ACP medicine, 3rd Edition

Clinical Essentials

On Being a Physician

David C. Dale MD, FACP1

Daniel D. Federman MD, MACP2

The Carl W. Walter Distinguished Professor of Medicine and Medical Education and Senior Dean for Alumni Relations and Clinical Teaching

1University of Washington School of Medicine

2Harvard Medical School

November 2006

Almost all human societies have persons who act in the role of healer. In early societies, the function had only a minimal basis in science, and the practice of the healing arts was highly dependent on a confident, personal relationship between patient and healer. In today's society, medicine combines a progressively enriched science base with an unequaled social connectedness between physician and patient.

In the community and in the patient-doctor relationship, physicians are seen as persons skilled in the art of healing and in teaching others about health and disease. Physicians are the ones who receive the extensive training, the licensure by the state, and the approval of society to provide all levels of care: to give advice for a healthy life, examine and diagnose illness, prescribe drugs to relieve suffering, and care for those who are seriously ill and dying. Although physicians now share the many responsibilities involved in patient care with nurses, physician assistants, pharmacists, technicians, therapists, and family members of patients, it is still the physician who bears most of the responsibility for the care of the patient.

Being a patient's physician carries many responsibilities and requires at least three attributes. First, knowledge of the applicable biomedical science and clinical medicine is necessary to understand a patient's problem. There is no limit to the knowledge that may be needed, but it is important to be able to answer correctly the patient's questions, such as “How did this happen to me?” and “Will I be better soon?” The physician needs to understand disease processes well enough to identify and categorize a patient's problem quickly. It is always important, and sometimes critical, to know whether the problem will resolve spontaneously or whether detailed investigation, consultation, or hospitalization is needed. A thorough and up-to-date understanding of diagnosis and treatment is essential for the day-to-day exchange of information that occurs between physicians as they solve the problems of individual patients and work together to organize systems to improve patient care.

Second, some specific skills are necessary to diagnose and treat a patient. The ability to communicate—both to speak and to listen—is essential, especially for physicians providing primary care. Effective and sensitive communication can be challenging in communities characterized by diverse cultures and languages. This is particularly challenging in the United States, where recent waves of immigration have created a patient community that is extraordinarily diverse, both linguistically and culturally. At times, the physician must be, in part, an anthropologist to grasp the patient's understanding of illness and of the roles of patient and doctor. Knowing how to communicate empathetically is also invaluable: it is important to welcome each patient at every visit, to reach out and hold the hand of a troubled person, and to express understanding and concern. The ability to balance the time spent with the patient and the time required for organizing services for the patient in a busy practice is an increasingly important skill.

The physical examination remains a fundamental skill; the ability to recognize the difference between normal and abnormal findings, adjusting for age, sex, ethnicity, and other factors, is crucial. Good record keeping is essential—with regard to both a written record and a mental record—so that the circumstances of visits are remembered and changes in a patient's appearance or other characteristics that may not have been written down can be recognized. With practice and attention, these skills—history taking, physical examination, and record keeping—can grow throughout a professional lifetime. Other aspects of care, such as selecting and performing diagnostic tests, procedures, and treatments, require evolving expertise. For all physicians, it is necessary both to practice medicine and to study regularly to maintain all of these essential skills.

The third, but by no means least important, attribute is the physician's responsibility to the patient and the medical community to conform to appropriate professional and ethical conduct. The first principle of the doctor-patient relationship is that the patient's welfare is paramount. Putting the patient first necessitates understanding the patient and the patient's values. It often means spending precious personal time explaining illness, determining the best method of treatment, or dealing with emergencies. It places the physician in service to the patient. Ethical conduct includes seeing clearly and acknowledging situations in which the physician's interest may conflict with the interest of the patient. Ethical conduct also requires recognizing and acknowledging conflicts of interest in profiting from the prescribing of services and treatments, in ownership of equities and properties, and in personal and business relationships. Finally, personal exploitation of the intimacy and privacy of the doctor-patient relationship is never allowed. The reassertion of professionalism and of medicine's core ideals has never been more important than in the context of today's constantly changing medical practice.

Almost daily there is new information regarding basic disease mechanisms and new therapies; these advances require us to reconsider how we diagnose and treat both common and rare diseases. The Internet has made available to any computer-savvy patient all the medical information formerly held by doctors; the abundance of information—and, in some cases, misinformation—challenges physicians to be more knowledgeable than any previous generation of medical practitioners.

Population growth, poverty, and emerging infectious diseases, as well as physical inactivity, dietary changes, and obesity, are problems that increase the worldwide burden of illness; these factors have immense implications for the medical profession—both the overall practice of medicine and the work of individual physicians. The aging of the United States? population and the corresponding increase in the prevalence of chronic disease have created new demands that health care be delivered by teams of physicians and other health providers.

The way that hospitals and clinics are organized, how we pay for health care, and how our services are evaluated are also changing. The aggregation of physicians and patients into large organizations places a premium on new systems of behavior, consultation, and communication. The limited supply of resources such as transplantable organs and ICU beds requires new training in distributive ethics. The emphasis on the control of risk factors for disease has allied physicians and their patients in initiatives to prevent or minimize morbidity and mortality.

If some changes in health care are challenging, others promise to benefit physicians by allowing the work of healing to be done with greater ease and precision. New information technologies aid the physician in accessing new findings and updating medical records. Application of discoveries from basic sciences and the human genome project permit a diagnosis to be more precise and treatment more specific. Increased understanding of normal physiology and disease processes has prompted development of new drugs and vaccines. Such benefits have added to the costs and the potential costs of almost every aspect of health care.

Efficiency and cost containment are now watchwords of the payers for health services. Practice guidelines, hospital care pathways, and other efforts to codify the practice of medicine are receiving much attention. When based on good evidence, these efforts are beneficial; they save precious resources—time and money—for both patients and physicians. The development of managed care in the United States has created a new challenge for physicians: to serve as advocates for their patients. In this role, physicians are responsible for overcoming organizational, geographic, and financial barriers to the provision of services that are important for their patients. In organizations in which guidelines for care have been established, it may be necessary for a physician to explain to administrators the specific needs and problems of individual patients—sometimes over and over again, because laypersons may be less apt to recognize that guidelines for clinical practice must remain simply guidelines. Because more and more physicians are salaried and thus bound to the needs of populations of patients, physicians face the problem of balancing the needs of individual patients with the expectations of the employer. This is a delicate and, in some places, even fragile balance. To serve both patients and the employer well, a physician must develop good judgment in managing patient care under conditions in which the allocation of resources is conservative.

The increasing organization of health care on a for-profit basis has raised new issues. The physician's obligation to put the patient first and the increasing costs of diagnostic tests and therapies can collide head-on with health care management's attempts to protect earnings for investors. Professional responsibility to patients and the public good is clear and at times poses difficult challenges for the physician.

A profession is defined by a specialized body of knowledge requiring advanced training and the dedication of its practitioners to the public good over their own enrichment. In exchange, professionals are granted considerable autonomy in setting standards and in the conduct of their work. Circumstances within the medical profession have changed. The public in general and patients in particular have much more knowledge of medicine than at any time in the past, and the modern organization of medicine has severely restricted the autonomy of physicians. But delivery of expert medical care and the welfare of the patient remain central to the physician's professional responsibility. The weight of all these responsibilities may suggest that it is impossible, or nearly impossible, to be a good physician. Quite the contrary; persons with vastly different personalities, interests, and intellects have become and are becoming good physicians and are deeply satisfied in this role. The information necessary for practicing medicine is now more accessible than ever before. The skills the physician needs can be learned through experience, sharpened through practice, and focused through specialization. The ethical requirements of physicians are not onerous. They are, in fact, expectations of all good citizens, regardless of their careers. Being a physician is both exciting and satisfying; it provides a unique opportunity to combine modern scientific knowledge with the traditions of an ancient and honored profession in serving and helping one's fellow man.

ACP Medicine is written and edited by physicians to help other physicians meet the ideals enunciated in this introduction. A principal goal ofACP Medicine is to be the most up-to-date textbook of medicine available. The Clinical Essentials section presents the contemporary skills and knowledge needed by all physicians to encourage and maintain good health, analyze medical information, deal compassionately with the end of life, and understand issues of medical ethics. The other sections organize and summarize the most important information on pathophysiology, diagnosis, and treatment for most problems encountered in practicing medicine for adults from general and specialty journals, as interpreted by experienced clinicians. The material is evidence-based, with extensive bibliographic citations that are updated regularly. Authors are selected who understand both the constraints of managed care and the quality of care that is possible with scientific advances. In short, ACP Medicine is committed to conveying the information necessary for physicians to provide excellent care to their patients.

Editors: Dale, David C.; Federman, Daniel D.