Medical.Profession Kalabay.Laszlo

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  • 1. MEDICINE AS A LEARNED AND HUMANE PROFESSION Dr. László Kalabay Department of Family Medicine Semmelweis University
  • 2. What is medical profession?
    • more than just a profession,
    • a „call”
  • 3. The attributes of medical profession
    • Scientific
    • Personal
    • Humanistic
    • Professional
    • Artistic
  • 4. 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
  • 5. 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.
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. „ 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)
  • 11. 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
  • 12. „ The humility that comes from others having faith in you” (Dag Hammarskjöld)
  • 13. The physician must be willing to
    • answer the patient’s needs
    • undertake a long-term commitment to the patient’s care
  • 14. 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)
  • 15. 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.
  • 16. 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
  • 17. Patient-centeredness makes medicine as an art
    • Sometimes it is more important who has the disease than the disease itself”
  • 18. 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
  • 19. 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
  • 20. 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
  • 22. The ecology of medical care revisited (Green, 2001)
  • 23. 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
  • 24. 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.
  • 25. 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”
  • 26. Percent of American Physicians in practice as General Practitioners, 1930-1970
  • 27. 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.
  • 28. 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
  • 29. „ 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
  • 30. The interrelated competence framework
  • 31. Something about learning new skills, acquiring and applying knowledge!
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. 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