Phylosophy of Doctor

8/12/2019 Phylosophy of Doctor

1/78

Phylosophy of MedicalProfession


2/78

An Overview of the Medical Care Sector

Patientsdemand fortreatment

Physician asdecisionmaker

Demand forinstitutional

setting

Prices andquantity of

services

Supply ofinstitutional

settings

The Supply SideThe Demand Side

Feldstein. Healt Care Economics, 1988

MARKET ECONOMY


3/78

An Overview of the Medical Care Sector

Patientsdemand fortreatment

Physician asdecisionmaker

Demand forinstitutional

setting

Prices andquantity of

services

Supply ofinstitutional

settings

The Supply SideThe Demand Side

Feldstein. Healt Care Economics, 1988

MARKET ECONOMYReregulation

InsuranceCompany


4/78


5/78


6/78

Now primarily a marketing machine to selldrugs of dubious benefit , this industry usesits wealth and power to co-opt everyinstitution that might stand in its way,

including the U.S. Congress, the Food andDrug Administration, academic medicalcenters, and the medical profession itself.

(Most of its marketing efforts are focused oninfluencing doctors, since they must write theprescription)

Marcia Angell, M.D., Former editor in chief of

The New England Journal of Medicine Winner of the Polk Award


7/78

Professional ResponsibilityViolations (in general)

Conflicts of interest

Mishandling of client Disclosure of confidential information


8/78


9/78


10/78

Twee koetsiers op een bok , dit gaat niet, zeiden dezegeneeshecren.Typisch symptoom van mata

doewiten " . Want, het moet gezegd worden,vele

lnlandsehe geneeskundigcnwer =den door dezedokteren gebezigd als apothekers en daardoorontbrakhen de gelegenheid er wat bij te verdienen.Het armzalig tractementvan f fo. toch maakte dat

stellig noodzakelijk.


11/78


12/78

Six of the values that commonly apply to medicalethics discussions are:

1. Beneficence - a practitioner should act in the bestinterest of the patient. ( Salus aegroti suprema lex .)

2. Non-maleficence - "first, do no harm" ( primum nonnocere ).

3. Autonomy - the patient has the right to refuse or choosetheir treatment. ( Voluntas aegroti suprema lex .)4. Justice - concerns the distribution of scarce health

resources, and the decision of who gets what treatment(fairness and equality).

5. Dignity - the patient (and the person treating the patient)have the right to dignity.6. Truthfulness and honesty - the concept of informed

consent has increased in importance since the historicalevents of the Doctors' Trial of the Nuremberg trials andTuskegee Syphilis Study .
http://en.wikipedia.org/wiki/Beneficencehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wiktionary.org/wiki/autonomyhttp://en.wikipedia.org/wiki/Justicehttp://en.wikipedia.org/wiki/Dignityhttp://en.wikipedia.org/wiki/Truthhttp://en.wikipedia.org/wiki/Honestyhttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Doctors%27_Trialhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Doctors%27_Trialhttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Honestyhttp://en.wikipedia.org/wiki/Truthhttp://en.wikipedia.org/wiki/Dignityhttp://en.wikipedia.org/wiki/Justicehttp://en.wiktionary.org/wiki/autonomyhttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Beneficence


13/78

No greater opportunity,

responsibility, or obligation canfall to the lot of a human beingthan to become a physician. Inthe care of the suffering, [the

physician] needs technical skill,

scientific knowledge, and humanunderstanding. . ..

Harrison's Principles of Internal Medicine , 1950


14/78

The Doctor for the 21 st Century

Promote health, prevent and treat disease, andrehabilitate the disable in a compassionate,ethical way (within resources constrain)

Providers of primary care Communicators Critical thinkers Motivated life-long learners Information specialist Citizen of the World Practitionars of applied economics, sociology,

anthropology, epidemiology and behaviouralmedicine Health team managers Advocate for communities

World Summit on Medical Education 1993


15/78


16/78

A 12 th centuryBysanthine manuscript

of the Oath

Hippocratic Oath

Hipocrates OathI swear by Apollo,

Asclepius, Hygieia, andPanacea, and I take to

witness all the gods, all thegoddesses, to keep according

to my ability and my judgment, the following

Oath
http://upload.wikimedia.org/wikipedia/commons/1/1a/HippocraticOath.jpg


17/78


18/78

PP 26/1960, LAFAL SUMPAH DOKTEROleh: PRESIDEN REPUBLIK INDONESIA

Nomor:26 TAHUN 1960 (26/1960)Tanggal:2 JUNI 1960 (JAKARTA)


19/78

"Saya bersumpah/berjanji bahwa: Saya akan membaktikan hidup saya guna kepentingan perikekemanusiaan; Saya akan menjalankan tugas saya dengan cara yang berhormat dan bersusila,

sesuai dengan martabat pekerjaan saya; Saya akan memelihara dengan sekuat tenaga martabat dan tradisi luhur jabatan

kedokteran; Saya akan merahasiakan segala sesuatu yang saya ketahui karena pekerjaan

saya dan karena keilmuan saya sebagai Dokter; Kesehatan penderita senantiasa akan saya utamakan;

Dalam m enunaikan kewaj iban terhadap pend er i ta" saya akan ber ikh t iardengan sunggu h-sunggu h supaya saya t idak terpengaruh o lehper t imbangan Keagamaan , Kebangsaan , Kesukuan , Poli t ik Kep artaian atau Kedudu kan Sos ial ;

Saya akan memberikan kepada Guru-guru saya penghormatan dan *14128 pernyataan terima kasih yang selayaknya;

Teman-sejawat saya akan saya perlakukan sebagai saudara kandung;

Saya akan menghormati setiap hidup insani mulai dari saat pembuahan; Sekalipun diancam, saya tidak akan mempergunakan pengetahuan Kedokteran

saya untuk sesuatu yang bertentangan dengan hukum perikemanusiaan; Saya ikrarkan sumpah ini dengan sungguh sungguh dan dengan

mempertaruhkan kehormatan diri saya"

Ditetapkan di Jakarta pada tanggal 2 Juni 1960. Pejabat Presiden Republik, Indonesia, DJUANDA

Diundangkan di Jakarta pada tanggal 2 Juni 1960. Menteri Kehakiman, SAHARDJO


20/78

The Medical Practice


21/78

Good Medical

Practice

Good Clinical

PracticePatient Safety


22/78

Good Medical Practice


23/78


24/78

Good Doctors

Good doctors make the care of theirpatients their first concern, they are

competent, keep their knowledge and skillsup to date, establish and maintain goodrelationships with patients and colleagues,

are honest and trustworthy, and act withintegrity.


25/78

Goo d m edic al p rac t ice setsout the pr inc ip les and values

on which good practice is

founded. The guidance is add ress ed to do c to rs , but is also intended to let th e

p u b l ic k n o w what they canexpect from doctors


26/78

The doctor-patient relationship

Explain the benefits to patients and othersof being the subject of education andrsearch, but respect their right to decline totake part in those activities


27/78

Management Decisions about access to

medical care A responsibility to the community at

large to foster the proper use ofresources

Use resources efficiently,consistent with good patientcare


28/78

Scholarship

Research Keeping up to date

Maintaining and improving yourperformance


29/78

Teach ing , t ra ining , ap pr ais in g andassess ing d oc to rs and s tuden ts areimportant for the care of patients nowand in the future. This is regarded as an in tegral par t o f p rofess io nal prac t ice

If you are inv olved in teach ing youmust develop the attitudes, awarenessand knowledge, skills and practices of a competent teacher


30/78

DOCTOR = DOCERE


31/78

Collaboration

Working in teams Arranging cover

The central role of the general practitioner Delegation and referral Working with colleagues


32/78

Informed Consent


33/78

Fundamental Elements ForDisclosure To Patients

Diagnosis and prognosis Nature of proposed intervention Reseonable alternative intervention

Risk associated with each alternativeintervention Benefits associated with each alternative

intervention

Probable outcomes of each alternativeintervention


34/78

Professionalism

Competence Honesty with patients Patients confidentiality Maintain appropriate relations with patients Improving the quality of care A just distribution of finite resources Scientific knowledge

Maintaining trust by managing con f l ic t o fin teres t

Brennan T et al. Ann Intern Med 2002; 1136: 243-246


35/78

The Twenty-First-Century

Physician: Expanding FrontiersThe era of "omics": genomics,

epigenomics, proteomics,microbiomics, metagenomics,

metabolomics

Harrisons Principles of Intermal Medicine


36/78


37/78

Logic in Medicine &Medical Decision Making


38/78


39/78


40/78

Science (Ilmu) ?

Knowledge (Pengetahuan) ?

Scientific methode ?


41/78

Medical knowledge is a scientificknowledge


42/78

Doctor vs Witch doctor ?

Physician - scientist


43/78

The Science : Diagnostic processThe Art : Clinical process

Medicine


44/78

Methods of Finding theScientific Truth(s)


45/78

Rasional - Empirical Deductive Inductive

Deducto hypothetico - verivicative


46/78

Diagnostic Process is a

scientific process


47/78

(Differential) Diagnosis, likescientific research is basedon methode of hypothesis

formulation

f h d


48/78

Scientific Method(Rasionalism+ Empirisism)

Problem statementData collectionData classificationHypothesis formulationTesting the hypothesis

Deduction and Induction

Th S i ifi P


49/78

The Scientific Process

Problem (illnesss)

Data collecting & dataanalysis

Hypothesis formulation &differential diagnosis

Hypothesis (diagnosis)proven or unproven(probability)

New Problems

Research Question (s)/Problem ?

Data collecting & dataanalysis

Hypothesis formulationHo/H1 Working hypoth.

Hypothesis accepted orrejected (probability)

New Research Questions

Diagnosis Research


50/78


51/78

Medical care is often said tobe the art of making decisionwithout adequate information

Harold C. Sox

Probabvility : quantifying the uncertainty

DATA


52/78

DATA Infinite data case sampling

Operational definition Probabilistic concept

AccuracyPrecision

Sensitivity

Specivicity

Predictive value (+/-)

Bayes theorem


53/78

Ilness(es) vs Disease(s) ??


54/78

Illness

The totality of signs (objectivefindings ) and symptomps ( subjectivefeelings ) that characterize a single(individuals) patient to an etiologicagent (i.e. infection)

Each such illness is unique , it happens tosingle individual over a restricted time period of time and will never happenagain in precisely the same way

Delp and Manning,1981

Ill


55/78

Illness

Tuberculosis the illness : is the patients reaction, not merely a tissue reaction


Illness is a process


56/78

Disease

Disease do not exist in reality,they are abstraction

Tuberculosis is defined variouslyby medical scientist (clinician aswell as basic scientist) i.e. :



57/78

In pathology we study disease inclinical training we work with illness Ideally, the physician should think in

terms of both disease and illness Educational separation of disease and

illness creates obstacles that can be

overcome by conscious effort



58/78

Evidence Base Medicine


59/78

Clinical Evidence

&Circumstances

Evidencefrom

Research

PatientsPreferences,Values, and

Rights


60/78

in any dynamic society the onlyconstant is change .

.not all the changes are brought by thediscoveries of the sicentist and the

advances made by techologists.

Some have economic roots and somestems from aspects of man unconquerablemind from the desire for social equity, ahatred of injustice, a wish to help the sick

and disadvantage, or a simple love of

humanity .


61/78

Medicine is advancing morerapidly than the capacity of

statemen and administratorsto deal with .

Roberts S. The Cost of Health. Turnstile PressLondon, 1958.


62/78

health is a political issue


63/78

Most illness has its origins insocial condition

health is a political issue and those enjoying care do notwant to share it ..

Both in the underdeveloped and thedeveloped world the medicalcontribution is largely inappropriate

to health need and does not copewith helath problems of the vastmajority

gap between health care andmedical care has become evenwider

the restricted ability of the poor to fullfill their


64/78

the restricted ability of the poor to fullfill theirneeds for health care, for they are not in a

position, economically or politicallyexcept

possibly of the traditional type.

In South Africa , infant mortality rates are roughlysixtimes as high for blacks and coloureds as they

are for whites in other underdeveloped countries the poor and therich are not distinguished by the color of their skin

.. No recorded infant mortality rates for poor and rich, but rather rates for the population as a whole

Indonesia ?

A safe water supplymakes a major


65/78

the success s to r ies ofbetter health in

underdeveloped countrieshave had more to do withchanged economic and political systems and

improved nutrition, water provision, and sanitation

than with technological

modern medicine

Adequate nutrition as a prerequisite for health

Environmental conditionhave major impact in

health

Agriculter and health aretwo closely related

factors

makes a majorcontribution to health


66/78

doctors and otherprofessional health workers

playing a major and essentialrole, but not necessarily thepredominant one


67/78

these technologicalinnovations have had onlymarginally effects, while othershave had no effect at all, andsome have had negative

ones

medical students are (usually)trained to pursue a

technological imperative, touse any available technique of

intervention

MEDICAL TECHNOLOGY


68/78


69/78

Market imperfections and Marketfailure

In situation of natural monopoly,

competition cannot exist


70/78

Social and Economical Context ?Integration to Health Care Services

?Interests ?

Which side ?

V i I


71/78

Various Interensts

Medical Nursing Owners

Investors Patients/Family Insurance Pharmaceutical

Industry

Government Medical Education

Medical Profession

Lawyer

Etc

Bargaining / Conflict


72/78


73/78

AccessibleAppropriate to needs

Afordab le
http://www.saibaba-fund.org/images/hospital.jpghttp://www.saibaba-fund.org/images/hospital.jpg


74/78

Who is She ???


75/78


76/78


77/78

Anak Krakatau, July 2011


78/78

Documents

Phylosophy of Doctor