Medicine

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The ancient Greek symbol today associated with medicine the world over: the rod of Asclepius with its encoiled serpent. The World Health Organization, the Royal Society of Medicine, the American Medical and Osteopathic Associations, the British and the Australian Medical Associations are some of the bodies that incorporate it in their insignia.

Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore 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.[1][2]

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. [3]

Contents

[edit] History

The ancient Sumerian god Ningishzida, the patron of medicine, accompanied by two gryphons. It is the oldest known image of a caduceus, the symbol of medicine in the form of two snakes coiled around an axial rod. It dates from more than 4000 years ago

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 and ancient Greek medicine. Early Greek doctor Hippocrates, who is also called the Father of 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.

An ancient Greek patient gets medical treatment: this aryballos (circa 480-470 BCE, now in Paris's Louvre Museum, probably contained healing oil

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.

Modern scientific biomedical research (where results are testable and reproducible) began to replace early Western traditions based on herbalism, the Greek "four humours" and other such pre-modern notions. The modern era really began with Robert Koch's discoveries around 1880 of the transmission of disease by bacteria, and then the discovery of antibiotics 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.

The Persian philosopher Avicenna, sometimes called the Father of Modern Medicine. His Canon of Medicine, written during the Islamic Golden Age, probed the nature of contagious disease, identified anaesthetics and medicinal drugs, introduced quarantine and experimental medicine, and even the idea of clinical trials

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]

[edit] Clinical practice

Girl having her head bandaged, as depicted by the portraitist Henriette Browne (1829-1901)

In clinical practice doctors personally assess patients in order to diagnose, treat, and prevent disease using clinical judgment. The doctor-patient relationship typically begins an interaction with an examination of the patient's medical history and medical record, followed a medical interview[11] and a physical examination. Basic diagnostic medical devices (e.g. stethoscope, endoscope) are typically used. After examination for signs and interviewing for symptoms, the doctor may order medical tests (e.g. blood tests), take a biopsy, or prescribe pharmaceutical drugs or other therapies. Differential diagnosis methods help to rule out conditions based on the information provided. During the encounter, properly informing the patient of all relevant facts is an important part of the relationship and the development of trust. The medical encounter is then documented in the medical record, which is a legal document in many jurisdictions.[12] Followups may be shorter but follow the same general procedure.

The components of the medical interview[11] and encounter 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:

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.

[edit] Institutions

Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations. The characteristics of any given health care system have significant impact on the way medical care is provided.

Advanced industrial countries (with the exception of the United States) [13][14] and many developing countries provide medical services though a system of universal health care which aims to guarantee care for all through a single-payer health care system, or compulsory private or co-operative health insurance. This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay. Delivery may be via private medical practices or by state-owned hospitals and clinics, or by charities; most commonly by a combination of all three.

Most tribal societies, but also some communist countries (e.g. China) and the United States,[13][14] 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.

Modern drug ampoules

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 [15], 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.

[edit] Delivery

Provision of medical care is classified into primary, secondary and tertiary care categories.

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.

[edit] 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:

[edit] Basic sciences

[edit] 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.

[edit] 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,Transplant 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)[16], 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.

[edit] 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 three 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.

[edit] Diagnostic specialties

[edit] Other

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

[edit] Interdisciplinary fields

Interdisciplinary sub-specialties of medicine are:

[edit] Education

Painted by Toulouse-Lautrec in the year of his own death: an examination in the Paris faculty of medicine, 1901

Medical education and training varies around the world. It typically involves entry level education at a university medical school, followed by a period of supervised practice or internship, and/or residency. This can be followed by postgraduate vocational training. A variety of teaching methods have been employed in medical education, still itself a focus of active research.

Many regulatory authorities require continuing medical education, since knowledge, techniques and medical technology continue to evolve at a rapid rate.

[edit] Legal controls

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 or intentionally harmful in their care of patients can face charges of medical malpractice and be subject to civil, criminal, or professional sanctions.

[edit] Controversy

The 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 and rendered many people in effect lifelong patients. He marshalled a body of statistics to show what he considered the shocking extent of post-operative side-effects and drug-induced illness in advanced industrial society. He was the first to introduce to a wider public the notion of iatrogenic disease. [17] Others have since voiced similar views, but none so trenchantly, perhaps, as Illich. [18]

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.[citation needed] 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.[19]

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 is recognized 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. Clinical versus statistical, algorithmic diagnostic methods were famously examined in psychiatric practice in a 1954 book by Paul E. Meehl, which controversially found statistical methods superior.[20] A 2000 meta-analysis comparing these methods in both psychology and medicine found that statistical or "mechanical" diagnostic methods were generally, although not always, superior.[20]

Disparities in quality of care given are often an additional cause of controversy.[21] For example, elderly mentally ill patients received poorer care during hospitalization in a 2008 study.[22] Rural poor African-American men were used in a study of syphilis that denied them basic medical care.

[edit] See also

[edit] References

  1. ^ Etymology: Latin: medicina, from ars medicina "the medical art," from medicus "physician."(Etym.Online) Cf. mederi "to heal," etym. "know the best course for," from PIE base *med- "to measure, limit. Cf. Greek medos "counsel, plan," Avestan vi-mad "physician")
  2. ^ "Medicine" Online Etymology Dictionary
  3. ^ Culliford Larry (December 2002). "Spirituality and clinical care (Editorial)". British Medical Journal 325 (7378): 1434. doi:10.1136/bmj.325.7378.1434. PMID 12493652. 
  4. ^ Useful known and unknown views of the father of modern medicine, Hippocrates and his teacher Democritus., U.S. National Library of Medicine
  5. ^ The father of modern medicine: the first research of the physical factor of tetanus, European Society of Clinical Microbiology and Infectious Diseases
  6. ^ Becka J (1980). "The father of medicine, Avicenna, in our science and culture: Abu Ali ibn Sina (980-1037) (Czech title: Otec lékarů Avicenna v nasí vĕdĕ a kulture)" (in Czech). Cas Lek Cesk 119 (1): 17–23. PMID 6989499. 
  7. ^ Medical Practitioners
  8. ^ Martín-Araguz A, Bustamante-Martínez C, Fernández-Armayor Ajo V, Moreno-Martínez JM (2002-05-01—15). "Neuroscience in al-Andalus and its influence on medieval scholastic medicine" (in Spanish). Revista de neurología 34 (9): 877–892. PMID 12134355. 
  9. ^ Medieval Sourcebook: Usmah Ibn Munqidh (1095-1188): Autobiography, excerpts on the Franks
  10. ^ Ezzo J, Bausell B, Moerman DE, Berman B, Hadhazy V (2001). "Reviewing the reviews. How strong is the evidence? How clear are the conclusions?". Int J Technol Assess Health Care 17 (4): 457–466. PMID 11758290. 
  11. ^ a b Coulehan JL, Block MR (2005). The Medical Interview: Mastering Skills for Clinical Practice (5th ed.). F. A. Davis. ISBN 0-8036-1246-X. OCLC 232304023. 
  12. ^ Addison K, Braden JH, Cupp JE, Emmert D, et al. (AHIMA e-HIM Work Group on the Legal Health Record) (September 2005). "Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes". Journal of AHIMA 78 (8): 64A–G. PMID 16245584. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921. 
  13. ^ a b Insuring America's Health: Principles and Recommendations, Institute of Medicine at the National Academies of Science, 2004-01-14
  14. ^ a b The Case For Single Payer, Universal Health Care For The United States
  15. ^ Martin Sipkoff (January 2004). "Transparency called key to uniting cost control, quality improvement". Managed Care. http://www.managedcaremag.com/archives/0401/0401.forum.html. 
  16. ^ Dorsey, et al., "Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students
  17. ^ Illich Ivan (1974). Medical Nemesis. London: Calder & Boyars. ISBN 0714510963. OCLC 224760852. 
  18. ^ [[Neil Postman |Postman Neil]] (1992). Technopoly: The Surrender of Culture to Technology. New York: Knopf. OCLC 24694343. 
  19. ^ The HealthWatch Award 2005: Prof. Edzard Ernst, Complementary medicine: the good the bad and the ugly. Retrieved 5 August 2006
  20. ^ a b Grove WH, Zald DH, Lebow BS, Snitz BE, Nelson C. (2000). "Clinical versus mechanical prediction: A meta-analysis" (w). Psychological Assessment 12 (1): 19–30. doi:10.1037/1040-3590.12.1.19. http://www.psych.umn.edu/faculty/grove/096clinicalversusmechanicalprediction.pdf. 
  21. ^ "Eliminating Health Disparities". American Medical Association. http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities.shtml. 
  22. ^ [[1] "Mental Disorders, Quality of Care, and Outcomes Among Older Patients Hospitalized With Heart Failure"]. [2]. 

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