Chapter 001. The Practice of Medicine (Part 1)

The Modern-Day PhysicianNo 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. . . . Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. [The patient] is human, fearful, and hopeful, seeking relief, help, and reassurance.–Harrisons Principles of Internal Medicine, 1950The practice of medicine has changed in significant ways since the first edition of this book...
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Chapter 001. The Practice of Medicine (Part 1) Chapter 001. The Practice of Medicine (Part 1) The Modern-Day Physician No greater opportunity, responsibility, or obligation can fall to the lot of ahuman being than to become a physician. In the care of the suffering, [thephysician] needs technical skill, scientific knowledge, and human understanding. .. . Tact, sympathy, and understanding are expected of the physician, for the patientis no mere collection of symptoms, signs, disordered functions, damaged organs,and disturbed emotions. [The patient] is human, fearful, and hopeful, seekingrelief, help, and reassurance. –Harrisons Principles of Internal Medicine, 1950 The practice of medicine has changed in significant ways since the firstedition of this book appeared in 1950. The advent of molecular biology with itsenormous implications for the biological sciences (the sequencing of the humangenome), sophisticated new imaging techniques, and advances in bioinformaticsand information technology have contributed to an explosion of scientificinformation that has fundamentally changed the way we define, diagnose, treat,and prevent disease. This explosion of scientific knowledge is not at all static as itcontinues to intensify with time. The widespread use of electronic medical records and the Internet havealtered the way we practice medicine and exchange information. As todaysphysician struggles to integrate the copious amounts of scientific knowledge intoeveryday practice, it is important to remember that the ultimate goal of medicine isto treat the patient. Despite more than 50 years of scientific advances since thefirst edition of this text, it is critical to underscore that cultivating the intimaterelationship that exists between physician and patient still lies at the heart ofsuccessful patient care. The Science and ART of Medicine Science-based technology and deductive reasoning form the foundation forthe solution to many clinical problems. Spectacular advances in biochemistry, cellbiology, and genomics, coupled with newly developed imaging techniques, allowaccess to the innermost parts of the cell and provide a window to the most remoterecesses of the body. Revelations about the nature of genes and single cells haveopened the portal for formulating a new molecular basis for the physiology ofsystems. Increasingly, we are understanding how subtle changes in many differentgenes can affect the function of cells and organisms. We are beginning to decipherthe complex mechanisms by which genes are regulated. We have developed a newappreciation of the role of stem cells in normal tissue function and in thedevelopment of cancer, degenerative disease, and other disorders. The knowledgegleaned from the science of medicine has already improved and undoubtedly willfurther improve our understanding of complex disease processes and provide newapproaches to disease treatment and prevention. Yet skill in the most sophisticatedapplication of laboratory technology and in the use of the latest therapeuticmodality alone does not make a good physician. When a patient poses challenging clinical problems, an effective physicianmust be able to identify the crucial elements in a complex history and physicalexamination, to order the appropriate laboratory tests, and to extract the key resultsfrom the crowded computer printouts of data to determine whether to treat or towatch. Deciding whether a clinical clue is worth pursuing or should bedismissed as a red herring and weighing whether a proposed treatment entails agreater risk than the disease itself are essential judgments that the skilled clinicianmust make many times each day. This combination of medical knowledge,intuition, experience, and judgment defines the art of medicine, which is asnecessary to the practice of medicine as is a sound scientific base. Clinical Skills History-Taking The written history of an illness should include all the facts of medicalsignificance in the life of the patient. Recent events should be given the mostattention. The patient should, at some early point, have the opportunity to tell hisor her own story of the illness without frequent interruption and, when appropriate,receive expressions of interest, encouragement, and empathy from the physician.Any event related by the patient, however trivial or seemingly irrelevant, mayprovide the key to solving the medical problem. In general, only patients who feelcomfortable will offer complete information, and thus putting the patient at ease tothe greatest extent possible contributes substantially to obtaining an adequatehistory. An informative history is more than an orderly listing of symptoms; bylistening t ...