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Medical.Profession Kalabay.Laszlo

Medical.Profession Kalabay.Laszlo






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    Medical.Profession Kalabay.Laszlo Medical.Profession Kalabay.Laszlo Presentation Transcript

    • MEDICINE AS A LEARNED AND HUMANE PROFESSION Dr. László Kalabay Department of Family Medicine Semmelweis University
    • What is medical profession?
      • more than just a profession,
      • a „call”
    • The attributes of medical profession
      • Scientific
      • Personal
      • Humanistic
      • Professional
      • Artistic
    • The physician as a scientist
      • Physicians must be trained as scientists to:
      • understand and apply the thinking patterns of the scientific method
      • to develop an inquiring mind
      • to know how to design experiments and obtain data
      • how to analyze the validity and generalizibility of those data
      • to ask questions and provide truthful answers
    • Most of these learned skills extend to the management of individual cases at the bedside, i.e.
      • how to gather information
      • how to synthesize it
      • how to interpret it to make a full diagnostic story
      • how to bring the collective wisdom together in the design and execution of appropriate therapy.
    • The central tenet is: „Could my conclusion be wrong?”
      • Scientific rigors provide the physician with:
      • learning skills
      • process of analysis, that is indispensable for dealing with individual patients
      • opportunity to contribute to medical progress and improvement of care
    • The effect of explosion of medical knowledge: increased specialization and subspecialization as
      • organ system (cardiology, pulmonology, etc.)
      • locus of principal activity (inpatient, outpatient)
      • reliance on manual skills (proceduralist or nonproceduralist)
      • participation in research
      • BUT
      • the same molecular and genetic mechanisms are broadly applicable across all organ systems
      • scientific methodologies of randomized trials and careful clinical observation span all aspects of medicine
      • need for large-scale testing of procedures, interventions, vaccines, and new drugs: multicenter approach provide opportunity to participate in clinical investigations
    • The clinical reasoning and decision making as scientific aspects of the patient-physician interaction
      • elucidation of complaints or concerns
      • inquiries or evaluation to address these concerns in increasingly precise ways
      • careful history or physical examination
      • ordering diagnostic tests
      • integration of clinical findings with the test results
      • understanding the risks and benefits of the possible courses of action
      • careful consultation with the patient and family to develop future plans
      • evidence based medicine and new scientific information are needed to solve these issues
    • The physician as caregiver 1
      • When patients week medical attention, they entrust their doctors with their very lives
      • The physician must earn such a complete trust
      • Technical abilities and skilled treatment of disease alone do not suffice
    • „ You give but little when you give of your possessions – it is when you give of yourself that you truly give” (Khalil Gibran: The Prophet)
    • The physician as caregiver 2
      • Being sensitive or insensitive to patients
      • „ Does my physician really care?”
      • „ Does what happens to me matter to the physician?”
      • „ Does my doctor show sensitivity and compassion beyond mere technical ability?”
      • Being both professional and caring is an acquired skill
    • „ The humility that comes from others having faith in you” (Dag Hammarskjöld)
    • The physician must be willing to
      • answer the patient’s needs
      • undertake a long-term commitment to the patient’s care
    • The patients still needs care
      • when data come back from the clinical laboratory, the radiology department, the cardiac catheterization laboratory, or the surgical pathology laboratory.
      • to understand their disease
      • dealing with family interactions,
      • to find a caring ear when they suffer most
      • assistance in obtaining necessary additional medical help from specialists or consultants
      • in processes involving personal situations (esp. when becoming old, frail, dependent, crippled, cognitively impaired)
    • The physician as a professional 1
      • Definition: Professionalism in internal medicine comprises those attributes and behaviors that serve to maintain the interest of the patient above one’s self-interest.
      • A commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge.
      • A commitment to the attitudes and behaviors that sustain the interest and welfare of patients.
      • A commitment to be responsive to the health needs of society. Professionalism aspires to altruism accountability, excellence, duty, service, honor, integrity, and respect of others.
    • The physician as a professional 2
      • The interest of the patient lies above self-interest
      • To remain professionals, dignity, and understanding must permeate all our interactions –all our thinking, teaching, learning, and listening
    • Patient-centeredness makes medicine as an art
      • Sometimes it is more important who has the disease than the disease itself”
    • Systems of patients care beyond the millennium
      • The evolving changes in the health care delivery system unavoidably affect the perceived historical independence of thought and action
      • Financing of health care has become the key issue
      • Aging of population
      • Decreasing number of active workers
      • Sheer mass of GDP spent on health care
      • Increasing costs ascribed to technology and professional subspecialization
      • Patient care in the mass is becoming a big business
      • Insurers – „covered lives” (patients)
      • Implementation of guidelines in order to increase cost-effectiveness
      • No country seems to be fully satisfied with its health care system, and experimentation abounds
    • The physician has now a dual responsibility to
      • the health care system as an expert who helps create standards, measures of outcome, clinical guidelines, and mechanisms to ensure high-quality, cost-effective care
      • the individual patients who entrust their well-being to that physician to promote their best interests within the reasonable limits of the system
    • Reform of national health systems
      • Changes in: demography; medical advances; health economics; patient needs and expectations
      • International evidences indicate: health systems based on effective primary care with highly trained generalist physicians provide both more cost and clinically effective care
      • Ever increasing importance of FM/GP
    • The ecology of medical care revisited (Green, 2001)
    • Levels of Health Care
      • Primary care physician
      • A physician from whatever discipline working in a primary care setting
      • Secondary care physician
      • A physician who has undergone a period of higher postgraduate training in an organ/disease based discipline, and who works predominantly in that discipline in a hospital setting
      • Specialist
      • A physician from whatever discipline who has undergone a higher postgraduate training
    • Basic definitions in general medicine
      • General Practitioner / Family Doctor
        • Synonyms, used to describe those doctors who have undergone postgraduate training in general practice at least to the level defined in Title 4 of the Doctors’ Directive.
      • General Practice / Family Medicine
        • An academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty oriented to primary care.
    • The History of Family Medicine
      • General Practitioner, Family Doctor, medicus universalis
      • Should there be a doctor, who is readily available, knows and is responsible for everything
      • I addition is a close friend
      • The image of the „benevolent good old doctor”
    • Percent of American Physicians in practice as General Practitioners, 1930-1970
    • General Practice – An Initial Approach
      • Essential part of medical care in all countries.
      • The GP is the first point of contact for most medical services.
      • Wide range of consultations and home visits.
      • GPs provide a complete spectrum of care within the local community – education, prevention, treatment.
      • No other specialty offers such a wide remit of treating everything from babies and from mental illnesses to sports medicine.
      • The opportunity of prevention is given only at the level of GP.
      • Most GPs are independent contractors of the national health system.
    • The Main Characteristics of Family Medicine preventive approach situative office home integrative complex, somatic, psychic, social independent from age, gender social status lasts for a lifetime continuous problem- oriented involves one-person responsibility provides definitive care individual family community
    • „ Old” and „new” models of general practice Some „non-care” services provided elsewhere Practice providing all care Local contract National contract GP as a member of a multi-disciplinary team The GP is the main provider Rapid access to care Personal & continuity of care
    • The interrelated competence framework
    • Something about learning new skills, acquiring and applying knowledge!
    • GMC for GPs - Good Clinical Care 1
      • The unacceptable GP
      • Has limited competence, and is unaware of where his or her competence lie
      • Consistently ignores, interrupts or contradicts his or her patients
      • Fails to elicit important parts of the history
      • Is unable to discuss sensitive and personal matters with patients
      • Fails to use the medical records as a source of information about past events
      • Fails to examine patients when needed
      • Undertakes inappropriate, cursory, or inadequate examinations
      The excellent GP
    • GMP for GPs - Good Clinical Care 2
      • The unacceptable GP
      • Does not possess or fails to use appropriate diagnostic and treatment equipment
      • Consistently undertakes inappropriate investigations
      • Show little evidence of a coherent or rational approach to diagnosis
      • Draws illogical conclusions from the information available
      • Gives treatments that are inconsistent with best practice or evidence
      • Has no way of organising care for long-term problems or for prevention
      The excellent GP
    • GMC for GPs – Keeping Records and Keeping Colleagues Informed
      • The unacceptable GP
      • Keeps records which are incomplete or illegible, and contain inaccurate details or gratuitously derogatory remarks
      • Does not keep records confidential
      • Does not take account of colleagues’ legitimate need for information
      • Keeps records that cannot readily be followed by another doctor
      • Consistently consults without records
      • Omits important information from a report which he or she has agreed to provide, or includes untruthful information in such a report.
      The excellent GP
    • GMC for GPs – Access, Availability and Providing Care Out of Hours
      • The unacceptable GP
      • Has very restricted opening hours
      • Does not have adequate arrangements for patients to contact the practice by phone
      • Provides no opportunity for patients to talk to a doctor or a nurse on the phone
      • Cannot be contacted when on duty, takes a long time to respond to calls, or does not take rapid action in an emergency situation
      • Has no system for transferring information about out-of-hours consultations to the patient’s usual doctor
      • Does not follow up relevant information about his or her patients that has been provided by another health professional.
      The excellent GP
    • GMC for GPs – Relationship with Patients, Avoiding Discrimination 1
      • The unacceptable GP
      • Ignores the patient’s best interests when deciding about treatment or referral
      • Consistently ignores, interrupts, or contradicts his or her patients
      • Is careless of the patient’s dignity, and assumes his or her willingness to submit to examination without seeking permission
      • Makes little effort to ensure that patient has understood his or her condition, its treatment, and prognosis
      • Is careless with confident i al information
      • Fails to obtain patients’ consent to treatment
      The excellent GP
    • GMC for GPs – Relationship with Patients, Avoiding Discrimination 2
      • The unacceptable GP
      • Has inappropriate financial or personal relationships with patients
      • Provides better care to some patients than others as a result of his or her own prejudice
      • Pressurises patients to act in line with his or her own beliefs and values
      • Refuses to register certain categories of patients, such as the homeless, the severely mentally ill, or those with problems or substance or alcohol misuse
      The excellent GP
    • GMC for GPs – Working with Colleagues, with Practice Team and Referrals 1
      • The unacceptable GP
      • Does not attempt to meet members of the primary care team (e.g. district nurses, health visitors), or even know who they are
      • Does not know how to contact primary care team members
      • Does not know what skills team members have
      • Delegates tasks to other members of the team for which they do not have appropriate skills
      • Does not encourage staff to develop new skills and responsibilities
      The excellent GP
    • GMC for GPs – Working with Colleagues, with Practice Team and Referrals 2
      • The unacceptable GP
      • Does not refer patients when specialist care is necessary
      • Consistently dismisses patients’ request for a second opinion
      • Consistently refers patients for care which would normally be regarded as part of general practice
      • Does not provide information in a referral that enables the specialist to give appropriate care
      The excellent GP
    • Give me a doctor … 1
        • Give me a doctor, partridge plump
        • Short in the leg and broad in the rump
        • An endomorph with gentle hands
        • Who’ll never make absurd demands
        • That I abandon all my vices,
        • Nor pull a long face in a crisis,
        • But with a twinkle in his eye
        • Will tell me that I have to die.
      • WH Auden
    • Give me a doctor (?) … 2
      • Give me a doctor, underweight,
      • Computerized and up-to-date,
      • A businessman who understands
      • Accountancy and target bands,
      • Who demonstrates sincere devotion
      • To audit and health promotion -
      • But when my outlook’s for the worse
      • Refers me to the Practice Nurse.
      • Marie Campkin