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,
The attributes of medical profession
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:
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
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
CONTINUOUS QUALITY IMPROVEMENT
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
INTRODUCTION TO FAMILY MEDICINE / GENERAL PRACTICE
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
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