Doctors Profession: Introduction

Djoko Wahono Soeatmadji

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, Edin urg ! " #$ %ugust #&&'

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

The Doctor for the 21st Century

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)romote health, pre*ent and treat disease, and reha ilitate the disa le (in a compassionate, ethical way), within resources constrain) )ro*iders of primar+ care Communicators Critical thinkers Moti*ated life-long learners /nformation specialist Citi1en of the World )ractitionars of applied economics, sociolog+, anthropolog+, epidemiolog+ and eha*ioural medicine 2ealth team managers %d*ocate for communities
The World Summit on Medical Education, Edin urg ! " #$ %ugust #&&'

DOCTOR = DOCERE = to te!ch"

4( ph+sicians should share information and medical kno5ledge 5ith colleagues, 5ith students of medicine and related professions, and 5ith their patients4

Ethic!# medicine stri$es to do good !nd to do no harm% The medic!# &rofession must fu##fi## its soci!# contr!ct better

'oci!# !nd Ethic!# Issues in (edicine

%pproach to Medicine, the )atient, and the Medical )rofession 6Medicine as a learned and humane profession7 8ioethics in the )ractice of Medicine Care of D+ing patients and Their 9amiles Social and Economic /ssues in Medicine

)h!t is E*&ected of the Physici!n +

%d*ances in: genetics iochemistr+ imaging technolog+ la orator+ technolog+ therapeutic maneu*ers and modalities

Does not m!,e ! -ood Physici!n

. good &hysici!n h!s the combin!tion of : Medical kno5ledge /ntuition ;udgement

(edicine is ! &rofession th!t incor&or!tes science !nd the scientific methode /ith the !rt of being ! &hysici!n%%0

The !rt of c!ring !nd comforting1 guided by mi##eni! of common sense !s /e## !s systemic !&&ro!ch to medic!# ethics rem!in the cornerstone of medicine%0

The essenti!# hum!nistic 2u!#ities of c!ring !nd comforting c!n !chie$e ! #itt#e if they !re not cou&#ed /ith underst!nding of ho/ medical science can and should be applied to patients%

Com&#ement!ry !nd .#tern!ti$e (edicine

Care gi*ers of ancient times and premodern cultures4 Some of their potions contained 5hat are kno5n to e acti*e ingredients that form the asis for pro*en medications4(( Modern medicine should not dismiss the possi ilit+ that this unpro*en approach ma+ e helpful, ut should adopt a guiding principles that all inter*entions 6traditional or ne5l+ de*eloped7 can e tested, 5ith the expectation that an+ eneficial effects can e explored further to determine their scientific basis%00

'cientific (edicine

00 The scientific b!sis of medicine is rem!r,eb#y recent com&!red /ith its #ong !nd gener!##y distinguished of c!ring !nd comforting &!tients%

(odern medicine h!s mo$ed r!&id#y &!st org!n &hysio#ogy to !n incre!sing#y det!i#ed underst!nding of ce##u#!r1 suce##u#!r1 !nd genetic mech!nism%0 3e!#th1 dises!se1 !nd indi$idu!#s inter!ction /ith en$ironment !re !#so determined subst!nti!##y by genetics%

(ethods for e$!#u!tion the !&&#ic!tion of scientific !d$!nces to the indi$idu!# &!tients !nd to &o&u#!tions

The randomized controlled trial sometimes /ith thous!nds &!tients !t mu#ti&#e institutions1 h!s re&#!ced !necdote !s the &referred methode for me!suring the benefits !nd uses of di!gnostic or trher!&eutic inter$ention%

P!tients C!re

Princi&#es of P!tient C!re

)rinciples of )atient Care )ractice <uidelines Medical Decision-Making E*aluation of =utcomes

.PPRO.C3 TO T3E P.TIE4T

P!tients common#y &resent /ith com&#!ints 5sym&toms61 these sym&toms1 m!y or m!y not be !ccom&!nied by !bnorm!#ities on e*!m 5signs6 or on #!bor!tory testing Con$erse#y1 !sym&tom!tic &!tients m!y h!$e signs or #!bor!tory !bnorm!#ities1 !nd #!bor!tory !bnorm!#ities c!n occur in the !bsence of symtoms or signs

I##ness 7 Dise!se

Tailoring
The &!tients8&hysici!n inter!ction &roceeds through m!ny &h!ses of c#inic!# re!soning !nd decision m!,ing% The !&&ro!ch to di!gnosis !nd ther!&y shou#d not be e2u!ted /ith cookbook medicine%

To c!re for &!tients !s !n indi$idu!#1 the &hysici!n must underst!nd the patient as a person (human)

.PPRO.C3 TO The (EDIC.9 PRO:E''IO4

;IOET3IC' I4 PR.CTICE O: (EDICI4E

'i* of the $!#ues th!t common#y !&&#y to medic!# ethics discussions !re:
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8eneficence - a practitioner should act in the est interest of the patient( 6Salus aegroti suprema lex(7 >on-maleficence - ?first, do no harm? 6primum non nocere7( %utonom+ - the patient has the right to refuse or choose their treatment( 6Voluntas aegroti suprema lex(7 ;ustice - concerns the distri ution of scarce health resources, and the decision of 5ho gets 5hat treatment 6fairness and e@ualit+7( Dignit+ - the patient 6and the person treating the patient7 ha*e the right to dignit+( Truthfulness and honest+ - the concept of informed consent has increased in importance since the historical e*ents of the DoctorsA Trial of the >urem erg trials and Tuskegee S+philis Stud+(

In ! &rofession1 the &r!ctitioner &uts the /e#f!re of the c#ient or &!tient above his or her o/n /e#f!re%00
The &hysici!ns res&onsibi#ity to re&resent the &!tient best interest !nd !$oid fin!nci!# conf#icts %0

Profession!# Res&onsibi#ities:
Commitment to

)rofessional competence 2onest+ 5ith patients )atients confidentialit+ Maintain appropriate relations 5ith patients /mpro*ing the @ualit+ of care % just distri ution of finite resources Scientific kno5ledge Maintaining trust + managing conflict of interest )rofessional responsi ilit+
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The e*&#osion in medic!# ,no/#edge h!s #ed to incre!sing specialization1 defined initi!##y by org!n system !nd more recent#y by #ocus of &rinci&!# !cti$ity 5in&!tient $s out&!tient6

The ch!nging medic!# c!re en$ironment &#!ces incre!sing em&h!sis on standards, outcomes, and accountability..
C#inic!# guide#ines !nd critic!# &!th/!ys deri$ed from r!ndomi<ed contro##ed tri!# !nd e$idence8b!sed medicine &otenti!##y c!n #e!d to more cost-effective and better outcomes

. health insurance system em&h!si<es cost8 effecti$e c!re1 gi$es &hysici!ns !nd he!#th c!re &ro$iders res&onsibi#ity for the he!#th of &o&u#!tion !nd the resources re2uired to !chie$e these go!#s1 must e*ist in ! com&etiti$e en$ironment in /hich patients can choose alternatives if they !re not s!tisfied /ith their c!re%0

In the current he!#th c!re en$ironment1 !## &hysici!ns !nd tr!inees must redoub#e their commitment to &rofession!#ism%

(odern !d$!nces in medic!# techno#ogy1 !ntibiotics1 di!#ysis1 tr!ns&#!nt!tion1 !nd intensi$e c!reunits h!$e cre!ted the bioethic!# di#emm!s th!t confront the &hysici!ns in the 21st century

P!tients8Physici!n Re#!tionshi&

Whate*er the patients attitude ideall+ should e ased on thorough kno5ledge of the patients, mutual trust, and a ilit+ to communicate 5ith one another

)atients as indi*iduals 5hose pro lems transcend their complaint )atient6s7 is not just a Ccase6s7D or Cdisease6s7D The dut+ of patientEs principal ph+sician is to guide them through illness

The ideal patient-ph+sician relationship should e ased on thorough kno5ledge of the patient, mutual trust and a ilit+ to communicate 5ith patient

=u!#tity of c#inici!n interest in hum!nity

eneficence $s !utonomy

Profession!# Res&onsibi#ity >io#!tions 5in gener!#6

Conflicts of interest Mishandling of client Disclosure of confidential information

Informed Consent

:und!ment!# E#ements :or Disc#osure To P!tients

Diagnosis and prognosis >ature of proposed inter*ention Reseona le alternati*e inter*ention Risk associated 5ith each alternati*e inter*ention 8enefits associated 5ith each alternati*e inter*ention )ro a le outcomes of each alternati*e inter*ention

Termin!ting (edic!# Inter$ention + .ssisted 'uicide !nd Euth!n!si! +

C!re of Dying &!tients

C!re of Dying &!tients :

/s the patient comforta le 6)ain and s+mptom control F %ll that hurts F7 Shared decision making 6What is a Cgood deathD F7 %re the ps+chosocial and spiritual concerns of the patients and famil+ eing address 6)s+chosocial and spiritual support7 F Where does the patient prefer to recei*e care F

Common 'ym&toms in 'erious#y I## 3os&it!#i<ed P!tients 5? @f Tot!# P!tients6

%t an+ time )ain D+spneu %nxiet+ Depression >ausea -# ,& ,0 ,', Se*ere and 9re@uent $' $' #. #, .

Des iens >% et al( ; pain Manage #&&&B#0:$,!-$--

P!tients Pers&ecti$e on . -ood De!thA

Control pain and other s+mptoms %*oid inappropriate prolongation of d+ing 5hen life no longer enjo+a le Relie*e urden on the famil+ %chie*e a sense of control Strenghten relationships 5ith lo*ed ones
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'h!red b!d ne/s +

P!##i!ti$e C!re
%pproaches to pro*iding comfort for d+ing persons 5ithout necessaril+ modif+ing the underl+ing medical condition

E*&erience1 common sense1 !nd sim&#y being ! good &erson do not gu!r!ntee th!t &hysici!ns c!n identify or reso#$e ethic!# di#emm!s

'OCI.9 .4D ECO4O(IC I''BE' I4 (EDICI4E

Medicine is practiced in a social, economic, and political context4 /t takes more than excellent medical care to impro*e the health of the patients4 Man+ of the determinants of the health of indi*iduals and populations lie outside traditional clinical acti*it+

Economic Consider!tions in the Pr!ctice of (edicine

 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 ma!es a major contribution to health

Adequate nutrition as a prerequisite for health

%the success stories of better he!#th in underde$e#o&ed countries h!$e h!d more to do /ith changed economic and political systems and improved nutrition, "ater provision, and sanitation th!n /ith techno#ogic!# modern medicine%
Agriculter and health are two closely related factors nvironmental condition have major impact in health

Appropriate to needs

Accessible

Afordable

Conf#ict of Interest

>!rious Interests

Medical >ursing =5ners /n*estors )atientsG9amil+ /nsurance )harmaceutical /ndustr+

<o*ernment Medical Education Medical )rofession Ha5+er Etc

Bargaining " #onflict

(EDIC.9 TEC34O9O-D

%these techno#ogic!#

inno$!tions h!$e h!d on#y m!rgin!##y effects1 /hi#e others h!$e h!d no effect !t !##1 !nd some h!$e h!d % neg!ti$e ones% %medic!# students !re 5usu!##y6 tr!ined to &ursue ! Ctechno#ogic!# im&er!ti$e1 to use !ny !$!i#!b#e techni2ue of inter$ention%

Doctor P!tient Re#!tionshi&

Em&!thy

'ym&!thy

Enemy

#he patient is human, fearful, and hopeful, seeking relief, help, and reassurance.

T5ee koetsiers op een ok, dit gaat niet, 1eiden de1e geneesheren(T+pisch s+mptoom *an Imata doe5iten?( Want, het moet ge1egd 5orden,*ele lnlandsehe geneeskundigcn5er Jden door de1e dokteren ge e1igd als apothekers en daardoor ont rakhen de gelegenheid er 5at ij te *erdienen( 2et arm1alig tractement*an f fo. toch maakte dat stellig nood1akelijk(

2ippocratic =ath
% T5elfth-centur+ 8+1antine manuscript of the =ath

$ipocrates %ath & swear by Apollo' Asclepius' $ygieia' and (anacea' and & ta!e to witness all the gods' all the goddesses' to !eep according to my ability and my judgment' the following %ath

Th!n, you for your !ttention

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