example, data sets based on clinical
trials include or exclude participants based
on certain characteristics, and the data
may not adequately reflect characteristics
of marginalized populations with less ac-
cess to care. Biases within the data may
unintentionally be reproduced by AI ap-
plications.
As noted here https://journalofethics.ama-
assn.org/article/can-ai-help-reduce-dispar-
ities-general-medical-and-mental-health-
care/2019-02:
“Advances in [AI] and machine learning
offer the potential to provide personalized
care by taking into account granular patient
differences.”
“However, this same ability to discern
among patients brings with it the risk of
amplifying existing biases, which can be
especially concerning in sensitive areas like
health care.”
There is also concern that AI is already out-
pacing the policy and ethics governing its
development and use. As noted here https://
journalofethics.ama-assn.org/article/ethical-
dimensions-using-artificial-intelligence-
health-care/2019-02:
“Nonetheless, this powerful technology cre-
ates a novel set of ethical challenges that
must be identified and mitigated since AI
technology has tremendous capability to
BACK TO CONTENTS
23
Physician 2030
threaten patient preference, safety, and pri-
vacy.”
“However, current policy and ethical guide-
lines for AI technology are lagging behind
the progress AI has made in the health care
field.”
The need for policy and ethical guidelines
around AI in health care necessitates the
involvement of physicians.
AMA policy on AI
Understanding that physicians must be in-
volved in the disruptive technology of AI,
the American Medical Association ad-
opted policy directives on AI at its Annual
Meeting in June 2018. In the same way, the
World Medical Association (WMA) is in
the process of developing a Statement on
AI. The Statement, approved by the WMA
Council in Santiago in April 2019, will be
considered by the WMA Assembly in Oc-
tober 2019.
Outlined below is a summary of the AMA’s
policy. We believe these are principles that
medical associations should consider as
they address the development of AI in their
countries.
Under our current policy, the AMA will:
1. Leverage its ongoing engagement in
digital health and other priority areas
for improving patient outcomes and
physicians’ professional satisfaction
to help set priorities for health care
AI.
2. Identify opportunities to integrate the
perspective of practicing physicians
into the development, design, validation
and implementation of health care AI.
3. Promote development of thoughtfully
designed, high-quality, clinically vali-
dated health care AI that:
a. is designed and evaluated in keeping
with best practices in user-centered
design, particularly for physicians and
other members of the health care team;
b. is transparent; 
c. conforms to leading standards for re-
producibility;
d. identifies and takes steps to address
bias and avoids introducing or exacer-
bating health care disparities including
when testing or deploying new AI tools
on vulnerable populations; and
e. safeguards patients’and other individu-
als’ privacy interests and preserves the
security and integrity of personal infor-
mation.
4. Encourage education for patients, phy-
sicians, medical students, other health
care professionals, and health adminis-
trators to promote greater understand-
ing of the promise and limitations of
health care AI.
5. Explore the legal implications of health
care AI, such as issues of liability or
intellectual property, and advocate for
appropriate professional and govern-
mental oversight for safe, effective, and
equitable use of and access to health
care AI.
Conclusion
As health care technology and AI advances
continue to transform the physician prac-
tice environment, there are two possible fu-
tures: One in which health care technology
and AI work for physicians and patients –
and one in which they don’t. The difference
depends on the degree to which physicians
are involved in shaping that future. Physi-
cians and medical associations must work
to shape the new environment rather than
simply react to it – and we must do it . . .
right now.
As we do this work, we must remember the
most important relationship in health care:
the physician-patient relationship. We
must continue to work with policymakers,
physician innovators, technology compa-
nies and other stakeholders to ensure the
development of clinically sound AI systems
that will enhance the quality of care and
support the physician-patient relationship,
rather than detracting from it.
The American Medical Association has
made involvement in AI development, pol-
icy and equity a key priority and encourages
other medical associations and interested
physicians to do the same.
For more information about the AMA’s
work on AI, visit: ama-assn.org/ai.
David O. Barbe, MD, MHA
Immediate Past President
American Medical Association
BACK TO CONTENTS
24
Training Needs
Introduction
The healthcare sector is an ever evolving
and changing environment and some of
the key changes are largely driven through
technology. It is therefore vital for health-
care organisations to continue to invest in
people, by upskilling them in areas that will
also give the company a competitive advan-
tage. This includes training on technology
and tools that seek to improve business pro-
cesses and efficiencies. Knowledge manage-
ment, training and development are the key
attributes to organisational growth and de-
velopment [10]. Most entities develop poli-
cies and procedures around this, to ensure
that there is continual training of staff on
key aspects of the business [9].
Continued Training
and Development
One of the most competitive advantages to a
health organisation is its workforce, and thus
continuous training and development is re-
quired,with efforts to respond to business de-
mands [4]. According to Maimuna, training
and development is an instrument that aid
human capital in exploring their dexterity as a
result training and development is vital to the
productivity of an organization’s workforce
[19]. Healthcare companies should continue
to view training as a strategic investment,as it
enhances and improves customer experience,
throughout the value chain [21].
The identification of training needs at or-
ganisational level needs to be aligned to key
strategic objectives and goals. Approaches
such as Gap analysis, SWOT or a Risk As-
sessment framework are key in assisting the
development of proactive strategies whereby
a healthcare organisation can optimise their
product offering and service delivery model.
It further assists companies, based on needs
assessments to identify the resources and
the systems needed.
Other methodologies of identifying gaps
couldbethroughconductingsurveys;through
using questionnaires which could comprise
a series of questions and other prompts, for
the purpose of gathering information from
respondents [25,27]. One typical example
could be that an organisation wants to reduce
costs associated with fraud, waste and abuse
or by developing cost containment strategies,
which could be achieved through proactive
identification of potential culprits. This in-
formation could be obtained by conducting
a survey where key questions are sourced for
fraud, waste and abuse, that could be identi-
fied through assessing the responses.
Respondents could also propose new ap-
proaches and provide further pointers to
new sources of fraud in healthcare and
could also provide methods that could be
used to pro-actively identify potential inci-
dents of fraud.
Training Needs on Health
Record Keeping
The keeping of medical records is a key at-
tribute for the efficiency of a health system.
In the main, it provides profiling and trace-
ability of patients and customers.The keep-
ing of medical records is also important for
ensuring that there is adequate care coor-
dination when a patient is transferred from
one provider or facility to another.There are
numerous studies that show that a lack of
training in patient record keeping is more
prevalent in the public healthcare sector
where there are no systems nor suitable hu-
man resources to manage and monitor this
function. Inadequate training is often stated
as one of the reasons that impacts negatively
on patients’ records processing.
There is also a culture issue, where there
needs to be commitment and support from
the top structure of a healthcare company.
Marutha and Ngoepe investigated the role
of medical records in the provision of pub-
lic healthcare services [15].The study found
that ninety percent (90%) of respondents
lacked adequate training on policies, pro-
cedures, norms and standards for managing
records and that only six percent (6%) of the
respondents stated that they had received
training in those areas. The other key fea-
ture regarding health records is data secu-
rity; particularly where confidential patient
information is concerned. Healthcare man-
agement companies should ensure that they
put processes and training programs on data
breaches and the proper guard of patient in-
formation in place, as these could negatively
impact an organisation.
Training Needs on Supply
Chain Management
One of the main strategies to reduce cost
and wastage in the healthcare sector is im-
proved contracting and supply chain man-
agement processes. SCM is also regarded as
one of the tools when effectively employed
Identifying Training Needs for Healthcare
Organisation
Michael Mncedisi Willie
BACK TO CONTENTS
25
Training Needs
could have a significant impact on reduc-
ing costs and improving performance in
health care organizations [18]. A recent ar-
ticle by Mathew, John and Kumar depicts
approaches to optimize costs in healthcare
supply chain operations, which includes the
virtual centralisation of supply chains, sup-
ply utilisation management practices, the
use of RFID technologies, the use of ana-
lytics and streamlining workflow [17].
The author further classifies stakeholders
into three major groups, namely:
• Producers;
• Purchaser, and
• providers.
Producers (comprise medical and surgical
supplies, medical devices, and pharmaceu-
ticals) who distribute these to the purchas-
ers (wholesalers, distributors and GPOs).
Purchasers then distribute them to the pro-
viders (hospitals, IDNs, physicians, clinics,
pharmacies, and nursing homes). Ryan, fur-
ther elaborates on the addition to the com-
plexity of the system,where there is involve-
ment and participation from governmental
institutions, regulatory agencies, and insur-
ance companies [23]. All these key compo-
nents of supply chain management need to
be integrated into an effective healthcare
management system.
Training Needs of
Products Offered
Product simplicity in healthcare is a very
difficult concept to quantify. There is also
the issue of information asymmetry, where
there is not enough detail about products.
Health  generally, is  not  considered a  pub-
lic good, because of non-paying individu-
als (without health insurance, healthy food,
etc.), and this makes it even more complex
than other products. Information in this re-
gard is key for choice optimisation by con-
sumers,when they purchase health insurance
plans. For example, consumers who are of-
ten not aware of the potential for receiving
subsidies for their premiums and cost shar-
ing, might choose not to enrol in coverage.
Similarly,consumers who enrol in plans with
expected spending greater than alternative
plans could end up spending far more on
their health care requires, during the year,
than they otherwise would have.
In a medical insurance setting,members en-
rol and purchase a product in the form of
health care plans so to be able to access care.
In the main, these products are often too
complex for the purchasers to understand.
The level of complexity is also twofold and
it affects, both the member and the medical
service provider. Various studies also show
that the purchase of care by citizens who
have low healthcare system literacy may
result in a struggle for them to make key
decisions.The more complex the product is,
the greater the risk is of it not being fully
understood by the purchasers.
During 2017, there were two hundred and
seventy-eight (278) registered benefit op-
tions operating in eighty-one (81) medical
schemes in South Africa; thus choosing a
benefit option remains a big challenge, as
there are many benefit options are often
not standardised [3]. Kaplan and Ranchod
contend that the number of benefit options
available in the medical scheme market cre-
ates complex environment impacting deci-
sion making [13]. An annual survey con-
ducted in 2017 depicted that consumers
were unsure of their own medical scheme
details and of the benefits that they were
entitled to [11].
The complexity of products offered by
health insurance companies has a positive
correlation with complaints and customer
satisfaction scores. It is thus critical for
health insurance and medical schemes to
invest in programmes that will educate and
train enrolees on the benefits and the prod-
ucts being offered.
Training Needs of Patient Cen-
teredness and Customer Care
Effective patient-centred care has become a
central aim for the nation’s health system,
yet patient experience surveys indicate that
the system is far from achieving it [26].
Based on interviews with leaders of pa-
tient-centred organisations and initiatives,
this report identifies seven key factors for
achieving patient-centred care at the organ-
isational level [26]:
• Top leadership engagement;
• A strategic vision, clearly and constantly
communicated to every member of the
organisation;
• The involvement of patients and families
at multiple levels;
Organization Level
Leadership development and training
Internal rewards and incentives
Trainingin quality improvement
Practical tools derived from an expanded
evidence base
System Level
Public education and patient engagement
Public reporting ofstandardized patient-
centered measures
Accreditation and certification requirements
Figure 1.
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26
Training Needs
• A supportive work environment for all
employees;
• Systematic measurement and feedback;
• The quality of the built environment; and
• Supportive information technology.
The two main strategies that have been
identified as necessary to overcome barriers
and to help leverage widespread implemen-
tation of patient-centred care at both the
organisation and at system Levels. Figure 1
depicts the characteristics of these.
There is comprehensive theoretical work be-
ing done on customer care,customer service,
quality and how these impact on customer
fulfilment, organisational performance and
customer retention. According to Sheahan,
customer service in health care is not the
same as in other industries,because custom-
ers are the receivers of the medical services
that are critical to their health [28].As such,
healthcare industries must maintain a good
customer service relationship with their
customers [28].
Mosadeghrad highlighted ten determinants
that could lead to better quality of service,
which, in turn, will lead to better customer
care [22]:
• Reliability – consistency of performance
and dependability.
• Responsiveness – the willingness or the
readiness to provide service.
• Competence – having the required skills
and the knowledge to perform the service.
• Access – approachability and ease of contact.
• Courtesy – politeness, respect, consider-
ation,and friendliness of contact personnel.
• Communication – keeping the customers
informed in a language that they can un-
derstand and listening to them.
• Credibility – trustworthiness, believabil-
ity, being honest.
• Security – freedom from danger, risk, or
doubt.
• Understanding – knowing that the heath
care provider is making the effort to un-
derstand the customer’s needs.
• Tangibles – the physical evidence of the
service.
Knowledge Management
According to Chong, knowledge manage-
ment is a broad subject with many facets,
ranging from databases to patents, from the
intranet to the mentor, from coldly techni-
cal to warmly personal concepts [4]. Differ-
ent academics and practitioners presented
a review of the literature, which concluded
that there is no clear definition and con-
cept of knowledge management [7]. Salleh
and Goh agreed that it is difficult to define
knowledge management since various per-
spectives and schools can define different
dimensions and meanings of knowledge
management [24]. A different perspective
on the concepts of knowledge can lead to
different definitions of knowledge manage-
ment [4].
Knowledge management is crucial for en-
terprises to determine where they are going
and for organisational survival in the long
run; given that knowledge creation is the
core competency of any organisation [4].
The human resources function in organisa-
tions needs to drive knowledge manage-
ment and create an enabling environment,
thus by creating a knowledge-sharing cul-
ture, nurturing and “learning‐by‐doing”can
yield to competitive advantage [2].
Financial Management
in healthcare
The primary role of financial management
in healthcare organisations is to manage
budgets and to ensure that financial risk is
mitigated. Companies need to be able to
have adequate systems to ensure that there
is adequate working capital management,
assurance on cost reduction and available
funds, to ensure that the organisation runs
effectively [29]. Furthermore, the financial
management staff of any healthcare or other
form of healthcare organisation should en-
sure that the organisation can meet its stra-
tegic goals, through proper planning and
budgeting processes. According to Deloof,
financial management includes evaluation
and planning, long-term investment deci-
sions, financing decisions, working capital
management, contract management, and fi-
nancial risk management and risk; in a way
that this helps to achieve the financial goals
of the organisation [6]. When a healthcare
organisation has strong and organised fi-
nancial management plans, which are also
managed efficiently, they are able to provide
efficient healthcare to all their patients.
Learning Organisation
The ‘learning organisation’ is a concept first
described as an organisation where people
continuously learn and enhance their capa-
bilities to create the results that they really
care about [1].
It consists of five main disciplines:
• team learning;
• shared vision;
• mental models;
• personal mastery; and
• systems thinking.
Al-Abri and Al-Hashmi further elaborates
that all five disciplines are dynamic, and
they interact with each other [1]. Further-
more, there are some educational concepts
and theoretical models, which are of rel-
evance to the learning organisation, and can
thus provide a framework for managerial
decisions. The aim of professional health
care education is to educate health care
personnel with up to date knowledge and
skills; either by theoretical learning through
attending courses or practically, through
training programmes. The core purpose of
health care education is to promote quality
in health care services by providing compe-
tent and safe personnel.Health care manag-
ers are obligated to acquire and to maintain
the expertise needed to undertake their pro-
fessional tasks. Additionally, they are also
obligated to undertake only those tasks that
are within their competence and to acquire
technical knowledge in their field of work.
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27
Training Needs
Governance for
Healthcare Managers:
Corporate governance involves more tradi-
tional managerial tasks of finances and bud-
gets, procurement and supply-chain man-
agement, human resource management, and
infrastructure [16].The principles underpin-
ning corporate governance include fairness,
accountability, responsibility and transpar-
ency [5]. At a global healthcare ecosystem
level, healthcare managers ranging from
practice managers, policy makers to govern-
ments, need to ensure that there are enough
two-way engagements and adequate com-
munication, where corporate governance is
concerned. Furthermore, there needs to be
adequate access to information on corporate
governance policies and continuous training
and development in this regard. The ability
to understand and to influence corporate
governance issues in the healthcare space
is complex, as most healthcare practitioners
are mainly trained more to practise health-
care than in an oversight role. Studies have
shown a clear distinction between clinical
and corporate governance. Maxwell and
Carswell depicts a clear linkage between
corporate governance and clinical gover-
nance [20]. The authors further depicts that
the management team should implement
clinical governance systems which ultimate-
ly get reported to the board.The table below
depicts a distinction between corporate and
clinical governance [20].
Conclusion
Healthcare management is a complex sector
to manage, this is mainly due to the risks
associated with it, ranging from financial
management and sustainability, business
improvement processes to the health and
the safety of patients or customer involve-
ment. The top structure of these organisa-
tions operates in a continually changing
business environment, ever-evolving tech-
nology, complex regulatory requirements
and changes in the profile of patients, such
as an increasing age profile and the burden
of disease.
All these require complex and demanding
health management; in order to manage
health organisations in an efficient, cost-ef-
fective, competent manner. Health manag-
ers require various leadership and manage-
rial skills and they need to be familiar with
the problems that exist in the health care
system. Continued identification, analy-
sis, and assessment of health management
training needs are pivotal, for the survival of
healthcare organisations [8].
References
1. AL-Abri, R., & Al-Hashmi, S. (2007). Learning
organisation and healthcare education.
2. Beyetlein, M., Collins, R., Jeong, S., Phillips, C.,
Sunalai, S & Xie, L. (2017). Knowledge sharing
and human resource development in innovative
organizations.Open access peer-reviewed chapter.
3. Council for Medical Schemes. CMS Annual
Report 2017-2018, 2018, www.medicalschemes.
com/Publications.aspx
4. Chong, S.C., & Choi, Y.S.(2005). Critical fac-
tors in the successful implementation of knowl-
edge management. Journal of Knowledge Man-
agement Practice.
5. Charkham, J. and Ploix, H. (2005). Keeping bet-
ter company – Corporate governance ten years
on. Oxford: Oxford University Press.
6. Deloof, M. (2003). Does working capital man-
agement affect profitability of Belgian firms?
Journal of business finance & amp; Accounting,
Volume 30, Issue 3 – 4.
7. Earl, M.J. (1999). Opinion: what is a chief
knowledge officer? Sloan Management Review.
8. Gaspard, J., & Yang, C.M. (2016). Training
needs assessment of health care professionals in
a developing country. US National Library of
Medicine National Institutes of Health.
9. Gesme, D.H., Towle, E.L., & Wiseman, M.
(2010). Essentials of staff development and why
you should care. Journal of oncology practice.
10. Gould, D., Kelly, D., & White, I. (2004). Train-
ing needs analysis: an evaluation framework.
2004 Jan 28 – Feb 3; 18(20): 33-6.
11. GTC (formerly Grant Thornton Capital). The
GTC Medical Aid Survey. Benet and cost com-
parisons 2018. The Wanderers Office Park,52
Corlett Drive, Illovo, 2196, 2018, http://www.
gtc.co.za. [Accessed February 2019].
12. Jacobs, S., Rouse, P., & Parsons, M. (2016).
Leading change within health services.
Table 1.  Difference between corporate and clinical governance
Clinical governance: Role of the Board Corporate Governance: Role of the Board
• 
endorse policies and clarify expecta-
tions. regarding the desired outcomes
for the CEO and the management
team, with respect to patient safety
and quality.
• 
receive, review and react to regular
reports on clinical performance from
the CEO and the management team.
• 
expect that such reports should be
sufficiently detailed so that the board
can assure itself that the organisa-
tion is performing in accordance with
formally recorded expectations, but
not be so exhaustive that potential
problem areas are lost or disguised in
the detail.
• 
Assure themselves that appropriate
remediation steps are activated for
problematic areas.
• 
appointment and evaluation of the CEO.
• 
engagement with the CEO and senior
management in setting-up the strategy of
the organization.
• 
identification and management of any real
or perceived conflicts of interest among
directors and/or officers.
• 
assessment of the contributions of each
individual board member, as well as the col-
lective performance of the board.
• 
enabling the chairman to effectively dis-
charge this/her special responsibilities as a
“first among equals”.
• 
ensuring that new board members are thor-
oughly oriented to the organization and the
operations of the board.
• 
underscoring that the interests of the
stakeholders are paramount (in the case of a
healthcare entity, this is the community the
institution serves).
Source: King IV compliance supplementary report [14]
BACK TO CONTENTS
28
In-Flight Medical Events
In 2017 I had the pleasure to write an infor-
mation paper on in-flight medical events at
the request of your association. Since then
the subject has remained and will continue
to remain an important and often misun-
derstood issue. One of the issues I raised
in the article was the lack of familiarity of
most physicians with the details of the flight
environment. I mentioned that the Aero-
space Medical Association (AsMA) has
produced a document called ‘Managing in-
flight medical events’to provide guidance to
health professionals that are called to help
during an in-flight medical event. While
I also wrote that an application for Android
and Apple (iOS) had also been created to
provide guidance on how to deal with the
in-flight medical events, I feel I did not in-
sist enough on this relatively new product
that can now be downloaded totally free
of charge on Apple Store or Google Play.
The app is updated regularly.It has been de-
signed by medical professionals knowledge-
able in medical emergencies and aerospace
medicine under a non-profit organization.
Information can be found on the follow-
ing web site: http://airrxmedical.com/index.
html. AirRX provides quick guides for the
23 most common medical emergencies, in-
formation regarding the legal right to treat
patients, lists of available equipment and
medications, and much more. Once down-
loaded on the mobile phone,the application
does not require internet access to operate
it, which is clearly an advantage when on
an airplane. As can be seen on the web site,
that application has already been down-
loaded in over 87 countries,but it is felt that
it could help a lot more physicians around
the world if it was better known, hence this
note so your association and its members
could spread the good news.
Claude Thibeault MD Consultant,
Médecine Aéronautique et Santé
au Travail Consultant,
Aerospace Medicine and
Occupational Health President,
Consultants Aeromed Inc.
13. Kaplan, J. & Ranchod, S. (2015). Analysing the
structure and nature of medical scheme ben-
efit design in South Africa. In: South African
Health Review.Eds.Padarath A,King J,English
R, 2015, Health Systems Trust, Durban.
14. King IV compliance supplementary report,
(2017).
15. Marutha, N.S. & Ngoepe, M. (2017). The role
of medical records in the provision of public
healthcare services in the Limpopo province of
South Africa,South African Journal of Informa-
tion Management 19(1).
16. Mash, R., Blitz, J., Malan, Z., & Von Pressentin,
K. (2016). Leadership and governance: learn-
ing outcomes and competencies required of the
family physician in the district health system.
South African Family Practice.
17. Mathew, J., John, J., and Kumar, S. (2013). New
trends in healthcare supply chain.Paper present-
ed at the International Annual Conference, Pro-
duction and Operations Management Society,
Denver, Colorodo.
18. Rotimi A.Gbadeyan,Rotimi A.Gbadeyan ,Fran-
cis O. Boachie-Mensah , Olubunmi F. Osemene
, Francis O. Boachie-Mensah , Olubunmi F. Os-
emene (2017).EFFECT OF SUPPLY CHAIN
MANAGEMENT ON PERFORMANCE IN
SELECTED PRIVATE HOSPITALS IN IL-
ORIN,NIGERIA .International Journal of Eco-
nomic Behavior, vol. 7, n. 1, pp. 99-116.
19. Maimuna, Muhammad & , Nda & Yazdani-
fard, Assc. Prof. Dr. Rashad. (2013). THE IM-
PACT OF EMPLOYEE TRAINING AND
DEVELOPMENT ON EMPLOYEE PRO-
DUCTIVITY. 2. 91-93.
20. Maxwell, D. & Carswell, P. (2011). Corporate
and clinical governance in the public health sec-
tor context: definitions and issues arising. AN-
ZAM 2011.
21. Mondy, R.W., Noe, R.M., & Premeaux, S.R.
(2002). Human resources management, 8th ed.
22. Mosadeghrad AM. (2014). Factors influencing
healthcare service quality. Int J Health Policy
Manag. 3(2):77–89.
23. Ryan, K. Jennifer. (2005). Systems Engineering:
Opportunities for Health Care, Building a Bet-
ter Delivery System: A New Engineering/ Health
Care Partnership. National Academy Press.
24. Salleh, Y. & Goh, W. (2002). Managing human
resources toward achieving knowledge manage-
ment. Journal of knowledge management.
25. Saunders, M., Lewis, P. & Thornhill, A. (2016).
7th edn. Harlow: Pearson education.
26. Shaller, Dale & Consulting, Shaller. (2007).
Patient-Centered Care: What Does It Take?.
Commonw. Fund. 68.
27. Shaw, E. (1999). A guide to the qualitative re-
search process: evidence from a small firm study.
Qualitative market Research.
28. Sheahan, K. (2017). Definition of customer ser-
vice in the health field.
29. Uhlers, N., Weimer-Elder, B., & Lee, J.G.
(2008). Simulation game provides financial
management training: all health care leaders
should grasp the essentials of financial manage-
ment. Health Finance management, 2008 Jan;
62(1): 82-8.
Michael Mncedisi Willie,
General Manager Research & Monitoring,
Council for Medical Schemes, South Africa
E-mail: m.willie@medicalschemes.com
In-Flight Medical Events: an Excellent
Application to Support Onboard Medical
Volunteers
Claude Thibeault
BACK TO CONTENTS
29
Naegleria infection
Introduction
Naegleria fowleri, also known as Primary
Amoebic meningoencephalitis, is a deadly
global waterborne disease, which infects the
brain of young children or adults,and which
requires immediate diagnosis and treatment
for successful outcomes.
Early recognition in Australia led to
naming of the organism attributed for
Dr. Malcolm Fowler from Adelaide Chil-
dren’s Hospital in Australia [1]. Overland
warm water pipes in Australia were a factor
in producing the infection there and the
USA southwest.
Global cases
Medscape has reviewed this deadly brain
infection in 2019 [1]. Globally, over 310
cases had occurred by 2012 [2]. Recent
cases from China and Pakistan are also il-
lustrative of its global nature [3, 4]. Paki-
stan currently has an outbreak of 11 cases
at Karachi alone  [4]. Indeed cases have
been seen on the six major continents of
the world.
Presentation
If patients present with a headache and fe-
ver, particularly in warmer months, physi-
cians globally should consider the diagnosis
of primary amoebic meningoencephalitis
(PAM). Careful history, special laboratory
testing, and special treatment may be ur-
gently needed to save the lives of these pa-
tients [1, 5, 6, 7]. The authors are including
elements of a summary letter published re-
cently in the American Family Physician by
Sherin, Linam and Jett [5].
Risk factors for
Naegleria infection
PAM is caused by Naegleria fowleri, a ther-
mophilic free-living ameba that occurs nat-
urally in warm freshwater. The trophozoite
form is believed to be the most infective.
Risk factors for infection include participa-
tion in freshwater-related activities such as
swimming underwater, diving, and head-
dunking; other similar activities that could
cause water to go up the nose; and nasal
irrigation for medical or religious pur-
poses [1, 5]. Wakeboarding is another risk
sport. The organism is believed to cross the
nasal cribriform plate and enter the olfac-
tory bulb and frontal lobe region to cause
the disease.
Tap water and
freshwater supplies
N. fowleri has also been detected in pub-
lic drinking water supplies. Even garden
hoses, water splash parks and artificial wa-
ter rafting activities have been implicated.
Irrigation of the nose other than with dis-
tilled or saline water carries substantial
risks.
Trends in the Geographic
Range
Recently, the geographic range of PAM has
expanded, with cases identified as far north
as Minnesota and Indiana since 2010 [5].
Climate change may be a factor in this
disease being reported in more temperate
zones. Widespread use of nasal ablution
or rinsing is a factor without proper dis-
tillation. Tap water or river water are both
Swanie Jett Steve Smelski
Michael J Muszynski
Primary Amoebic Meningoencephalitis as a Cause of Headache and
Fever – a Global Waterborne Disease
Kevin Sherin
BACK TO CONTENTS
30
Naegleria infection
grossly insufficient for safety for this nasal
procedure. These nasal techniques are often
done with Neti pots.
Rapid diagnosis is essential
Effective treatment and cure is however
possible without residual sequelae, rapid
diagnosis is therefore essential  [1, 6, 7].
The first step is identifying at-risk patients:
those presenting with fever, headache, and
recent freshwater exposure. A preliminary
diagnosis can be made by observing mo-
tile amoebae in a wet mount of cerebro-
spinal fluid (CSF) or visualization of the
organisms on CSF Wright or Giemsa stain.
N multiplex tests can add Naegleria antigen
to a CSF antigen panel.
Immediate treatment
Treatment requires immediate administra-
tion of a combination of systemic and in-
trathecal antibiotics such as Amphotericin
B and including oral miltefosine, which
is available commercially, and by contact
for guidance from the Centers for Disease
Control and Prevention (CDC) [7]. If you
have a patient with a suspected infection,
you can call call the CDC’s 24/7 emergency
consultation telephone to: 001-770-488-
7100 for diagnostic and treatment recom-
mendations. Laboratory confirmation is not
necessary before consultation or treatment.
The CDC can confirm the organism from a
CSF sample or N multiplex Naegleria anti-
gen assay. Equally important is the manage-
ment of cerebral edema, which is typically
severe and requires critical care manage-
ment. Strategies to reduce intracranial pres-
sure include: steroids, CSF drainage, hyper-
ventilation,hyperosmolar therapy,mannitol,
and hypothermia [1, 6]. The Medscape 2019
reference provides an excellent overview of
these points [1].
Future directions
Currently,only three USA states specifically
require reporting of PAM cases (Florida,
Louisiana, and Texas). No nations yet re-
quire reporting of PAM.
Readers of The World Medical Journal are
urged to learn more about this deadly
but highly treatable disease and promote
prompt effective treatment. WHO could
set up a passive case reporting system as a
next step. We urge considerations of global
surveillance, active reporting of cases, and
sharing of treatment enhancements. Warn-
ing labels on Neti pots for nasal ablution or
rinsing are also suggested along with post-
ing health warnings at warm water swim-
ming points in lakes or rivers for bathers or
religious worshippers.
A summit on Naegleria is being streamed
from Orlando FL USA on September 13,
2019 and will have an ongoing link. The
links are here:
http://hospitalchurch.org/sermons/watch-live/
after the Summit the recordings will be here:
http://hospitalchurch.org/sermon/
just look for Amoeba Summit 2019.
This conference is supported by the Jordan
Smelski Foundation and named in Jordan’s
honor. Jordan Smelski, a young healthy
boy, died of Naegleria in 2014 after a fam-
ily vacation to Central America. No cases
of Naegleria had ever been reported in that
region before.
References
1. Subhash Chandra Parija; Chief Editor: Mark R
Wallace.Naegleria Infection and Primary Amoe-
bic Meningoencephalitis (PAM). Medscape.
May 22, 2019. Accessed 08-27-2019. URL htt-
ps://emedicine.medscape.com/article/223910-
overview
2. Naegleriasis Global Impact. Published in the
website of CPIPD (The Center for Parasitic and
Infectious Diseases at the University of Cali-
fornia, San Diego, California, USA). Accessed
08-27-2019. URL http://www.cdipd.org/index.
php/naegleriasis-global-
3. A case of Naegleria fowleri related primary
amoebic meningoencephalitis in China diag-
nosed by next-generation sequencing. Qiang
Wang, Jianming Li, […]Yingxia Liu ; BMC In-
fectious Diseases Vol 18 (349); 2018
4. Karachi: 11 Naegleria fowleri deaths in 2019
through July according to Pakistan media.
Outbreak News Today. outbreaknewstoday.
com Published 08-13-2019;. Published news
desk by @infectiousdidesenews. Accessed 08-
27-2019. URL https://www.google.com/amp/
outbreaknewstoday.com/karachi-11-naeg-
leria-fowleri-deaths-in-2019-through-july-
according-to-pakistan-media-15269/amp/
5. Sherin KM, Jett S, Linam M. Letters to the
Editor. Primary Amoebic Meningoencephali-
tis as Cause of Headache and Fever. American
Family Physician. 2016 Apr 15; 93(8):644. Ac-
cessed 08-27-2019. URL https://www.aafp.org/
afp/2016/0415/p644.html
6. Liman WM, Ahmed M, Cope JR, Chu C, Vis-
vesvara GS, da Silva AJ, et al. Successful treat-
ment of an adolescent with Naegleria fowleri
primary amoebic meningoencephalitis. Pediat-
rics. 2015; 135(3):e744–e748
7. Parasites: Naegleria fowleri. Primary Amoebic
meningoencephalitis PAM. Treatment. Pub-
lished online by The Centers for Disease Control
and Prevention, Atlanta GA, USA. Accessed
08-23-2019. URL https://www.cdc.gov/para-
sites/naegleria/treatment-hcp.html
*British spelling of Amoeba is used throughout.
Ameba and Amebic is also correct.
Kevin Sherin, MD, MPH, FAAFP,
FACPM Orlando, Fla.
E-mail: Sherinkmj@gmail.com
Swanie Jett,
DrPH, MSC Brookline MA
Michael Muszynski MD, MS,
FAAFP. Orlando, FL pielikumā
Steven Smelski
BA. Orlando FL
BACK TO CONTENTS
31
Physician 2030
When the German Emperor, Kaiser Wil-
helm II, saw a motor vehicle for the first
time, he said that he was sure that “…the
horse would prevail over the motorcar…”.
And when the world’s first train crawled
from Nuremberg to Fürth, the medical
society of Bavaria published a sharp warn-
ing that there was scientific evidence that
speeds over 25 kilometers per hour were ex-
tremely dangerous to humans.
And Dr. Watson, the first CEO of a firm
named Integrated Business Machines – better
known as IBM – risked the prognosis that no
more than 5 “supercomputers”of the post-war
period would ever be built or needed.
Humans have always been reluctant to eas-
ily accept progress.On the other hand,there
were visionaries…
In 1925, just over a century before the year
we have been asked to envision today, in-
ventor and futurist Hugo Gernsback was
already dreaming about a device that would
allow physicians to treat their patients from
afar at the touch of a button.
This contraption, which he called the Tele-
dactyl, would allow the “doctor of the fu-
ture…to be able to feel his patient, as it
were, at a distance”. The instrument he de-
scribed would have both visual and haptic
elements. Doctors would see their patients
on a screen, while also physically examining
and reacting to the patient using remote-
controlled arms.
What would Kaiser Wilhelm or Hugo
Gernsback say when they looked at our so-
ciety and our situation today?
They didn’t know the words, but they were
faced with the three key issues of todays
meeting.
Digitalization, Migration and Globaliza-
tion.
Gernsback’s vision, it turns out, was not
that far off from what we are technically
capable of doing now. While modern vir-
tual communication as we know it today
and the implementation of robotics and
augmented intelligence in medicine were
more or less the stuff of science fiction
in 1925, the germ of an idea of what the
future of medicine could look like had al-
ready begun to form. Nowadays DaVinci
robot techniques and teleconsultations
have become unspectacular normality of
medical practice. Digitalization is already
over our doorstep!
And the future is closer than ever. Today
we have been asked to look not 100 years
into the future, but rather just over a de-
cade, to the year 2030. As a point of com-
parison, ten years ago Google wasn’t yet a
teenager. Dr. Google hadn’t even applied
for medical school. The iPhone was but a
toddler and a fledgling messaging service
called WhatsApp had 250,000 active us-
ers (that number, by the way, is now 1.5
billion). The world, and the way we com-
municate, is changing at lightning speed.
There has been a fundamental shift in the
way we interact with each other, and the
medical profession is, of course, not im-
mune to that fact.
In ancient Greek this was called “panta rhei”
everything flows.This was always the case –
only the speed of change has altered!
The developments we have seen in the med-
ical profession in recent decades extend far
beyond communication, which is an issue
I’ll return to later. To understand what the
future might hold for the patient-physician
relationship, it is important to first take
stock of where we are today and how we got
here.
Advancements in medicine, state-of-the-
art medical devices and modern treat-
ment options mean that certain diseases
that were once more or less considered
a death sentence for patients have now
been transformed into manageable, treat-
able chronic conditions. Just look at cancer
and HIV. And many patients are surviv-
ing long enough to have the “chance” to
be diagnosed with a second formerly fatal
disease. In the past they would have died
of the first and not lived to the diagnosis
of the second.
Demographic changes in the form of aging
populations are a fact that cannot be ig-
nored in any country of the world. The de-
mographic shift has an impact on society as
Frank Ulrich Montgomery
Statement by Frank Ulrich Montgomery.
“Physician 2030: the Future is around the corner”
BACK TO CONTENTS
32
Physician 2030
a whole, the healthcare system and the way
it is organized and financed. And it has an
impact on migration. You don’t find skilled
health care professionals in Sub-Saharan
Africa but you do find them in richer so-
cieties.
And by the way, demography doesn’t ex-
clude our profession: Just as our patients
are aging, physicians in the more affluent
countries of this world have been getting
older, too, and the number of physicians is
growing too slowly to compensate for the
challenges that lie ahead for our healthcare
system.
And governments are hesitant to react to
this shortage in a sensible manner: instead
of increasing the number of students in uni-
versities and the number of training posts
for specialization, they opt for cheaper al-
ternatives instead.
One approach which is often touted by na-
tional governments and other authorities
as a solution to personnel shortages in the
medical profession is that of task shifting.
The World Health Organization defines
task shifting as
“A process of delegation whereby tasks are
moved, where appropriate, to less special-
ized health workers. By reorganizing the
workforce in this way, task shifting can
make more efficient use of the human re-
sources currently available.”
But in the eyes of the medical community,
this is a fallacy. Patients deserve physicians.
Quality of medical care and the right of ac-
cess to a fully trained doctor are basic hu-
man rights.Of course – in cases where there
is no physician – it is helpful to have a nurse
on hand. And of course, where there is a
lack of nurses, community health workers
might come in handy. No one denies that –
not even us. But we cannot accept that gov-
ernments or international organizations like
the WHO or the World Bank promote the
training of nurses and community health
workers rather than fully trained physicians.
This is equivalent to denying patients ac-
cess to quality health care.We must be clear
and firm that under a concept of Universal
Health Coverage, health care must involve
physician-led teamwork and this must be
thoroughly financed.
And let’s be very clear: a patient-physician
relationship demands a physician  – not a
substitute or surrogate.
Physician shortages are not a problem fac-
ing lower-income countries alone. One
change I continue to campaign for in Ger-
many is at least a 10% increase in the num-
ber of slots available for students to study
medicine. And I mean thorough training of
students at Universities.
This is not without pitfalls: As Richard Ri-
ley, Secretary of Education under Bill Clin-
ton once said: “…we are currently prepar-
ing students for jobs that don’t yet exist, using
technologies that haven’t yet been invented, in
order to solve problems we don’t even know are
problems yet”.
And this is where our approach to global-
ization comes in. We have to maintain and
develop standards we do not even know of
(yet)….
But the overarching issue however is the
human relationship between a patient and
his or her physician. All these modern tech-
niques that we talk of, are only tools in this
relationship,they cannot be substitutes.And
we have to recognize this as well in medi-
cal training. The trend to blended learning
institutions of training with “home studies”
at your own computer and some practical
training in local hospitals, is not equivalent
to a decent University or Medical School
training curriculum. Our students need
more practical experience; we need more
direct contact between student and teacher
and we definitely do not need more elec-
tronic “Open Universities” in medicine.
I firmly believe that if we do not actively
address physician shortages now, the situa-
tion for patients will deteriorate in the years
ahead.
In addition, efforts must be made to in-
crease the attraction of going into general
practice, since this is precisely where we are
falling short. Models in which rural hospi-
tals cover tuition and, in exchange, medical
students must agree to work at said hospital
for a certain number of years – could help
insure that the patient-physician remains
balanced and robust despite challenging de-
mographic changes.
What we must avoid at all costs, however,
is the impracticable expectation for over-
worked physicians to add more consultation
hours to their schedules.
As I mentioned at the very top of my ad-
dress, technological advancements have not
only had a positive impact on the types of
medical treatments available and, by exten-
sion, patient outcomes, but also on how pa-
tients access this treatment and how doctors
and patients communicate with each other.
Digitization is ubiquitous.
It is changing how we read, how we order
products and how we consume media con-
tent. And now it is changing how health
services are delivered, how patients book
doctor’s appointments, follow up on medi-
cal exams and order medicine.
In the best cases, technology improves ef-
ficiency and reduces the burden of admin-
istrative work for physicians and their col-
leagues – all while ensuring quality of care
and maintaining the highest standards of
medical excellence.
In the worst case it substitutes human em-
pathy with “artificial intelligence”.
When Hugo Gernsback conjured up the
Teledactyl more than a century ago, it was
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33
Physician 2030
as if he had foreseen modern-day telemedi-
cine. The World Medical Association de-
fines telemedicine as “the practice of medi-
cine over a distance, in which interventions,
diagnostics and treatment decisions and
recommendations are based on data,includ-
ing voice and images, documents and other
information transmitted through telecom-
munication systems.”
The digital tools we now have at our dis-
posal – from medical apps to wearables to
online portals for making appointments –
offer tremendous opportunities to enhance
the healthcare experience for our patients.
But we have to keep in mind: they are only
tools, not substitutes.
And whether we wanted it or not  – they
have become a reality. And whether we like
it or not, younger generations use them
today like we used Walkmans and cassette
players when they were the latest invention,
leading our parents to shake their heads
over all these new – in their eyes totally use-
less – modern gadgets…
But what impact do these new techniques
have on the patient-physician relationship?
In an ideal world, physicians should always
provide medical consultation and treatment
to patients through direct, personal contact.
That is the “Gold Standard”.
However, as we saw earlier, this is not always
as simple as it sounds, particularly in remote
areas where physician shortages are and will
likely continue to be an issue going forward.
And we also have to accept a generational
change in our societies.The smartphone has
become a constant companion of our days.
It has become an extension of our senses.
And digital natives don’t understand why
we conventional, old-fashioned grufties
prefer a look in the eyes, a touch on the skin
or physical examination.
Question is: WHO has to change? I believe:
We have to adapt. We have to learn.
For years it has been permissible in Ger-
many for physicians to use communications
media only to supplement, but not replace
in-person patient care. Last year’s German
Medical Assembly, however, paved the way
for physicians, at least in individual, medi-
cally justifiable cases, to provide medical
consultation or treatment exclusively via
communications media. Generally speak-
ing,there is no difference in the responsibil-
ity for the medical act of a physician. He or
she must know what they are doing – and
this applies to electronic consultation just as
much as to conventional physical contact.
Virtual treatment raises important ethical
questions which we must continue to ad-
dress in the years ahead. And we have to be
aware that there are still impediments asso-
ciated with this type of contact, which place
more responsibility on doctors’ shoulders.
In addition to concerns about data privacy,
it could, if used incorrectly, undermine the
relationship of trust or at the very end de-
personalize the relationship between physi-
cians and their patients.
Some might argue that some forms of tech-
nology – for example, the use of robotics in
surgery and AI, could render doctors obso-
lete in the future.
Here’s why I think that will not happen:
The physician-patient relationship has been
evolving for generations from a paternalistic
model, in which the patient was essentially
expected to do what the physician said, no
questions asked, to a model of shared, par-
ticipative decision making.
Digital technology has increased patients’
access to – and hunger for – information. It
has made them more informed and empow-
ered participants in their medical destiny
and contributed to symmetry of communi-
cation between patients and physicians.
However,there is a downside to the flood of
information patients have at their disposal.
As we see on a daily basis, social media – for
all its positive aspects – can also be used as a
breeding ground for misinformation.
A prime example of this is anti-vaccination
discourse, which is having a serious detri-
mental impact on public health.
Patients will always need physicians to be
a source of professional expertise and em-
pathy  – perhaps even more so as sources
of dubious online health content are called
into question.
And we have to maintain and fight for our
position as serious information brokers to
our patients.
We will not win this battle by simply calling
electronic evidence from Dr. Google, Wat-
son or whatever “poppycock”.
We have to seriously engage as reliable
translators of a lot of nonsense to discrimi-
nate good from bad for our patients. They
need – and mostly want – our help!
And of course, every disruptive change in a
healthcare system brings with it the poten-
tial for failure of mutual trust and respect
between physicians and patients. This is
something we must always keep in mind
and actively resist.
For this reason, it is essential that we con-
tinue to adhere to – and update where nec-
essary – the key ethical guidelines that unite
our profession, like the WMA’s Declaration
of Geneva and the WMA International
Code of Medical Ethics. For example, the
newest version of the DoG incorporates
greater emphasis on the autonomy and self-
determination of the patient.
A positive patient-physician relationship
based on mutual trust is good for patient
health outcomes and it is good for physi-
cians, too. Physician well-being is another
BACK TO CONTENTS
34
Physician 2030
issue that was integrated into the revised
version of the DoG, as there is a direct cor-
relation between self-care of physicians and
their ability to provide care of the highest
standards.
Modern technologies, new techniques of
communication and robotics tend to fright-
en us and the public, when they are brand-
new.That’s a fact – and that is normal.
But the key ingredients of the patient-phy-
sician relationship have not changed. And
they must not change. After some time we
often realize that what once frightened us
has become a useful, sometimes inevitable
tool of our profession. It became part of
patient-physician partnership.
That’s why I am not afraid of the future.
And I am sure the future will be bright –
actually it has to be, because looking at my
own age I will in the future definitely have
more physician-patient encounters from the
other side of this relationship.
It sometimes opens your eyes when you
change sides.
And medicine is extremely successful.
And it will stay to be.
In the most affluent countries of the world
the average life-expectancy of the people
will increase by four years over the next two
decades. So having listened to me at this
conference has increased your personal life-
expectancy for at least ten minutes. I hope
it was worth ist.
For centuries, our profession has under-
stood the importance of adhering to ethical
codes – from the Hippocratic Oath to our
modern-day WMA policies. And this will
still be the case in 2030 and beyond, so long
as we safeguard professional autonomy, re-
spect patient self-determination and remain
focused on the primacy of patient health and
well-being as the cornerstone of our profes-
sion.
Prof. Dr. Frank Ulrich Montgomery
Chairperson of the WMA
Council, at the conference
One of two WMA conferences this year
was dedicated to the future of medicine,
namely, medicine round the corner. The
conference took place in Israel, Herzley, in
May 2019, and was organised by WMA
President, Professor Leonid Eidelman,
together with the Israel Medicine Asso-
ciation. Fantastic lecturers were welcomed
who considered future medicine from very
different viewpoints, both geographic (Ja-
pan, Brazil, Kenya, Israel, USA, Germany,
etc.) and medical (primary care, prevention,
radiology, functional diagnostics, etc.). I re-
quested a number of lecturers to share their
views in WMJ.
Inspired by conference reports and articles
in different medical journals of the world
on medical futurology, I have outlined some
vision of where to medicine and health care
will develop in the next 10-30 years. Un-
like clinical medicine or molecular biology,
medical futurology approaches vary from
country to country. Writing this article, to
a large extent, is due to impressions I have
from the lectures and publications by the
President of the CPME, Chairman of the
Council of the World Medical Association
Frank Ulrich Montgomery and the Secre-
tary General of the World Medical Associ-
ation Otmar Kloiber, representing the views
of the world leading medical organisation.
There are many people talking and writing
about where medicine is going to develop.
Everyone, who writes about the future,
looks into the past, and their assumptions
are based on different axioms and theories.
Discussions and conferences on the future
directions of medicine are dominated by
precision or personalized medicine, genome
research and gene therapy, modern technol-
ogies (diagnostic geeks) and artificial intel-
ligence, new drugs and personalized drugs.
For a physician to make any forecasts for
the future is a dangerous project. On De-
cember 7, 1835, after the first train in the
world crashed on its way from Nuremberg
to Fürth, the Bavarian Society of Doctors
Physician in 30 years from Now – will Technology and Politics
Change Physician – Patient Relationships or Change Doctor’s Place
in Society and Medicine?
Peteris Apinis
BACK TO CONTENTS
35
Physician 2050
published a sharp warning of scientific
evidence that speed exceeding 25 kilome-
ters per hour is extremely dangerous to
human health. Dr. Watson, the first head
of the company Integrated Business Ma-
chine, once forecasted that no more than
5 supercomputers will ever be built in the
world because nobody will need it. The
company’s name was shortened to IBM,
but computerization has taken over the
entire world.
Describing future medicine (a view in the
30-year future – 2049), the key words are:
(i) biochemistry and biology;
(ii) business;
(iii) chemistry;
(iv) mathematics and computer science;
(v) engineering and nanotechnology;
(vi) genomics.
In 2049, medicine will be personalised, pre-
dictable, preventive, co-sustainable, with
high technology, high data processing,
informatics and artificial intelligence in-
volved.The three major discoveries that will
rapidly advance medical development over
the next 30 years will include:
(i) artificial lungs (or rather artificial gills):
very close supersensitive membranes, blood
flowing between them and oxygen-rich air
or liquid on the other side;
(ii) artificial blood, a fluid that will be able
to flow through the blood vessels and to at-
tract and return oxygen to tissues;
(iii) stem cell studies, gene engineering and
3D printing or in vivo breeding abilities in
another organism will certainly allow the
development of such important structures
as kidneys, liver, and I believe, even lungs.
Certainly, in 2049 you won’t be able to print
or grow new brains.
It is essential that among basic medical em-
ployments  – diagnostics, treatment, reha-
bilitation, prevention, the emphasis in the
future will shift to rehabilitation (currently
the emphasis is placed on diagnosis, often
paying more attention to diagnosis than
treatment or rehabilitation facilities).
A Modern Doctor’s Viewpoint
on Medicine in 2049. A 2049
Doctor’s Viewpoint on Medicine
and Healthcare in 2019
For those reading this article, I suggest imag-
ining oneself in 2049. Let us agree that all
those doctors, who now are 50-55 year old,
will work as doctors also in 2049 because not
only society, but medicine, too, will grow old
globally, and working life will be long. But
all those, who are over the age of 55, should
imagine that in the doctor-patient dialogue
they will take the patient’s part. It is essential
that life expectancy has increased significantly,
and according to social determinants of health,
a retired doctor will live in good conditions,in
a good urban area,will move a lot,eat healthily,
be well diagnosed and treated, so will live for
over 100 years. For all those, who have adopt-
ed these rules, I would add that they will also
have to experience the demographic global
megatrends: the ageing of the planet’s people,
urbanisation and an increase of total wealth,
which will lead to three global pandemics: de-
mentia, depression and diabetes affecting ev-
eryone – all three together or one by one.
I recommend to everyone today, in 2019,
to remember medicine in 1989, it means
30 years back:
(i) even though single use tools and equip-
ment had already entered the world,most of
the world’s blood transfusion systems,injec-
tion syringes, surgical needles, endotracheal
tubes were sterilized and used many times;
(ii) the world had learned something about
HIV/AIDS, but knew nothing about hepa-
titis C;
(iii) penicillin was administered to muscular
injections for 2 million six times a day;
(iv) invasive cardiology and invasive angio-
logical diagnostics took first steps and was
ultimately not available daily;
(v) resection in the event of gastric bleeding;
(vi) there were no ventilation units on emer-
gency ambulance cars;
(vii) had to look in the arthroscope and en-
doscope instead of looking at the screen;
(viii) a lot of small hospitals with a very long
hospital treatment time. Hospital as a social
assistance institution.
Each of us has our own memories of 1989,
but more than half of the drugs that were
available and used in medicine at the time
are not manufactured and used today, but
some have been found to be harmful and
dangerous.
Now let us imagine ourselves living in
2049. How would we remember the 2019
medicine? What will we think of the public
health of 2019?
(i) The majority of the diseases for which
we treated our patients were chronic non-
communicable diseases, but health care had
remained the one created in the early 20th
century to treat injuries and acute diseases;
(ii) Treatment was determined not by the
doctor’s knowledge and patient participa-
tion, but by hospital, a large unfriendly
building. The patient had occasionally to
stay in hospital only for one non-essential
diagnostic or medical manipulation;
(iii) Occasionally you couldn’t see a doc-
tor immediately once you were in hospital.
There were waiting lines for medical treat-
ment and diagnostics.There were practically
no options for talking to a doctor in a digital
environment;
(iv) The digitalisation of health data was so
different that the majority of data in medi-
cine was not available in other countries,
but often – in another medical institution
of one country;
(v) Medical hardware and devices were huge
and scary, patients had to travel to perform
a CT or MRI;
(vi) The drugs were produced by BigPharma
companies,which for decades were preparing
the same drugs and trying to sell the same
doses to millions of people.Everyone got the
same pills – no personalised medicines;
(vii) Inventing of new treatments and
health-care techniques, but mainly regis-
tering them, took a lifetime. Patients died
waiting for a new treatment because of the
lack of officials to register methods and
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Physician 2050
medicines. Clinical trials – long and incred-
ibly expensive. The medicinal product was
tested on real patients;
(viii) The patient was not only treated while
in hospital, but also got new infections in
hospital;
(ix) In hospital, professionals often made
mistakes because of the lack of algorithms,
depletion of physical resources, fault of the
medical organisation. In 2019, medical er-
rors were the third or fourth most frequent
cause of death;
(x) Epidemiological studies were slow and
many were completely redundant;
(xi) Cancer was considered a dramatic life
event, not a chronic disease.
You have the opportunity to supplement this
reflection from the perspective of your spe-
cialty and the ability to look into the future.
Key Factors Determining
Medicine and Public Health
Over the Next 30 years
In terms of the future of medicine, many
known and unknown factors have to be tak-
en into account. I have chosen 10 essential
factors that will determine medicine and
population health over the next 30 years,
and ranked them by personal sense:
(i) climate change. It is climate change that
will cause a very significant humanitarian
crisis in Subsaharan and North Africa and
possibly South Asia over the next 15-20
years. This humanitarian crisis will cause
migration of more than 200 million people,
with very high pressure on health systems of
the migration target countries;
(ii) planet pollution. Household chemicals
as poison, excessive armament and military
actions as planet degradation factors. En-
docrine disruptors will be a birth limiting
factor further affecting the loss of flora and
fauna global biodiversity. Excessive use of
chemical substances will also result in an
increase in hereditary pathologies and in-
herited defects;
(iii) overuse of pesticides, fungicides, herbi-
cides as well as antimicrobial therapies used
in medicine and veterinary medicine will
affect the characteristics and resistance of
bacteria. Pathogenic bacteria resistant to all
antibiotics will develop. Antimicrobial re-
sistance will lead to very serious morbidity
and mortality. The control of infections will
be based on vaccination against antibiotic-
resistant micro-organisms.Over the next 30
years, one or more global epidemics caused
by viruses will spread around the world.
People will start avoiding hospitalization
afraid of contagion risk;
(iv) the overpopulation of the planet and
demographic changes, a significant increase
in life expectancy (in both rich and poor
countries). This will lead to a number of
consequences:
• medical treatment,provided it has sufficient
resources,might ensure extending the life of
each individual very significantly;
• eachindividualwillclaimaverylargeamount
of the money resources to extend their indi-
vidual life and, regardless of the country’s
economic wealth, medicine will start to run
out of funds in a catastrophic way;
• any resource (medical knowledge, intu-
ition, experience, working time, premises,
hardware, medicines, money) that will be
invested in health care, specific preven-
tion, diagnosis, medicine and rehabilita-
tion will extend the human lifespan and
improve the quality of life;
• the fundamental paradox of medicine will
come true: if greater sums are invested in
health care,the longer people will live and
more resources will be needed for health
care. Consequently, there will be public
discontent in all countries with the health
care system and its financing;
(v) an ever greater role of social determi-
nants between the rich and the poor,educat-
ed and uneducated – the predictable length
of human life will be more determined by
the ZIP code than the genetic code (in any
country in the world, a wealthy and edu-
cated person lives on average a significantly
longer life than poor and uneducated);
(vi) the ageing of the population  – both
patients and doctors. Epidemics of chronic
diseases, multimorbidity (patients with
multiple diseases) and polypragmasia (a
patient taking many different drugs at the
same time);
(vii) lack of doctors and medical profession-
als;
(viii) digital technologies, particularly in di-
agnostics; artificial intelligence as a key ele-
ment of diagnostic and screening;
(ix) rehabilitation as the leading medical
sector;
(x) healthcare, medicine and pharmaceuti-
cal market (together) as the main economic
sector of any country with a share of at least
25% of gross national product.
Ranking all this in different order, remov-
ing one piece of the puzzle and replacing
it by another, anyway, the conclusion is that
the worst that may characterise medicine in
the 21st
century is the following: overpopu-
lation, new deadly global fast-spreading
viruses, antimicrobial resistance, medical er-
rors and lack of clinicians, but demographi-
cally: a senior patient with chronic diseases,
multimorbidity and polypragmasia.
The positive scenario rests upon the fact
that medical development, state-of-the-art
diagnostic equipment and modern medi-
cal treatment will translate diseases previ-
ously considered a death sentence for pa-
tients into treatable chronic diseases such as
cancer or HIV/AIDS. Many patients with
these diseases will survive long enough to
await the diagnosis of another deadly dis-
ease. In the past, they would have died from
their first diagnosis and would not have
lived long enough to learn about another
fatal diagnosis. In the past, it was easier to
create mortality statistics, but thirty years
later, the pataloganatomist will find it dif-
ficult to state clearly from which disease the
patient died.
Thirty years later, immortality would not be
achieved. Everyone who will be born will
die sooner or later. Human organs from
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Physician 2050
one’s own cells and genes will be “grown”af-
ter some 15-20 years, but not all body cells
and organs will be replaced.
In the next thirty years, the main vector in
medicine will be doctor-patient relation-
ship. Politicians, officials and journalists use
two expressions – “team work”and “patient-
centered” in this situation. The concept of
“team work” is synonymous with “I  don’t
know what to say, but I want to pretend
to be smart”. The concept of “patient-cen-
tered” means the personal experience of a
politician or an official in hospital, dental
chair, pharmacy or ambulance, which is
generalized and based on a complete lack
of knowledge. This lack of knowledge is ac-
companied by an inability to believe that
the doctor has undergone training for many
years and therefore understands human
anatomy, physiology, health, disease, drug
use, motion, thinking, brain activity and in-
ternal secretion, immunology, cell symbio-
sis, microbiome and many other things at
a completely different level and in a com-
pletely different context. Therefore, a poli-
tician and an official responsible for global
health quickly is exposed to the disease of
a second year medical student, caused by
thinking about money, magnetic resonance,
ibumetin and hospital repair. The igno-
rance of both – the average politician and
the average official  – will increase in the
next 30 years, with only a negative impact
upon medicine. Any disruptive change in
the health system (usually referred to as re-
forms) undermines mutual trust and respect
between doctors and patients.
On Remote Communication
Between the Doctor
and the Patient, Called
Telemedicine (WhatsApp,
Apps, Skype and e-Health)
Let’s return in the past to look at the future.
In 1925, namely, nearly a century ago, the
German inventor and futurist Hugo Gern-
sback described a device of the future that
would allow doctors to treat their patients
from a distance, and the doctor would do
so by touching the button. Gernsbak called
his futurological prediction a teledactyl that
would allow the future doctor not only to
see, but also to feel his patient from a dis-
tance, using long–distance hands. Gerns-
bak’s vision is pretty close to modern tele-
medicine and da-Vinci’s surgical robot.
WMA defines telemedicine as a medical
practice from a distance where interven-
tional, diagnostic and medical decisions
and recommendations are based on voice
communication, data, images, documents
and other information transmitted through
telecommunication systems.
Digitization is ubiquitous. Changes affect
the extent healthcare services are provided
and the way patients reserve or apply for
their visit to a doctor, how doctors and pa-
tients follow medical examinations and orga-
nise the medical treatment process. At best,
technology improves efficiency and reduces
the burden of administrative work for physi-
cians, while ensuring the quality of care for
all patients and maintaining high medical
standards.At worst,it replaces human empa-
thy with notional artificial intelligence.Med-
ical politicians’ fascination with the digitiza-
tion of medicine often puts the computer in
the centre of health care, but the patient and
doctor are expelled from the centre.
Remote communication is an instrument,not
replacement of a doctor. Avoiding doctor-pa-
tient communication is impossible, and com-
munication via computer or mobile phone
will become a commonplace way of commu-
nicating between a doctor and a patient.
How do the new communication methods
affect patient–doctor relationships? In an
ideal world, the gold standard means that
a doctor should always provide medical ad-
vice and treatment to patients through di-
rect, personal contact. At the same time, for
patients a visit to a doctor means spending a
lot of time and financial resources.The doc-
tor’s workload is heavy enough and to save
time short advice provided on the internet
might be preferred.
The smartphone has become a constant
guide in our daily life. Digital oriented
young generation does not understand why
doctors due to old-fashioned traditions
should prefer looking into eyes, touching
skin, conversation in a low-pitched voice
about individual health history, ausculta-
tion, percussion or physical testing rather
than conversation in WhatsApp or Skype.
Different types of remote communication
between a doctor and a patient will become
commonplace worldwide, developing con-
tinuously together with the technological
developments. The world and the way we
communicate are changing very quickly.
The fundamental change takes place in the
way we interact one with another, and the
medical profession is certainly not immune
to general trends.
Virtual conversation between a doctor and
a patient, virtual diagnostics and treatments
create new ethical challenges. The biggest
concern is data privacy. Virtual diagnostics
and treatments, used incorrectly, can un-
dermine confidence in the doctor-patient
relationship or even depersonalize relation-
ships between the doctor and the patient.
In addition to the benefits of communica-
tion between the doctor and the patient in
the internet environment, there is a concern
that the computer will be fully positioned
between the doctor and the patient. The
digitalisation and remoteness of diagnostics
from the treating physician, and particularly
the direct transfer of the examination data
to the patient, leads to leaving the patient
alone with their health problems, com-
plaints and numerous worries.
In this situation, artificial intelligence
comes in, or in a simple case an algorithm,
which allows data to be analyzed: there is
something too much here, too little here,
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Physician 2050
some sort of formation in the picture, etc.
It is important – who has sent the patient
to a diagnostic test – a GP or a specialist.
Unfortunately, a CT or MRI study, as a law,
has been performed a few weeks or even
months after administration, the examina-
tion result is ready in a few more days, and
now is stored somewhere in the depths of
DataMed. The patient hopes that someone
is following what happens with this study,
but the GP does not even know about the
existence of any other test appointed by a
narrow-sector specialist. If the patient on
his own initiative finds and receives the
answer of the radiologist or laboratory, the
examination and diagnostics will continue
or the treatment started. If a patient has
been referred for testing by a narrow-sector
specialist, there are concerns whether the
indications in the study’s response to pa-
thology under the responsibility of another
narrow-sector specialist will be evaluated.
In this case, the only one capable of help-
ing, directing diagnostics and treatment is a
doctor of general practice – a GP.
In addition to supporting the system of gen-
eral practitioners,its development,the devel-
opment of expertise,and for the search of op-
timal organisational forms no effort should
be spared both in professional organisations
and in national ministries, and parliaments.
Supporting family doctors means additional
funding,additional support of municipalities,
additional training, serious red tape reduc-
tion. A doctor of primary care or a GP will
be needed and will be a key stage in medicine
even after thirty years, regardless of how the
profession will be called.
Digital technology has increased patient
access to information. Digital technology
has made patients more informed and em-
powered over their health and health care
and promoted symmetric communication
between patients and doctors. The claim
that a patient can be as informed as a doc-
tor is exaggerated because it is more difficult
for a patient without medical knowledge to
distinguish between honest, modern medi-
cal information on social networks and in-
ternet portals from erroneous messages or
fake news.
Over the next thirty years, patients will
need doctors as a source of professional
experience and empathy, particularly when
a patient sees highly questionable online
health content. The doctor will have to be
a middleman for information between the
digital information platform and the pa-
tient in the future.
The biggest lie is replacing a doctor with
an app. Every day, an average of 100 new
medical or health applications are created in
the world, while on average one person uses
10 to 20 applications on his mobile phone,
even if he has installed a hundred. The cre-
ation of apps is synonymous with the extor-
tion of money.
Regardless of enjoyment or trouble, data
storage and analysis will play a huge role in
the future. The digitisation of health data
will open the possibility of legally, semi-le-
gally or illegally manipulating a huge array
of health data, both for marketing purposes
and in optimising insurance issues, more or
less ethically questionable,acceptable or un-
acceptable research, etc.
As well as attempts to digitize everything –
from a doctor’s and patient’s direct or imag-
inative recording and a full MRI study in
digital form to self-sensing and temperature
readings, the need to hide the information
will appear. Sooner or later, the doctor will
need not to provide the whole world with
information on decision-making, reason-
ing, risks.The problem of keeping a doctor’s
secret separate from the huge global data
cemetery will have to be addressed.
This will be the matter of significant differ-
ence between the European and Chinese
approaches: in China, all medical docu-
mentation will be available for research, in-
cluding the gene map of each citizen. Due
to legislative differences, China’s medical
science will have great breakthrough op-
portunities in the near future. And there is
no envy or regret: Europeans and Ameri-
cans prefer to take care of their data security
rather than global achievements.
Task Shifting – Attempts of
the World Politicians and
Financiers to Replace a Doctor
With a Nurse or Public Health
Worker as Preparing Physicians
Seems too Expensive
Artificial intelligence will not replace the
doctor, but will slowly push the human fac-
tor out of digital diagnostics and medicine.
The world health care is not driven by mon-
ey and new technologies, but by the doctor-
patient relationship.The eternal question in
medicine is about the main decision maker:
who is it – the doctor, patient, doctor and
patient (and relative), payer?
Demographic changes and population age-
ing are some of the essential factors to be
taken into account for distant and not too
distant future, visualizing national or even
world development scenarios.Demographic
change – population ageing, drain of work-
ing population to cities or global megalo-
poli – have an impact on society as a whole,
the health system and the way healthcare is
organised and funded.
The demographic impact is equally felt on
the whole of society, including the age of
medical specialists. Doctors in the rich-
est countries of the world are aging, but
the number of doctors increases too slowly,
and this increase does not compensate for
the growing health care problems. At Eu-
ropean level, governments are hesitant to
react sensibly to this situation, namely, to
address the lack of medical staff by increas-
ing the number of students and residents in
universities, but supports the redeployment
of the workforce from (slightly or signifi-
cantly) poorer countries. The other solu-
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Physician 2050
tion, included in their strategy by national
governments and politicians, is the change
of tasks or task shifting. The World Health
Organisation defines the task shifting as a
delegation process, where appropriate, the
tasks and functions of medical treatment
are delegated to less specialised healthcare
workers.This redeployment of workforce al-
lows task shifting using the currently avail-
able human resources more efficienly.
Task shifting means delegation of a function
to someone else. For example, at the begin-
ning of the 20th
century it was hard to imag-
ine that a doctor might not perform an in-
jection. At the beginning of the 21th
century,
this function is entirely delegated to a nurse,
whose training is shorter and cheaper. Ini-
tially,only the doctor was entitled to measure
blood pressure, do cupping and apply leech-
es, make incisions and perform other similar
manipulations. Later these functions were
assigned to nurses, paramedics or nursing
assistants with some training. Governments
are interested in making task shifting their
strategy. There is the illusion that funds will
be economised in this way.As a rule,govern-
ments take over from one another only the
negative experience. A  variant of the task
shifting are efforts to reduce the professional
autonomy of physicians and pharmacists.
There are attempts to allow physicians to sell
drugs or pharmacists to prescribe drugs.
To a large extent, task shifting is also pro-
moted by a global document such as the
2018 WHO Declaration of Astana (now
Nursultan), which directs universal and
global medical coverage.The Astana confer-
ence was dedicated to the 40th
anniversary
of the AlmaAta conference.
Since the AlmaAta conference in 1978, the
World Health Organization has set the task
of providing primary care for every citizen
of the planet. It is known as universal cover-
age and it became the basis of the Astana
declaration. This document is carefully pre-
pared, but the feeling still remains that its
creators did not know or did not want to
know about social determinants, the docu-
ment reminds of a debut in a global race.
The document was produced by many
governments and financial donors, but the
result goes against the intent of the docu-
ment: Instead of building stable health sys-
tems with high-quality primary care at the
centre, the document looks like an excuse
for a minimalist approach.
Patients around the world deserve physi-
cians care. The quality of medical care and
the right to access a fully trained doctor is
a fundamental human right. Of course, in
cases where there is no doctor (e.g.in certain
African countries), it is helpful if there is at
least a nurse in the village. And, of course,
where there are no nurses (in the poor-
est countries of Africa or small islands), it
might seem good if there is a public health
worker trained for at least three months.
States should forget their pipe dreams that
overloaded and burnout doctors will add
even more working hours to their schedules.
States should make every effort to increase
the attractiveness of the GP service because
it is this area that provides universal cover-
age and it is in this area that there are many
opportunities for medicine to develop in ev-
ery country of the world.
Future Medicine Means
High-Quality Training of
Students and Residents
Those, who after thirty years will be pro-
fessors, specialty leaders in clinics and top
specialists are finishing medical faculty or
residency right now. In the world’s richest
countries, the average lifespan of people
will increase by 6-10 years over the next
thirty years, and in developing countries
by 12 years. Advanced technologies in di-
agnostics and treatment, new communica-
tion techniques in medicine, but especially
robotics tend to frighten both doctors and
society only as long as they are completely
new. After a while, we often realize that
what frightened us has become a useful tool
in our profession. Science is increasingly
distancing from everyday practices. There is
no much difference for a general practitio-
ner whether or not a particular patient has
a certain genotype. Even if a doctor knows
from the gene analysis that a particular
patient is likely to develop obesity and hy-
percholesterolemia, he would suggest more
moving around and sticking to a diet, just
like he advises all other patients.
The more we will know and acquire knowl-
edge via computer, the less we will under-
stand what to do with this knowledge: we
will diagnose a rare disease or a rare virus,
but we will treat with bed rest and addi-
tional fluid intake, or we will ask permission
and genotype every person on the planet,
but 99.9% will not be able to use this in-
formation. Therefore, empathy and medi-
cal ethics should also be at the heart of the
training process for future doctors. There is
no reason to think that thirty years later de-
vices like mobile phones and computers will
have taken a full fledged place between a
doctor and a patient.The main components
of the doctor-patient relationship have not
changed. They must not change, and it is
unlikely to change in the next thirty years.
A positive relationship between a doctor
and a patient based on mutual trust is and
will be an important factor for the patient
health outcomes, and will always be good
for doctors. For centuries, doctors in their
profession have understood the importance
of the code of ethics – from the Hippocrat-
ic Oath to the political documents of the
World Medical Association. They define
the professional autonomy of doctors as a
cornerstone of the profession for ensuring
patient health and well-being.
Physician autonomy and/or professional
freedom are integral to ethics, empathy
and deontology. A key prerequisite for this
is high-level education, intelligence, integ-
rity, courage and other virtues of the doc-
tor himself. Artificial intelligence will also
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Physician 2050
come into post-graduate training and pro-
fessional evaluation of doctors and it will be
assessed not only by the number of confer-
ences and lectures visited, but also based on
such criteria as education, empathy, courage
and integrity. On the other hand, the doc-
tor’s own well-being and attending to his
health are finally included in the Declara-
tion of Geneva because there is a direct cor-
relation between the doctor’s state of health,
well-being and the ability to provide high
standards of health care.
Future Hospitalisation –
Change of the Direction from
the Patient – the Medical
Device to the Medical
Device – the Patient
Today’s hospital largely rests on the para-
digm – devices are big and expensive, so the
patient should go to hospital for examina-
tion or treatment. The future hospital will
be a hospital at home:
(i) future hospitals will be designed around
the patient, not around the diagnostic de-
vices. So, a hospital at home;
(iv) a large part of the investigations will
move from hospital to outpatient institu-
tion or, rather, home hospital;
(iii) hospitals will be intended only for the
critically ill;
(iv) hospitals will be smaller than they are
now, and there will be many intensive ther-
apy beds, but very few other beds. Hospitals
will look more like a hotel.
Future Pharmaceuticals –
More Personalised Medicines,
Digitized Administration and
Computer Virus as a Real Threat
of a Global Deadly Epidemic
Future medicine will largely advance to per-
sonalized medicine; a genome reader will
enter medicine that will be able to read a
human genetic code within minutes. This
information will play a key role in determin-
ing specific doses of medicines and choosing
alternative medicines. Medicines prepared
for an individual patient with a specified
dosage and administration time will be com-
mon practice as commerce will be involved.
In richer countries, drug dosing will be fully
automated. The types of administration will
change, but in any case, the share of oral
medicinal products will be proportionally
greater than that of parenteral products.New
ways of medicine administration will appear.
The increase of polypragmasia will be at-
tempted to be put on brakes by the prepara-
tion of individual polydrug capsules.If people
monitor smart devices,and they will not only
report health problems but also administer
medicines,these sensors,devices and systems
will be networked, then the computer virus
will be much more dangerous because it can
actually kill someone. Cyber security will be
much more significant.
Future Medical Triad:
Doctor-Device-Patient
A future rank-and-file doctor is most eas-
ily to be imagined with expensive, small
size and sophisticated tools. The following
medical and diagnostic technology can be
predicted with the highest probability:
(i) miniature portable laboratories;
(ii) substantially increased use of ultrasound
in diagnostic and visualization, miniature
ultrasound machines;
(iii) dermatoscopes for each doctor,but with
a high resolution image and immediately
transmittable on the internet;
(iv) a computer-like object used increasing-
ly in daily diagnostics collecting a variety of
data (genetic, laboratory, clinical);
(v) the genome sequencing so cheap that it
will allow the detection of disease-causing
genes at a very low cost; it may be assumed
that the genome will be determined at birth.
Medical and diagnostic patient technologies
will be worn (clothes, glasses, footwear with
sensors), implanted or installed at home or
workplace. It will be the internet of things
in combination with fee-based intelligence
in the sense that the flow of information will
be exposed to artificial intelligence analy-
sis, turning a stream of raw data into a thin,
highly personalized knowledge beam. Digi-
tal companies with phenotyping (an Amazon
phenotype that already knows everything
about your shopping habits today) will trans-
fer skills to digital medicines, but they will
also let someone know what medicines the
patient needs, how the body responds to
medicines and specifies digital medicines. As
a result, the data will become more specific,
accurate and usable instead of general, vari-
able and entertaining. Focusing on the reli-
ability of data in health care will make it pos-
sible to focus on data compatibility arising
from many different signals about the con-
sumer life flow, which is much more impor-
tant information for health-care knowledge
than the payer’s cash flow, a digital record
with a doctor or a doctor’s schedule.
Technology will therefore continuously mea-
sure patients’ physiological and biochemical
parameters by observing their behaviour,
eating, breathing, elimination and living
space. A patient will visit his GP with an
even greater amount of data, especially about
biochemistry and genetics. And it is still go-
ing to be screened with artificial intelligence.
The data amount that will be provided by a
universal coverage of patients and their en-
vironmental sensors, combined with genome
and microbioma information, will be much
greater than the ability of the human (doc-
tor) to understand and summarize. Most
of the futurological articles admire smart
computer like small objects that will diag-
nose, monitor, report problems to the doc-
tor today and in the future. It will indeed be
a reminder of the need for tablets or other
medicines, healthy lifestyle and proper eat-
ing, but following advice of the gadgets, like
that given by medical practitioners of today,
will be mostly determined by the patient co-
operation,the ability to listen to the views on
regular drug use, ­
recommended sports ac-
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Physician 2050
tivities and non-smoking. It can be assumed
that smart computer like small objects would
serve more as an indulgence for not doing
anything for the benefit of one’s own health.
Therefore, even after 30 years, talking with
a doctor (both a family doctor and a spe-
cialist) will be a “gold standard”, but virtual
reality will come into this discussion (prob-
ably not more than 10 years left for mobile
phones).GPS 6 will replace avatars.30 years
later, there will be already expanded reality.
The main megatrend that will transform
medicine is digital technology.
TheAnswertotheHeadlineQues-
tion:willTechnologyandPolicy
ChangetheDoctor-PatientRela-
tionshiporChangetheDoctor’s
PlaceinSocietyandMedicine?
Technology will affect physician-patient
relationships, they will become increas-
ingly remote, and a computer or a simi-
lar smart object in different forms will
be increasingly in the middle. Artificial
intelligence will enter diagnostics, show
potential diagnoses in radiological exami-
nations, laboratory parameters, but deci-
sion-making and further treatment will
remain between doctors and patients. In
medicine, if not through the door, global
digital technology and programming will
come through the window to analyse the
patient’s genome, viruses, drug effective-
ness, risks and treatment scenarios by tak-
ing a large part of the funding. But here
too, for at least the next thirty years, the
decision will be taken and upon action de-
cided between the physician and the pa-
tient during their conversation.
With the population ageing, the proportion
of chronic patients increasing, combined
with multimorbidity and polypragmasia,
the number of doctors will grow globally,
at both absolute and relative rates, and after
30 years on average doctors will be signifi-
cantly older than today. Unfortunately, the
role of each particular doctor in society will
be reduced, while the overall share of medi-
cine in national economy will grow: health-
care,medicine and pharmaceuticals together
will be the main economic sector exceeding
25% of gross national product. Today, the
global health care industry is estimated at
seven trillion. Half of the earnings, with the
largest share of the profit, are in the USA.
By 2049, globally, there will be forty trillion
dollars worth of vodsel hardware, tools and
pharmaceutical industry,and more than half
of that, with most of its profits in Asia and
more than 15% in Africa.Global megatrend
is the globalization of the free market and
capitalism; health care and medicine will
move toward population growth over the
next 30 years.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief
of the World Medical Journal
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IV
WMA News
WMA General Assembly
The participians of the 212th
WMA Council Session, April, 2019, Santiago, Chile
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