A plea to merge clinical and public health practices: reasons and consequences

Revisiting professionalism, both as a medical ideal and educational topic, this paper asks whether, in the rise of artificial intelligence, healthcare commoditisation and environmental challenges, a rationale exists for merging clinical and public health practices. To optimize doctors' impact on community health, clinicians should introduce public health thinking and action into clinical practice, above and beyond controlling nosocomial infections and iatrogenesis. However, in the interest of effectiveness they should do everything possible to personalise care delivery. To solve this paradox, we explore why it is necessary for the boundaries between medicine and public health to be blurred.

Proceeding sequentially, we derive standards for medical professionalism from care quality criteria, neo-Hippocratic ethics, public health concepts, and policy outcomes. Thereby, we formulate benchmarks for health care management and apply them to policy evaluation. During this process we justify the social, professional - and by implication, non-commercial, non-industrial - mission of healthcare financing and policies. The complexity of ethical, person-centred, biopsychosocial practice requires a human interface between suffering, health risks and their therapeutic solution - and thus legitimises the medical profession's existence. Consequently, the universal human right to healthcare is a right to access professionally delivered care. Its enforcement requires significant updating of the existing medical culture, and not just in respect of the man/machine interface. This will allow physicians to focus on what artificial intelligence cannot do, or not do well. These duties should become the touchstone of their practice, knowledge and ethics. Artificial intelligence must support medical professionalism, not determine it. Because physicians need sufficient autonomy to exercise professional judgement, medical ethics will conflict with attempts to introduce clinical standardisation as a managerial paradigm, which is what happens when industrial-style management is applied to healthcare.

Public healthcare financing and policy ought to support medical professionalism, alongside integrated clinical and public health practice, and its management. Publicly-financed health management should actively promote ethics in publicly- oriented services. Commercialised healthcare is antithetical to ethical medical, and to clinical / public health practice integration. To lobby governments effectively, physicians need to appreciate the political economy of care.