Medicine

See drugs , medication , and pharmacology for substances that treat patients. This article is aboutmedical practice.

Medicine is a branch of health science concernedwith restoring and maintaining health and wellness . Broadly, it is the practical science of preventing andcuring diseases . However, medicine often refers more specifically tomatters dealt with by physicians and surgeons .

Medicine is both an area of knowledge (a science ), and the application of thatknowledge (the medical profession). The various specialized branches of the science of medicine correspond to equally specializedmedical professions dealing with particular organs or diseases. The science ofmedicine is the body of knowledge about body systems and diseases, while the profession of medicine refers to the social structure of the group of people formally trained to apply thatknowledge to treat disease.

There are traditional and schools of healing which are usually not considered to be part of (Western) medicine in a strictsense (see health science for an overview). The most highly developedsystems of medicine outside of the Western or Hippocratic tradition are the Ayurvedic school (of India ) and traditional Chinesemedicine . The remainder of this article focuses on modern (Western) medicine.

History of medicine

See the main articles History of medicine and Timeline of medicine andmedical technology

Medicine as it is practiced now is rooted in various traditions, but developed mainly in the late 18th and early 19th century in Germany ( Rudolf Virchow ) and France ( Jean-MartinCharcot and others). The new, "scientific" medicine replaced more traditional views based on the " Four humours ". The development of clinical medicine shifted to the United Kingdom and the USA during the early 1900s ( Sir William Osler , Harvey Cushing ).

Evidence-based medicine is the recent movement tolink the practice and the science of medicine more closely through the use of the scientific method and modern informationscience .

Genomics is already having a large influence on medical practice, as most monogenic geneticdisorders have now been linked to causative genes , and molecular biological techniques are influencing medicaldecision-making.

The practice of medicine

The medical encounter or patient - doctor relationship is what medicine is about. A person with a health problem or concern sees a doctor forhelp. The practice of medicine combines both science and art . Science and technology are the evidence base for many clinicalproblems for the general population at large. The art of medicine is the application of this medical knowledge in combinationwith intuition and clinical judgment to determine the proper diagnoses and treatment plan for this unique patient.

The doctor needs to:

• develop a relationship with the patient
• gather data (medical history and physical examination combined with laboratory or imaging studies)
• analyze and synthesize that data (assessment and/or differential diagnosis ), and then
• develop a treatment plan (more testing, therapy, watchful observation, referral and follow-up).

The medical encounter is documented in a medical record. One method that is used is called the Problem Oriented MedicalRecord (POMR), which includes a problem list of diagnoses and a "SOAP" method of documentation for each visit:

• S - Subjective, the medical history of the problem from the point-of-view of the patient.
• O - Objective, the physical examination and any laboratory or imaging studies.
• A - Assessment, is the medical decision-making process including the differential diagnoses and most probablediagnoses.
• P - Plan, the way resolve the problem and monitor progress

Patient-doctor relationship

The patient-doctor relationship is important in order to obtain an accurate medical history and obtain compliance with thetreatment plan; respect, understanding, and trust is important.

Clinical skills

A complete medical evaluation includes a medical history, a physical examination, appropriate laboratory or imaging studies,analysis of data and medical decision making to obtain diagnoses, and treatment plan.

The components of the medical history are:

• Chief complaint (CC) - the reason for the current medical visit.
• History of present illness (HPI) - the chronological order of events of symptoms. A mnemonic PQRST is sometimes helpful is obtaining the history:
  • Provocative-Palliative factors - what makes a symptom worse or better.
  • Quality - description of the symptom
  • Region - which part of the body is affected
  • Severity - what is the intensity of the symptom; using a scale of 0-10 (10 worst)
  • Timing - what is the course of the symptom
• Current activity - occupation, hobbies, what the patient actually does.
• Medications - what drugs including OTCs , and home remedies. Drug allergies are important
• Past medical history (PMH) - other medical diagnoses, past hospitalizations and operations , injuries, past infectious diseases and/or vaccinations
• Review of systems (ROS) - an outline of additional symptoms to ask which may be missed on HPI, generally following thebody's main organ systems (heart, lungs, digestive tract , urinary tract , etc.)
• Social history (SH) - birthplace, residences, marital history, social and economic status, habits including diet , drugs , tobacco , alcohol
• Family history (FH) - listing of diseases in the family that may impact the patient. A family tree is sometimesused.

The physical examination is the examination of thepatient from head to toe looking for signs of disease. The doctor uses his senses of sight, hearing, touch, and sometimes smell(taste has been replaced by modern lab tests). Four chief methods are used: inspection, palpation, percussion, and auscultation;smelling may be useful (e.g. infection, uremia , diabetic ketoacidosis ).

• Vital signs include height, weight, body temperature, blood pressure, pulse ,respiration rate
• General appearance of the patient
• Skin
• Head, eye, ear, nose, and throat (HEENT)
• Cardiovascular - heart and vessels
• Respiratory - lungs
• Abdomen and rectosigmoid
• Genitalia
• Spine and extremities - musculoskeletal
• Neuropsychiatric

Laboratory and imaging studies results, if any.

Medical decision making (MDM) process involves the analysis and synthesis of all the above data to come with a list ofpossible diagnoses (the differential diagnoses ) andwhat needs to be done to come up with a final diagnosis which would explain the patient's problem.

Treatment plan may include ordering additional labs and studies, starting therapy, referring to a specialist, or watchfulobservation. Follow-up may be needed.

This process is used by primary care providers and well as specialists. It may take only a few minutes if the problem issimple and straightforward. Or it may take weeks for a patient who has been hospitalized with multiple system problems involvingseveral specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physicalfindings, and lab or imaging results or specialist consultations.

Medical sciences and health professions

The delivery of modern health care depends, not just on medical practitioners, but on an expanding group of highly trained professionals coming together as an interdisciplinary team . A full list is given on the health profession page. Some examples include: nurses , laboratoryscientists, pharmacists , physiotherapists , speech therapists , occupational therapists , dieteticians and bioengineers .

The scope and sciences underpinning human medicine overlap many other fields. Dentistry and psychology , while separatedisciplines from medicine, are sometimes also considered medical fields. Physician assistants , nurse practitioners and midwives treat patients andprescribe medication in many legal jurisdictions. Veterinarymedicine applies similar techniques to the care of animals.

Medical doctors have many specializations and subspecializations which are listed below.

Basic, supplementary, and related sciences

• Anatomy is the study of the physical structure of organisms. In contrastto macroscopic or gross anatomy, cytology and histology are concerned with microscopicstructures.
• Biochemistry is the study of the chemistry taking place inliving organisms, especially the structure and function of their chemical components.
• Bioethics is a field of study which concerns the relationshipbetween biology, science, medicine and ethics, philosophy and theology.
• Biostatistics is the application of statistics to biologicalfields in the broadest sense. A knowledge of biostatistics is essential in the planning, evaluation, and interpretation ofmedical research. It is also fundamental to epidemiology and evidence-basedmedicine.
• Cytology is the microscopic study of individual cells .
• Embryology is the study of the early development oforganisms.
• Epidemiology is the study of the demographics of diseaseprocesses, and includes, but is not limited to, the study of epidemics.
• Genetics is the study of genes, and their role in biological inheritance .
• Histology is the study of the structures of biological tissues by light microscopy, electron microscopy andhistochemistry.
• Immunology is the study of the immune system , which includes the innate and adaptive immune system in human, for example.
• Microbiology is the study of microorganisms, includingprotozoa, bacteria, fungi, and viruses.
• Neuroscience is a comprehensive term for those disciplines ofscience that are related to the study of the nervous system. A main focus of neuroscience is the biology and physiology of thehuman brain.
• Nutrition is the study of the relationship of food and drink tohealth and disease, especially in determining an optimal diet. Medical nutrition therapy is done by dietitians and is prescribed for diabetes, cardiovascular diseases, weight and eating disorders, allergies,malnutrition and neoplastic diseases.
• Pathology is the study of disease - the causes, course, progressionand resolution thereof.
• Pharmacology is the study of drugs and their actions.
• Physiology is the study of the normal functioning of the body andthe underlying regulatory mechanisms.
• Toxicology is the study of hazardous effects of drugs and poisons .

Diagnostic and imaging specialties

• Clinical laboratory sciences are the clinical diagnostic services which apply laboratorytechniques to diagnosis and management of patients. In the United States theseservices are supervised by a Pathologist. The personnel that work in these medical laboratory departments are technically trained staff, each of whom usually hold a medical technology degree, who actually perform the tests, assays, andprocedures needed for providing the specific services.
  • Transfusion medicine is concerned with thetransfusion of blood and blood component, including the maintenance of a " bloodbank ".
  • Cellularpathology is concerned with diagnosis using samples from patients taken as tissues and cells using histology and cytology .
  • Clinical chemistry is concerned with diagnosis bymaking biochemical analysis of blood, body fluids and tissues.
  • Hematology is concerned with diagnosis by looking at changes inthe cellular composition of the blood and bone marrow as well as the coagulation system in the blood.
  • Clinicalmicrobiology is concerned with the in vitro diagnosis of diseasescaused by bacteria , viruses , fungi , and parasites .
  • Clinicalimmunology is concerned with disorders of the immune system andrelated body defenses. It also deals with diagnosis of allergy .
• Radiology is concerned with imaging of the human body, e.g. byx-ray, x-ray computed tomography , ultrasonography , and nuclear magnetic resonance tomography .
  • Interventional radiology is concernedwith using imaging of the human body, usually from CT, ultrasound, or fluoroscopy, to do biopsies , place certain tubes, and perform intravascular procedures.
  • Nuclear Medicine uses radioactive substances for in vivo and in vitro diagnosis using either imaging of the location of radioactive substancesplaced into a patient, or using in vitro diagnostic tests utilizing radioactive substances.

Disciplines of clinical medicine

• Anesthesiology ( AE ), Anaesthesia ( BE ), is theclinical discipline concerned with providing anesthesia . Pain medicine is often practiced by specialised anesthesiologists.
• Dermatology is concerned with the skin and its diseases.
• Emergency medicine is concerned with the diagnosisand treatment of acute or life-threatening conditions, including trauma, surgical, medical, pediatric, and psychiatricemergencies.
• General practice or family medicine orprimary care is, in many countries, the first port-of-call for patients with non-emergency medical problems. Familydoctors are usually able to treat over 90% of all complaints without referring to specialists.
• Geriatrics is concerned with medical care of the elderly.
• Hospital medicine is the general medical care ofhospitalized patients. Doctors whose primary professional focus is hospital medicine are called hospitalist.
• Intensive care medicine is concernedwith the therapy of patients with serious and life-threatening disease or injury. Intensive care medicine employs invasivediagnostic techniques and (temporary) replacement of organ functions by technical means.
• Internal medicine is concerned with diseases ofinner organs and systemic dieseases of adults, i.e. such that affect the body as a whole. There are several subdisciplines ofinternal medicine:
  • Cardiology is concerned with the heart and cardiovascular systemand their diseases.
  • Clinicalpharmacology is concerned with how systems of therapeutics interact with patients.
  • Gastroenterology is concerned with the organs ofdigestion.
  • Endocrinology is concerned with the endocrine system, i.e.endocrine glands and hormones.
  • Hematology (or haematology) is concerned with the bloodand its diseases.
  • Infectious diseases is concerned with the study,diagnosis and treatment of diseases caused by biological agents.
  • Nephrology is concerned with diseases of the kidneys.
  • Oncology is devoted to the study, diagnosis and treatment of cancer and other malignant diseases.
  • Pulmonology (or chest medicine, respiratorymedicine or lung medicine) is concerned with diseases of the lungs and the respiratory system.
  • Rheumatology is devoted to the diagnosis and treatment ofinflammatory diseases of the joints and other organ systems.
• Neurology is concerned with the diagnosis and treatment of nervous system diseases.
• Obstetrics and gynecology are concerned respectively with childbirth and the female reproductive and associated organs. Reproductivemedicine and fertility medicine is generally practiced by gynecological specialists.
• Palliative care is a relatively modern branch ofclinical medicine that deals with pain and symptom relief and emotional support in patients with terminal disease ( cancer , heart failure ).
• Pediatrics (or paediatrics) is devoted to the care ofchildren, and adolescents. Like internal medicine, there are many pediatric supspecialities for specific age ranges, organsystems, disease classes and sites of care delivery. Most subspecialities of adult medicine have a pediatric equivalent such as pediatriccardiology , pediatric endocrinology , pediatricgastroenterology , pediatric hematology , and pediatric oncology .
• Physical medicine and rehabilitation (or physiatry) is concerned withfunctional improvement after injury, illness, or congenital abnormality.
• Preventivemedicine
  • Communityhealth care or public health
  • Occupationalmedicine
• Psychiatry is a branch of medicine that studies and treats mentaldisorders. Related non-medical fields are psychotherapy and clinical psychology . There are several subdisciplines of Psychiatry:
  • Child & adolescent psychiatry focuses on the care of children and adolescentswith mental/emotional/learning problems (i.e., ADHD, Autism, family conflicts).
  • Geriatricpsychiatry focuses on the care of elderly people with mental illnesses (i.e., dementias, post stroke cognitive changes,depression).
  • Addictionpsychiatry focuses on substance abuse and its treatment.
  • Forensic psychiatry focuses on the interface ofpsychiatry and the Law.
• Radiation therapy is concerned with the therapeuticuse of ionizing radiation and high energy elementary particle beams in patient treatment.
• Surgical specialties - there are many medical disciplines that employ operative treatment. Some of these are highlyspecialized and are often not considered subdisciplines of surgery, although their naming might suggest so.
  • General surgery is the specialty of surgery of the skin,locomotor system, and abdominal organs. In the past, it was deemed the pre-requisite training prior to progression to othersub-specialty training, but lately has evolved into its own sub-specialty.
  • Cardiovascular surgery is the surgical specialty that is concerned with the heart and major blood vessels of the chest.
  • Neurosurgery is concerned with the operative treatment ofdiseases of the nervous system.
  • Oromaxillofacial surgery (technically a subspeciality of dentistry )
  • Ophthalmology deals with the diseases of the eye and theirtreatment.
  • Orthopedic surgery , surgery of the locomotorsystem, is generally practiced together with trauma surgery and/or traumatology .
  • Otolaryngology (or otorhinolaryngology orENT/ear-nose-throat) is concerned with treatment of ear, nose and throat disorders.
  • Pediatricsurgery
  • Plastic surgery includes aesthetic surgery (operationsthat are done for other than medical purposes) as well as reconstructive surgery (operations to restore function and/orappearance after traumatic or operative mutilation).
  • SurgicalOncology is concerned with ablative and palliative surgical approaches to cancer treatment
  • Urology focuses on the urinary tracts of males and females, and on themale reproductive system. It is often practiced together with andrology ("men'shealth").
  • Vascular surgery is surgery of the blood vessels,usually outside of the chest.

Interdisciplinary medical fields

Interdisciplinary sub-specialties of medicine are:

• Aerospacemedicine deals with medical problems related to flying and spacetravel .
• Divingmedicine (or hyperbaric medicine ) is the preventionand treatment of diving-related problems.
• Forensicmedicine deals with medical questions in legal context, such as determination ofthe time and cause of death.
• Medical informatics and medical computer science are relatively recent fieldsthat deal with the application of computers and information technology to medicine.
• Nosology is the classification of diseases for various purposes.

Settings where medical care is delivered

See also clinic , hospital , and hospice

Medicine is a diverse field and the provision of medical care is therefore provided in a variety of locations.

Primary care medical services are provided by physicians or other healthprofessionals who has first contact with a patient seeking medical treatment or care. These occur in physician's office, clinics , nursing homes , schools , home visits and other places close to patients. About 90% of medical visits can betreated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and healtheducation for all ages and both sex.

Secondary care medical services are provided by medical specialists in their offices or clinics or at local communityhospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made forthose 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 medicalimaging services, hospice centers, etc. Some primary care providers may also takecare 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 treatmentfacilities not generally available at local hospitals. These include traumacenters , 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, butincreasingly nowadays by electronic means.

Teaching of medicine

See also the main articles Medical doctor ( BE ) and Physician ( AE )

Medical training is involves several years of university study followed by several more years of residential practice at ahospital. Entry to a medical degree in some countries (such as the UnitedStates ) requires the completion of another degree first, while in other countries (such as the United Kingdom ) medical training can be commenced as an undergraduate degree immediately after secondary education . Once graduated from medical school mostphysicians begin their residency training, where skills in a speciality of medicine are learned, supervised by more experienceddoctors. The first year of residency is known as the " intern " year. The duration ofresidency training depends on the speciality.

In the USA , physician training generally follows the followingtimeline (with age of completion):

• Finish high school at 18
• College/university, 4 years, graduate at 22
• Medical school , 4 years, graduate at 26 with M.D. degree
• Residency (internship usually synonymous with first year of residency), 3 years, finish at 29. Physicians are generallyeligible for independent licensure to practice primary care specialties at this point. Many surgical residencies are longer than3 years.
• Fellowship, 3 year, finish at 32. Fellowships are taken to become eligible for board certification in subspecialties.

The name of the medical degree gained at the end varies: somecountries (e.g. the US) call it 'Doctor of Medicine' (abbreviated 'M.D.'), while others (e.g. Australia , Britain , Pakistan ) call it "Bachelor of Medicine/Bachelor of Surgery" ( French : "Chirurgie"); this is technically a double degree, frequently abbreviated 'M.B.B.S' or'M.B.B.Ch.', dependent on the medical school. In either case graduates of a medical degree may call themselves physician. In theUS and some other contries there is a parallel system of medicine called " osteopathy " which awards the degree D.O. (doctor of osteopathy). In many countries, a doctorate of medicine does not require original research as does, indistinction, a PhD .

A medical graduate can then enter general practice and become a general practitioner (or primary care internist in the USA ); trainingfor these is generally shorter, while specialist training is typically longer.

Legal restrictions

In most countries, it is prohibited to practice medicine without a proper degree in that field and doctors must be licensed bya medical board or some other equivalent organization. This is meant as asafeguard against charlatans . These laws are obstacles to those who would want topretend to training and expertise they have not earned, such as practitioners of alternative medicine or faith healing .

Criticism

Criticism against medicine has a long history. In the Middle Ages , it wasnot considered a profession suitable for Christians, as disease was considered Godsent, and interfering with the process a formof blasphemy . Barber-surgeons generally had a bad reputation that was not toimprove until the development of academic surgery as a specialism of medicine, rather than an accessory field.

Through the course of the twentieth century, doctors naturally focused increasingly on the technology that was enabling themto make dramatic improvements in patients' health. This resulted in criticism for the loss of compassion and mechanistic,detached treatment. This issue started to reach collective professional consciousness in the 1970s and the profession had begunto respond by the 1980 and 1990s.

Perhaps the most devastating criticism came from Ivan Illich in his 1976 work Medical Nemesis. In his view, modern medicine only medicalisesdisease, causing loss of health and wellness , while generally failing to restorehealth by eliminating disease. The human being thus becomes a lifelong patient. Other less radical philosophers havevoiced similar views, but none were as virulent as Illich. (Another example can be found in Technopoly: The Surrender ofCulture to Technology by Neil Postman , 1992 , which criticises overreliance on technological means in medicine.)

Criticism against modern medicine has led to some improvements in the curricula of medical schools, which now teach studentssystematically on medical ethics , holistic approaches tomedicine, the biopsychosocial model and similarconcepts.

The inability of modern medicine to properly address many common complaints continues to prompt many people to seek supportfrom alternative medicine . Although a large number ofalternative approaches to health await scientific validation, many report improvement of symptoms after obtaining alternativetherapies.

See also

• Big killers
• Complementary andalternative medicine
• Health profession
• Healthcare system
• Iatrogenesis
• List of diseases
• List of medical abbreviations
• List of medical schools inthe U.S.
• Medical equipment
• Rare diseases
• Important publications inmedicine

External links

• NLM ( National Library of Medicine , contains resources for patients and healthcareprofessionals)
• Virtual Hospital (digital health sciences library by the University of Iowa )
• OnlineMedical Dictionary - by the University of Newcastle upon Tyne department of Medical Oncology