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Medicine

The Rod of Asclepius, with its single snake, is an ancient Greek symbol associated with medicine. The American Medical Association, the American Osteopathic Association, the Royal Society of Medicine, the Australian Medical Association, the British Medical Association, and the World Health Organization display the Rod of Asclepius in their logos or emblems.
The Rod of Asclepius, with its single snake, is an ancient Greek symbol associated with medicine. The American Medical Association, the American Osteopathic Association, the Royal Society of Medicine, the Australian Medical Association, the British Medical Association, and the World Health Organization display the Rod of Asclepius in their logos or emblems.

Medicine is the science and "art" of maintaining and/or restoring human health through the study, diagnosis, and treatment of patients. The term is derived from the Latin ars medicina meaning the art of healing.[1][2]

The modern practice of medicine occurs at the many interfaces between the art of healing and various sciences. Medicine is directly connected to the health sciences and biomedicine. Broadly speaking, the term 'Medicine' today refers to the fields of clinical medicine, medical research and surgery, thereby covering the challenges of disease and injury.

History of medicine

Physician treating a patient. Louvre Museum, Paris, France.
Physician treating a patient. Louvre Museum, Paris, France.
Main article: History of medicine

The earliest type of medicine in most cultures was the use of empirical natural resources like plants (herbalism), animal parts and minerals. In all societies, even in Western ones, there were also religious, ritual and magical resources. In aboriginal societies, there is a large scope of medical systems related to religious thinking, cultural experience, and natural resources. The religious ones more known are : animism (the notion of inanimate objects having spirits); spiritualism (here meaning an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (the supposed obtaining of truth by magic means). The field of medical anthropology studies the various medical systems and their interaction with society, while prehistoric medicine addresses diagnosis and treatment in prehistoric times.

The practice of medicine developed gradually in ancient Egypt, Babylonia, India, China, Greece, Persia, the Islamic world, medieval Europe, and elsewhere. Medicine as it is now practiced largely developed during the Middle Ages and early modern period in Persia (Rhazes and Avicenna), Spain (Abulcasis and Avenzoar), Syria/Egypt (Ibn al-Nafis, 13th century), England (William Harvey, 17th century), Germany (Rudolf Virchow, 19th century) and France (Jean-Martin Charcot, Claude Bernard and others). The new "scientific" or "experimental" medicine (where results are testable and repeatable) replaced early Western traditions of medicine, based on herbalism, the Greek "four humours" and other pre-modern theories.

The Sumerian god Ningizzida was the patron of medicine. In the image he is accompanied by two gryphons. It is the oldest known image of snakes coiling around an axial rod, dating from before 2000 BCE. A similar image with two snakes coiling around a rod is called the Caduceus and, although historically inappropriate, appears in the logo/emblem of a significant number of private (rather than professional or academic) medical practices.
The Sumerian god Ningizzida was the patron of medicine. In the image he is accompanied by two gryphons. It is the oldest known image of snakes coiling around an axial rod, dating from before 2000 BCE. A similar image with two snakes coiling around a rod is called the Caduceus and, although historically inappropriate, appears in the logo/emblem of a significant number of private (rather than professional or academic) medical practices.

The focal points of development of clinical medicine shifted to the United Kingdom and the USA by the early 1900s (Canadian-born) Sir William Osler, Harvey Cushing). Possibly 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, Galen and Avicenna), many of whose theories were in time discredited. Such new attitudes were made possible in Europe by the weakening of the Roman Catholic church's power in society, especially in the Republic of Venice.

Evidence-based medicine is a recent movement to establish the most effective algorithms of practice (ways of doing things) through the use of the scientific method and modern global information science by collating all the evidence and developing 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.

Drug ampoules
Drug ampoules

Genomics and knowledge of human genetics is already 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 practice and decision-making.

Pharmacology has developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). 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 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. The first major class of antibiotics was the sulfa drugs, derived by French chemists originally from azo dyes. Throughout the twentieth century, major advances in the treatment of infectious diseases were observable in (Western) societies. The medical establishment is now developing drugs targeted towards one particular disease process. Thus drugs are being developed to minimise the side effects of prescribed drugs, to treat cancer, geriatric problems, long-term problems (such as high cholesterol), chronic diseases type 2 diabetes, lifestyle and degenerative diseases such as arthritis and Alzheimer's disease.

Practice of medicine

Artificial biomedical insemination
Artificial biomedical insemination

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 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 enquiry, 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.[3]

Health care 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 health 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 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 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.

Health care delivery

See also: clinic, hospital, and hospice
Painting of Henriette Browne
Painting of Henriette Browne

Medical care delivery is classified into primary, secondary and tertiary care.

Primary care medical services are provided by physicians or other health professionals who have first contact with a patient seeking medical treatment or care. These occur in physician offices, clinics, nursing homes, schools, home visits and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes.

Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.

Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.

Modern medical care also depends on information - still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.

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

Main articles: Medical history and Physical examination

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.[4]

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 (DHx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies such as St John's wort. 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, 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 of medicine

Asclepius was the demigod of medicine, and the Rod of Asclepius with its single snake, is an ancient Greek symbol associated with medicine. The American Medical Association, the American Osteopathic Association, the Royal Society of Medicine, the Australian Medical Association, the British Medical Association, and the World Health Organization display the Rod of Asclepius in their logos or emblems.
Asclepius was the demigod of medicine, and the Rod of Asclepius with its single snake, is an ancient Greek symbol associated with medicine. The American Medical Association, the American Osteopathic Association, the Royal Society of Medicine, the Australian Medical Association, the British Medical Association, and the World Health Organization display the Rod of Asclepius in their logos or emblems.

Working together as an interdisciplinary team, many highly trained health profession also besides medical practitioners are involved in the delivery of modern health care. Some examples include: nurse(s) 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 and psychology, while separate disciplines from medicine, are considered medical fields.

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

Medical specialties

Main article: Medical speciality

In the broadest meaning of 'medicine', there are many different specialties, which additionally have many sub-specialties. However, within medical circles, medicine usually denotes doctors that specialise in one internal medicine specialties, as opposed to surgery or radiology. The various specialties can be categorised thus:

  • Surgical specialities - the use of manually operative and instrumental techniques to treat disorders.
  • Internal medicine - concerns the diagnosis and nonsurgical treatment of diseases in adults, especially of internal organs.
  • Diagnostic specialties, rather examines disorders (especially imaging specialities) than directly attempts to cure.
  • Anaesthetics - specialise in anaesthetising patients for procedures and optimising analgesia

Surgical

Surgical specialties employ operative treatment. Some disciplines are highly specialized and are often not considered subdisciplines of surgery, although their naming might suggest so.

It has many subspecialties, e.g. general surgery, cardiovascular surgery, maxillofacial surgery, orthopedic surgery, otolaryngology, plastic surgery, oncologic surgery, vascular surgery, Neurosurgery and pediatric surgery.

In some centres, anesthesiology is part of the division of surgery (for logistical and planning purposes), although it is not a surgical discipline.

Internal 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, gynaecology and obstetrics, and psychiatry. Practitioners of such specialties are referred to as Physicians. There are several subdisciplines of internal medicine:

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:

  


 
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