Phylosophy of Medical Profession

The Demand Side

Patients demand for treatment Physician as decision maker

The Supply Side

MARKET ECONOMY

Demand for institutional setting

Prices and quantity of services

Supply of institutional settings

An Overview of the Medical Care Sector

Feldstein. Healt Care Economics, 1988

The Demand Side

Patients demand for treatment Physician as decision maker

The Supply Side

Insurance Company

Demand for institutional setting

MARKET ECONOMY Reregulation

Prices and quantity of services

Supply of institutional settings

An Overview of the Medical Care Sector

Feldstein. Healt Care Economics, 1988

Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the U.S. Congress, the Food and Drug Administration, academic medical centers, and the medical profession itself. (Most of its marketing efforts are focused on influencing doctors, since they must write the prescription)
Marcia Angell, M.D., Former editor in chief of The New England Journal of Medicine Winner of the Polk Award

Professional Responsibility Violations (in general)

Conflicts of interest Mishandling of client Disclosure of confidential information

Twee koetsiers op een bok, dit gaat niet, zeiden deze geneeshecren.Typisch symptoom van mata doewiten".Want, het moet gezegd worden,vele lnlandsehe geneeskundigcnwer =den door deze dokteren gebezigd als apothekers en daardoor ontbrakhen de gelegenheid er wat bij te verdienen. Het armzalig tractementvan f fo. toch maakte dat stellig noodzakelijk.

Phylosophy : "love of wisdom"

Greek

Six of the values that commonly apply to medical ethics discussions are:
1. 2. 3. Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) Non-maleficence - "first, do no harm" (primum non nocere). Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.) Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality). Dignity - the patient (and the person treating the patient) have the right to dignity. Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study.

4.
5. 6.

No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding. . ..
Harrison's Principles of Internal Medicine, 1950

The Doctor for the 21st Century

Promote health, prevent and treat disease, and rehabilitate the disable in a compassionate, ethical way (within resources constrain) Providers of primary care Communicators Critical thinkers Motivated life-long learners Information specialist Citizen of the World Practitionars of applied economics, sociology, anthropology, epidemiology and behavioural medicine Health team managers Advocate for communities
World Summit on Medical Education 1993

World Summit on Medical Education : The Changing Medical

Profession

RECOMMENDATION Edinburg 8 12 August 1993

Hippocratic Oath
A 12th century Bysanthine manuscript of the Oath

Hipocrates Oath I swear by Apollo, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath

PP 26/1960, LAFAL SUMPAH DOKTER Oleh: PRESIDEN REPUBLIK INDONESIA Nomor:26 TAHUN 1960 (26/1960) Tanggal:2 JUNI 1960 (JAKARTA)

"Saya bersumpah/berjanji bahwa:

Saya akan membaktikan hidup saya guna kepentingan perikekemanusiaan; Saya akan menjalankan tugas saya dengan cara yang berhormat dan bersusila, sesuai dengan martabat pekerjaan saya; Saya akan memelihara dengan sekuat tenaga martabat dan tradisi luhur jabatan kedokteran; Saya akan merahasiakan segala sesuatu yang saya ketahui karena pekerjaan saya dan karena keilmuan saya sebagai Dokter; Kesehatan penderita senantiasa akan saya utamakan; Dalam menunaikan kewajiban terhadap penderita" saya akan berikhtiar dengan sungguh-sungguh supaya saya tidak terpengaruh oleh pertimbangan Keagamaan, Kebangsaan, Kesukuan, Politik Kepartaian atau Kedudukan Sosial; Saya akan memberikan kepada Guru-guru saya penghormatan dan *14128 pernyataan terima kasih yang selayaknya; Teman-sejawat saya akan saya perlakukan sebagai saudara kandung; Saya akan menghormati setiap hidup insani mulai dari saat pembuahan; Sekalipun diancam, saya tidak akan mempergunakan pengetahuan Kedokteran saya untuk sesuatu yang bertentangan dengan hukum perikemanusiaan; Saya ikrarkan sumpah ini dengan sungguh sungguh dan dengan mempertaruhkan kehormatan diri saya"

Ditetapkan di Jakarta pada tanggal 2 Juni 1960. Pejabat Presiden Republik, Indonesia, DJUANDA Diundangkan di Jakarta pada tanggal 2 Juni 1960. Menteri Kehakiman, SAHARDJO

The Medical Practice

Good Medical Practice

Patient Safety

Good Clinical Practice

Good Medical Practice

Patients are entitled to good doctors..

Patients must be able to trust doctors with their lives and wellbeing..

Good Doctors
Good doctors make the care of their patients their first concern, they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.

Good medical practice sets out the principles and values on which good practice is founded. The guidance is addressed to doctors, but is also intended to let the public know what they can expect from doctors

The doctor-patient relationship

Explain the benefits to patients and others of being the subject of education and rsearch, but respect their right to decline to take part in those activities

Management Decisions about access to medical care

A responsibility to the community at large to foster the proper use of resources

Use resources efficiently, consistent with good patient care

Scholarship
Research Keeping up to date Maintaining and improving your performance

 Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future. This is regarded as an integral part of professional practice If you are involved in teaching you must develop the attitudes, awareness and knowledge, skills and practices of a competent teacher

DOCTOR = DOCERE

Collaboration
Working in teams Arranging cover The central role of the general practitioner Delegation and referral Working with colleagues

Informed Consent

Fundamental Elements For Disclosure To Patients

Diagnosis and prognosis Nature of proposed intervention Reseonable alternative intervention Risk associated with each alternative intervention Benefits associated with each alternative intervention Probable outcomes of each alternative intervention

Professionalism
Competence Honesty with patients Patients confidentiality Maintain appropriate relations with patients Improving the quality of care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflict of interest
Brennan T et al. Ann Intern Med 2002; 1136: 243-246

The Twenty-First-Century Physician: Expanding Frontiers The era of "omics": genomics, epigenomics, proteomics, microbiomics, metagenomics, metabolomics
Harrisons Principles of Intermal Medicine

Logic in Medicine & Medical Decision Making

WHO ARE YOU ?

Medicine (Kedokteran) The Science & The Art

Science (Ilmu) ? Knowledge (Pengetahuan) ? Scientific methode ?

Medical knowledge is a scientific knowledge

Doctor vs Witch doctor ? Physician - scientist

Medicine
The Science : Diagnostic process The Art : Clinical process

Methods of Finding the Scientific Truth(s)

 Rasional - Empirical Deductive Inductive Deducto hypothetico - verivicative

Diagnostic Process is a scientific process

(Differential) Diagnosis, like scientific research is based on methode of hypothesis formulation

Scientific Method (Rasionalism+ Empirisism)

Problem statement Data collection Data classification Hypothesis formulation Testing the hypothesis

Deduction and Induction

The Scientific Process

Diagnosis
Problem (illnesss)
Data collecting & data analysis Hypothesis formulation & differential diagnosis Hypothesis (diagnosis) proven or unproven (probability) New Problems

Research
Research Question (s) /Problem ? Data collecting & data analysis Hypothesis formulation Ho/H1 Working hypoth. Hypothesis accepted or rejected (probability)
New Research Questions

Various Interensts
Medical Nursing Owners Investors Patients/Family Insurance Pharmaceutical Industry Government Medical Education Medical Profession Lawyer Etc

Bargaining / Conflict

Medical care is often said to be the art of making decision without adequate information Harold C. Sox
Probabvility : quantifying the uncertainty

DATA
Infinite data case sampling Operational definition Probabilistic concept Accuracy

Precision
Sensitivity Specivicity Predictive value (+/-) Bayes theorem

Ilness(es) vs Disease(s) ??

Illness
The totality of signs (objective findings) and symptomps (subjective feelings) that characterize a single (individuals) patient to an etiologic agent (i.e. infection) Each such illness is unique, it happens to single individual over a restricted time period of time and will never happen again in precisely the same way
Delp and Manning,1981

Illness
Illness is a process

Tuberculosis the illness : is the patients reaction, not merely a tissue reaction

Delp and Manning,1981

Disease
Disease do not exist in reality, they are abstraction Tuberculosis is defined variously by medical scientist (clinician as well as basic scientist) i.e. :
Delp and Manning,1981

 In pathology we study disease in clinical training we work with illness Ideally, the physician should think in terms of both disease and illness Educational separation of disease and illness creates obstacles that can be overcome by conscious effort
Delp and Manning,1981

Evidence Base Medicine

Clinical Evidence & Circumstances

Evidence from Research

Patients Preferences, Values, and Rights

 in any dynamic society the only constant is change . .not all the changes are brought by the discoveries of the sicentist and the advances made by techologists. Some have economic roots and some stems from aspects of man unconquerable mind from the desire for social equity, a hatred of injustice, a wish to help the sick and disadvantage, or a simple love of humanity.

Medicine is advancing more rapidly than the capacity of statemen and administrators to deal with .
Roberts S. The Cost of Health. Turnstile Press London, 1958.

 health is a basic human entitlement, to which all should have equal access and equal right
Paine and Tjam. WHO 1988

 health is a political issue and those enjoying care do not want to share it ..
Both in the underdeveloped and the developed world the medical contribution is largely inappropriate to health need and does not cope with helath problems of the vast majority
gap between health care and medical care has become even wider
Most illness has its origins in social condition

 the restricted ability of the poor to fullfill their needs for health care, for they are not in a position, economically or politicallyexcept possibly of the traditional type. In South Africa , infant mortality rates are roughly sixtimes as high for blacks and coloureds as they are for whites

in other underdeveloped countries the poor and the rich are not distinguished by the color of their skin
.. No recorded infant mortality rates for poor and rich, but rather rates for the population as a whole Indonesia ?

A safe water supply makes a major contribution to health

Adequate nutrition as a prerequisite for health

the success stories of better health in underdeveloped countries have had more to do with changed economic and political systems and improved nutrition, water provision, and sanitation than with technological modern medicine

Agriculter and health are two closely related factors

Environmental condition have major impact in health

 doctors and other professional health workers playing a major and essential role, but not necessarily the predominant one

MEDICAL TECHNOLOGY

these technological
innovations have had only marginally effects, while others have had no effect at all, and some have had negative ones
medical students are (usually) trained to pursue a technological imperative, to use any available technique of intervention

...The economies of underdeveloped countries have becoming increasingly controlled by huge foreignowned enterprises in alliance with a local rulling class..
Sanders & Carver. The Struggle for Health. Macmilland Education, London 1985. Paine and Tjiam. Hospitals and the Health care revolution, WHO 1988.

Market imperfections and Market failure

In situation of natural monopoly, competition cannot exist

Social and Economical Context ? Integration to Health Care Services ? Interests ? Which side ?

Various Interensts
Medical Nursing Owners Investors Patients/Family Insurance Pharmaceutical Industry Government Medical Education Medical Profession Lawyer Etc

Bargaining / Conflict

The Real Purpose of Health Care ? Political, Social and Economical

Context ?

Sickness care system ? Health care system ?

Appropriate to needs

Accessible

Afordable

Who is She ???

MOST BEATIFUL TRANS-SEXUAL

She is a MAN. The most beautiful trans-sexual who won Ms. Tiffany 1999 contest

Anak Krakatau, July 2011