“The only rules that really matter are these: what a man can do and what a man can’t do” Captain Jack Sparrow
(Pirates of the Caribbean)
WORK as we know it may cease to exist in its current form in the near future because of a tectonic shift in the evolution of intelligent connected technology.
Our profession is not immune to the impact of this change. This article is an appeal to the readers to acknowledge the dawn of a new industrial era, in which the relationship between the doctors and their employers could be changed forever. We should also not forget the silent loss of industrial rights and protections that could happen with the blind adoption of certain technologies.
Connected technology is already making a significant impact on medical practice models. Today, radiological diagnosis can be made by a teleradiology facility situated thousands of kilometres away from the patient. The results can be transmitted back at the speed of light.
Without doubt, such technology has immeasurable benefits for mankind.
But it is easy to forget that this endeavour is performed on a “platform”, which enables patients and service providers to meet, straddling geopolitical borders and time zones. Such platforms have slowly, steadily, and robustly, taken shape in what was originally a nebulous network of computers called the internet. And they have grown to be more complicated than the above mentioned simpler example. There are now ride-sharing platforms, gaming platforms, and even dating platforms.
Platforms challenge and disrupt the modus operandi of many industries and deliver a palpable economic impact, so much so that a part of the contemporary economy is named the “platform economy”. Platforms, in my view, blur the lines that delineate professions, making the role of the employer vague and redefining work itself.
Take, for instance, the popular ride-sharing platform Uber. With a few clicks of a smartphone screen, you are matched to a car and driver. You, the customer, can create a “job” on the fly. Such platforms revolutionise transportation, without doubt. They perform the “middle man” job, extracting a commission out of the transaction happening between the customer and the service provider.
The platforms also perform the roles of matchmaking, cost fixing and reputation management.
This model has become so popular that an entirely new term, “uberisation”, has entered the colloquial lexicon.
If you thought medicine was immune to uberisation and that we could wander through another century arguing whether a doctor is an “employee” or a “contractor”, I invite you to please think again.
There is now a new category of service providers – the independent workers – which arises as a result of uberisation. A significant number of doctors could be interested in such an arrangement, in which there is no need for them to be restricted to one hospital, practice group, health system, or locum agency. They could provide their services on a unified platform — an Uber for health. This brings into question the traditional “terms of engagement” like staff specialists, visiting medical officers and locums.
The emergence of electronic credentialing systems, electronic registration databases and other human resource management systems means conditions are ripe for the rise of a new platform – a platform for doctor placements. I am not saying this is inevitable, but you would agree that it is perfectly possible, nothwithstanding the obvious differences between the transportation industry and medicine.
You might ask what’s wrong with this? Uberisation could make health care more accessible. It could reduce maldistribution of specialists. Cost seems to be determined fair and square dynamically, which is an advantage to the providers. Reputation management helps patients avoid low quality providers.
But just when we close the case saying all is well in the best of all worlds, a tinge of caution seeps in.
For the most part, platforms such as Uber are privately owned, which, in itself, may not be an issue. But how transparent private enterprises can be is definitely an issue. For example, there could be inadequate transparency with the cost-fixing algorithms or reputation management models within private platforms. In this new working environment where a freelance service provider’s (aka, the “independent worker”) livelihood could be affected by unvalidated reviews among other reasons, such semi-transparency could put the service provider in a relatively powerless situation, with insufficient industrial protection if removed from the platform for undisclosed reasons.
Some disputes cited with Uber and its service providers attest to such possibilities. Such situations would be unpalatable for “independent worker” medical service providers.
Should we then take pre-emptive steps and claim ownership of such a platform that could have an impact on medicine? If so, how?
“Platform cooperativism” is an innovative concept in which collective groups take ownership of such platforms by funding it with a part of the transaction. Everyone is a shareholder of the platform. While exploiting benefits of platforms such as improved access and flexibility of service provision, which could even mitigate some effects of maldistribution of medical workforce, we could also ensure protection for the providers with such platforms cooperatives.
Interestingly, such cooperatives could also be union-backed. Every member could have voting rights to select the board of operatives.
I invite readers to check out Loconomics, which is a new initiative to create member-owned cooperative platforms. We could easily make a platform for medicine, with such a framework already available.
Uberisation of medicine may require a redesign of the current indemnity insurance model as the dynamically and unpredictably changing association between the “independent worker” doctor and their employers and expansion of their territory of practice, may open up hitherto unknown medico-legal risks. It is to be noted that the service providers with Uber are covered by a unique scheme of insurance that activates and expires at the start and end of the engagement by the client respectively
It is high time that we start the discussion on the multiple facets of this techno-reality confronting us to ensure that doctors derive the advantages but at the same time are industrially protected from the emergence of the platform economy. If we ignore this, the problem isn’t one of ignoring the elephant in the room, but one of not realising that we are in the jungle.
Adjunct Associate Professor Balaji Bikshandi is the clinical lead of ICU at North West Regional Hospital, Burnie, Tasmania; Adjunct Associate Professor at the University of Canberra; and Senior Clinical Lecturer at the University of Tasmania.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.