MEDICINE
History
Physician treating a patient. Louvre Museum, Paris, France.
Prehistoric medicine incorporated plants (herbalism), animal parts and minerals. In many cases these materials were used ritually as magical substances by priests, shamans, or medicine men. Well-known spiritual systems include animism (the notion of inanimate objects having spirits), spiritualism (an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (magically obtaining the truth). The field of medical anthropology studies the various prehistoric medical systems and their interaction with society.
Early records on medicine have been discovered from early Ayurvedic medicine in the Indian subcontinent, ancient Egyptian medicine, traditional Chinese medicine, the Americas, and ancient Greek medicine. Early Grecian doctors Hippocrates, who is also called the Father of Modern Medicine,[4][5] and Galen laid a foundation for later developments in a rational approach to medicine. After the fall of Rome and the onset of the Dark Ages, Islamic physicians made major medical breakthroughs, supported by the translation of Hippocrates' and Galen's works into Arabic. Notable Islamic medical pioneers include polymath Avicenna, who is also called the Father of Modern Medicine,[6][7] Abulcasis, the father of surgery, Avenzoar, the father of experimental surgery, Ibn al-Nafis, the father of circulatory physiology, and Averroes.[8] Rhazes, who is called the father of pediatrics, first disproved the Grecian theory of humorism, which nevertheless remained influential in Western medieval medicine. While major developments in medicine were occurring in the Islamic world during the medieval period, the Western world remained dependent upon the Greco-Roman theory of humorism, which led to questionable treatments such as bloodletting. Islamic medicine and medieval medicine collided during the crusades, with Islamic doctors receiving mixed impressions.[9] As the medieval ages ended, important early figures in medicine emerged in Europe, including Gabriele Falloppio and William Harvey.
The Sumerian god Ningizzida was the patron of medicine. In the image he is accompanied by two gryphons. A similar image with two snakes coiling around a rod is called the Caduceus and, although historically inappropriate, appears in the logo/emblem of a significant number of private (rather than professional or academic) medical practices.
The focal points of development of clinical medicine shifted to the United Kingdom and the USA by the early 1900s. The major shift in medical thinking was the gradual rejection, especially during the Black Death in the 14th and 15th centuries, 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). Physicians like Ibn al-Nafis and Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past (such as Hippocrates, and Galen), many of whose theories were in time discredited.
During the Islamic Golden Age, the Persian scientist Avicenna introduced experimental medicine, discovered contagious diseases, introduced quarantine and clinical trials, and described many anaesthetics and medical and therapeutic drugs, in The Canon of Medicine. He was later to be given the title of the Father of Modern Medicine.
The modern scientific biomedical research (where results are testable and reproducible) began to replace early Western traditions of medicine, based on herbalism, the Greek "four humours" and other premodern theories. 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 post-18th century modernity period brought more groundbreaking researchers from Europe. From Germany and Austrian doctors such as Rudolf Virchow, Wilhelm Conrad Röntgen, Karl Landsteiner, and Otto Loewi) made contributions. In the United Kingdom Alexander Fleming, Joseph Lister, Francis Crick, and Florence Nightingale are considered important. From New Zealand and Australia came Maurice Wilkins, Howard Floery, and Frank Macfarlane Burnet). In the United States William Williams Keen, Harvey Cushing, William Coley, James D. Watson, Italy (Salvador Luria), Switzerland (Alexandre Yersin), Japan (Kitasato Shibasaburo), and France (Jean-Martin Charcot, Claude Bernard, Paul Broca and others did significant work. Russian (Nikolai Korotkov also did significant work, as did Sir William Osler and Harvey Cushing.
Drug ampoules
As science and technology developed, medicine became more reliant upon medications. Pharmacology developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). 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. Vaccines were discovered by Edward Jenner and Louis Pasteur. The first major class of antibiotics was the sulfa drugs, derived by French chemists originally from azo dyes. This has become increasingly sophisticated; modern biotechnology allows drugs targeted towards specific physiological processes to be developed, sometimes designed for compatibility with the body to reduce side-effects. Genomics and knowledge of human genetics is 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 technology, practice and decision-making.
Evidence-based medicine is a contemporary movement to establish the most effective algorithms of practice (ways of doing things) through the use of systematic reviews and meta-analysis. The movement is facilitated by the modern global information science, which allows all evidence to be collected and analyzed according to 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. The Cochrane Collaboration leads this movement. A 2001 review of 160 Cochrane systematic reviews revealed that, according to two readers, 21.3% of the reviews concluded insufficient evidence, 20% concluded evidence of no effect, and 22.5% concluded positive effect.[10]
Practice
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 individual 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:
develop a relationship with the patient
gather data (medical history, systems inquiry, and physical examination, combined with laboratory or imaging studies (investigations))
analyze and synthesize that data (assessment and/or differential diagnoses), and then:
develop a treatment plan (further testing, therapy, watchful observation, referral and follow-up)
treat the patient accordingly
assess the progress of treatment and alter the plan as necessary (management).
The medical encounter is documented in a medical record, which is a legal document in many jurisdictions.[11]
[edit] 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.
All wealthy, industrialized countries (except for the United States),[12][13] and many developing countries deliver health care though a system of universal health care which guarantees care for all through a system of compulsory private or co-operative health insurance funds or via government-backed social insurance. This insurance (in effect, a form of taxation) ensures that the entire population has access to medical care on the basis of need rather than ability to pay. The delivery systems may be provided by private medical practices or by state-owned hospitals and clinics, or by charities.
Most tribal societies but also some communist countries (e.g. China) and one industrialized capitalist country (the United States),[12][13] provide no guarantee of health care for the population as a whole. In such societies, health care is available to those that can afford to pay for it or have self insured it (either directly or as part of an employment contract) or who may be covered by care financed by the government or tribe directly.
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 the US health care system has come under fire for lack of openness [14], 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.
Delivery
Painting of Henriette Browne
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
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
Patient-physician-relationship
This kind of relationship an interaction is a central process in the practice of Western 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.
A patient typically 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 and often laboratory tests; the findings are recorded, leading to a list of possible diagnoses. These will be investigated 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.
In non-Western societies, the physician/patient relationship may be couched in different terms. The illness may be seen as a violation of the spiritual realm and the cure will be seen likewise as having to take place in the spiritual realm. Violation of some spiritual rule can result in illness; persons distant to the patient may have caused illness by manoeuvres in the spiritual realm, by cursing or causing another practitioner / shaman / healer to place the curse. Powerful faith in these factors can result in serious illness or cure. Spirits can be part of a culture's usual pantheon, ancestor spirits or arbitrary new spirit forces arising independently or as derived from an existing object in the real world: such as an animist spirit coming from a totem animal, mountain or other thing. As in the scientific West, the practitioner is assumed to have special knowledge or power, and is paid by the patient in some form.
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.
A patient typically 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 and often laboratory tests; the findings are recorded, leading to a list of possible diagnoses. These will be investigated 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.
In non-Western societies, the physician/patient relationship may be couched in different terms. The illness may be seen as a violation of the spiritual realm and the cure will be seen likewise as having to take place in the spiritual realm. Violation of some spiritual rule can result in illness; persons distant to the patient may have caused illness by manoeuvres in the spiritual realm, by cursing or causing another practitioner / shaman / healer to place the curse. Powerful faith in these factors can result in serious illness or cure. Spirits can be part of a culture's usual pantheon, ancestor spirits or arbitrary new spirit forces arising independently or as derived from an existing object in the real world: such as an animist spirit coming from a totem animal, mountain or other thing. As in the scientific West, the practitioner is assumed to have special knowledge or power, and is paid by the patient in some form.
