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TheModernDayPhysician
Nogreateropportunity,responsibility,orobligationcanfalltothelotofahuman
beingthantobecomeaphysician.Inthecareofthesuffering,[thephysician]needs
technicalskill,scientificknowledge,andhumanunderstanding....Tact,sympathy,
andunderstandingareexpectedofthephysician,forthepatientisnomerecollection
ofsymptoms,signs,disorderedfunctions,damagedorgans,anddisturbedemotions.
[Thepatient]ishuman,fearful,andhopeful,seekingrelief,help,andreassurance.
Harrison'sPrinciplesofInternalMedicine,1950
Thepracticeofmedicinehaschangedinsignificantwayssincethefirsteditionofthisbook
appearedin1950.Theadventofmolecularbiologywithitsenormousimplicationsforthe
biologicalsciences(thesequencingofthehumangenome),sophisticatednewimaging
techniques,andadvancesinbioinformaticsandinformationtechnologyhavecontributedto
anexplosionofscientificinformationthathasfundamentallychangedthewaywedefine,
diagnose,treat,andpreventdisease.Thisexplosionofscientificknowledgeisnotatallstatic
asitcontinuestointensifywithtime.
ThewidespreaduseofelectronicmedicalrecordsandtheInternethavealteredthewaywe
practicemedicineandexchangeinformation.Astoday'sphysicianstrugglestointegratethe
copiousamountsofscientificknowledgeintoeverydaypractice,itisimportanttoremember
thattheultimategoalofmedicineistotreatthepatient.Despitemorethan50yearsof
scientificadvancessincethefirsteditionofthistext,itiscriticaltounderscorethatcultivating
theintimaterelationshipthatexistsbetweenphysicianandpatientstillliesattheheartof
successfulpatientcare.

THESCIENCEANDARTOFMEDICINE
Sciencebasedtechnologyanddeductivereasoningformthefoundationforthesolutionto
manyclinicalproblems.Spectacularadvancesinbiochemistry,cellbiology,andgenomics,
coupledwithnewlydevelopedimagingtechniques,allowaccesstotheinnermostpartsofthe
cellandprovideawindowtothemostremoterecessesofthebody.Revelationsaboutthe
natureofgenesandsinglecellshaveopenedtheportalforformulatinganewmolecularbasis
forthephysiologyofsystems.Increasingly,weareunderstandinghowsubtlechangesin
manydifferentgenescanaffectthefunctionofcellsandorganisms.Wearebeginningto
decipherthecomplexmechanismsbywhichgenesareregulated.Wehavedevelopedanew
appreciationoftheroleofstemcellsinnormaltissuefunctionandinthedevelopmentof
cancer,degenerativedisease,andotherdisorders.Theknowledgegleanedfromthescience
ofmedicinehasalreadyimprovedandundoubtedlywillfurtherimproveourunderstandingof
complexdiseaseprocessesandprovidenewapproachestodiseasetreatmentandprevention.
Yetskillinthemostsophisticatedapplicationoflaboratorytechnologyandintheuseofthe

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latesttherapeuticmodalityalonedoesnotmakeagoodphysician.
Whenapatientposeschallengingclinicalproblems,aneffectivephysicianmustbeableto
identifythecrucialelementsinacomplexhistoryandphysicalexamination,toorderthe
appropriatelaboratorytests,andtoextractthekeyresultsfromthecrowdedcomputer
printoutsofdatatodeterminewhetherto"treat"orto"watch."Decidingwhetheraclinical
clueisworthpursuingorshouldbedismissedasa"redherring"andweighingwhethera
proposedtreatmententailsagreaterriskthanthediseaseitselfareessentialjudgmentsthat
theskilledclinicianmustmakemanytimeseachday.Thiscombinationofmedicalknowledge,
intuition,experience,andjudgmentdefinestheartofmedicine,whichisasnecessaryto
thepracticeofmedicineasisasoundscientificbase.

ClinicalSkills
HISTORYTAKING
Thewrittenhistoryofanillnessshouldincludeallthefactsofmedicalsignificanceinthelife
ofthepatient.Recenteventsshouldbegiventhemostattention.Thepatientshould,atsome
earlypoint,havetheopportunitytotellhisorherownstoryoftheillnesswithoutfrequent
interruptionand,whenappropriate,receiveexpressionsofinterest,encouragement,and
empathyfromthephysician.Anyeventrelatedbythepatient,howevertrivialorseemingly
irrelevant,mayprovidethekeytosolvingthemedicalproblem.Ingeneral,onlypatientswho
feelcomfortablewilloffercompleteinformation,andthusputtingthepatientateasetothe
greatestextentpossiblecontributessubstantiallytoobtaininganadequatehistory.
Aninformativehistoryismorethananorderlylistingofsymptomsbylisteningtopatients
andnotingthewayinwhichtheydescribetheirsymptoms,physicianscangainvaluable
insightintotheproblem.Inflectionsofvoice,facialexpression,gestures,andattitude,i.e.,
"bodylanguage,"mayrevealimportantcluestothemeaningofthesymptomstothepatient.
Becausepatientsvaryintheirmedicalsophisticationandabilitytorecallfacts,thereported
medicalhistoryshouldbecorroboratedwheneverpossible.Thesocialhistorycanalsoprovide
importantinsightsintothetypesofdiseasesthatshouldbeconsidered.Thefamilyhistorynot
onlyidentifiesrareMendeliandisorderswithinafamilybutoftenrevealsriskfactorsfor
commondisorderssuchascoronaryheartdisease,hypertension,orasthma.Athorough
familyhistorymayrequireinputfrommultiplerelativestoensurecompletenessandaccuracy.
However,oncerecorded,itcanbereadilyupdated.Theprocessofhistorytakingprovidesan
opportunitytoobservethepatient'sbehaviorandtowatchforfeaturestobepursuedmore
thoroughlyduringthephysicalexamination.
Theveryactofelicitingthehistoryprovidesthephysicianwiththeopportunitytoestablishor
enhancetheuniquebondthatformsthebasisfortheidealpatientphysicianrelationship.This
processhelpsthephysiciandevelopanappreciationofthepatient'sperceptionoftheillness,
thepatient'sexpectationsofthephysicianandthehealthcaresystem,andthefinancialand
socialimplicationsoftheillnesstothepatient.Althoughcurrenthealthcaresettingsmay
imposetimeconstraintsonpatientvisits,itisimportantnottorushthehistorytakingsince
thepatientmaygettheimpressionthatwhatheorsheisrelatingisnotofimportancetothe
physicianandthereforemayholdbackrelevantinformation.Theconfidentialityofthe
patientphysicianrelationshipcannotbeoveremphasized.

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PHYSICALEXAMINATION
Thepurposeofthephysicalexaminationistoidentifythephysicalsignsofdisease.The
significanceoftheseobjectiveindicationsofdiseaseisenhancedwhentheyconfirma
functionalorstructuralchangealreadysuggestedbythepatient'shistory.Attimes,however,
thephysicalsignsmaybetheonlyevidenceofdisease.
Thephysicalexaminationshouldbeperformedmethodicallyandthoroughly,with
considerationforthepatient'scomfortandmodesty.Althoughattentionisoftendirectedby
thehistorytothediseasedorganorpartofthebody,theexaminationofanewpatientmust
extendfromheadtotoeinanobjectivesearchforabnormalities.Unlessthephysical
examinationissystematicandperformedinaconsistentmannerfrompatienttopatient,
importantsegmentsmaybeinadvertentlyomitted.Theresultsoftheexamination,likethe
detailsofthehistory,shouldberecordedatthetimetheyareelicited,nothourslaterwhen
theyaresubjecttothedistortionsofmemory.Skillinphysicaldiagnosisisacquiredwith
experience,butitisnotmerelytechniquethatdeterminessuccessinelicitingsignsof
disease.Thedetectionofafewscatteredpetechiae,afaintdiastolicmurmur,orasmallmass
intheabdomenisnotaquestionofkeenereyesandearsormoresensitivefingers,butofa
mindalerttothesefindings.Becausephysicalfindingscanchangewithtime,thephysical
examinationshouldberepeatedasfrequentlyastheclinicalsituationwarrants.Becausea
largenumberofhighlysensitivediagnostictestsareavailable,particularlyimaging
techniques,itmaybetemptingtoputlessemphasisonthephysicalexamination.Indeed,
manypatientsareseenforthefirsttimeafteraseriesofdiagnostictestshavealreadybeen
performedandtheresultsknown.Thisshouldnotdeterthephysicianfromperforminga
thoroughphysicalexaminationsinceclinicalfindingsareoftenpresentthathave"escaped"
thebarrageofpreexaminationdiagnostictests.

DIAGNOSTICSTUDIES
Wehavebecomeincreasinglyreliantonawidearrayoflaboratoryteststosolveclinical
problems.However,accumulatedlaboratorydatadonotrelievethephysicianfromthe
responsibilityofcarefullyobserving,examining,andstudyingthepatient.Itisalsoessential
toappreciatethelimitationsofdiagnostictests.Byvirtueoftheirimpersonalquality,
complexity,andapparentprecision,theyoftengainanauraofauthorityregardlessofthe
fallibilityoftheteststhemselves,theinstrumentsusedinthetests,andtheindividuals
performingorinterpretingthem.Physiciansmustweightheexpenseinvolvedinthe
laboratoryproceduresrelativetothevalueoftheinformationtheyarelikelytoprovide.
Singlelaboratorytestsarerarelyordered.Rather,physiciansgenerallyrequest"batteries"of
multipletests,whichoftenproveuseful.Forexample,abnormalitiesofhepaticfunctionmay
providethecluetosuchnonspecificsymptomsasgeneralizedweaknessandincreased
fatigability,suggestingthediagnosisofchronicliverdisease.Sometimesasingleabnormality,
suchasanelevatedserumcalciumlevel,pointstoaparticulardisease,suchas
hyperparathyroidismorunderlyingmalignancy.
Thethoughtfuluseofscreeningtests,suchaslowdensitylipoproteincholesterol,maybe
quiteuseful.Agroupoflaboratorydeterminationscanbecarriedoutconvenientlyonasingle
specimenatrelativelylowcost.Screeningtestsaremostinformativewhendirectedtoward

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commondiseasesordisordersandwhentheirresultsindicatetheneedforotherusefultests
orinterventionsthatmaybecostlytoperform.Ontheonehand,biochemicalmeasurements,
togetherwithsimplelaboratoryexaminationssuchasbloodcount,urinalysis,and
sedimentationrate,oftenprovideamajorcluetothepresenceofapathologicprocess.On
theotherhand,thephysicianmustlearntoevaluateoccasionalabnormalitiesamongthe
screeningteststhatmaynotnecessarilyconnotesignificantdisease.Anindepthworkup
followingareportofanisolatedlaboratoryabnormalityinapersonwhoisotherwisewellis
almostinvariablywastefulandunproductive.Amongthemorethan40teststhatareroutinely
performedasscreening,itwouldnotbeunusualforoneortwoofthemtobeslightly
abnormal.Ifthereisnosuspicionofanunderlyingillness,thesetestsareordinarilyrepeated
toensurethattheabnormalitydoesnotrepresentalaboratoryerror.Ifanabnormalityis
confirmed,itisimportanttoconsideritspotentialsignificanceinthecontextofthepatient's
conditionandothertestresults.
Thedevelopmentoftechnicallyimprovedimagingstudieswithgreatersensitivityand
specificityisoneofthemostrapidlyadvancingareasofmedicine.Thesetestsprovide
remarkablydetailedanatomicinformationthatcanbeapivotalfactorinmedicaldecision
making.Ultrasonography,avarietyofisotopicscans,CT,MRI,andpositronemission
tomographyhavebenefitedpatientsbysupplantingolder,moreinvasiveapproachesand
openingnewdiagnosticvistas.Cognizantoftheircapabilitiesandtherapiditywithwhichthey
canleadtoadiagnosis,itistemptingtoorderabatteryofimagingstudies.Allphysicians
havehadexperiencesinwhichimagingstudiesturnedupfindingsleadingtoanunexpected
diagnosis.Nonetheless,patientsmustendureeachofthesetests,andtheaddedcostof
unnecessarytestingissubstantial.Askilledphysicianmustlearntousethesepowerful
diagnostictoolsjudiciously,alwaysconsideringwhethertheresultswillaltermanagementand
benefitthepatient.

PrinciplesofPatientCare
EVIDENCEBASEDMEDICINE
Evidencebasedmedicinereferstotheconceptthatclinicaldecisionsareformallysupported
bydata,preferablydatathatarederivedfromprospectivelydesigned,randomized,controlled
clinicaltrials.Thisisinsharpcontrasttoanecdotalexperience,whichmayoftenbebiased.
Unlesstheyareattunedtotheimportanceofusinglarger,moreobjectivestudiesformaking
decisions,eventhemostexperiencedphysicianscanbeinfluencedbyrecentencounterswith
selectedpatients.Evidencebasedmedicinehasbecomeanincreasinglyimportantpartofthe
routinepracticeofmedicineandhasledtothepublicationofanumberofpracticeguidelines.

PRACTICEGUIDELINES
Professionalorganizationsandgovernmentagenciesaredevelopingformalclinicalpractice
guidelinestoaidphysiciansandothercaregiversinmakingdiagnosticandtherapeutic
decisionsthatareevidencebased,costeffective,andmostappropriatetoaparticularpatient
andclinicalsituation.Astheevidencebaseofmedicineincreases,guidelinescanprovidea
usefulframeworkformanagingpatientswithparticulardiagnosesorsymptoms.Theycan
protectpatientsparticularlythosewithinadequatehealthcarebenefitsfromreceiving
substandardcare.Guidelinescanalsoprotectconscientiouscaregiversfrominappropriate
chargesofmalpracticeandsocietyfromtheexcessivecostsassociatedwiththeoveruseof

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medicalresources.Thereare,however,caveatsassociatedwithclinicalpracticeguidelines
sincetheytendtooversimplifythecomplexitiesofmedicine.Furthermore,groupswith
differingperspectivesmaydevelopdivergentrecommendationsregardingissuesasbasicas
theneedforperiodicsigmoidoscopyinmiddleagedpersons.Finally,guidelinesdonotand
cannotbeexpectedtoaccountfortheuniquenessofeachindividualandhisorherillness.
Thephysician'schallengeistointegrateintoclinicalpracticetheusefulrecommendations
offeredbyexpertswithoutacceptingthemblindlyorbeinginappropriatelyconstrainedby
them.

MEDICALDECISIONMAKING
Medicaldecisionmakingisanimportantresponsibilityofthephysicianandoccursateach
stageofthediagnosticandtreatmentprocess.Itinvolvestheorderingofadditionaltests,
requestsforconsults,anddecisionsregardingtreatmentandprognosis.Thisprocessrequires
anindepthunderstandingofthepathophysiologyandnaturalhistoryofdisease.Asdescribed
above,medicaldecisionmakingshouldbeevidencebasedsothatpatientsderivethefull
benefitofthescientificknowledgeavailabletophysicians.Formulatingadifferentialdiagnosis
requiresnotonlyabroadknowledgebasebutalsotheabilitytoassesstherelative
probabilitiesofvariousdiseases.Applicationofthescientificmethod,includinghypothesis
formationanddatacollection,isessentialtotheprocessofacceptingorrejectingaparticular
diagnosis.Analysisofthedifferentialdiagnosisisaniterativeprocess.Asnewinformationor
testresultsareacquired,thegroupofdiseaseprocessesbeingconsideredcanbecontracted
orexpandedappropriately.
Despitetheimportanceofevidencebasedmedicine,muchofmedicaldecisionmakingrelies
ongoodclinicaljudgmentaprocessthatisdifficulttoquantifyoreventoassess
qualitatively.Physiciansmustusetheirknowledgeandexperienceasabasisforweighing
knownfactorsalongwiththeinevitableuncertaintiesandtheneedtousesoundjudgment
thisisparticularlyimportantwhenarelevantevidencebaseisnotavailable.Several
quantitativetoolsmaybeinvaluableinsynthesizingtheavailableinformation,including
diagnostictests,Bayes'theorem,andmultivariatestatisticalmodels.Diagnostictestsserveto
reduceuncertaintyaboutadiagnosisorprognosisinaparticularindividualandtohelpthe
physiciandecidehowbesttomanagethatindividual'scondition.Thebatteryofdiagnostic
testscomplementsthehistoryandthephysicalexamination.Theaccuracyofagiventestis
ascertainedbydeterminingitssensitivity(truepositiverate)andspecificity(truenegative
rate)aswellasthepredictivevalueofapositiveandnegativeresult.Bayes'theoremuses
informationonatest'ssensitivityandspecificity,inconjunctionwiththepretestprobabilityof
adiagnosis,todeterminemathematicallytheposttestprobabilityofthediagnosis.More
complexclinicalproblemscanbeapproachedwithmultivariatestatisticalmodels,which
generatehighlyaccurateinformationevenwhenmultiplefactorsareactingindividuallyor
togethertoaffectdiseaserisk,progression,orresponsetotreatment.Studiescomparingthe
performanceofstatisticalmodelswiththatofexpertclinicianshavedocumentedequivalent
accuracy,althoughthemodelstendtobemoreconsistent.Thus,multivariatestatistical
modelsmaybeparticularlyhelpfultolessexperiencedclinicians.SeeChap.3foramore
thoroughdiscussionofdecisionmakinginclinicalmedicine.

ELECTRONICMEDICALRECORDS

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Ourgrowingrelianceoncomputersandthestrengthofinformationtechnologyareplayingan
increasinglyimportantroleinmedicine.Laboratorydataareaccessedalmostuniversally
throughcomputers.Manymedicalcentersnowhaveelectronicmedicalrecords,computerized
orderentry,andbarcodedtrackingofmedications.Someofthesesystemsareinteractive
andprovideremindersorwarnofpotentialmedicalerrors.Inmanyways,thehealthcare
systemhaslaggedbehindotherindustriesintheadoptionofinformationtechnology.
Electronicmedicalrecordshaveextraordinarypotentialforprovidingrapidaccesstoclinical
information,imagingstudies,laboratoryresults,andmedications.Thistypeofinformationis
invaluableforongoingeffortstoenhancequalityandimprovepatientsafety.Ideally,patient
recordsshouldbeeasilytransferredacrossthehealthcaresystem,providingreliableaccess
torelevantdataandhistoricinformation.However,technologylimitationsandconcernsabout
privacyandcostcontinuetolimitabroadbasedutilizationofelectronichealthrecordsin
mostclinicalsettings.Itshouldalsobeemphasizedthatinformationtechnologyismerelya
toolandcanneverreplacetheclinicaldecisionsthatarebestmadebythephysician.Inthis
regard,clinicalknowledgeandanunderstandingofthepatient'sneeds,supplementedby
quantitativetools,stillseemtorepresentthebestapproachtodecisionmakinginthepractice
ofmedicine.

EVALUATIONOFOUTCOMES
Cliniciansgenerallyuseobjectiveandreadilymeasurableparameterstojudgetheoutcomeof
atherapeuticintervention.Forexample,findingsonphysicalorlaboratoryexaminationsuch
asthebloodpressurelevel,thepatencyofacoronaryarteryonanangiogram,orthesizeof
amassonaradiologicexaminationcanprovidecriticallyimportantinformation.However,
patientsusuallyseekmedicalattentionforsubjectivereasonstheywishtoobtainrelieffrom
pain,topreserveorregainfunction,andtoenjoylife.Thecomponentsofapatient'shealth
statusorqualityoflifecanincludebodilycomfort,capacityforphysicalactivity,personaland
professionalfunction,sexualfunction,cognitivefunction,andoverallperceptionofhealth.
Eachoftheseimportantareascanbeassessedbymeansofstructuredinterviewsorspecially
designedquestionnaires.Suchassessmentsalsoprovideusefulparametersbywhichthe
physiciancanjudgethepatient'ssubjectiveviewofhisorherdisabilityandtheresponseto
treatment,particularlyinchronicillness.Thepracticeofmedicinerequiresconsiderationand
integrationofbothobjectiveandsubjectiveoutcomes.

WOMEN'SHEALTHANDDISEASE
Althoughpastepidemiologicstudiesandclinicaltrialshaveoftenfocusedpredominantlyon
men,morerecentstudieshaveincludedmorewomen,andsome,liketheWomen'sHealth
Initiative,haveexclusivelyaddressedwomen'shealthissues.Significantgenderdifferences
existindiseasesthatafflictbothmenandwomen.Muchisstilltobelearnedinthisarena,
andongoingstudiesshouldenhanceourunderstandingofthemechanismsofgender
differencesinthecourseandoutcomeofcertaindiseases.Foramorecompletediscussionof
women'shealth,seeChap.6.

CAREOFTHEELDERLY
Therelativeproportionofelderlyindividualsinthepopulationsofdevelopednationshasbeen
growingconsiderablyoverthepastfewdecadesandwillcontinuetogrow.Inthisregard,the

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practiceofmedicinewillcontinuetobegreatlyinfluencedbythehealthcareneedsofthis
growingelderlypopulation.Thephysicianmustunderstandandappreciatethedeclinein
physiologicreserveassociatedwithagingthediminishedresponsesoftheelderlyto
vaccinationssuchasthoseagainstinfluenzathedifferentresponsesoftheelderlyto
commondiseasesanddisordersthatoccurcommonlywithaging,suchasdepression,
dementia,frailty,urinaryincontinence,andfractures.Foramorecompletediscussionof
medicalcarefortheelderly,seeChap.9.

ERRORSINTHEDELIVERYOFHEALTHCARE
AreportfromtheInstituteofMedicinecalledforanambitiousagendatoreducemedicalerror
ratesandimprovepatientsafetybydesigningandimplementingfundamentalchangesin
healthcaresystems.Adversedrugreactionsoccurinatleast5%ofhospitalizedpatients,and
theincidenceincreaseswithuseofalargenumberofdrugs.Nomatterwhattheclinical
situation,itistheresponsibilityofthephysiciantousepowerfultherapeuticmeasureswisely,
withdueregardfortheirbeneficialaction,potentialdangers,andcost.Itisalsothe
responsibilityofhospitalsandhealthcareorganizationstodevelopsystemstoreduceriskand
ensurepatientsafety.Medicationerrorscanbereducedthroughtheuseoforderingsystems
thateliminatemisreadingofhandwriting.Implementationofinfectioncontrolsystems,
enforcementofhandwashingprotocols,andcarefuloversightofantibioticusecanminimize
complicationsofnosocomialinfections.

THEROLEOFTHEPHYSICIANINTHEINFORMEDCONSENTOF
THEPATIENT
Thefundamentalprinciplesofmedicalethicsrequirephysicianstoactinthepatient'sbest
interestandtorespectthepatient'sautonomy.Thisisparticularlyrelevanttotheissueof
informedconsent.Mostpatientspossessonlylimitedmedicalknowledgeandmustrelyon
theirphysiciansforadvice.Physiciansmustrespecttheirpatients'autonomy,fullydiscussing
thealternativesforcareandtherisks,benefits,andlikelyconsequencesofeachalternative.
Patientsarerequiredtosignaconsentformforessentiallyanydiagnosticortherapeutic
procedure.Insuchcases,itisparticularlyimportantforthepatienttounderstandclearlythe
risksandbenefitsoftheseproceduresthisisthedefinitionofinformedconsent.Itis
incumbentonthephysiciantoexplaintheproceduresinaclearandunderstandablemanner
andtoascertainthatthepatientcomprehendsboththenatureoftheprocedureandthe
attendantrisksandbenefits.Thedreadoftheunknown,inherentinhospitalization,canbe
mitigatedbysuchexplanations.

THEAPPROACHTOGRAVEPROGNOSESANDDEATH
Noproblemismoredistressingthanthediagnosisofanincurabledisease,particularlywhen
prematuredeathisinevitable.Whatshouldthepatientandfamilybetold?Whatmeasures
shouldbetakentomaintainlife?Whatcanbedonetomaintainthequalityoflife?
Althoughsomewouldargueotherwise,thereisnoironcladrulethatthepatientmust
immediatelybetold"everything,"evenifthepatientisanadultwithsubstantialfamily
responsibilities.Howmuchistoldatagivenpointintimeshoulddependontheindividual's
abilitytodealwiththepossibilityofimminentdeathoftenthiscapacitygrowswithtime,and,

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wheneverpossible,gradualratherthanabruptdisclosureisthebeststrategy.Awiseand
insightfulphysicianisoftenguidedbyanunderstandingofwhatapatientwantstoknowand
whenheorshewantstoknowit.Thepatient'sreligiousbeliefsmayalsobetakeninto
consideration.Thepatientmustbegivenanopportunitytotalkwiththephysicianandask
questions.Patientsmayfinditeasiertosharetheirfeelingsaboutdeathwiththeirphysician,
whoislikelytobemoreobjectiveandlessemotional,thanwithfamilymembers.AsWilliam
Oslerwrote,"Onethingiscertainitisnotforyoutodontheblackcapand,assumingthe
judicialfunction,takehopeawayfromanypatient."Evenwhenthepatientdirectlyinquires,
"AmIdying?"thephysicianmustattempttodeterminewhetherthisisarequestfor
informationorforreassurance.Onlyopencommunicationbetweenthepatientandthe
physiciancanresolvethisquestionandguidethephysicianinwhattosayandhowtosayit.
Thephysicianshouldprovideorarrangeforemotional,physical,andspiritualsupportand
mustbecompassionate,unhurried,andopen.Thereismuchtobegainedbythelayingonof
hands.Painshouldbeadequatelycontrolled,humandignitymaintained,andisolationfrom
familyandclosefriendsavoided.Theseaspectsofcaretendtobeoverlookedinhospitals,
wheretheintrusionoflifesustainingapparaticansoeasilydetractfromattentiontothe
wholepersonandencourageconcentrationinsteadonthelifethreateningdisease,against
whichthebattlewillultimatelybelostinanycase.Inthefaceofterminalillness,thegoalof
medicinemustshiftfromcuretocare,inthebroadestsenseoftheterm.Inofferingcareto
thedyingpatient,thephysicianmustbepreparedtoprovideinformationtofamilymembers
andtodealwiththeirgriefandsometimestheirfeelingsofguilt.Itisimportantforthedoctor
toassurethefamilythateverythingpossiblehasbeendone.Foramorecompletediscussion
ofendoflifecare,seeChap.11.

ThePatientPhysicianRelationship
Thesignificanceoftheintimatepersonalrelationshipbetweenphysicianandpatient
cannotbetoostronglyemphasized,forinanextraordinarilylargenumberofcases
boththediagnosisandtreatmentaredirectlydependentonit.Oneoftheessential
qualitiesoftheclinicianisinterestinhumanity,forthesecretofthecareofthe
patientisincaringforthepatient.
FrancisW.Peabody,18811927
Physiciansmustneverforgetthatpatientsareindividualhumanbeingswithproblemsthatall
toooftentranscendtheirphysicalcomplaints.Theyarenot"cases"or"admissions"or
"diseases."Thispointisparticularlyimportantinthiseraofhightechnologyinclinical
medicine.Mostpatientsareanxiousandfearful.Physiciansshouldinstillconfidenceand
shouldbereassuringbutshouldneverbearrogant.Aprofessionalattitude,coupledwith
warmthandopenness,candomuchtoalleviateanxietyandtoencouragepatientstoshare
allaspectsoftheirmedicalhistory.Whateverthepatient'sattitude,thephysicianneedsto
considerthesettinginwhichanillnessoccursintermsnotonlyofthepatientsthemselves
butalsooftheirfamilial,social,andculturalbackgrounds.Theidealpatientphysician
relationshipisbasedonthoroughknowledgeofthepatient,onmutualtrust,andonthe
abilitytocommunicate.

THEDICHOTOMYOFINPATIENTANDOUTPATIENTINTERNAL

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MEDICINE
Thehospitalenvironmenthastransformeddramaticallyoverthepastfewdecades.Inmore
recenttimes,emergencydepartmentsandcriticalcareunitshaveevolvedtoidentifyand
managecriticallyillpatients,allowingthemtosurviveformerlyfataldiseases.Thereis
increasingpressuretoreducethelengthofstayinthehospitalandtomanagecomplex
disordersintheoutpatientsetting.Thistransitionhasbeendrivennotonlybyeffortsto
reducecostsbutalsobytheavailabilityofnewoutpatienttechnologies,suchasimagingand
percutaneousinfusioncathetersforlongtermantibioticsornutrition,andbyevidencethat
outcomesareoftenimprovedbyminimizinginpatienthospitalization.Hospitalsnowconsistof
multipledistinctlevelsofcare,suchastheemergencydepartment,procedurerooms,
overnightobservationunits,criticalcareunits,andpalliativecareunits,inadditionto
traditionalmedicalbeds.Aconsequenceofthisdifferentiationhasbeentheemergenceofnew
specialtiessuchasemergencymedicine,intensivists,hospitalists,andendoflifecare.
Moreover,thesesystemsfrequentlyinvolve"handoffs"fromtheoutpatienttotheinpatient
environment,fromthecriticalcareunittoageneralmedicinefloor,andfromthehospitalto
theoutpatientenvironment.Clearly,oneoftheimportantchallengesininternalmedicineisto
maintaincontinuityofcareandinformationflowduringthesetransitions,whichthreatenthe
traditionalonetoonerelationshipbetweenpatientandphysician.Inthecurrent
environment,teamsofphysicians,specialists,andotherhealthcareprofessionalshaveoften
replacedthepersonalinteractionbetweendoctorandpatient.Thepatientcanbenefitgreatly
fromeffectivecollaborationamonganumberofhealthcareprofessionalshowever,itisthe
dutyofthepatient'sprincipalorprimaryphysiciantoprovidecohesiveguidancethroughan
illness.Inordertomeetthischallenge,theprimaryphysicianmustbefamiliarwiththe
techniques,skills,andobjectivesofspecialistphysiciansandalliedhealthprofessionals.The
primaryphysicianmustensurethatthepatientwillbenefitfromscientificadvancesandfrom
theexpertiseofspecialistswhentheyareneeded,whilestillretainingresponsibilityforthe
majordecisionsconcerningdiagnosisandtreatment.

APPRECIATIONOFTHEPATIENT'SHOSPITALEXPERIENCE
Thehospitalisanintimidatingenvironmentformostindividuals.Hospitalizedpatientsfind
themselvessurroundedbyairjets,buttons,andglaringlightsinvadedbytubesandwires
andbesetbythenumerousmembersofthehealthcareteamnurses,nurses'aides,
physicians'assistants,socialworkers,technologists,physicaltherapists,medicalstudents,
houseofficers,attendingandconsultingphysicians,andmanyothers.Theymaybe
transportedtospeciallaboratoriesandimagingfacilitiesrepletewithblinkinglights,strange
sounds,andunfamiliarpersonneltheymaybeleftunattendedforperiodsoftimetheymay
beobligedtosharearoomwithotherpatientswhohavetheirownhealthproblems.Itislittle
wonderthatpatientsmaylosetheirsenseofreality.Physicianswhocanappreciatethe
hospitalexperiencefromthepatient'sperspectiveandmakeanefforttodevelopastrong
personalrelationshipwiththepatientwherebytheymayguidethepatientthroughthis
experiencecanmakeastressfulsituationmoretolerable.

TRENDSINTHEDELIVERYOFHEALTHCARE:ACHALLENGETO
THEHUMANEPHYSICIAN
Manytrendsinthedeliveryofhealthcaretendtomakemedicalcareimpersonal.These

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trends,someofwhichhavebeenmentionedalready,include(1)vigorouseffortstoreduce
theescalatingcostsofhealthcare(2)thegrowingnumberofmanagedcareprograms,
whichareintendedtoreducecostsbutinwhichthepatientmayhavelittlechoiceinselecting
aphysicianorinseeingthatphysicianconsistently(3)increasingrelianceontechnological
advancesandcomputerizationformanyaspectsofdiagnosisandtreatment(4)theneedfor
numerousphysicianstobeinvolvedinthecareofmostpatientswhoareseriouslyilland(5)
anincreasednumberofmalpracticesuits,someofwhicharejustifiablebecauseofmedical
errors,butothersofwhichreflectanunrealisticexpectationonthepartofmanypatientsthat
theirdiseasewillbecuredorthatcomplicationswillnotoccurduringthecourseofcomplex
illnessesorprocedures.
Giventhesechangesinthemedicalcaresystem,itisamajorchallengeforphysiciansto
maintainthehumaneaspectsofmedicalcare.TheAmericanBoardofInternalMedicine,
workingtogetherwiththeAmericanCollegeofPhysiciansAmericanSocietyofInternal
MedicineandtheEuropeanFederationofInternalMedicine,haspublishedaCharteron
MedicalProfessionalismthatunderscoresthreemainprinciplesinphysicians'contractwith
society:(1)theprimacyofpatientwelfare,(2)patientautonomy,and(3)socialjustice.
Medicalschoolshavealsoincreasedtheiremphasisonphysicianprofessionalisminrecent
years(Fig.11).Thehumanisticqualitiesofaphysicianmustencompassintegrity,respect,
andcompassion.Availability,theexpressionofsincereconcern,thewillingnesstotakethe
timetoexplainallaspectsoftheillness,andanonjudgmentalattitudewhendealingwith
patientswhosecultures,lifestyles,attitudes,andvaluesdifferfromthoseofthephysicianare
justafewofthecharacteristicsofthehumanephysician.Everyphysicianwill,attimes,be
challengedbypatientswhoevokestronglynegativeorpositiveemotionalresponses.
Physiciansshouldbealerttotheirownreactionstosuchpatientsandsituationsandshould
consciouslymonitorandcontroltheirbehaviorsothatthepatient'sbestinterestremainsthe
principalmotivationfortheiractionsatalltimes.

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Atypical"whitecoat"ceremonyinmedicalschoolwherestudentsareintroducedtothe
responsibilitiesofpatientcare.(CourtesyofTheUniversityofTexasHealthScienceCenteratSan
Antonio.)

Animportantaspectofpatientcareinvolvesanappreciationofthepatient's"qualityoflife,"a
subjectiveassessmentofwhateachpatientvaluesmost.Suchanassessmentrequires
detailed,sometimesintimateknowledgeofthepatient,whichcanusuallybeobtainedonly
throughdeliberate,unhurried,andoftenrepeatedconversations.Timepressureswillalways
threatentheseinteractions,buttheyshouldnotdiminishtheimportanceofunderstanding
andseekingtofulfilltheprioritiesofthepatient.

TheTwentyFirstCenturyPhysician:ExpandingFrontiers
THEERAOFGENOMICS
Inthespringof2003,thecompletesequencingofthehumangenomewasannounced,
officiallyusheringinthegenomicera.However,evenbeforethislandmarkaccomplishment,
thepracticeofmedicinehadbeenevolvingasaresultoftheinsightsgainedfroman
understandingofthehumangenomeaswellasthegenomesofawidevarietyofmicrobes,
whosegeneticsequenceswerebecomingwidelyavailableasaresultofthebreathtaking
advancesinsequencingtechniquesandinformatics.Examplesofthelatterincludethe
identificationofanovelcoronavirusastheetiologicagentofthesevereacuterespiratory
syndrome(SARS)andthetrackingoftheevolutionofapotentiallypandemicinfluenzavirus
foundinbirds.Today,geneexpressionprofilesarebeingusedtoguidetherapyandinform
prognosisforanumberofdiseasestheuseofgenotypingisprovidinganewmeanstoassess
theriskofcertaindiseasesaswellasvariationinresponsetoanumberofdrugsweare
understandingbettertheroleofcertaingenesinthecausalityofcertaincommonconditions

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suchasobesityandallergies.Despitetheseadvances,wearestillintheinfancyof
understandingandutilizingthecomplexitiesofgenomicsinthediagnosis,prevention,and
treatmentofdisease.Ourtaskiscomplicatedbythefactthatphenotypesaregenerally
determinednotbygenesalonebutbytheinterplayofgeneticandenvironmentalfactors.
Indeed,wehavejustbeguntoscratchthesurfaceofpossibilitiesthattheeraofgenomicswill
providetothepracticeofmedicine.
Therapidityoftheseadvancesmayseemoverwhelmingtothepracticingphysician.However,
heorshehasanimportantroletoplayinensuringthatthesepowerfultechnologiesand
sourcesofnewinformationareappliedwithsensitivityandintelligencetothepatient.Since
genomicsissucharapidlyevolvingfield,physiciansandotherhealthcareprofessionalsmust
continuetoeducatethemselvessothattheycanapplythisnewknowledgetothebenefitof
theirpatients'healthandwellbeing.Genetictestingrequireswisecounselbasedonan
understandingofthevalueandlimitationsofthetestsaswellastheimplicationsoftheir
resultsforspecificindividuals.Foramorecompletediscussionofgenetictesting,seeChap.
64.

THEGLOBALIZATIONOFMEDICINE
Physiciansshouldbecognizantofdiseasesandhealthcareservicesbeyondlocalboundaries.
Globaltravelhasimplicationsfordiseasespread,anditisnotuncommonfordiseases
endemictocertainregionstobeseeninotherregionsafterapatienthastraveledand
returnedfromtheseregions.Patientshavebroaderaccesstouniqueexpertiseorclinicaltrials
atdistantmedicalcenters,andthecostoftravelmaybeoffsetbythequalityofcareatthese
distantlocations.Asmuchasanyotherfactorinfluencingglobalaspectsofmedicine,the
Internethastransformedthetransferofmedicalinformationthroughouttheworld.This
changehasbeenaccompaniedbythetransferoftechnologicalskillsthroughtelemedicineand
internationalconsultationforradiologicimagesandpathologicspecimens.Foracomplete
discussionofglobalissues,seeChap.2.

MEDICINEONTHEINTERNET
Onthewhole,theInternethashadaverypositiveeffectonthepracticeofmedicineawide
rangeofinformationisavailabletophysiciansandpatientsthroughpersonalcomputers
almostinstantaneouslyatanytimeandfromanywhereintheworld.Thismediumholds
enormouspotentialfordeliveringuptodateinformation,practiceguidelines,stateoftheart
conferences,journalcontents,textbooks(includingthistext),anddirectcommunicationswith
otherphysiciansandspecialists,therebyexpandingthedepthandbreadthofinformation
availabletothephysicianaboutthediagnosisandcareofpatients.Mostmedicaljournalsare
nowaccessibleonline,providingrapidandcomprehensivesourcesofinformation.This
mediumalsoservestolessentheinformationgapfeltbyphysiciansandhealthcareproviders
inremoteareasoftheworldbybringingthemintodirectandinstantcontactwiththelatest
developmentsinmedicalcare.
Patients,too,areturningtotheInternetinincreasingnumberstoacquireinformationabout
theirillnessesandtherapiesandtojoinInternetbasedsupportgroups.Physiciansare
increasinglyfacedwiththeprospectofdealingwithpatientswhoarrivewithsophisticated
informationabouttheirillness.Inthisregard,physiciansarechallengedinapositivewayto

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keepthemselvesabreastofthelatestrelevantinformationwhileservingasan"editor"forthe
patientsastheynavigatethroughthisseeminglyendlesssourceofinformation.
AcriticallyimportantcaveatisthatvirtuallyanythingcanbepublishedontheInternet,with
easycircumventionofthepeerreviewprocessthatisanessentialfeatureofquality
publications.PhysiciansorpatientswhosearchtheInternetformedicalinformationmustbe
awareofthisdanger.Notwithstandingthislimitation,appropriateuseoftheInternetis
revolutionizinginformationaccessforphysiciansandpatientsandinthisregardisagreat
benefitthatwasnotavailabletoourpredecessors.

PUBLICEXPECTATIONSANDACCOUNTABILITY
Thelevelofknowledgeandsophisticationregardinghealthissuesonthepartofthegeneral
publichasgrownrapidlyoverthepastfewdecades.Asaresult,expectationsofthehealth
caresystemingeneralandofphysiciansinparticularhaverisen.Physiciansareexpectedto
masterrapidlyadvancingfields(thescienceofmedicine)whileconsideringtheirpatients'
uniqueneeds(theartofmedicine).Thus,physiciansareheldaccountablenotonlyforthe
technicalaspectsofthecarethattheyprovidebutalsofortheirpatients'satisfactionwiththe
deliveryandcostsofcare.
Inmanypartsoftheworld,physiciansareincreasinglyexpectedtoaccountforthewayin
whichtheypracticemedicinebymeetingcertainstandardsprescribedbyfederalandlocal
governments.Thehospitalizationofpatientswhosehealthcarecostsarereimbursedbythe
governmentandotherthirdpartiesissubjectedtoutilizationreview.Thus,thephysician
mustdefendthecauseforanddurationofapatient'shospitalizationifitfallsoutsidecertain
"average"standards.Authorizationforreimbursementisincreasinglybasedondocumentation
ofthenatureandcomplexityofanillness,asreflectedbyrecordedelementsofthehistory
andphysicalexamination.Thereisagrowing"payforperformance"movement,whichseeks
tolinkreimbursementtoqualityofcare.Thegoalofthismovementistoimprovestandards
ofhealthcareandtocontainspiralinghealthcarecosts.Physiciansarealsoexpectedtogive
evidenceoftheircontinuingcompetencethroughmandatorycontinuingeducation,patient
recordaudits,maintenanceofcertification,orrelicensing.

MEDICALETHICSANDNEWTECHNOLOGIES
Therapidpaceoftechnologicaladvanceshasprofoundimplicationsformedicalapplications
farbeyondtheirtraditionalrolestoprevent,treat,andcuredisease.Cloning,genetic
engineering,genetherapy,humancomputerinterfaces,nanotechnology,anddesignerdrugs
havethepotentialtomodifyinheritedpredispositionstodisease,selectdesiredcharacteristics
inembryos,augment"normal"humanperformance,replacefailingtissues,andsubstantially
prolonglifespan.Becauseoftheiruniquetraining,physicianshavearesponsibilitytohelp
shapethedebateconcerningtheappropriateusesof,andlimitsthatshouldbeplacedon,
thesenewtechniques.

THEPHYSICIANASPERPETUALSTUDENT
Itbecomesalltooapparentfromthetimewegraduatefrommedicalschoolthatasphysicians
ourlotisthatofthe"perpetualstudent"andthemosaicofourknowledgeandexperiencesis
eternallyunfinished.Thisconceptcanbeatthesametimeexhilaratingandanxiety

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provoking.Itisexhilaratingbecausewewillcontinuetoexpandourknowledgethatcanbe
appliedtoourpatientsitisanxietyprovokingbecausewerealizethatwewillneverknowas
muchaswewantorneedtoknow.Atbest,wewilltranslatethislatterfeelingintoenergyto
continuetoimproveourselvesandrealizeourpotentialasphysicians.Inthisregard,itisthe
responsibilityofaphysiciantopursuenewknowledgecontinuallybyreading,attending
conferencesandcourses,andconsultingcolleaguesandtheInternet.Thisisoftenadifficult
taskforabusypractitionerhowever,suchacommitmenttocontinuedlearningisanintegral
partofbeingaphysicianandmustbegiventhehighestpriority.

RESEARCH,TEACHING,ANDTHEPRACTICEOFMEDICINE
ThetitledoctorisderivedfromtheLatindocere,"toteach,"andphysiciansshouldshare
informationandmedicalknowledgewithcolleagues,withstudentsofmedicineandrelated
professions,andwiththeirpatients.Thepracticeofmedicineisdependentonthesumtotalof
medicalknowledge,whichinturnisbasedonanunendingchainofscientificdiscovery,
clinicalobservation,analysis,andinterpretation.Advancesinmedicinedependonthe
acquisitionofnewinformationthroughresearch,andimprovedmedicalcarerequiresthe
transmissionofthisinformation.Aspartofbroadersocietalresponsibilities,thephysician
shouldencouragepatientstoparticipateinethicalandproperlyapprovedclinical
investigationsiftheydonotimposeunduehazard,discomfort,orinconvenience.Ontheother
hand,physiciansengagedinclinicalresearchmustbealerttopotentialconflictsofinterest
betweentheirresearchgoalsandtheirobligationstoindividualpatientsthebestinterestsof
thepatientmustalwaystakepriority.
Towrestfromnaturethesecretswhichhaveperplexedphilosophersinallages,to
tracktotheirsourcesthecausesofdisease,tocorrelatethevaststoresof
knowledge,thattheymaybequicklyavailableforthepreventionandcureof
diseasetheseareourambitions.
WilliamOsler,18491919

FurtherReadings
BlankLetal:Medicalprofessionalisminthenewmillennium:Aphysiciancharter15months
later.AnnInternMed138:839,2003[PMID:12755556]
CouncilonGraduateMedicalEducation:ThirteenthReport:PhysicianEducationfora
ChangingHealthCareEnvironment.USDepartmentofHealthandHumanServices,March
1999
GuttmacherAE,CollinsFS:Welcometothegenomicera.NEnglJMed349:996,2003[PMID:
12954750]
LudmererKM,JohnsMME:Reforminggraduatemedicaleduction.JAMA294:1083,2005
[PMID:16145029]
StrausSEetal:Teachingevidencebasedmedicineskillscanchangepracticeinacommunity
hospital.JGenInternMed20:340,2005[PMID:15857491]

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