Medicine

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Medicine is the oldest branch of health science. The name Medicine refers to an area of knowledge, human biology, diseases and treatment); as well as the applied practice of that knowledge. The profession of Medicine promotes human health through the study, diagnosis and treatment of disease and injury. The practice of Medicine is both an art and an applied science. That art lays in the personal therapeutic interaction, the doctor-patient relationship, that underlies the gathering of data, its interpretation, and the provision of therapy in clinical medicine. The practitioners of medicine, called physicians, hold doctorate degrees and have undergone a period of clinical apprenticeship called internship and residency training.

Medical doctors have established a protocol in the evaluation of patients that is uniform around the world and throughout the varying medical and surgical specialties: the patient history, physical examination and the analysis of laboratory results.

The way that a patient's case is considered is also formulated in a manner that is generally accepted among all of the world's physicians. This involves establishing a diagnosis and prognosis for each presenting complaint, and has been used, by and large, since Aristotle's time in the Fourth Century BC. (Reference: Loriaux, D Lynn MD, PhD Aristotle (384-322 BC). Endocrinologist. 15(4):197-198, July/August 2005).

Overview

File:Physcian examining a child.jpg
Physician examining a child.

The medical profession (physicians or doctors) Nearly all countries and legal jurisdictions have legal limitations on who may practice medicine.

Medicine comprises various specialized sub-branches, such as cardiology, pulmonology, neurology, or other fields such as sports medicine, or public health. One of the most basic distinction in medical specialties is between surgical and non-surgical areas. The word "Medicine" is also often used amongst medical professionals as shorthand for internal medicine, the non-surgical aspects of adult care. The various specialties and subspecialties of medicine are listed at the end of this article with brief descriptions and links to further information.

Veterinary medicine is the practice of health care in animal species other than human beings.

History of medicine

Physician treating a patient. Louvre Museum, Paris, France.
For more information, see: History of medicine.

The earliest type of medicine in most cultures was the use of plants (Herbalism) and animal parts. This was usually in concert with 'magic' of various kinds in which: animism (the notion of inanimate objects having spirits); spiritualism (here meaning an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (the supposed obtaining of truth by magic means), played a major role.

The practice of medicine developed gradually, and separately, in ancient Egypt, India, China, Greece, Persia and elsewhere. Medicine as it is practiced now developed largely in the late eighteenth century and early nineteenth century in England (William Harvey, seventeenth century), Germany (Rudolf Virchow) and France (Jean-Martin Charcot, Claude Bernard and others). The new, "scientific" medicine (where results are testable and repeatable) replaced early Western traditions of medicine, based on herbalism, the Greek "four humours" and other pre-modern theories.Template:Fact The focal points of development of clinical medicine shifted to the United Kingdom and the USA by the early 1900s (Canadian-born)Sir William Osler, Harvey Cushing). Possibly the major shift in medical thinking was the gradual rejection in the 1400's of what may be called the 'traditional authority' approach to science and medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, and anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general - see Copernicus's rejection of Ptolemy's theories on astronomy). People like Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past such as Galen, Hippocrates, and Avicenna/Ibn Sina, all of whose theories were in time almost totally discredited. Such new attitudes were also only made possible by the weakening of the Roman Catholic church's power in society, especially in the Republic of Venice.

Evidence-based medicine is a recent movement to establish the most effective algorithms of practice (ways of doing things) through the use of the scientific method and modern global information science by collating all the evidence and developing standard protocols which are then disseminated to doctors. One problem with this 'best practice' approach is that it could be seen to stifle novel approaches to treatment.


Practice of medicine

The practice of medicine combines both science as the evidence base and art in the application of this medical knowledge in combination with intuition and clinical judgement to determine the treatment plan for each patient.

Central to medicine is the patient-doctor relationship established when a person with a health concern seeks a physician's help; the 'medical encounter'. Other health professionals similarly establish a relationship with a patient and may perform various interventions, e.g. nurses, radiographers and therapists.

As part of the medical encounter, the doctor needs to:

  • develop a relationship with the patient
  • gather data (medical history, systems enquiry, and physical examination, combined with laboratory or imaging studies (investigations))
  • analyze and synthesize that data (assessment and/or differential diagnoses), and then:
  • develop a treatment plan (further testing, therapy, watchful observation, referral and follow-up)
  • treat the patient accordingly
  • assess the progress of treatment and alter the plan as necessary (management).

The medical encounter is documented in a medical record, which is a legal document in many jurisdictions.[1]

Health care delivery systems

Medicine is practiced within the medical system, which is a legal, credentialing and financing framework, established by a particular culture or government. The characteristics of a health care system have significant effect on the way medical care is delivered.

Financing has a great influence as it defines who pays the costs. Aside from tribal cultures, the most significant divide in developed countries is between universal health care and market-based health care (such as practiced in the U.S.). Universal health care might allow or ban a parallel private market. The latter is described as single-payor system.

Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality and pricing greatly affects the choice by patients / consumers and therefore the incentives of medical professionals. While US health care system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.

Health care delivery

See also: clinic, hospital, and hospice
Paint of Henriette Browne

Medical care delivery is classified into primary, secondary and tertiary care.

Primary care medical services are provided by physicians or other health professionals who has first contact with a patient seeking medical treatment or care. These occur in physician's office, clinics, nursing homes, schools, home visits and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sex.

Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.

Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.

Modern medical care also depends on information - still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.

Doctor-patient relationship

The doctor-patient relationship and interaction is a central process in the practice of medicine. There are many perspectives from which to understand and describe it.

An idealized physician's perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning the patient's symptoms, concerns and values; in response the physician examines the patient, interprets the symptoms, and formulates a diagnosis to explain the symptoms and their cause to the patient and to propose a treatment. The job of a doctor is essentially to be a human biologist: that is, to know the human frame and situation in terms of normality. Once the doctor knows what is normal and can measure the patient against those norms the doctor can then determine the particular departure from the normal and the degree of departure. This is called the diagnosis.

The four great cornerstones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy and physiology) and psychology (mind and behaviour). In addition, the doctor should consider the patient in their 'well' context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient's condition and further management. In more detail, the patient presents a set of complaints (the symptoms) to the doctor, who then obtains further information about the patient's symptoms, previous state of health, living conditions, and so forth. The physician then makes a review of systems (ROS) or systems enquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination; the findings are recorded, leading to a list of possible diagnoses. These will be in order of probability. The next task is to enlist the patient's agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the doctor educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant "teacher" in Latin. The patient-doctor relationship is additionally complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his/her own. The doctor's expertise comes from his knowledge of what is healthy and normal contrasted with knowledge and experience of other people who have suffered similar symptoms (unhealthy and abnormal), and the proven ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge.

The doctor-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of both doctors and patients in many ways.

The quality of the patient-doctor relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the doctor's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another doctor may be sought.

In some settings, e.g. the hospital ward, the patient-doctor relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.

Clinical skills

For more information, see: Medical history and Physical examination.


A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and a treatment plan.[2]

The components of the medical history are:

  • Chief complaint (CC): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'
  • History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.
  • Current activity: occupation, hobbies, what the patient actually does.
  • Medications: what drugs the patient takes including over-the-counter, and home remedies, as well as herbal medicines/herbal remedies such as St. John's Wort. Allergies are recorded.
  • Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
  • Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
  • Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
  • Review of systems (ROS)or systems enquiry: an set of additional questions to ask which may be missed on HPI, generally following the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc).

The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'signs' are what the doctor detects by examination). The doctor uses his senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:

  • Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
  • General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)
  • Skin
  • Head, eye, ear, nose, and throat (HEENT)
  • Cardiovascular (heart and blood vessels)
  • Respiratory (large airways and lungs)
  • Abdomen and rectum
  • Genitalia (and pregnancy if the patient is or could be pregnant)
  • Musculoskeletal (spine and extremities)
  • Neurological (consciousness, awareness, brain, cranial nerves, spinal cord and peripheral nerves)
  • Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

Laboratory and imaging studies results may be obtained, if necessary.

The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.

Branches of medicine

Medical doctors have many specializations and subspecializations which are listed below. There are variations from country to country regarding which specialities certain subspecialities are in.

Diagnostic specialties

Clinical specialties

Medical education

An image of a 1901 examination in the faculty of medicine.
For more information, see: Medical education and Medical school.


Medical education is education related to the practice of being a medical practitioner, either the initial training to become a doctor or further training thereafter.

Medical education and training varies considerably across the world, however typically involves entry level education at a university medical school, followed by a period of supervised practise (Internship and/or Residency) and possibly postgraduate vocational training. Continuing medical education is a requirement of many regulatory authorities.

Various teaching methodologies have been utilised in medical education, which is an active area of educational research.

Legal restrictions

In most countries, it is a legal requirement for medical doctors to be licensed or registered. In general, this entails a medical degree from a university and accreditation by a medical board or an equivalent national organization, which may ask the applicant to pass exams. This restricts the considerable legal authority of the medical profession to doctors that are trained and qualified by national standards. It is also intended as an assurance to patients and as a safeguard against charlatans that practice inadequate medicine for personal gain. While the laws generally require medical doctors to be trained in "evidence based", Western, or Hippocratic Medicine, they are not intended to discourage different paradigms of health and healing, such as alternative medicine or faith healing.

Criticism

Criticism of medicine has a long history. In the Middle Ages, some people did not consider it a profession suitable for Christians, as disease was often considered God sent. God was considered to be the 'divine physician' who sent illness or healing depending on his will. However many monastic orders, particularly the Benedictines, considered the care of the sick as their chief work of mercy. Barber-surgeons (they had the sharpest knives) generally had a bad reputation that was not to improve until the development of academic surgery as a speciality of medicine, rather than an accessory field. Template:Fact

Through the course of the twentieth century, doctors focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. The ensuing development of a more mechanistic, detached practice, with the perception of an attendant loss of patient-focused care, known as the medical model of health, led to further criticisms. This issue started to reach collective professional consciousness in the 1970s and the profession had begun to respond by the 1980s and 1990s. Template:Fact

Perhaps the most devastating criticism of modern medicine came from Ivan Illich. In his 1976 work Medical Nemesis, Illich stated that modern medicine only medicalises disease and causes loss of health and wellness, while generally failing to restore health by eliminating disease. This medicalisation of disease forces the human to become a lifelong patient.[3]Other less radical philosophers have voiced similar views, but none were as virulent as Illich. Another example can be found in Technopoly: The Surrender of Culture to Technology by Neil Postman, 1992, which criticises overreliance on technological means in medicine. Template:Fact

Criticism of modern medicine has led to some improvements in the curricula of medical schools, which now teach students systematically on medical ethics, holistic approaches to medicine, the biopsychosocial model and similar concepts.

The inability of modern medicine to properly address many common complaints continues to prompt many people to seek support from alternative medicine. Although most alternative approaches lack scientific validation, some may be effective in individual cases. The bioscience and alternative health care paradigms may differ to such an extent that what constitutes scientific evidence is contested.Template:Fact Many doctors practice alternative medicine alongside "orthodox" approaches but the general body of medical practitioners is often criticised for ignoring the purported value of alternative medicine.Template:Fact

Medical errors are also the focus of many complaints and negative coverage. Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety, where it was long ago realized that it is dangerous to place too much responsibility on one "superhuman" individual and expect him or her not to make errors. Reporting systems and checking mechanisms are becoming more common in identifying sources of error and improving practice.

Radical critics of certain medical traditions may hold that whole fields or traditions of medicine are intrinsically harmful or ineffective. They would reject any use or support of practices belonging to that tradition.Template:Fact However, generally, there is a spectrum of efficacy on which all traditions lie; some are more effective, some are less effective, but nearly all contain some harmful practices and some effective ones. Naturally, though, most individuals or groups seeking a health care practice to improve their own health would seek a tradition with the maximum degree of efficacy. There is no doubt whatsoever that Western Allopathic medicine, together with its cohorts of improved hygiene and nutrition, have been collectively responsible for most of the improvements in health worldwide over the last century or so, including: increasing longevity, decreased child mortality, increasing population numbers, better ability to monitor and halt disease spread and outbreaks, improved access to health care for all strata of society.

See also

References

  1. ↑ AHIMA e-HIM Work Group on the Legal Health Record. (2005). "Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes.". Journal of AHIMA 78 (8): 64A–G.
  2. ↑ Coulehan JL, Block MR (2005). The Medical Interview: Mastering Skills for Clinical Practice, 5th ed.. F. A. Davis. ISBN 0-8036-1246-X. 
  3. ↑ Ivan Illich (1976). Medical Nemesis. ISBN 0-394-71245-5 ISBN 0-7145-1095-5 ISBN 0-7145-1096-3. 

External links

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