Medicine

The medical encounter is documented in a medical record. One method that is used is called the problem-oriented medical record (POMR), which includes a problem list of diagnoses and a "SOAPS" method of documentation for each visit:

Medical systems

Patient-doctor relationship

An idealized physician's perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning from the patient his 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. In more detail, the patient presents a set of complaints or concerns about his health to the doctor, who then obtains further information about the patient's symptoms, previous state of health, living conditions, and so forth, and then formulates a diagnosis and enlists the patient's agreement to a treatment plan. 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 comes from the Latin patiens, "suffering") and limited ability to relieve it on his own. The doctor's expertise comes from his knowledge about, or experience with, other people who have suffered similar symptoms, and his presumed ability to relieve it with medicines 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.

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

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

The components of the medical history are:

The physical examination is the examination of the patient looking for signs of disease. The doctor uses his senses of sight, hearing, touch, and sometimes smell (taste has been replaced by modern lab tests). Four chief methods are used: inspection, palpation, percussion, and auscultation; smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis).

• Vital signs include height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
• General appearance of the patient
• Skin
• Head, eye, ear, nose, and throat (HEENT)
• Cardiovascular - heart and blood vessels
• Respiratory - lungs
• Abdomen and rectosigmoid
• Genitalia
• Spine and extremities - musculoskeletal
• Neuropsychiatric

Medical decision making (MDM) process involves the analysis and synthesis of all the above data to come with a list of possible diagnoses (the differential diagnoses) and what needs to be done to come up with a final diagnosis which would explain the patient's problem.

Treatment plan may include ordering additional labs and studies, starting therapy, referring to a specialist, or watchful observation. Follow-up may be needed.

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. Or it may take weeks for a patient who has been hospitalized with multiple system problems involving 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.

Settings where medical care is delivered

Medicine is a diverse field and the provision of medical care is therefore provided in a variety of locations.

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.

Branches of medicine

The scope and sciences underpinning human medicine overlap many other fields. Dentistry and psychology, while separate disciplines from medicine, are sometimes also considered medical fields. Physician assistants, nurse practitioners and midwives treat patients and prescribe medication in many legal jurisdictions. Veterinary medicine applies similar techniques to the care of animals.

Medical doctors have many specializations and subspecializations which are listed below.

Basic sciences

Diagnostic specialties

Clinical disciplines

Interdisciplinary fields

Medical education

Medical training involves several years of university study followed by several more years of residential practice at a hospital. Entry to a medical degree in some countries (such as the United States) requires the completion of another degree first, while in other countries (such as the United Kingdom, Australia and New Zealand) medical training can be commenced as an undergraduate degree immediately after secondary education.

The name of the medical degree gained at the end varies: some countries (e.g. the US) call it "Doctor of Medicine" (abbreviated 'M.D.'), while other countries (mostly following the British Oxbridge system) call it "Medicinæ Baccalaureus & Baccalaureus Chirurgiæ" (Latin for "Bachelor of Medicine/Bachelor of Surgery", Old English: "Chirurgie"); this is technically a double degree, frequently abbreviated 'MB BChir\', 'MB ChB', 'MB BS' (or variations thereof), dependent on the medical school. In either case, graduates of a medical degree may call themselves physician. In the US and some other countries there is a parallel system of medicine called "osteopathy" which awards the degree D.O (doctor of osteopathy). In many countries, a doctorate of medicine does not require original research as does, in distinction, a Ph.D.

Once graduated from medical school most physicians begin their residency/house post training, where skills in a speciality of medicine are learned, supervised by more experienced doctors. The first year of residency is known as the "intern" year (USA) or "junior/pre-registration house officer" year (UK). The duration of residency training depends on the speciality.

A medical graduate can then enter general practice and become a general practitioner (or primary care internist in the USA); training for these is generally shorter, while specialist training is typically longer.

Legal restrictions

Criticism

Through the course of the twentieth century, doctors naturally focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. This resulted in criticism for the loss of compassion and mechanistic, detached treatment. This issue started to reach collective professional consciousness in the 1970s and the profession had begun to respond by the 1980 and 1990s.

Perhaps the most devastating criticism came from Ivan Illich in his 1976 work Medical Nemesis. In his view, modern medicine only medicalises disease, causing loss of health and wellness, while generally failing to restore health by eliminating disease. The human being thus becomes a lifelong patient. 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.)

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, many report improvement of symptoms after obtaining alternative therapies.

Medical errors are the focus of many complaints and negative coverage. In many ways the prevention of error in medicine is thought by many practitioners of human factors engineering to be similar yet far behind 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.

See also

External links