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The modern practice of medicine occurs at the many interfaces between the art of healing and various sciences. Medicine is directly connected to the health sciences and biomedicine. Broadly speaking, the term 'Medicine' today refers to the fields of clinical medicine, medical research and surgery, thereby covering the challenges of disease and injury.
History of medicine
The earliest type of medicine in most cultures was the use of empirical natural resources like plants (herbalism, animal parts and minerals. In all societies, even in Western ones, there were also religious, ritual and magical resources. In aboriginal societies, there is a large scope of medical systems related to religious thinking, cultural experience, and natural resources. The religious ones more known are : animism (the notion of inanimate objects having spirits); spiritualism (here meaning an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (the supposed obtaining of truth by magic means). The field of medical anthropology studies the various medical systems and their interaction with society.
The practice of medicine developed gradually in ancient Egypt, Babylonia, India, China, Greece, Persia, the Islamic world, medieval Europe, and elsewhere. Medicine as it is now practiced largely developed during the Middle Ages and early modern period in Persia (Rhazes and Avicenna), Spain (Abulcasis and Avenzoar), Syria/Egypt (Ibn al-Nafis, 13th century), England (William Harvey, 17th century), Germany (Rudolf Virchow, 19th century) and France (Jean-Martin Charcot, Claude Bernard and others). The new "scientific" or "experimental" medicine (where results are testable and repeatable) replaced early Western traditions of medicine, based on herbalism, the Greek "four humours" and other pre-modern theories.
The focal points of development of clinical medicine shifted to the United Kingdom and the USA by the early 1900s (Canadian-born) Sir William Osler, Harvey Cushing). Possibly the major shift in medical thinking was the gradual rejection in the 1400s during the Black Death of what may be called the 'traditional authority' approach to science and medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, and anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general - see Copernicus's rejection of Ptolemy's theories on astronomy). People like Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past such as Galen, Hippocrates, and Avicenna/Ibn Sina, all of whose theories were in time almost totally discredited. Such new attitudes were also only made possible by the weakening of the Roman Catholic church's power in society, especially in the Republic of Venice.
Evidence-based medicine is a recent movement to establish the most effective algorithms of practice (ways of doing things) through the use of the scientific method and modern global information science by collating all the evidence and developing standard protocols which are then disseminated to healthcare providers. One problem with this 'best practice' approach is that it could be seen to stifle novel approaches to treatment. Genomics and knowledge of human genetics is already having some influence on medicine, as the causative genes of most monogenic genetic disorders have now been identified, and the development of techniques in molecular biology and genetics are influencing medical practice and decision-making.
Pharmacology has developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). The modern era began with Robert Koch's discoveries around 1880 of the transmission of disease by bacteria, and then the discovery of antibiotics shortly thereafter around 1900. The first of these was arsphenamine / Salvarsan discovered by Paul Ehrlich in 1908 after he observed that bacteria took up toxic dyes that human cells did not. The first major class of antibiotics was the sulfa drugs, derived by French chemists originally from azo dyes. Throughout the twentieth century, major advances in the treatment of infectious diseases were observable in (Western) societies. The medical establishment is now developing drugs targeted towards one particular disease process. Thus drugs are being developed to minimise the side effects of prescribed drugs, to treat cancer, geriatric problems, long-term problems (such as high cholesterol), chronic diseases type 2 diabetes, lifestyle and degenerative diseases such as arthritis and Alzheimer's disease.
Practice of medicine
The practice of medicine combines both science as the evidence base and art in the application of this medical knowledge in combination with intuition and clinical judgment to determine the treatment plan for each patient.
Central to medicine is the patient-physician relationship established when a person with a health concern seeks a physician's help; the 'medical encounter'. Other health professionals similarly establish a relationship with a patient and may perform various interventions, e.g. nurses, radiographers and therapists.
As part of the medical encounter, the healthcare provider needs to:
Health care delivery systems
Medicine is practiced within the medical system, which is a legal, credentialing and financing framework, established by a particular culture or government. The characteristics of a health care system have significant effect on the way medical care is delivered.
Financing has a great influence as it defines who pays the costs. Aside from tribal cultures, the most significant divide in developed countries is between universal health care and market-based health care (such as practiced in the U.S.). Universal health care might allow or ban a parallel private market. The latter is described as single-payer system.
Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality and pricing greatly affects the choice by patients / consumers and therefore the incentives of medical professionals. While US health care system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.
Health care delivery
Medical care delivery is classified into primary, secondary and tertiary care.
Primary care medical services are provided by physicians or other health professionals who have first contact with a patient seeking medical treatment or care. These occur in physician offices, clinics, nursing homes, schools, home visits and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes.
Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.
Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.
Modern medical care also depends on information - still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.
This kind of relationship and interaction is a central process in the practice of medicine. There are many perspectives from which to understand and describe it.
An idealized physician's perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning the patient's symptoms, concerns and values; in response the physician examines the patient, interprets the symptoms, and formulates a diagnosis to explain the symptoms and their cause to the patient and to propose a treatment. The job of a physician is similar to a human biologist: that is, to know the human frame and situation in terms of normality. Once the physician knows what is normal and can measure the patient against those norms, he or she can then determine the particular departure from the normal and the degree of departure. This is called the diagnosis.
The four great cornerstones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy and physiology) and psychology (mind and behavior). In addition, the physician should consider the patient in their 'well' context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient's condition and further management. In more detail, the patient presents a set of complaints (the symptoms) to the physician, who then obtains further information about the patient's symptoms, previous state of health, living conditions, and so forth. The physician then makes a review of systems (ROS) or systems inquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination; the findings are recorded, leading to a list of possible diagnoses. These will be in order of probability. The next task is to enlist the patient's agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the healthcare provider educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant "teacher" in Latin. The patient-physician relationship is additionally complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his/her own. The physician's expertise comes from his knowledge of what is healthy and normal contrasted with knowledge and experience of other people who have suffered similar symptoms (unhealthy and abnormal), and the proven ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge.
The physician-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.
The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of healthcare providers and patients in many ways.
The quality of the patient-physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another doctor.
In some settings, e.g. the hospital ward, the patient-physician relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.
A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and a treatment plan.
The components of the medical history are:
The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'Signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:
The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.
The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.
This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.
On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.
Branches of medicine
Working together as an interdisciplinary team, many highly trained health profession also besides medical practitioners are involved in the delivery of modern health care. Some examples include: nurse(s) emergency medical technicians and paramedics, laboratory scientists, (pharmacy, pharmacists), (physiotherapy,physiotherapists), respiratory therapists, speech therapists, occupational therapists, radiographers, dietitians and bioengineers.
The scope and sciences underpinning human medicine overlap many other fields. Dentistry and psychology, while separate disciplines from medicine, are considered medical fields.
A patient admitted to hospital is usually under the care of a specific team based on their main presenting problem, eg the Cardiology team, who then may interact with other specialties, eg surgical, radiology, to help diagnose or treat the main problem or any subsequent complications/ developments.
Physicians have many specializations and subspecializations into certain branches of medicine, which are listed below. There are variations from country to country regarding which specialties certain subspecialties are in.
The main branches of medicine used in Wikipedia are:
In the broadest meaning of 'medicine', there are many different specialties, which additionally have many sub-specialties. However, within medical circles, medicine usually denotes doctors that specialise in one internal medicine specialties, as opposed to surgery or radiology. The various specialties can be categorised thus:
It has many subspecialties, e.g. general surgery, cardiovascular surgery, maxillofacial surgery, orthopedic surgery, otolaryngology, plastic surgery, oncologic surgery, vascular surgery and pediatric surgery.
In some centres, anesthesiology is part of the division of surgery (for logistical and planning purposes), although it certainly is not a surgical discipline.
Following are some selected fields of medical specialties that don't directly fit into any of the above mentioned groups.
Interdisciplinary sub-specialties of medicine are:
Medical education is education connected to the practice of being a medical practitioner, either the initial training to become a physician or further training thereafter.
Medical education and training varies considerably across the world, however typically involves entry level education at a university medical school, followed by a period of supervised practice (Internship and/or Residency) and possibly postgraduate vocational training. Continuing medical education is a requirement of many regulatory authorities.
Various teaching methodologies have been utilised in medical education, which is an active area of educational research.
Presently, in England, a typical medicine course at university is 5 years (4 if the student already holds a degree). Amongst some institutions and for some students, it may be 6 years (including the selection of an intercalated BSc - taking one year - at some point after the pre-clinical studies). This is followed by 2 Foundation years afterwards, namely F1 and F2. Students register with the UK General Medical Council at the end of F1. At the end of F2, they may pursue further years of study.
In the US and Canada, a potential medical student must first complete an undergraduate degree in any subject before applying to a graduate medical school to pursue an (M.D.) program. Some students opt for the research-focused MD/PhD dual degree, which is usually completed it 7-8 years.
In Australia, students have two options. They can choose to take an accelerated six-year undergraduate Bachelor of Medicine/Bachelor of Surgery (MBBS) straight from high school, or complete a bachelors degree (usually in the medical sciences) and then apply for a four year graduate entry Bachelor of Medicine/Bachelor of Surgery (MBBS) program.
In most countries, it is a legal requirement for a medical doctor to be licensed or registered. In general, this entails a medical degree from a university and accreditation by a medical board or an equivalent national organization, which may ask the applicant to pass exams. This restricts the considerable legal authority of the medical profession to physicians that are trained and qualified by national standards. It is also intended as an assurance to patients and as a safeguard against charlatans that practice inadequate medicine for personal gain. While the laws generally require medical doctors to be trained in "evidence based", Western, or Hippocratic Medicine, they are not intended to discourage different paradigms of health.
Criticism of medicine has a long history. In the Middle Ages, some people did not consider it a profession suitable for Christians, as disease was often considered God-sent. God was considered to be the 'divine physician' who sent illness or healing depending on his will. However, many monastic orders, particularly the Benedictines, considered the care of the sick as their chief work of mercy. Barber-surgeons generally had a bad reputation that was not to improve until the development of academic surgery as a speciality of medicine, rather than an accessory field.
Through the course of the twentieth century, healthcare providers focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. The ensuing development of a more mechanistic, detached practice, with the perception of an attendant loss of patient-focused care, known as the medical model of health, led to further criticisms. This issue started to reach collective professional consciousness in the 1970s and the profession had begun to respond by the 1980s and 1990s.
The noted anarchist Ivan Illich heavily criticized modern medicine. In his 1976 work Medical Nemesis, Illich stated that modern medicine only medicalises disease and causes loss of health and wellness, while generally failing to restore health by eliminating disease. This medicalisation of disease forces the human to become a lifelong patient. Other less radical philosophers have voiced similar views, but none were as virulent as Illich. Another example can be found in Technopoly: The Surrender of Culture to Technology by Neil Postman, 1992, which criticises overreliance on technological means in medicine.
Criticism of modern medicine has led to some improvements in the curricula of medical schools, which now teach students systematically on medical ethics, holistic approaches to medicine, the biopsychosocial model and similar concepts.
The inability of modern medicine to properly address some common complaints continues to prompt many people to seek support from alternative medicine. Although most alternative approaches lack scientific validation, some may be effective in individual cases. Some physicians combine alternative medicine with orthodox approaches.
Medical errors and overmedication are also the focus of many complaints and negative coverage. Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety, where it was long ago realized that it is dangerous to place too much responsibility on one "superhuman" individual and expect him or her not to make errors. Reporting systems and checking mechanisms are becoming more common in identifying sources of error and improving practice.
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Medicine". A list of authors is available in Wikipedia.|