medicine

medicine

[med-uh-sin or, especially Brit., med-suhn]
medicine, the science and art of treating and preventing disease.

History of Medicine

Ancient Times

Prehistoric skulls found in Europe and South America indicate that Neolithic man was already able to trephine, or remove disks of bone from, the skull successfully, but whether this delicate operation was performed to release evil spirits or as a surgical procedure is not known. Empirical medicine developed in ancient Egypt, and involved the use of many potent drugs still in use today, such as castor oil, senna, opium, colchicine, and mercury. In spite of their skill in embalming, however, the Egyptians had little knowledge of anatomy.

In Sumerian medicine the Laws of Hammurabi established the first known code of medical ethics, and laid down a fee schedule for specific surgical procedures. In ancient Babylonia, every man considered himself a physician and, according to Herodotus, gave advice freely to the sick man who was willing to exhibit himself to passersby in the public square. The Mosaic Code of the Hebrews indicated concerns with social hygiene and prevention of disease by dietary restrictions and sanitary measures.

Although ancient Chinese medicine was also influenced adversely by the awe felt for the sanctity of the human body, the Nei Ching, attributed to the emperor Huang-Ti (2698-2598 B.C.), contains a reference to a theory of the circulation of the blood and the vital function of the heart that suggests familiarity with anatomy. In addition, accurate location of the proper points for the traditional Chinese practice of acupuncture implies some familiarity with the nervous and vascular systems. The Chinese pharmacopoeia was the most extensive of all the older civilizations. The Hindus seem to have been familiar with many surgical procedures, demonstrating skill in such techniques as nose reconstruction (rhinoplasty) and cutting for removal of bladder stones.

In Greek medicine the impetus for the rational approach came largely from the speculations of the pre-Socratic philosophers and such philosopher-scientists as Pythagoras, Democritus, and Empedocles. Hippocrates, the father of Western medicine, taught the prevention of disease through a regimen of diet and exercise; he emphasized careful observation of the patient, the recuperative powers of nature, and a high standard of ethical conduct, as incorporated in the Hippocratic Oath. By the 4th cent. B.C., Aristotle had already stimulated interest in anatomy by his dissections of animals, and work in the 3d cent. B.C. on human anatomy and physiology was of such high quality that it was not equaled for fifteen hundred years.

The Romans advanced public health and sanitation through the construction of aqueducts, baths, sewers, and hospitals. The encyclopedic writings of Galen constitute a final synthesis of the medicine of the ancient world. Revered by Arabic and Western physicians alike, his concepts stood virtually unchallenged until the 16th cent. Unfortunately, his prolific researches on anatomy and physiology were not invariably accurate, and reliance on them impeded subsequent progress in anatomy.

The Middle Ages

With the destruction or neglect of the Roman sanitary facilities, there followed a series of local epidemics that culminated many centuries later in the great plague of the 14th cent. known as the Black Death. During the Middle Ages certain monastic libraries, notably those at Monte Cassino, Bobbio, and St. Gall, preserved a few ancient medical manuscripts, and Arab and Jewish physicians such as Avicenna and Maimonides continued medical investigation.

The first real light on modern medicine in Europe came with the translation of many writings from the Arabic at Salerno, Italy, and through a continuing trade and cultural exchange with Byzantium. By the 13th cent. there were flourishing medical schools at Montpellier, Paris, Bologna and Padua, the latter being the site of production of the first accurate books on human anatomy. At Padua, Vesalius proved that Galen had made anatomical mistakes. Prominent among those who pursued the new interest in experimental medicine were Paracelsus, Ambroise Paré, and Fabricius, who discovered the valves of the veins.

The Birth of Modern Medicine

In the 17th cent. William Harvey, using careful experimental methods, demonstrated the circulation of the blood, a concept that met with considerable early resistance. The introduction of quinine marked a triumph over malaria, one of the oldest plagues of mankind. The invention of the compound microscope led to the discovery of minute forms of life, and the discovery of the capillary system of the blood filled the final gap in Harvey's explanation of blood circulation.

In the 18th cent. the heart drug digitalis was introduced, scurvy was controlled, surgery was transformed into an experimental science, and reforms were instituted in mental institutions. In addition, Edward Jenner introduced vaccination to prevent smallpox, laying the groundwork for the science of immunization.

The 19th cent. saw the beginnings of modern medicine when Pasteur, Koch, Ehrlich and Semmelweis proved the relationships between germs and disease. Other invaluable developments included the use of disinfection and the consequent improvement in medical, particularly obstetrical, care; the use of inoculation; the introduction of anesthetics in surgery (see anesthesia); and a revival of better public health and sanitary measures. A significant decline in maternal and infant mortality followed.

Modern Medicine

Medicine in the 20th cent. received its impetus from Gerhard Domagk who discovered the first antibiotic, sulfanilamide, and the groundbreaking advancements in the use of penicillin. Further progress has been characterized by the rise of chemotherapy, especially the use of new antibiotics; increased understanding of the mechanisms of the immune system (see immunology) and the increased prophylactic use of vaccination; utilization of knowledge of the endocrine system to treat diseases resulting from hormone imbalance, such as the use of insulin to treat diabetes; and increased understanding of nutrition and the role of vitamins in health.

In Mar., 1953, at the Univ. of Cambridge, England, Francis Crick, age 35, and James Watson, age 24, announced "We have discovered the secret of life." Indeed, they had unraveled the chemical structure of the fundamental molecule of heredity, deoxyribonucleic acid (DNA), giving science and medicine the basis for molecular genetics and leading to a continuing revolution in modern medicine.

Much medical research is now directed toward such problems as cancer, heart disease, AIDS, reemerging infectious diseases such as tuberculosis and dengue fever, and organ transplantation. Currently, the largest worldwide study is the Human Genome Project, which will identify all hereditary traits and body functions controlled by specific areas on the chromosomes. Gene therapy, the replacement of faulty genes, offers possible abatement of hereditary diseases. Genetic engineering has led to the development of important pharmaceutical products and the use of monoclonal antibodies, offering promising new approaches to cancer treatment. The discovery of growth factors has opened up the possibility of growth and regeneration of nerve tissues.

With the surge of general and specialized medical knowledge, the educational requirements of the medical profession have increased. In addition to the four-year medical course and the general hospital internship required almost everywhere, additional years of study in a specialized field are usually required. Similar progress and increased requirements in education are reflected in ancillary professions such as nursing.

Modern Health Care Management

Modern medicine, characterized by growing specialization and a complex diagnostic and therapeutic technology, faces problems in the allocation of capital and personnel resources. Some authorities advocate an increase in the use of paramedical personnel to supervise the care of individuals with common, chronic, or terminal illnesses, leaving the physician in charge of treating curable disease. Others emphasize the physician's responsibility to help patients and families in the overall management of their health problems, many of which are thought to reflect the social ills of living in an urban, industrialized society.

In some countries, such as Great Britain, medical care is under government control and is available virtually without charge to all. In the United States, medical practice is characterized by a patchwork mixture of government and private control. The Kefauver-Harris amendments to the federal Food, Drug, and Cosmetic Act of 1962 empower the Food and Drug Administration to require stricter testing and licensing of new drugs. There have also been federal, state, and local programs for mass vaccination and other public health programs. The Medicare program, enacted in 1965, provides subsidized hospital and nursing-home care for persons over 65 and, with the Hill-Burton Act, provides funds for state aid to the medically indigent (Medicaid).

A wide variety of private medical insurance plans are also available to those who can afford them, and many employers pay all or part of their employees' health insurance premiums. In addition, health maintenance organizations (HMOs), or group practice plans, are designed to promote disease prevention and reduce medical expenditures.

Bibliography

See J. Walton et al., ed., The Oxford Companion to Medicine (2 vol., 1986); historical study by H. E. Sigerist (2 vol., 1951-61); studies by R. Hudson (1983), P. Starr (1983), D. Dutton (1988), and E. Shorter (1991).

Medical field dealing with animals and with diseases that are transmissible between animals and humans. It was practiced as a specialty in ancient Egypt and Babylonia; the first veterinary schools in Europe were founded in the mid-18th century. Veterinarians practice internal medicine, surgery, and preventive medicine, using the same techniques used on humans. They serve worldwide in private and corporate clinical practice, academic programs, private industry, government service, public health, and military services. Many specialize in either small animals (pets) or large ones (livestock); a few specialize in wild animals.

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Science of diseases seen primarily in tropical or subtropical climates. It arose in the 19th century when European colonial doctors encountered infectious diseases unknown in Europe. The discovery that many tropical diseases (e.g., malaria, yellow fever) were spread by mosquitoes led to discovery of other vectors' roles (see sleeping sickness, plague, typhus) and to efforts to destroy vector breeding grounds (e.g., by draining swamps). Later, antibiotics came to play an increasingly important role. Research institutes and national and international commissions were organized to control common tropical illnesses, at least in areas with Europeans. As colonies became independent, their governments took over most of these efforts, with help from the World Health Organization and the former colonizing countries.

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Medical and paramedical supervision and treatment of athletes. It has four aspects. Preparation (conditioning) uses diet, exercises, and monitoring of practice sessions to improve performance. Prevention identifies any predisposition to injury or illness and covers warmup, stretching, and design and use of protective equipment. Many surgical techniques developed in sports medicine, particularly for knee injuries, are now used for the general population. Rehabilitation (see physical medicine and rehabilitation) prepares an injured or ill athlete to return to activity after initial treatment.

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Branch of medicine, pioneered by Paul Bert, dealing with atmospheric flight (aviation medicine) and space flight (space medicine). Intensive preflight simulator training and attention to design of equipment and spacecraft promote the safety and effectiveness of humans exposed to the stresses of flight and can prevent some problems. The world's first unit for space research was established in the U.S. in 1948. Physicians trained in aerospace medicine are known as flight surgeons.

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Efforts toward disease prevention in the community and the individual. It covers patient interviews and testing to detect risk factors; sanitary measures in homes, communities, and medical facilities; patient education; and diet and exercise programs as well as preventive drugs and surgery. It has three levels: primary (e.g., prevention of coronary heart disease in a healthy person), secondary (e.g., prevention of heart attack in a person with heart disease), and tertiary (e.g., prevention of disability and death after a heart attack). The first is by far the most economical. Important advances in preventive medicine include vaccination (see vaccine), antibiotics, diagnostic imaging, and recognition of psychological factors. Seealso epidemiology, immunology, industrial medicine, quarantine.

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or physiatry or physical therapy or rehabilitation medicine

Medical specialty treating chronic disabilities through physical means to help patients return to a comfortable, productive life despite a medical problem. Its objectives are pain relief, functional improvement or maintenance, training in essential activities, and functional testing of areas such as strength, mobility, breathing capacity, and coordination. Physical medicine may use diathermy, hydrotherapy, massage, exercise, and functional training. The last can mean learning to work with a guide dog or a prosthesis or learning new ways to carry out everyday activities with a limb missing, sometimes by using assistive devices. Physician specialists head rehabilitation teams including a physical therapist, rehabilitation engineer, rehabilitation nurse, psychological counselor, and sometimes a respiratory or speech therapist. Seealso occupational therapy; orthopedics.

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Health-care profession founded by the U.S. physician Andrew Taylor Still (1828–1917) as a reform movement against the rather primitive 19th-century drugs and surgical techniques. It emphasizes the relationship between musculoskeletal structure and organ function. Osteopathic physicians learn to recognize and correct structural problems through manipulative and other therapies. Osteopathic hospitals provide general or specialized health care, including maternity and emergency care.

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or occupational medicine

Branch of medicine dealing with workers' health and the prevention and treatment of diseases and injuries in the workplace. Workplace hazards include exposure to dangerous materials including asbestos and coal dust, radiation exposure, and machinery capable of causing injuries ranging from minor to life-threatening. Industrial medical programs mandate protective devices around machines' moving parts, proper ventilation of work areas, use of less toxic materials, containment of production processes, and protective equipment and clothing. Good industrial medical programs improve labour-management relations, increase workers' overall health and productivity, and reduce insurance costs.

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Medical specialty using radioactive elements or isotopes for diagnosis and treatment of disease. A radioisotope is introduced into the body (usually by injection). The radiation it emits, detected by a scanner and recorded, reflects its distribution in different tissues and can reveal the presence, size, and shape of abnormalities in various organs. The isotopes used have short half-lives and decay before radioactivity causes any damage. Different isotopes tend to concentrate in particular organs (e.g., iodine-131 in the thyroid). Radioactive substances are also implanted to treat small, early-stage cancers. This yields a slow, continuous dose that limits damage to normal cells while destroying tumour cells. Seealso computerized axial tomography; diagnostic imaging; positron emission tomography; radiation therapy; radiology.

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Priestly healer or shaman, especially among the American Indians. The medicine man (often a woman in some societies) commonly carries a kit of objects such as feathers, stones, or hallucinogenic plants that have magical associations. The work of healing often involves the extraction—by sucking, pulling, or other means—of offending substances from the patient's body. Singing, recitation of myths, and other ceremonies often accompany the healing rite.

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Set of scientific fields related to prevention, diagnosis, and treatment of disease and maintenance of health, practiced in doctors' offices, health maintenance organization facilities, hospitals, and clinics. In addition to family practice, internal medicine, and specialties for specific body systems, it includes research, public health, epidemiology, and pharmacology. Each country sets its own requirements for medical degrees (M.D.'s) and licenses. Medical boards and councils set standards and oversee medical education. Boards of certification have stringent requirements for physicians seeking to practice a specialty and stress continuing education. Advances in therapy (see therapeutics) and diagnosis have raised complex legal and moral issues in areas such as abortion, euthanasia, and patients' rights. Recent changes include treating patients as partners in their own care and taking cultural factors into consideration.

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Medical specialty dealing with the entire patient rather than a particular organ system, covering diagnosis and medical (rather than surgical) treatment in adults. Its development began in the 17th century with Thomas Sydenham's concept of disease, but until disease-specific therapies were developed in the 20th century, internists could do little to treat diseases. As more specific treatments became available, medical knowledge increased, and subspecialties in specific organ systems were defined, internal medicine became recognized as a specialty.

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Doctrine of prevention and treatment that emphasizes looking at the whole person—body, mind, emotions, and environment—rather than a single function or organ. It promotes use of a wide range of health practices and therapies, including acupuncture, homeopathy, and nutrition, stressing “self-care” with traditional commonsense essentials. In the extreme, it may accord equal validity to a wide range of health-care approaches, some incompatible and not all scientific. It does not ignore mainstream Western medical practices but does not see them as the only effective therapies. Seealso alternative medicine.

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Science of applying medical knowledge to legal questions, recognized as a specialty since the early 19th century. Its primary tool has always been the autopsy, to identify the dead (e.g., plane-crash victims) or determine cause of death, which can significantly affect trials dealing with insurance and inheritance. Forensic psychiatry determines the mental health of an individual about to stand trial. Forensic genetics allows paternity to be determined and can identify blood or other tissue samples as coming from a particular person (see DNA fingerprinting). Forensic toxicology, concerned with such topics as intentional poisonings and drug use, is increasingly important in cases of industrial and environmental poisoning.

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or family medicine or general practice

Field of medicine that stresses comprehensive primary health care, emphasizing the family unit. Practitioners must be familiar to some degree with medical specialties and, especially in health maintenance organizations, are now often gatekeepers who refer patients to specialists when necessary. Once virtually the only kind of medicine, family practice has been defined as a separate field only since increasing specialization in medicine led to a shortage of practitioners. A 1963 World Health Organization report stressing the need for medical education to focus on the patient as a whole throughout life led to specific programs in family practice.

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Field of medicine concerned with the prompt treatment of wounded military personnel. Developments in battlefield medicine have focused on treatment to quickly stop bleeding and on provision of immediate medical care. In the early 21st century these developments, combined with improvements in body armour and helmets, have resulted in the survival of many casualties of war who nonetheless have debilitating injuries such as the loss of a limb. Soldiers who have been wounded are taken from the scene of battle to their unit's closest treatment facility. There a team of surgeons and medical staff stabilize the wounded for transport to a larger facility with more specialized staff and equipment. Wounded military personnel may then be transferred for further treatment; those who cannot be returned to duty receive extended care and rehabilitation. Challenges facing military medicine today include the treatment of post-traumatic stress disorder and other psychological damage resulting from service in a war zone, as well as the development of better prosthetics for soldiers surviving the loss of a limb.

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Northwest section of the Front Range, in the central Rocky Mountains, U.S. Averaging a height of 10,000 ft (3,050 m), the mountains run southeast for about 100 mi (160 km) from Medicine Bow, Wyo., to Cameron Pass, Colo., just northwest of Rocky Mountain National Park. The highest summit, Medicine Bow Peak, reaches 12,014 ft (3,662 m). The name refers to the practices of local Indians, who collected wood for bows in the area and held ceremonial medicine dances.

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Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore human health by the prevention and treatment of illness. Contemporary medicine applies health science, biomedical research, and medical technology to diagnose and treat injury and disease, typically through medication, surgery, or some other form of therapy. The word medicine is derived from the Latin ars medicina, meaning the art of healing. Though medical technology and clinical expertise are pivotal to contemporary medicine, successful face-to-face relief of actual suffering continues to require the application of ordinary human feeling and compassion, known in English as "bedside manner."

History

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 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, Abulcasis, the father of surgery, Avenzoar, the father of experimental surgery, Ibn al-Nafis, the father of circulatory physiology, and Averroes. 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. As the medieval ages ended, important early figures in medicine emerged in Europe, including Gabriele Falloppio and William Harvey.

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.

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.

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.

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.

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.

Most industrialized countries 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 at least one industrialized capitalist country (the United States) 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 , 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

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 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.

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.

Clinical skills

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:

  • Chief complaint (cc): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'
  • History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.
  • Current activity: occupation, hobbies, what the patient actually does.
  • Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies. Allergies are also recorded.
  • Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
  • Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
  • Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
  • Review of systems (ROS) or systems inquiry: a set of additional questions to ask which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc).

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:

  • Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
  • General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)
  • Skin
  • Head, eye, ear, nose, and throat (HEENT)
  • Cardiovascular (heart and blood vessels)
  • Respiratory (large airways and lungs)
  • Abdomen and rectum
  • Genitalia (and pregnancy if the patient is or could be pregnant)
  • Musculoskeletal (spine and extremities)
  • Neurological (consciousness, awareness, brain, cranial nerves, spinal cord and peripheral nerves)
  • Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

Laboratory and imaging studies results may be obtained, if necessary.

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

Working together as an interdisciplinary team, many highly-trained health professionals besides medical practitioners are involved in the delivery of modern health care. Examples include: nurses, 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, while a separate discipline from medicine, is considered a medical field.

A patient admitted to hospital is usually under the care of a specific team based on their main presenting problem, e.g. the Cardiology team, who then may interact with other specialties, e.g. 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:

Basic sciences

Specialties

In the broadest meaning of "medicine", there are many different specialties. However, within medical circles, there are two broad categories: "Medicine" and "Surgery." "Medicine" refers to the practice of non-operative medicine, and most subspecialties in this area require preliminary training in "Internal Medicine". "Surgery" refers to the practice of operative medicine, and most subspecialties in this area require preliminary training in "General Surgery." There are some specialties of medicine that do not fit into either of these categories, such as radiology, pathology, or anesthesia, and those are also discussed further below.

Surgery

Surgical specialties employ operative treatment. In addition, surgeons must decide when an operation is necessary, and also treat many non-surgical issues, particularly in the surgical intensive care unit (SICU), where a variety of critical issues arise. Surgery has many subspecialties, e.g. general surgery, trauma surgery, cardiovascular surgery, neurosurgery, maxillofacial surgery, orthopedic surgery, otolaryngology, plastic surgery, oncologic surgery, vascular surgery, and pediatric surgery. In some centers, anesthesiology is part of the division of surgery (for logistical and planning purposes), although it is not a surgical discipline.

Surgical training in the U.S. requires a minimum of five years of residency after medical school. Sub-specialties of surgery often require seven or more years. In addition, fellowships can last an additional one to three years. Because post-residency fellowships can be competitive, many trainees devote two additional years to research. Thus in some cases surgical training will not finish until more than a decade after medical school. Furthermore, surgical training can be very difficult and time consuming. A surgical resident's average work week is approximately 75 hours. Some subspecialties of surgery, such as neurosurgery, require even longer hours, and utilize an extension to the 80 hour regulated work week, allowing up to 88 hours per week. Many surgical programs still exceed this work hour limit. Attempts to limit the amount of hours worked has been difficult because of the large volume of patients who require surgical care, the limited amount of resources (including a shortage of people willing to enter into surgery as a career), the need to perform long operations and still provide care to all pre- and post-operative patients, and the need to provide constant coverage in the OR, ICU, and ER.

Medicine

  • Internal medicine is concerned with systemic diseases of adults, i.e. those diseases that affect the body as a whole (restrictive, current meaning), or with all adult non-operative somatic medicine (traditional, inclusive meaning), thus excluding pediatrics, surgery, gynecology and obstetrics, and psychiatry. Practitioners of such specialties are referred to as physicians. There are several subdisciplines of internal medicine:

Generally, Pediatrics and Family Practice are also considered to fall under the category of "Medicine".

Medical training, as opposed to surgical training, requires three years of residency training after medical school. This can then be followed by a one to two year fellowship in the subspecialties listed above. In general, resident work hours in medicine are less than those in surgery, averaging about 60 hours per week in the USA.

Diagnostic specialties

Other

Following are some selected fields of medical specialties that don't directly fit into any of the above mentioned groups.

Interdisciplinary fields

Interdisciplinary sub-specialties of medicine are:

Education

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 utilized in medical education, which is an active area of educational research.

Legal restrictions

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.

Doctors who are negligent in their care of patients can face charges of medical malpractice and subject to legal or professional sanctions.

Criticism

The anti-authoritarian Catholic social theorist Ivan Illich subjected contemporary western medicine to detailed attack in his Medical Nemesis, first published in 1975. He argued that the medicalization in recent decades of so many of life's vicissitudes — birth and death, for example — frequently caused more harm than good, rendering many in effect lifelong patients. Marshalling a body of statistics that indicated what he considered the shocking extent in advanced industrial society of post-operative side-effects and drug-induced illness , Illich was the first to introduce to a wider public the notion of iatrogenesis Other critics have since voiced similar views but none so trenchantly, perhaps, as Illich.

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 criticisms that medicine was neglecting a holistic model. 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, notably acupuncture for some conditions and certain herbs, are backed by evidence.

Medical errors and overmedication are also the focus of 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. Paul E. Meehl's 1954 book Clinical vs. Statistical Prediction: A Theoretical Analysis and a Review of the Evidence compared clinical predictions with algorithmic ones, and concluded that statistical, algorithmic ones were superior.

See also

References

External links

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