Although it is generally true that emails, like diamonds, are forever, in that an ill-advised message sent long ago and long ago forgotten can suddenly resurface with unpleasant consequences, the last 30 years are probably going to be extremely frustrating for historians to deal with: Written correspondence persists while electronic correspondence is more likely to vanish. As Walter Isaacson found when writing biographies of Steve Jobs and Leonardo da Vinci, proportionally far more of Leonardo’s correspondence has survived the past 400 years than Jobs’ messages of two decades ago. Personal diaries, written in confidence and carefully safeguarded, have always formed an important part of the historical record. Blog posts are more likely to disappear forever into the ether. Like so much in our throw-away society, it seems that we have once again sacrificed permanence for convenience.
While this is a cause of great anguish to archivists, the peculiar profession of ‘futurist’ undoubtedly rejoices, because it has become more difficult to hold futurists accountable for their missed guesses. Moldering paperback copies of books like Future Shock can be read with glee as we count the instances where Toffler guessed disastrously badly. But it’s harder to attribute other wildly incorrect forecasts if they are made electronically. I am reminded of one of the biggest misses of the past two decades, when some seer predicted with confidence that the internet would never be widely used by people in China because of the difficulty in rendering Mandarin characters into electronic form. But just try and track down who made that prediction—their electronic tracks have been covered by trillions of electrons laid down on top of them.
I imagine that you guess what this is leading up to. In spite of the fact that the margin of error of future predictions is incalculably large, and I should therefore know better, I am going to make some guesses about what the decade of the Millennial Roaring 20s will bring. I do so with confidence that if I’m wrong (as I’m almost certain to be), these incriminating electrons will soon be blown to the four corners of the internet (wait—does the internet have corners?), never to be found again.
Prediction #1. Health service psychology as a profession will continue to prosper. We have over the past two decades seen remarkable changes in how we are perceived by the public and how organizations value our contributions. Hiring of psychologists by very large government agencies, such as DoD and the VA, continues to be extremely robust. Psychologists are more and more frequently seen in leadership roles in these and other organizations. No longer relegated to a faceless “ancillary health profession,” category, our status will continue to increase. We will continue to be in demand, if for no other reason than the US population is increasing far more rapidly than the number of graduates of clinical doctoral programs. But aside from demographics, we can also credit anti-stigma campaigns as a factor in making psychological intervention both more understood and more acceptable to the public at large. Anti-stigma campaigns have been compared to the seat-belt campaigns of the 1970s and anti-tobacco use campaigns of later decades—highly effective public health initiatives that have been credited for material reductions in the incidence of lung cancer and survivability of automobile accidents. It is also sadly true that the fortunes of psychology in America have, since the experimental use of the Army Alpha and Beta tests in WWI, been tied to war. As the Long War (now the longest period of armed conflict in American history) shows no signs of winding down, the psychological sequelae of conflict will continue to be in the public eye. Psychologists are now an established component of the battle plan, and the number of psychologists deployed with operational units will continue to rise. Our value to the military has clearly been proven. Our services to returning servicemembers, veterans, and their families will also continue to be necessary. For better or for worse, our profession’s salience to policy makers and the public will grow.
2. Health care reform will remain elusive. A comprehensive health care solution will continue to elude American policy makers, and Americans will continue to pay disproportionate amounts of their income for health services that globally rank as no better than mediocre. Big Health Care is like Big Oil or Big Banking. Just as Big Oil places profit before environment and Big Banking places profit above the needs of the individual wage earner, Big Health Care places profit over patients and thrives in an unregulated environment. More regulatory chaos means more loopholes to exploit, which means that more of your tax dollars contribute to the bottom line of Big Health Care. Big Health Care has been remarkably successful in influencing members of Congress to impede any kind of meaningful reform. The portion of the American treasure (as measured by our GDP) that goes into the coffers of Big Health Care continues to grow (17% of GDP in 2018, 5 percentage points higher than Switzerland, our closest competitor in a dismal competition). This is very much what the economists used to quaintly call the “guns or butter” argument, meaning that you can have either guns or butter but not both. The more of our GDP we spend on health care, the less we have for infrastructure development, education, mass transit, and the like. There is no rational argument against health care reform, as evidenced by the fact that other developed countries have far more efficient and affordable health care systems. Indeed, the only arguments that can be advanced against health care reform are inherently irrational because they ignore the basic fact that if you spend your treasure fixing pathology, you have little left for preventive initiatives. Every other developed country on the planet understands that social determinants of health are huge drivers of healthcare costs and they allocate resources accordingly. If rational arguments are lacking, it follows that only political arguments will succeed, and political healthcare arguments rely primarily on two factors: the ability to get the electorate to vote against its own best interests, and money. Since Big Health Care is one of the most profitable industries in the country, of the latter they have plenty.
3. Graduate student debt will slowly decline. Student debt loads will trend down and this may make graduate education more affordable for many. It seems that the tide is slowly turning where the cost of higher education is concerned. Universities are waking up to the fact that massive endowments can be used to fund things other than swanky new buildings, and that the cost of higher education is excluding more and more American youth. Higher education has always been expensive, but comparatively never more expensive than it is now. In spite of the current Department of Education’s unwavering support of for-profit education, it is my prediction that land-grant and private institutions are beginning to realize that they’ve strayed from their basic mission and will try to set things aright.
4. Psychologists will address climate change. The voice of psychology as a factor in combating climate change will grow, but it may be too late. Behavior change is essential if we are to address this human-caused crisis. Though we have wasted much of the past two decades on fruitless political arguments, psychology can play a conspicuous role in helping citizens address and make the behavioral modifications needed to challenge what is perhaps the most pressing issue of our time.
5. Integrated care will be a growing component of psychologists’ repertoire. More and more psychological services will be delivered from integrated care platforms, but we have work to do before we can be counted as integral members of the primary health care delivery team. Graduate curricula do not equip students with the necessary skills to work effectively in the integrated care environment. We can and will do better than the on-the-job training models that we employ today. The Register’s publication on a revised curriculum to better train students to work in organized healthcare delivery systems is under review as I write this, so more later on that, but I think you will agree that change is needed if we are to efficiently prepare graduate students to work in the healthcare environment of the future.
6. The Electronic Health Record will never go away. This is an easy one. The EHR is here, so we’ve got to learn to love it. Billing and coding will increasingly be driven by the EHR as will the data that such systems generate. For a long time, psychology was in the “just-say-no” camp when the EHR was concerned. It’s time to face reality and recognize that like any tool, we can shape how we use it as well as be shaped by its use. The data that accrue from large-scale collection are neither good nor bad. Properly used, EHR data can help develop ideology-free treatment delivery methods. Poorly used, EHRs represent a threat to privacy that we as individuals and professionals must continue to guard against.
7. Clinical practice guidelines will continue not to guide very well. Human beings are not algorithms, and algorithmic treatment planning will continue to fail. Big-data derived practice guidelines can teach us what not to do, but they are very bad at teaching us what the patient actually sitting in front of us needs. Complex clinical decision making can be aided by big data, but psychological illness is unique to every sufferer, and only by attending to that patient’s unique needs can we make a difference. Algorithmically driven treatment fads come and go, clinical practice guidelines are developed and quickly forgotten, but clinical judgement never goes out of style.
So there are my predictions for the 2020s. Check back in 10 years to see how wrong I was, and welcome to the new decade!
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