Practice of-medicine

Dr. Suhail S. Kishawi
The Practice of MedicineThe Practice of Medicine

““Medicine is medicineMedicine is medicine””

What's an "InternistWhat's an "Internist"?"?
 Internal medicine physicians are specialists who apply
scientific knowledge and clinical expertise to the diagnosis,
treatment, and care of adults across the spectrum from health
to complex illness.
 At least three of their seven or more years of medical school
and postgraduate training are dedicated to learning how to
prevent, diagnose, and treat diseases that affect adults.
 Internists are sometimes referred to as the "doctor's doctor,"
because they are often called upon to act as consultants to
other physicians to help solve puzzling diagnostic problems.

What's an "InternistWhat's an "Internist"?"?
 Simply, internists are Doctors of Internal Medicine.
( )
 They may be referred by several names, including "internists,"
"general internists" and "doctors of internal medicine." But don't
mistake them with "interns," who are doctors in their first year of
residency training.
 Although internists may act as primary care physicians, they are
not "family physicians," "family practitioners," or "general
practitioners," whose training is not solely concentrated on adults
and may include surgery, obstetrics and pediatrics.

Internal Medicine SubspecialtiesInternal Medicine Subspecialties
 Internists can choose to focus their practice on
general internal medicine, or may take additional
training to "subspecialize" in one of 13 areas of
internal medicine.
 Cardiologists, for example, are doctors of internal
medicine who subspecialize in diseases of the heart.
 The training an internist receives to subspecialize in
a particular medical area is both broad and deep.

Internal Medicine SubspecialtiesInternal Medicine Subspecialties
 Internists can choose to focus their practice on general internal medicine or take
additional training to "subspecialize" in additional areas of internal medicine. The 13
subspecialties of internal medicine that internists can subspecialize in after medical
school include:
1) Adolescent medicine
2) Allergy and immunology
3) Cardiology (heart)
4) Endocrinology (diabetes and other glandular disorders)
5) Gastroenterology (colon and intestinal tract)
6) Geriatrics (care of the elderly)
7) Hematology (blood)
8) Infectious disease
9) Nephrology (kidneys)
10)Oncology (cancer)
11)Pulmonology (lungs)
12)Rheumatology (arthritis)
13)Sports medicine

The history of dentistry and medicine relationship:The history of dentistry and medicine relationship:
could the mouth finally return to the bodycould the mouth finally return to the body??
Oral health means much more than beautiful teeth. It
means freedom from chronic oral-facial pain, oral
and throat cancers, oral soft tissue lesions, birth
defects such as cleft lip and palate, and other
diseases and disorders that affect the craniofacial
complex.
The relationship between dentistry and medicine has
been acknowledged throughout the history of
humanity.

The history of dentistry and medicine relationship:The history of dentistry and medicine relationship:
could the mouth finally return to the bodycould the mouth finally return to the body??
 This relationship was documented in ancient medicine
accounts, and has survived until the present day,
accompanied by the evolution of molecular technologies.
 This, was emphasized in a World Health Assembly resolution
which called for oral health to be integrated into chronic
disease prevention programs in 2007. This was a significant
indicator of changing perceptions of oral health over the past
several decades.

Oral infections and systemic diseaseOral infections and systemic disease
(An emerging problem in medicine(An emerging problem in medicine))
 The relationship between oral and general health has been
increasingly recognized during the past two decades.
 Several epidemiological studies have linked poor oral health with
cardiovascular disease, poor glycemic control in diabetics, low birth-
weight pre-term babies, and a number of other conditions, including
rheumatoid arthritis and osteoporosis.
 Oral infections are also recognized as a problem for individuals
suffering from a range of chronic conditions, including cancer and
infection with human immunodeficiency virus, as well as patients
with ventilator-associated pneumonia.

Oral infections and systemic diseaseOral infections and systemic disease
(An emerging problem in medicine(An emerging problem in medicine))
 Oral infections have become an increasingly
common risk-factor for systemic disease, which
clinicians should take into account.
 Clinicians should increase their knowledge of oral
diseases, and dentists must strengthen their
understanding of general medicine, in order to avoid
unnecessary risks for infection that originate in the
mouth.

Internal medicine and DentistryInternal medicine and Dentistry
 The objectives of linking internal medicine to
dentistry :
• Dentists don’t treat only healthy people
• Dental treatments can affect the patient health
• Dentists can discover some signs of special
diseases
• Emergency treatments of medical emergencies
encountred in dental practice

Internal medicine and DentistryInternal medicine and Dentistry
 Roles and responsibiliteis for dental profession :
• Early detection of systemic diseases and recognition of
oral manifestations of common diseases
• Often first to identify a systemic health problem based
on what they see in the patient’s mouth
• Oral evaluation and diagnosis
• Make approprite referral to physician when needed

WHAT IS EXPECTED OF THE PHYSICIANWHAT IS EXPECTED OF THE PHYSICIAN
 The accelerating pace of change in medicine comes from an
explosion of scientific information and the need to blend this
information into the art and practice of medicine.
 The role of science in medicine is clear. Science-based
technology and deductive reasoning form the foundation for
the solution to many clinical problems.
 Spectacular advances in genetics, biochemistry, and imaging
techniques allow access to the innermost parts of the cell and
the most remote recesses of the body.

Discoveries about the nature of genes and single
cells have opened the portal for formulating a new
molecular basis for the physiology of systems.
These physiologic insights will undoubtedly result
in a better understanding of complex disease
processes and new approaches to disease
treatment and prevention.

Highly advanced therapeutic maneuvers are
increasingly a major part of medical practice.
Yet skill in the most sophisticated application of
laboratory technology and in the use of the latest
therapeutic modality alone does not make a good
physician.

Changing Times: Healthcare is Increasingly ComplexChanging Times: Healthcare is Increasingly Complex
40 years ago
1 doctor
1 pharmacist
No forms
In-patient
650 medications
Today
Multiple providers
Chain drug stores
Numerous forms
Out-patient
24,000 meds

The responsibility of the physician inThe responsibility of the physician in
interacting with the patientinteracting with the patient
In the care of the suffering, [the physician] needs
technical skill, scientific knowledge, sympathy and
human understanding that the patient is no mere
collection of symptoms, signs, disordered
functions, damaged organs, and disturbed
emotions.
[The patient] is human, fearful, and hopeful, seeking
relief, help, and reassurance.

The responsibility of the physician inThe responsibility of the physician in
interacting with the patientinteracting with the patient
 When a patient poses challenging clinical problems, an
effective physician must be able to identify the crucial
elements in a complex history and physical examination and to
extract the key laboratory results in order to determine
whether to “treat” or to “watch.”
 This combination of medical knowledge, experience, and
judgment defines the art of medicineart of medicine, which is as necessary to
the practice of medicine as is a sound scientific base.

History-TakingHistory-Taking
 The written history of an illness should include all the facts of
medical significance in the life of the patient.
 Recent events should be given the most attention.
 The patient should have the opportunity to tell his or her own
story of the illness without frequent interruption and, when
appropriate, receive expressions of interest, encouragement,
and sympathy from the physician.

History-TakingHistory-Taking
 Any event related by the patient, however trivial or
apparently remote, may be the key to the solution of
the medical problem.
 In general, only patients who feel comfortable will
provide the physician with complete information.

History- TakingHistory- Taking
 An informative history is more than an orderly listing of
symptoms; something is always gained by listening to patients
and noting the way in which they describe their symptoms.
 Inflections of voice, facial expression, gestures, and attitude
may reveal important clues to the meaning of the symptoms to
the patient.
 Because patients vary in their medical sophistication and
ability to recall facts, the reported medical history should be
documented whenever possible.

 The family and social history can also provide important
insights into the types of diseases that should be considered.
 In listening to the history, the physician discovers not only
something about the disease but also something about the
patient.
 The process of history-taking provides an opportunity to
observe the patient's behavior and to watch for features to be
pursued more thoroughly during the physical examination.

 Eliciting the history provides the physician with the opportunity to
establish or enhance the unique bond that is the basis for the ideal
patient-physician relationship.
 The confidentiality of the patient-physician relationship should be
emphasized, and the patient should be given the opportunity to
identify any aspects of the history that should not be disclosed to
others.

Outline for the InterviewOutline for the Interview
 The Opening
 Chief Complaint(s)
 History of Present Illness (HPI)
 Primary
 Secondary (focused ROS): associated symptoms
 Tertiary (focused PMH)
 Review of Systems
 Past Medical History

PRESENTING COMPLAINT
 This may be achieved by asking :“What problems
brought you to the doctors today?”
 Use the patient’s own words to describe the chief
complaint
 The chief complaint and associated symptoms/signs
or lab/imaging findings constitute the “clinical
problem”

The other Pieces of the PuzzleThe other Pieces of the Puzzle
 Past medical history (PMH)
 Surgical history
 Drug history
 Social/occupational history
 Family history

Physical ExaminationPhysical Examination
 Physical signs are objective indications of disease whose
significance is enhanced when they confirm a functional or
structural change already suggested by the patient's history.
At times, however, the physical signs may be the only evidence
of disease.
 The physical examination should be performed methodically
and thoroughly, with consideration for the patient's comfort
and modesty.

Physical ExaminationPhysical Examination
 Although attention is often directed by the history to
the diseased organ or part of the body, the
examination of a new patient must extend from head
to toe in an objective search for abnormalities.
 Unless the physical examination is systematic,
important segments may be omitted.

Laboratory Tests and Imaging StudiesLaboratory Tests and Imaging Studies
 The availability of a wide range of laboratory tests
has increased our reliance on these studies for the
solution of clinical problems.
 The accumulation of laboratory data does not
relieve the physician from the responsibility of
careful observation, examination, and study of the
patient.

 It is also essential to bear in mind the limitations of such tests.
By virtue of their impersonal quality, complexity, and apparent
precision, and the individuals performing or interpreting them.
 Physicians must weigh the expense involved in the laboratory
procedures they order relative to the value of the information
they are likely to provide.

 Single laboratory tests are rarely ordered. Physicians
generally request “batteries” of multiple tests, which are often
useful. For example, abnormalities of hepatic function may
provide the clue to such nonspecific symptoms as
generalized weakness and increased fatigability, suggesting
the diagnosis of chronic liver disease.
 Sometimes a single abnormality, such as an elevated serum
calcium level, points to particular diseases, such as
hyperparathyroidism or underlying malignancy.

 The technical capability of imaging studies is one of
the most rapidly advancing areas of medicine.
 These tests provide remarkably detailed anatomical
information that can be a pivotal factor in medical
decision-making.

Laboratory Tests and Imaging Studies
 Ultrasonography, a variety of isotopic scans, computed
tomography (CT), magnetic resonance imaging(MRI) and
positron emission tomography (PET) have benefited
patients by opening new diagnostic views and by largely
avoiding the older patients , more invasive approaches.
 In our effort to make diagnoses quickly, it is tempting to
order a battery of imaging studies. All physicians have
had cases in which imaging studies turned up findings
leading to an unexpected diagnosis.

Laboratory Tests and Imaging Studies
 Nonetheless, patients must endure each of these
tests, and the added cost of unnecessary testing is
substantial.
 A skilled physician must learn to use these powerful
diagnostic tools judiciously, always asking whether
the results will alter management and benefit the
patient.

Interpreting Diagnostic Studies

The History and Physical in Perspective
 70% of diagnoses can be made based on history alone.
 90% of diagnoses can be made based on history and physical exam.
 Expensive tests often confirm what is found during the history and physical
examination.

Equipment for physical examinationEquipment for physical examination
 Required
 Stethoscope
 Tongue blades
 Penlight
 Tape measure

Sphygmomanometer
 Reflex hammer
 Safety pins
Optional
Glove
Gauze pads
Lubricant gel
Nasal speculum
Turning fork
Oto-
ophthalmoscope

Important aspects of physical examinationImportant aspects of physical examination
(Physician)(Physician)
 Elegant appearance
 Decent manner
 Kind attitude
 High responsibility
 Good medical
morals

Important aspects of physical examinationImportant aspects of physical examination
(Physician)(Physician)
 Wash your hands,
preferably while the
patient is watching
 Washing with soap
and water is an
effective way to
reduce the
transmission of
disease

How to perform the physicalHow to perform the physical
examination?examination?
 Exposing only the
area that are being
examined
 Offer a chaperone for
both sexes.
 Explain what you're
going to do

Important aspects of physicalImportant aspects of physical
examinationexamination
 The examiner should
continue speaking to the
patient
 Showing care to his
disease and answer to
patient’s questions
 It can not only release
patient’s nerviness, but
also help to establish the
good physician-patient
relationship

Gloves should be worn when..Gloves should be worn when..
 Examining any
individual with
exudative lesions or
weeping dermatitis
 When handling
blood-soiled or body
fluid-soiled sheets or
clothing

General principles of examGeneral principles of exam
Good light
Relaxed patient
Full exposure of
the examined part

 Have the patient empty their
bladder before examination
 Have the patient lie in a
comfortable, flat, supine
position
 Have them keep their arms at
their sides or folded on the
chest

 Before the exam, ask the
patient to identify painful
areas so that you can
examine those areas last
 During the exam pay
attention to their facial
expression to assess for
sign of discomfort

 Use warm hand, warm
stethoscope, and have
short finger nails
 Approach the patient
slowly and deliberately
explaining what you will
be doing

 Stand right side of the bed
 Exam with right hand
 Head just a little elevated
 Ask the patient to keep the
mouth partially open and
breathe gently

PRINCIPLES OF PATIENT CAREPRINCIPLES OF PATIENT CARE
 Evidence-Based Medicine
 Evidence-based medicine is defined as “the conscientious,
explicit and judicious use of current best evidence in making
decisions about the care of individual patients.”
 Even the most experienced physicians can be influenced by
recent experiences with selected patients, unless they are aware
of the importance of using larger, more objective studies for
making decisions.
 The prospectively designed, double-blind, randomized clinical
trial represents the “gold standard” for providing evidence
regarding therapeutic decisions.

PRINCIPLES OF PATIENT CARE
 Care of the Elderly
 Over the next several decades, the practice of medicine will be
greatly influenced by the health care needs of the growing
elderly population. In the United States the population over age
65 will almost triple over the next 30 years.
 The physician must understand and appreciate the decline in
physiologic reserve associated with aging; the different
responses of the elderly to common diseases; and disorders
that occur commonly with aging, such as depression, dementia,
urinary incontinence, and fractures.

PRINCIPLES OF PATIENT CAREPRINCIPLES OF PATIENT CARE
 Diseases in Women versus Men
 In the past, many epidemiologic studies and clinical trials
focused on men.
 More recently, studies have included representative numbers of
women, and some, like the Women's Health Initiative, have
specifically addressed women's health issues.
 Significant sex differences exist in diseases that afflict both men
and women. Ongoing study should enhance our understanding
of the mechanisms of sex differences in the course and outcome
of certain diseases.

 Medical Errors
 “To err is human” but efforts should be done to reduce medical-
error rates and improve patient safety by designing and
implementing fundamental changes in health care systems.
 Adverse drug reactions occur in at least 5% of hospitalized
patients, and the incidence increases with use of a large number
of drugs.

 Medical Errors
 No matter what the clinical situation, it is the responsibility of
the physician to use powerful therapeutic measures wisely, with
due regard for their beneficial action, potential dangers, and
cost.
 It is also the responsibility of hospitals and health care
organizations to develop systems to reduce risk and ensure
patient safety.
 Medication errors can be reduced through the use of ordering
systems that eliminate misreading of handwriting and through
vigilance regarding dilution errors.

 Incurable Disorders and Death
 No problem is more distressing than that presented by the
patient with an incurable disease, particularly when premature
death is inevitable.
 What should the patient and family be told?
 What measures should be taken to maintain life?
 What can be done to maintain the quality of life?
 How much is told should depend on the individual's ability to
deal with the possibility of imminent death; often this capacity
grows with time, and, whenever possible, gradual rather than
abrupt disclosure is the best strategy.

 Incurable Disorders and Death
 A wise and insightful physician is often guided by an understanding of
what a patient wants to know and when he or she wants to know it.
 The patient's religious beliefs may also be taken into consideration. The
patient must be given an opportunity to talk with the physician and ask
questions. Patients may find it easier to share their feelings about death
with their physician, who is likely to be more objective and less
emotional, than with family members.
 Only open communication between the patient and the physician can
resolve this question and guide the physician in what to say and how to
say it.

Practice of-medicine

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