MEDICINE AS A LEARNED AND HUMANE PROFESSION

1. MEDICINE AS A LEARNED AND HUMANE PROFESSION Dr. László Kalabay Department of Family Medicine Semmelweis University

2. What is medical profession? • more than just a profession, • a „call”

3. The attributes of medical profession • Scientific • Personal • Humanistic • Professional • Artistic

4. The physician as a scientist Physicians must be trained as scientists to: • understand and apply the thinking patterns of the scientific method • to develop an inquiring mind • to know how to design experiments and obtain data • how to analyze the validity and generalizibility of those data • to ask questions and provide truthful answers

5. Most of these learned skills extend to the management of individual cases at the bedside, i.e. • how to gather information • how to synthesize it • how to interpret it to make a full diagnostic story • how to bring the collective wisdom together in the design and execution of appropriate therapy.

6. The central tenet is:„Could my conclusion be wrong?” Scientific rigors provide the physician with: • learning skills • process of analysis, that is indispensable for dealing with individual patients • opportunity to contribute to medical progress and improvement of care

7. The effect of explosion of medical knowledge: increased specialization and subspecialization as • organ system (cardiology, pulmonology, etc.) • locus of principal activity (inpatient, outpatient) • reliance on manual skills (proceduralist or nonproceduralist) • participation in research BUT • the same molecular and genetic mechanisms are broadly applicable across all organ systems • scientific methodologies of randomized trials and careful clinical observation span all aspects of medicine • need for large-scale testing of procedures, interventions, vaccines, and new drugs: multicenter approach provide opportunity to participate in clinical investigations

8. The clinical reasoning and decision making as scientific aspects of the patient-physician interaction • elucidation of complaints or concerns • inquiries or evaluation to address these concerns in increasingly precise ways • careful history or physical examination • ordering diagnostic tests • integration of clinical findings with the test results • understanding the risks and benefits of the possible courses of action • careful consultation with the patient and family to develop future plans evidence based medicine and new scientific information are needed to solve these issues CONTINUOUS QUALITY IMPROVEMENT

9. The physician as caregiver 1 • When patients week medical attention, they entrust their doctors with their very lives • The physician must earn such a complete trust • Technical abilities and skilled treatment of disease alone do not suffice

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. The physician as caregiver 2 Being sensitive or insensitive to patients • „Does my physician really care?” • „Does what happens to me matter to the physician?” • „Does my doctor show sensitivity and compassion beyond mere technical ability?” Being both professional and caring is an acquired skill

12. „The humility that comes from others having faith in you” (Dag Hammarskjöld)

13. The physician must be willing to • answer the patient’s needs • undertake a long-term commitment to the patient’s care

14. The patients still needs care • when data come back from the clinical laboratory, the radiology department, the cardiac catheterization laboratory, or the surgical pathology laboratory. • to understand their disease • dealing with family interactions, • to find a caring ear when they suffer most • assistance in obtaining necessary additional medical help from specialists or consultants • in processes involving personal situations (esp. when becoming old, frail, dependent, crippled, cognitively impaired)

15. The physician as a professional 1 Definition: Professionalism in internal medicine comprises those attributes and behaviors that serve to maintain the interest of the patient above one’s self-interest. • A commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge. • A commitment to the attitudes and behaviors that sustain the interest and welfare of patients. • 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.

16. The physician as a professional 2 • The interest of the patient lies above self-interest • To remain professionals, dignity, and understanding must permeate all our interactions –all our thinking, teaching, learning, and listening

17. Patient-centeredness makes medicine as an art Sometimes it is more important who has the disease than the disease itself”

18. Systems of patients care beyond the millennium The evolving changes in the health care delivery system unavoidably affect the perceived historical independence of thought and action Financing of health care has become the key issue • Aging of population • Decreasing number of active workers • Sheer mass of GDP spent on health care • Increasing costs ascribed to technology and professional subspecialization • Patient care in the mass is becoming a big business • Insurers – „covered lives” (patients) • Implementation of guidelines in order to increase cost-effectiveness No country seems to be fully satisfied with its health care system, and experimentation abounds

19. The physician has now a dual responsibility to • 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 • the individual patients who entrust their well-being to that physician to promote their best interests within the reasonable limits of the system

20. Reform of national health systems • Changes in: demography; medical advances; health economics; patient needs and expectations • International evidences indicate: health systems based on effective primary care with highly trained generalist physicians provide both more cost and clinically effective care • Ever increasing importance of FM/GP

21. INTRODUCTION TO FAMILY MEDICINE / GENERAL PRACTICE

22. The ecology of medical care revisited(Green, 2001)

23. Levels of Health Care Primary care physician • A physician from whatever discipline working in a primary care setting Secondary care physician • 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 Specialist • A physician from whatever discipline who has undergone a higher postgraduate training

24. Basic definitions in general medicine General Practitioner / Family Doctor • 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. General Practice / Family Medicine • An academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty oriented to primary care.

25. The History of Family Medicine • General Practitioner, Family Doctor, medicus universalis • Should there be a doctor, who is readily available, knows and is responsible for everything • I addition is a close friend • The image of the „benevolent good old doctor”

26. Percent of American Physicians in practice as General Practitioners, 1930-1970

27. General Practice – An Initial Approach • Essential part of medical care in all countries. • The GP is the first point of contact for most medical services. • Wide range of consultations and home visits. • GPs provide a complete spectrum of care within the local community – education, prevention, treatment. • No other specialty offers such a wide remit of treating everything from babies and from mental illnesses to sports medicine. • The opportunity of prevention is given only at the level of GP. • Most GPs are independent contractors of the national health system.

28. The Main Characteristics of Family Medicine

29. „Old” and „new” models of general practice

30. The interrelated competence framework

31. Something about learning new skills, acquiring and applying knowledge!

32. GMC for GPs - Good Clinical Care 1

33. GMP for GPs - Good Clinical Care 2

34. GMC for GPs – Keeping Records and Keeping Colleagues Informed

35. GMC for GPs – Access, Availability and Providing Care Out of Hours

36. GMC for GPs – Relationship with Patients, Avoiding Discrimination 1

37. GMC for GPs – Relationship with Patients, Avoiding Discrimination 2

38. GMC for GPs – Working with Colleagues, with Practice Team and Referrals 1

39. GMC for GPs – Working with Colleagues, with Practice Team and Referrals 2

40. Give me a doctor … 1 Give me a doctor, partridge plump Short in the leg and broad in the rump An endomorph with gentle hands Who’ll never make absurd demands That I abandon all my vices, Nor pull a long face in a crisis, But with a twinkle in his eye Will tell me that I have to die. WH Auden

41. Give me a doctor (?) … 2 Give me a doctor, underweight, Computerized and up-to-date, A businessman who understands Accountancy and target bands, Who demonstrates sincere devotion To audit and health promotion - But when my outlook’s for the worse Refers me to the Practice Nurse. Marie Campkin