MEDICINE AS A LEARNED AND HUMANE PROFESSION Dr. László Kalabay Department of Family Medicine Semmelweis University
What is medical profession? <ul><li>more than just a profession, </li></ul><ul><li>a „call” </li></ul>
The attributes of medical profession <ul><li>Scientific </li></ul><ul><li>Personal </li></ul><ul><li>Humanistic </li></ul>...
The physician as a scientist <ul><li>Physicians must be trained as scientists to: </li></ul><ul><li>understand and apply t...
Most of these learned skills extend to the management of individual cases at the bedside, i.e. <ul><li>how to gather infor...
The central tenet is: „Could my conclusion be wrong?” <ul><li>Scientific rigors provide the physician with: </li></ul><ul>...
The effect of explosion of medical knowledge: increased specialization and subspecialization as  <ul><li>organ system (car...
The clinical reasoning and decision making as scientific aspects of the patient-physician interaction <ul><li>elucidation ...
The physician as caregiver 1 <ul><li>When patients week medical attention, they entrust their doctors with their very live...
„ You give but little when you give of your possessions – it is when you give of yourself that you truly give” (Khalil Gib...
The physician as caregiver 2 <ul><li>Being sensitive or insensitive to patients </li></ul><ul><li>„ Does my physician real...
„ The humility that comes from others having faith in you” (Dag Hammarskjöld)
The physician must be willing to <ul><li>answer the patient’s needs </li></ul><ul><li>undertake a long-term commitment to ...
The patients still needs care <ul><li>when data come back from the clinical laboratory, the radiology department, the card...
The physician as a professional 1 <ul><li>Definition:  Professionalism in internal medicine comprises those attributes and...
The physician as a professional 2 <ul><li>The interest of the patient lies above self-interest </li></ul><ul><li>To remain...
Patient-centeredness makes medicine as an art <ul><li>Sometimes it is more important who has the disease than the disease ...
Systems of patients care beyond the millennium <ul><li>The evolving changes in the health care delivery system unavoidably...
The physician has now a dual responsibility to  <ul><li>the health care system  as an expert who helps create standards, m...
Reform of national health systems <ul><li>Changes in: demography; medical advances; health economics; patient needs and ex...
INTRODUCTION TO FAMILY MEDICINE / GENERAL PRACTICE
The ecology of medical care revisited (Green, 2001)
Levels of Health Care <ul><li>Primary care physician </li></ul><ul><li>A physician from whatever discipline working in a p...
Basic definitions in general medicine <ul><li>General Practitioner / Family Doctor </li></ul><ul><ul><li>Synonyms, used to...
The History  of  Family Medicine <ul><li>General Practitioner, Family Doctor,  medicus universalis </li></ul><ul><li>Shoul...
Percent of American Physicians in practice as General Practitioners, 1930-1970
General Practice – An Initial Approach <ul><li>Essential part of medical care in all countries. </li></ul><ul><li>The GP i...
The Main Characteristics of Family Medicine preventive approach situative office home integrative complex,  somatic, psych...
„ Old” and „new” models of general practice Some „non-care” services provided elsewhere Practice providing all care Local ...
The interrelated competence framework
Something about learning new skills, acquiring and applying knowledge!
GMC for GPs - Good Clinical Care 1 <ul><li>The unacceptable GP </li></ul><ul><li>Has limited competence, and is unaware of...
GMP for GPs - Good Clinical Care 2 <ul><li>The unacceptable GP </li></ul><ul><li>Does not possess or fails to use appropri...
GMC for GPs – Keeping Records and Keeping Colleagues Informed <ul><li>The unacceptable GP </li></ul><ul><li>Keeps records ...
GMC for GPs – Access, Availability and Providing Care Out of Hours <ul><li>The unacceptable GP </li></ul><ul><li>Has very ...
GMC for GPs – Relationship with Patients, Avoiding Discrimination 1 <ul><li>The unacceptable GP </li></ul><ul><li>Ignores ...
GMC for GPs – Relationship with Patients, Avoiding Discrimination 2 <ul><li>The unacceptable GP </li></ul><ul><li>Has inap...
GMC for GPs – Working with Colleagues, with Practice Team and Referrals 1 <ul><li>The unacceptable GP </li></ul><ul><li>Do...
GMC for GPs – Working with Colleagues, with Practice Team and Referrals 2 <ul><li>The unacceptable GP </li></ul><ul><li>Do...
Give me a doctor … 1 <ul><ul><li>Give me a doctor, partridge plump </li></ul></ul><ul><ul><li>Short in the leg and broad i...
Give me a doctor (?) … 2 <ul><li>Give me a doctor, underweight, </li></ul><ul><li>Computerized and up-to-date, </li></ul><...
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Medical.Profession Kalabay.Laszlo

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Medical.Profession Kalabay.Laszlo

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

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