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Being a doctor

Being a doctor

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Being a doctor

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  1. Being a doctor

  2. Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult. It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well and the circumstances must be favourable. Aphorisms: Hippocratic Writings, Penguin Books, 1983, page 206

  3. Three Paradoxes • Doctors have never before been able to do so much for patients but doctors are still criticised and unhappy • Society has never spent so much on health care but health care is still short of resources • People have never lived so long but the prevalence of disease and disability has never been higher

  4. THE IMPLICATIONS OF MODERN MEDICAL PRACTICE Before Simple, ineffective, and safe (mystical authority) Now Complex, effective, and dangerous (partnership)

  5. The Role of Doctors • Diagnosis and Treatment: Need for a broad and deep scientific education • Caring: Understanding humanity through education and reflective practice and with well developed communication skills • Research: Basic, clinical and population based • Leadership: Learning to work in and with multidisciplinary teams • Management: Taking responsibility for individual patients,population health and the delivery of health care

  6. DIAGNOSIS • What is wrong • Why is it wrong

  7. WHAT IS WRONG? • WHY IS IT WRONG? • WHAT CAN BE DONE? • WHAT SHOULD BE DONE? • WHO SHOULD DO IT? • WHAT CAN I EXPECT?

  8. What can be done: Integrative MedicinePatient-centered care and focuses on healing the whole person – mind, body and spirit in the context of community. Educates and empowers people to be active participants in their own care, and to take responsibility for their own health and wellness.Integrates the best of Western scientific medicine with a broader understanding of the nature of illness, healing and wellness.Makes use of all appropriate therapeutic approaches and evidence-based global medical modalities to achieve optimal health and healing.Encourages partnerships between the provider and patient, and supports the individualization of care.Creates a culture of wellness. Bravewell Collaborative. 2008. Definition of integrative medicine. http://www.bravewell.org/integrative_medicine/integrative_care

  9. What should be done • Depends on patients circumstances medical and social • Involves discussions between the whole health care team • Needs to be informed by community knowledge • Cost as well as clinically efficient • Involves discussions with the patient and family • Above all the patient must decide and have the necessary understanding to make choices

  10. First of all I would define medicine as the complete removal of the distress of the sick, the alleviation of the more violent diseases and the refusal to undertake to cure cases in which the disease has already won the mastery, knowing that everything is not possible to medicine. The Science of Medicine:Hippocratic Writings, Penguin Books 1983, page 140

  11. Who should make treatment decisions?Gallup telephone survey of 1,008 adults in UK, Aug 2002

  12. Difference between preferred and actual place of deaths 57 SE London National Preference* Preferences for place of deaths may change with altered circumstances, e.g., difficult symptoms, lack of particular help at home etc. • SE London has a high share of deaths in hospitals • Given patient preferences, there seems to be a discrepancy between place of death and patient preference, mainly: • Hospital to home setting • Hospital to hospice setting -58 +37 +20 Hospital Hospice/ specialist palliative care centre Care home Home * Values have been scaled up to allocate 5% not accounted for in originally reported data, 2% on hospital, 1% on each of other three groups Source: England, Wales and Scotland (2000); Telephone survey; Priorities and preferences for end of life care in England, Wales and Scotland (2003) Telephone Survey NCHPCS/ Cicely Saunders Foundation; National statistics 2003 15

  13. END OF LIFE End of Life Service Provider (ELSP) will: Offer opportunity to join the care at EOL register Provide for a structured conversation about preferences, support and anticipatory planning Provide comprehensive information concerning services and support for the person and carers A comprehensive care plan A single point of contact e.g. via an 0800 number

  14. JAMA, November 8, 2006 Vol 296 2255-2258

  15. Introduction of shared electronic records: multi-site case study using diffusion of innovation theory Trisha Greenhalgh, Katja Stramer, Tanja Bratan, Emma Byrne, Yara Mohammad, Jill Russell, BMJ 2008;337:a1786

  16. PATIENT HELD RECORD WITH COPIES OF SUMMARIES, PLANS, AND LETTERS • Increase patient autonomy • Improve information availability • Facilitate electronic substitution • Facilitate patient choice in primary care

  17. The Role of Doctors Diagnosis and Treatment: Need for a broad and deep scientific education Caring: Understanding humanity through education and reflective practice and with well developed communication skills Research: Basic, clinical and population based Leadership: Learning to work in and with multidisciplinary teams Management: Taking responsibility for individual patients,population health and the delivery of health care

  18. The Hippocratic Oath I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging any man by it. Whatever I see or hear, professionally or privately which ought not to be divulged I will keep secret and tell no one.

  19. THE DUTIES OF CARE • To protect life and health • To respect autonomy • To treat justly

  20. General Medical Council (www.gmc-uk.org) • Good medical practice (2001) • Seeking patients consent (1998) • Confidentiality:Protecting and providing information (2000) • Withholding and withdrawing treatment (2002)

  21. Conscience Contract

  22. Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors. • Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well being. This purpose is realised through a partnership between the patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability. • In their day to day practice, doctors are committed to: • integrity • compassion • altruism • continuous improvement • excellence • working in partnership with members of a wider health care team • Doctors in Society, Royal College of Physicians, 2005 www.rcplondon.ac.uk

  23. The Role of Doctors • Diagnosis and Treatment: Need for a broad and deep scientific education • Caring: Understanding humanity through education and reflective practice and with well developed communication skills • Research: Basic, clinical and population based • Leadership: Learning to work in and with multidisciplinary teams • Management: Taking responsibility for individual patients,population health and the delivery of health care

  24. Clinical research

  25. Forty-two clinical cases I have written this down deliberately, believing it to be valuable to learn of unsuccessful experiences and to know the cause of their failure. Hippocrates

  26. “The chief cause of poverty in science is imaginary wealth. The chief aim of science is not to open a door to infinite wisdom but to set a limit to infinite error.” Bertolt Brecht, Galileo Quoted by Skrabanek and McCormick in Follies and Fallacies in Medicine 1989

  27. It is a bad sign in acute illnesses when the extremities become cold. Aphorisms:Hippocratic Writings,Penguin Books 1983, page 231

  28. Undetected hypovolaemia leading to Hyponatraemia and death • Intravenous fluids for seriously ill children: time to reconsider Duke T, Molyneux EM, Lancet 2003, 362, 1320-1323 • Intravenous fluids for seriously ill children Holliday MA et al, Lancet 2004, 363, 241

  29. Gene therapy for primary immunodeficiency: a clinical reality Molecular Immunology Unit – ICH Dept of Immunology – GOSH Dept of Pharmacy – GOSH Thrasher et al, American Society of Gene Therapy, Boston 2002

  30. Penicillin Quinine Smallpox vaccination Nitrous oxide, ether Antihistamines Nitrogen mustard Oral contraceptives Cervical smears X-Rays Heliobacter Polyethylene, artificial hips Aspirin Chlorpromazine Imipramine Lithium Valium Cephalosporins cyclosporin Serendipity and medical discovery Serendipity, Royston M Roberts; John Wiley and Sons Inc. 1989

  31. The Role of Doctors • Diagnosis and Treatment: Need for a broad and deep scientific education • Caring: Understanding humanity through education and reflective practice and with well developed communication skills • Research: Basic, clinical and population based • Leadership: Learning to work in and with multidisciplinary teams • Management: Taking responsibility for individual patients,population health and the delivery of health care

  32. Leadership is of the spirit, compounded of personality and vision; its practice is an art. Management is of the mind, a matter of calculation, of statistics, timetables and routine; its practice is a science. Managers are necessary, Leaders are essential Field Marshal Viscount Slim

  33. Team work,management and leadership

  34. T together E everyone Who is responsible? A achieves M more

  35. Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy

  36. Why should doctors be involved with management? • Ethical responsibility to practise with efficacy, effectiveness,efficiency,equity and economy • To maximise clinical freedom for the benefit of patients • To provide LEADERSHIP

  37. The Six E’s • EFFICACY Does the treatment work • EFFECTIVENESS How well does it work in practice (outcome) • EFFICIENCY Is maximum output obtained for minimum input • EQUITY Are those most in need receiving priority • ECONOMY Is expenditure justified compared to opportunity costs • EXCELLENCE Quality

  38. Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult. It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well and the circumstances must be favourable. Aphorisms: Hippocratic Writings, Penguin Books, 1983, page 206

  39. The organisation of healthcare

  40. 80% of health care spending is on chronic conditions which afflict 44% of the population

  41. Framework for Action • Chronic Disease Management • Access • Inequalities and Health Status