Doctors Profession: Introduction

Djoko Wahono Soeatmadji

To greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding. . . . Tact, sympathy, and understanding are expected of the physician, for 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 Doctor for the 21st Century

The Issues - The Wider Context - Emerging Challenges - The Responses of Medical Education - The Direction of Reform

The World Summit on Medical Education, Edinburg 8 12 August 1993

The doctor of the 21st century must be redesign !!!

The Doctor for the 21st Century

1.

2. 3. 4. 5. 6. 7. 8.

9. 10.

Promote health, prevent and treat disease, and rehabilitate the disable (in a compassionate, ethical way), within resources constrain) Providers of primary care Communicators Critical thinkers Motivated life-long learners Information specialist Citizen of the World Practitionars of applied economics, sociology, anthropology, epidemiology and behavioural medicine Health team managers Advocate for communities
The World Summit on Medical Education, Edinburg 8 12 August 1993

DOCTOR = DOCERE = to teach"

. physicians should share information and medical knowledge with colleagues, with students of medicine and related professions, and with their patients

Ethical medicine strives to do good and to do no harm The medical profession must fullfill its social contract better

Social and Ethical Issues in Medicine

Approach to Medicine, the Patient, and the Medical Profession (Medicine as a learned and humane profession) Bioethics in the Practice of Medicine Care of Dying patients and Their Familes Social and Economic Issues in Medicine

APPROACH TO THE MEDICINE: Medicine as a learned and humane profession

What is Expected of the Physician ?

The practice of medicine combines both science and art Science base technology Deductive reasoning Knowledge of he patient, mutual trust and ability to communicate with patient

Advances in: genetics biochemistry imaging technology laboratory technology therapeutic maneuvers and modalities

Does not make a Good Physician

A good physician has the combination of :

Medical knowledge Intuition Judgement

Medicine is a profession that incorporates science and the scientific methode with the art of being a physician.

The art of caring and comforting, guided by millenia of common sense as well as systemic approach to medical ethics remain the cornerstone of medicine.

The essential humanistic qualities of caring and comforting can achieve a little if they are not coupled with understanding of how

medical science can and should be applied to patients

Care givers of ancient times and premodern cultures..Some of their potions contained what are known to be active ingredients that form the basis for proven medications.. Modern medicine should not dismiss the possibility that this unproven approach may be helpful, but should adopt a guiding principles that all interventions (traditional or newly developed) can be tested, with the expectation that any beneficial effects can be explored further to determine their scientific basis..

Internal Medicine (Inneren Medizin):

Emphasized the physiology and chemistry of disease; not just the pattern or progression of clinical manifestation.

.. The scientific basis of medicine is remarkebly recent compared with its long and generally distinguished of caring and comforting patients
Hospitalism referred not to expertise in hospital care, but rather to the aggregate of iatrogenic affections that were induced by hospital itself.

Modern medicine has moved rapidly past organ physiology to an increasingly detailed understanding of cellular, sucellular, and genetic mechanism. Health, disesase, and individuals interaction with environment are also determined substantially by genetics

Methods for evaluation the application of scientific advances to the individual patients and to populations

The randomized controlled trial sometimes with thousands patients at multiple institutions, has replaced anecdote as the preferred methode for measuring the benefits and uses of diagnostic or trherapeutic intervention

Principles of Patient Care

Principles of Patient Care Practice Guidelines Medical Decision-Making Evaluation of Outcomes

APPROACH TO THE PATIENT

Patients commonly present with complaints (symptoms), these symptoms, may or may not be accompanied by abnormalities on exam (signs) or on laboratory testing
Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symtoms or signs

Illness & Disease

Tailoring
The patients-physician interaction proceeds through many phases of clinical reasoning and decision making The approach to diagnosis and therapy should not be equated with cookbook medicine

To care for patients as an individual, the physician must understand the patient

as a person (human)

APPROACH TO The MEDICAL PROFESSION

In a profession, the practitioner puts the welfare of the client or patient above his or her own welfare..

Professional Responsibilities:
Commitment to

Professional competence Honesty with patients Patients confidentiality Maintain appropriate relations with patients Improving the quality of care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflict of interest Professional responsibility
Brennan T et al. Ann Intern Med 2002; 1136: 243-246

The explosion in medical knowledge has led to increasing specialization, defined initially by organ system and more recently by locus of principal activity (inpatient vs outpatient)

The changing medical care environment places increasing emphasis on standards, outcomes,

and accountability..

Clinical guidelines and critical pathways derived from randomized controlled trial and evidence-based medicine potentially can lead to more cost-effective and

better outcomes

A health insurance system emphasizes costeffective care, gives physicians and health care providers responsibility for the health of population and the resources required to achieve these goals, must exist in a competitive environment in which patients can choose alternatives if they are not satisfied with their care.

The physicians responsibility to represent the patient best interest and avoid financial conflicts . If the limitting of options is based overhelmingly on cost rather than on measures on quality, outcomes, and patient satifaction it is likely that the historic relationship between the patient and the truly profesional physician will be fundamentally compromised

In the current health care environment, all physicians and trainees must redouble their commitment to professionalism

BIOETHICS IN PRACTICE OF MEDICINE

Modern advances in medical technology, antibiotics, dialysis, transplantation, and intensive careunits have created the bioethical dilemmas that confront the physicians in the 21st century

Patients-Physician Relationship

Whatever the patients attitude ideally should be based on thorough knowledge of the patients, mutual trust, and ability to communicate with one another

Patients as individuals whose problems transcend their complaint Patient(s) is not just a case(s) or disease(s) The duty of patients principal physician is to guide them through illness

The ideal patient-physician relationship should be based on thorough knowledge of the patient, mutual trust and ability to communicate with patient

Qualtity of clinician interest in humanity

Informed Consent

Fundamental Elements For Disclosure To Patients

Diagnosis and prognosis Nature of proposed intervention Reseonable alternative intervention Risk associated with each alternative intervention Benefits associated with each alternative intervention Probable outcomes of each alternative intervention

Terminating Medical Intervention ?

Assisted Suicide and Euthanasia ?

Care of Dying patients

Care of Dying patients :

Is the patient comfortable (Pain and symptom control ? All that hurts ?) Shared decision making (What is a good death ?) Are the psychosocial and spiritual concerns of the patients and family being address (Psychosocial and spiritual support) ? Whre does the patient prefer to receive care ?

Common Symptoms in Seriously Ill Hospitalized Patients (% 0f Total Patients)

At any time
Pain Dyspneu Anxiety Depression Nausea 51 49 47 45 34

Severe and Frequent

23 23 16 14 6

Desbiens NA et al. J pain Manage 1999;17:248-255

Patients Perspective on A Good Death

Control pain and other symptoms Avoid inappropriate prolongation of dying when life no longer enjoyable Relieve burden on the family Achieve a sense of control Strenghten relationships with loved ones
Singer PA et al. JAMA 1999; 218:163 - 168

Shared bad news ?

Palliative Care
Approaches to providing comfort for dying persons without necessarily modifying the underlying medical condition

Medical Ethics

Six of the values that commonly apply to medical ethics discussions are:
1. 2. 3.

4.

5. 6.

Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) Non-maleficence - "first, do no harm" (primum non nocere). Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.) Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality). Dignity - the patient (and the person treating the patient) have the right to dignity. Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study.

Beneficence vs Autonomy

Professional Responsibility Violations (in general)

Conflicts of interest Mishandling of client Disclosure of confidential information

Experience, common sense, and simply being a good person do not guarantee that physicians can identify or resolve ethical dilemmas

SOCIAL AND ECONOMIC ISSUES IN MEDICINE

Medicine is practiced in a social, economic, and political context
It takes more than excellent medical care to improve the health of the patients Many of the determinants of the health of individuals and populations lie outside traditional clinical activity

Economic Considerations in the Practice of Medicine

 health is a political issue and those enjoying care do not want to share it ..
Both in the underdeveloped and the developed world the medical contribution is largely inappropriate to health need and does not cope with helth problems of the vast majority
gap between health care and medical care has become even wider
Most illness has its origins in social condition

A safe water supply makes a major contribution to health

the success stories of better health in underdeveloped countries have had more to do with
Adequate nutrition as a prerequisite for health

changed economic and political systems and improved nutrition, water provision, and sanitation than with
technological modern medicine
Agriculter and health are two closely related factors Environmental condition have major impact in health

Appropriate to needs

Accessible

Afordable

Conflict of Interest

Hippocratic Oath
A Twelfth-century Byzantine manuscript of the Oath

Hipocrates Oath I swear by Apollo, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath

Doctor Patient Relationship

Empathy

Sympathy

Enemy

Various Interests

Medical Nursing Owners Investors Patients/Family Insurance Pharmaceutical Industry

Government Medical Education Medical Profession Lawyer Etc

Bargaining / Conflict

Thank you for your attention

Batu, July 1, 2006

To greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding. . . . Tact, sympathy, and understanding are expected of the physician, for 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