Chapter 1: The Practice of Medicine

ENDURING VALUES OF THE MEDICAL PROFESSION

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. 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.

— Harrison’s Principles of Internal Medicine, 1950

The practice of medicine has changed significantly since the first edition of this book in 1950. The advent of molecular genetics, sophisticated imaging techniques, robotics, and advances in bioinformatics and information technology have contributed to an explosion of scientific information that fundamentally changed how physicians define, diagnose, treat, and prevent disease. This growth of scientific knowledge continues to evolve rapidly.

The widespread use of electronic medical records (EMRs) and the Internet have altered how physicians and health care providers access and exchange information as part of medical education and practice (Fig. 1-1). Despite the expansion of scientific knowledge, two key principles remain critical:

The ultimate goal of medicine is to prevent disease, and when disease occurs, to diagnose early and provide effective treatment.
A trusting relationship between physician and patient remains at the heart of effective care.

FIGURE 1-1

The Doctor by Luke Fildes depicts the caring relationship between a Victorian physician and a very ill child. Painted in 1891, the artwork reflects the compassionate care of physicians even when unable to alter the course of disease. (Source: History and Art Collection/Alamy Stock Photo)

THE SCIENCE AND ART OF MEDICINE

Deductive reasoning and applied technology form the foundation for clinical problem-solving. Extraordinary advances in biochemistry, cell biology, immunology, and genomics, along with new imaging techniques, have allowed unprecedented access to the body's systems and cellular functions.

Understanding of gene regulation and integrative gene interactions reveals how subtle genetic changes affect cell and organism function.
The role of stem cells in normal tissue, cancer development, and treatment is increasingly appreciated.
New research areas such as the human microbiome, epigenetics, and noncoding RNAs enhance understanding of health and disease.
Information technology allows interrogation of millions of medical records, leading to new insights into disease etiology, prognosis, and stratification.
The rise of big data, machine learning, and artificial intelligence enhances clinical predictive accuracy.
This science of medicine enriches understanding of pathology and improves disease prevention, diagnosis, and treatment.
Advances such as vaccine platform technology and cryo-electron microscopy enabled the rapid COVID-19 vaccine development.

When facing complex clinical problems, an effective physician must:

Identify key elements in history and physical exam.
Order and interpret appropriate tests.
Decide when to treat or observe.
Evaluate incidental findings for clinical relevance.
Weigh risks of tests and treatments against disease risks.

This combination of medical knowledge, intuition, experience, and judgment defines the art of medicine, which remains vital alongside scientific advances.

CLINICAL SKILLS

History-Taking

A thorough history includes all medically significant facts, focusing on recent events.
Patients should have the opportunity to tell their story uninterrupted; physicians show interest, encouragement, and empathy.
Even seemingly trivial details may hold diagnostic clues.
A systematic review of systems helps uncover hidden diseases.
Comfort with the physician fosters more complete information.
Nonverbal cues (voice, expression, gestures) offer insights into patient perception.
Social and family histories inform disease risks and management.
Experienced clinicians often develop a differential diagnosis from history alone.
The history-taking process builds a unique patient–physician bond essential for trust.
Confidentiality is critical.

Physical Examination

Purpose: To identify objective signs of disease.
Should be methodical, thorough, and considerate of patient comfort and modesty.
Exam of a new patient should be head-to-toe.
Findings should be recorded promptly.
Skills improve with observation, coaching, and experience.
Alertness to subtle findings (e.g., petechiae, murmurs) is crucial.
Exams may need repetition as clinical situations evolve.
Despite advanced diagnostics, physical exams remain valuable for uncovering findings and fostering communication.

Diagnostic Studies

Physicians increasingly rely on laboratory and imaging tests but must appreciate their limitations.
Tests often ordered in batteries for efficiency.
Screening tests help early detection but require thoughtful interpretation.
Abnormal screening results must be evaluated cautiously to avoid unnecessary workups.
Advanced imaging (MRI, CT, PET) provides detailed anatomic info but should be used judiciously to avoid unnecessary costs and iatrogenic harm.

MANAGEMENT OF PATIENT CARE

Team-Based Care

Modern medicine involves multidisciplinary teams: physicians, nurses, physician assistants, allied health professionals.
Care coordination and clear communication among team members is essential.
Patients often receive multiple and sometimes conflicting messages; consistency is important.
Teams include physical therapists, pharmacists, social workers, dieticians, etc.
Medical education increasingly incorporates interprofessional teamwork.
Technology aids communication but should not replace direct colleague interaction.

The Dichotomy of Inpatient and Outpatient Internal Medicine

Hospitals now include emergency, observation, critical care, and palliative units.
Emergence of specialties like hospitalists and intensivists to manage inpatient care.
Care transitions (handoffs) between settings complicate continuity.
Primary care physicians must coordinate care and communicate with specialists.
The concept of a “medical home” integrates team-based and subspecialty care for smooth transitions.

Mitigating the Stress of Acute Illness

Acute diagnoses (cancer, MI, stroke) cause fear and distress.
Physicians should provide clear, calm, consistent, and repeated information.
Hospital environments can be intimidating and stressful.
Attention to patient experience can improve recovery chances.

Medical Decision-Making

Fundamental responsibility involving test ordering, consultation, treatment, and prognosis.
Requires knowledge of disease pathophysiology and natural history.
Differential diagnosis is an iterative process using scientific method.
Preference for evidence-based medicine, though some decisions rely on clinical judgment.
Tools include Bayes’ theorem, diagnostic test sensitivity/specificity, and statistical models.

Practice Guidelines

Developed by professional bodies to aid diagnostic and therapeutic decisions.
Help ensure evidence-based, cost-effective, and appropriate care.
Protect patients and caregivers and contain costs.
Guidelines may oversimplify and not suit every individual.
Physicians must integrate guidelines thoughtfully, not blindly.

Precision Medicine

Recognizes heterogeneity within diseases based on genetics, biomarkers, phenotypes, and psychosocial factors.
Aims to target therapies to improve outcomes and reduce side effects.
Represents evolution of clinical guidelines with refined recommendations.
Best illustrated in cancer treatment guided by genetic testing.
Applications expanding to pharmacogenomics and immunologic disorders.

Evaluation of Outcomes

Use objective measures (mortality, length of stay) often risk-adjusted.
Patients seek relief from symptoms impacting quality of life (comfort, function, cognition).
Subjective outcomes assessed via structured interviews and questionnaires.
Patient satisfaction and access are monitored through surveys like HCAHPS and social media feedback.

Errors in the Delivery of Health Care

Institute of Medicine reports emphasize reducing medical errors and improving patient safety.
Hospitals must develop systems to reduce risks:
Electronic ordering systems reduce medication errors.
Infection control and hand-washing protocols reduce nosocomial infections.
Standardized protocols reduce surgical errors and patient falls.
These measures save thousands of lives yearly.

Electronic Medical Records (EMRs)

Central to modern medicine for data access and error reduction.
Provide rapid access to clinical data, monitoring, and outcome info.
Barriers include technology limitations, privacy concerns, and cost.
Risk of distancing physician–patient relationship if not managed well.
EMRs require significant training and time; risks include copy-paste errors.
Despite frustrations, EMRs improve access to information.
Information technology is a tool and cannot replace clinical judgment.

THE PATIENT–PHYSICIAN RELATIONSHIP

“The secret of the care of the patient is in caring for the patient.”
— Francis W. Peabody, 1925

Patients are individuals, not cases or diseases.
Physicians should be empathetic, compassionate, patient, and open.
Consider familial, social, and cultural backgrounds.
The relationship is based on mutual trust, communication, and thorough knowledge.

Physicians must act in patients' best interest and respect autonomy.
Requires clear, understandable discussion of risks, benefits, and alternatives.
Encouragement of patient questions and repeated discussion improves understanding.
Special care to avoid conflicts of interest.

Approach to Grave Prognoses and Death

Transparency in communication is essential.
Patients often have varying awareness of their condition.
The physician must tailor information timing and pacing.
Focus shifts from cure to care, maintaining dignity and pain control.
Emotional, physical, and spiritual support are critical.
Consistent communication among care teams is vital.
Expert advice in palliative care improves patient and family support.

Maintaining Humanism and Professionalism

Trends toward impersonal care include cost containment, managed care, technology reliance, and team-based care.
Physicians must maintain humane care emphasizing:
Primacy of patient welfare.
Respect for patient autonomy.
Commitment to social justice.
Qualities include integrity, respect, compassion, and availability.
Physicians should manage their own emotional responses.
Understanding quality of life is essential, requiring time and repeated conversations.

EXPANDING FRONTIERS IN MEDICAL PRACTICE

The Era of “Omics”

The genomic era began with the human genome sequencing in 2003.
Gene expression and genotyping guide therapy and risk assessment.
Epigenetics, proteomics, microbiomics, metagenomics, metabolomics, and exposomics are expanding fields influencing health.
These new data sources challenge traditional medical models.
Tools from systems biology and network medicine help classify disease based on complex data.
Physicians must engage in continuous learning to apply omics effectively.
Genetic testing requires wise counsel.

The Globalization of Medicine

Physicians must consider global disease patterns due to travel and migration.
Technology facilitates telemedicine and international consultation.
The Internet has transformed the transfer of medical information worldwide.

Medicine on the Internet

The Internet provides near-instantaneous access to vast information for physicians and patients.
Physicians act as editors to guide patients through information of varying quality.
Awareness of the lack of peer-review online is crucial.

Public Expectations and Accountability

Public knowledge and expectations have risen sharply.
Physicians must master both the science and art of medicine.
Increasing demands for accountability, documentation, and quality standards.
Trends include pay-for-performance and managed care.
Physicians must maintain competence through continuing education and certification.

Medical Ethics and New Technologies

Emerging technologies (cloning, gene therapy, nanotech) raise ethical issues.
Physicians must help shape ethical boundaries.
Shared decision-making is increasingly important.

Learning Medicine

Curricula emphasize lifelong learning, teamwork, communication, and system-based practice.
Training must adapt to new tools like EMRs, robotics, and imaging.
Duty-hour restrictions impact training, increasing handoffs and continuity challenges.

The Physician as Perpetual Student

Graduation is symbolic; physicians must embrace continuous learning.
Continued education via reading, courses, and collaboration is essential.

The Physician as Citizen

Physicians have a social responsibility beyond individual care.
Must act ethically, remove bias, promote health, and sometimes provide uncompensated care.

Research, Teaching, and the Practice of Medicine

Physicians are teachers and researchers.
Medical knowledge depends on ongoing scientific discovery and dissemination.
Ethical participation of patients in research is important.
Patient welfare remains paramount.

“To wrest from nature the secrets which have perplexed philosophers in all ages...these are our ambitions.”
— William Osler, 1849–1919