On Being a Physician

Medical practice is constantly changing. Almost daily there is important new information regarding basic disease mechanisms and new therapies. There is a constant need to reconsider how we diagnose and treat both common and rare diseases. The way that hospitals and clinics are organized, how we pay for health care, and how our services are evaluated are also changing. The future promises more changes, some of which will undoubtedly increase the burden of illness and the work for physicians. Population growth, poverty, and emerging infectious diseases, as well as inactivity, dietary changes, and obesity, are worldwide problems that have immense medical implications. Other changes are coming rapidly that should improve health care and be helpful to physicians—new information technologies to aid in obtaining current medical information and record keeping, applications of discoveries from basic sciences and the human genome project to make diagnosis more precise and treatments more specific, and the development of new drugs and vaccines on the basis of increasing understanding of normal physiology and disease processes.

Although change is a watchword for medicine, many aspects of medicine are not changing rapidly; some of these are the most important and most satisfying aspects of being a physician. In the community and in the patient-doctor relationship, physicians are still seen as persons skilled in the art of healing and in teaching others about health and disease. Physicians are still the ones who receive the extensive training, the li-censure by the state, and the approval of society to provide all levels of care: to give advice for a healthy life, to examine and diagnose illness, to prescribe drugs to relieve suffering, and to care for those who are seriously ill and dying. Although physicians now share the many responsibilities involved in patient care and work closely 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 important, and sometimes critical, to know whether the problem will resolve spontaneously or whether detailed investigations, consultations, 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. 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 empathically 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 recorded 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, ownerships of equities and properties, and personal and business relationships. Finally, personal exploitation of the intimacy and privacy of the doctor-patient relationship is never allowed.

Thus, the work of the physician—recognizing illness, providing advice and comfort, relieving pain and suffering, and dealing with illness and death—has not changed much even since ancient times. On another level, however, the work has changed greatly. Better medical record keeping, quantitative observation, meticulous experimentation, and carefully conducted clinical trials have contributed to the rapid evolution of medical practice in this century. Simultaneously, medical education at the undergraduate, graduate, and postgraduate levels has been dedicated to the organization of a truly scientific knowledge base and its translation into intellectually cohesive approaches to understanding disease. Extraordinary advances in the biologic sciences, the development of medical and surgical specialties, and the explosion of medical information have brought with them great benefits. They have also 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 service. 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—some-times over and over again, because laypersons may be less apt to recognize that guidelines for clinical practice must remain just 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, the thoroughness inculcated in physicians throughout their training, 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 by 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. Maintaining professionalism as the ground moves under us is more important than ever.

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.The section Clinical Essentials presents the contemporary skills and knowledge needed by all physicians to encourage and maintain good health, to analyze medical information, to deal compassionately with the end of life, and to 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.

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