Post on 03-Jun-2018
8/13/2019 HUMANIORA PENGANTAR KLINIK
1/69
Doctors Profession:
Introduction
Djoko Wahono Soeatmadji
8/13/2019 HUMANIORA PENGANTAR KLINIK
2/69
http://images.google.co.id/imgres?imgurl=http://www.bermuda-online.org/HospitalEmergency.jpg&imgrefurl=http://www.bermuda-online.org/kemh.htm&usg=__YQX0WkOCBhN3FG1ZNSztRVNjHGU=&h=378&w=550&sz=30&hl=en&start=20&tbnid=adEoEGfJZSdCLM:&tbnh=91&tbnw=133&prev=/images%3Fq%3Dhospital%26gbv%3D2%26hl%3Den%26sa%3DG8/13/2019 HUMANIORA PENGANTAR KLINIK
3/69
To greater opportunity, responsibility, or obligationcan fall to the lot of a human being than to become aphysician. In the care of the suffering, [the
physician] needs technical skill, scientific knowledge,and human understanding. . . . Tact, sympathy, andunderstanding are expected of the physician, for thepatient 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
8/13/2019 HUMANIORA PENGANTAR KLINIK
4/69
The Doctor for the 21st
Century The Issues
-The Wider Context
- Emerging Challenges- The Responses of Medical Education
- The Direction of Reform
The World Summit on Medical Education,
Edinburg 8 12 August 1993
8/13/2019 HUMANIORA PENGANTAR KLINIK
5/69
The doctor of the 21st
century must be redesign !!!
http://images.google.co.id/imgres?imgurl=http://2.bp.blogspot.com/_VVUpMQNZneQ/Sb_IBqA2ZwI/AAAAAAAAACE/TYGwMTcfA-Q/s400/puskesmas3.jpg&imgrefurl=http://khalikholic.blogspot.com/&usg=__xeD9sZHYxbw0DxfDzkSgRP_rj3A=&h=256&w=400&sz=26&hl=id&start=113&tbnid=Ay8BJzTbn2uouM:&tbnh=79&tbnw=124&prev=/images%3Fq%3DPUSKESMAS%26gbv%3D2%26ndsp%3D18%26hl%3Did%26sa%3DN%26start%3D1088/13/2019 HUMANIORA PENGANTAR KLINIK
6/69
The Doctor for the 21st Century1. Promote health, prevent and treat disease,
and rehabilitate the disable (in acompassionate, ethical way), within resourcesconstrain)
2. Providers of primary care3. Communicators
4. Critical thinkers5. Motivated life-long learners6. Information specialist7. Citizen of the World
8. Practitionars of applied economics, sociology,anthropology, epidemiology and behaviouralmedicine
9. Health team managers10. Advocate for communities
The World Summit on Medical Education, Edinburg 8 12 August 1993
8/13/2019 HUMANIORA PENGANTAR KLINIK
7/69
DOCTOR = DOCERE =to teach"
. physicians should share information andmedical knowledge with colleagues, withstudents of medicine and related professions,and with their patients
8/13/2019 HUMANIORA PENGANTAR KLINIK
8/69
Ethical medicine strives todo goodand to do no
harm The medicalprofession must fullfill its
social contract better
8/13/2019 HUMANIORA PENGANTAR KLINIK
9/69
Social and Ethical Issues
in MedicineApproach to Medicine, the Patient, and
the Medical Profession (Medicine as a
learned and humane profession) Bioethics in the Practice of Medicine
Care of Dying patients and Their
Familes
Social and Economic Issues in Medicine
8/13/2019 HUMANIORA PENGANTAR KLINIK
10/69
APPROACH TO THEMEDICINE:Medicine as a
learned and humaneprofession
8/13/2019 HUMANIORA PENGANTAR KLINIK
11/69
What is Expected of thePhysician ?
The practice of medicine combines both scienceand art
Science base technology
Deductive reasoning
Knowledge of he patient, mutual trust and ability tocommunicate with patient
8/13/2019 HUMANIORA PENGANTAR KLINIK
12/69
Does not make a GoodPhysician
Advances in:
genetics
biochemistryimaging technology
laboratory technology
therapeutic maneuvers and modalities
8/13/2019 HUMANIORA PENGANTAR KLINIK
13/69
A good physician has thecombination of :
Medical knowledgeIntuitionJudgement
8/13/2019 HUMANIORA PENGANTAR KLINIK
14/69
Medicine is a profession
that incorporates scienceand the scientific methodewith the art of being aphysician.
8/13/2019 HUMANIORA PENGANTAR KLINIK
15/69
The art of caring andcomforting, guided bymillenia of common senseas well as systemic
approach to medical ethicsremain the cornerstone of
medicine.
8/13/2019 HUMANIORA PENGANTAR KLINIK
16/69
The essential humanistic qualitiesof caring and comforting can
achieve a little if they are notcoupled with understanding of howmedical science can and should be
applied to patients
8/13/2019 HUMANIORA PENGANTAR KLINIK
17/69
Care givers of ancient times and premodern
cultures..Some of their potions contained whatare known to be active ingredients that form thebasis for proven medications..
Modern medicine should not dismissthepossibility that this unproven approach may behelpful, but should adopt a guiding principlesthat all interventions (traditional or newlydeveloped) can be tested, with the expectationthat any beneficial effects can be exploredfurther to determine their scientific basis..
8/13/2019 HUMANIORA PENGANTAR KLINIK
18/69
Internal Medicine(Inneren Medizin):Emphasized the physiology andchemistry of disease; not just
the pattern or progression ofclinical manifestation.
8/13/2019 HUMANIORA PENGANTAR KLINIK
19/69
.. The scientific basis of medicineis remarkebly recent compared
with its long and generallydistinguished of caring andcomforting patients
Hospitalism referred not to expertise inhospital care, but rather to the
aggregate of iatrogenic affections thatwere induced by hospital itself.
8/13/2019 HUMANIORA PENGANTAR KLINIK
20/69
Modern medicine has moved rapidlypast organ physiology to anincreasingly detailed understanding
of cellular, sucellular, and geneticmechanism.
Health, disesase, and individuals
interaction with environment arealso determined substantially bygenetics
8/13/2019 HUMANIORA PENGANTAR KLINIK
21/69
Methods for evaluation theapplication of scientific
advances to the individualpatients and to populations
8/13/2019 HUMANIORA PENGANTAR KLINIK
22/69
The randomized controlled trialsometimes with thousands patients
at multiple institutions, has replacedanecdote as the preferred methodefor measuring the benefits and usesof diagnostic or trherapeuticintervention
8/13/2019 HUMANIORA PENGANTAR KLINIK
23/69
Principles of Patient Care
Principles of Patient Care
Practice Guidelines
Medical Decision-Making
Evaluation of Outcomes
8/13/2019 HUMANIORA PENGANTAR KLINIK
24/69
APPROACH TO THE
PATIENT
8/13/2019 HUMANIORA PENGANTAR KLINIK
25/69
Patients commonly present withcomplaints (symptoms), these
symptoms, may or may not beaccompanied by abnormalities onexam (signs) or on laboratory
testing
Conversely, asymptomatic patientsmay have signs or laboratoryabnormalities, and laboratoryabnormalities can occur in theabsence of symtoms or signs
8/13/2019 HUMANIORA PENGANTAR KLINIK
26/69
Illness & Disease
8/13/2019 HUMANIORA PENGANTAR KLINIK
27/69
The patients-physician interactionproceeds through many phases ofclinical reasoning and decisionmaking
The approach to diagnosis and
therapy should not be equated withcookbookmedicine
Tailoring
8/13/2019 HUMANIORA PENGANTAR KLINIK
28/69
To care for patients as anindividual, the physicianmust understand thepatientas a person (human)
8/13/2019 HUMANIORA PENGANTAR KLINIK
29/69
APPROACH TO The
MEDICAL PROFESSION
8/13/2019 HUMANIORA PENGANTAR KLINIK
30/69
In a profession, thepractitioner puts the welfare
of the client or patient abovehis or her own welfare..
8/13/2019 HUMANIORA PENGANTAR KLINIK
31/69
Professional Responsibilities:
Commitment to Professional 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
Professional responsibility
Brennan T et al. Ann Intern Med 2002; 1136: 243-246
8/13/2019 HUMANIORA PENGANTAR KLINIK
32/69
The explosion in medicalknowledge has led to
increasing specialization,defined initially by organsystem and more recentlyby locus of principal activity(inpatient vs outpatient)
8/13/2019 HUMANIORA PENGANTAR KLINIK
33/69
The changing medical care
environment places increasingemphasis onstandards, outcomes,and accountability..
Clinical guidelines and critical pathwaysderived from randomized controlled trialand evidence-based medicine potentially
can lead to morecost-effective andbetteroutcomes
8/13/2019 HUMANIORA PENGANTAR KLINIK
34/69
A health insurance systememphasizes cost-effective care, gives physicians and health
care providers responsibility for the healthof population and the resources required toachieve these goals, must exist in acompetitive environment in whichpatients
can choose alternativesif they are notsatisfied with their care.
8/13/2019 HUMANIORA PENGANTAR KLINIK
35/69
The physicians responsibility to
represent the patient best interestand avoid financial conflicts .
If the limitting of options is basedoverhelmingly on cost rather than onmeasures on quality, outcomes, andpatient satifaction it is likely that the
historic relationship between the patientand the truly profesional physician will befundamentally compromised
8/13/2019 HUMANIORA PENGANTAR KLINIK
36/69
In the current health careenvironment, all physiciansand trainees must redoubletheir commitment to
professionalism
8/13/2019 HUMANIORA PENGANTAR KLINIK
37/69
BIOETHICS IN
PRACTICE OF MEDICINE
8/13/2019 HUMANIORA PENGANTAR KLINIK
38/69
Modern advances in medicaltechnology, antibiotics, dialysis,
transplantation, and intensivecareunits have created thebioethical dilemmas that confront
the physicians in the 21
st
century
8/13/2019 HUMANIORA PENGANTAR KLINIK
39/69
Patients-Physician
Relationship Whatever the patients attitude ideally
should be based on thorough
knowledge of the patients, mutual trust,and ability to communicate with oneanother
8/13/2019 HUMANIORA PENGANTAR KLINIK
40/69
Patients as individuals whose problemstranscend their complaint
Patient(s) is not just a case(s) ordisease(s)
The duty of patients principal
physician is to guide them throughillness
8/13/2019 HUMANIORA PENGANTAR KLINIK
41/69
The ideal patient-physician relationshipshould be based on thorough knowledge ofthe patient, mutual trust and ability to
communicate with patient
Qualtity of clinician interest in
humanity
8/13/2019 HUMANIORA PENGANTAR KLINIK
42/69
Informed Consent
8/13/2019 HUMANIORA PENGANTAR KLINIK
43/69
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
8/13/2019 HUMANIORA PENGANTAR KLINIK
44/69
Terminating MedicalIntervention ?
Assisted Suicide andEuthanasia ?
8/13/2019 HUMANIORA PENGANTAR KLINIK
45/69
Care of Dying patients
8/13/2019 HUMANIORA PENGANTAR KLINIK
46/69
Care of Dying patients : Is the patient comfortable (Pain and symptom
control ? All that hurts ?)
Shared decision making (What is a gooddeath ?)
Are the psychosocial and spiritual concerns ofthe patients and family being address
(Psychosocial and spiritual support) ?
Whre does the patient prefer to receive care ?
C S t i
8/13/2019 HUMANIORA PENGANTAR KLINIK
47/69
Common Symptoms inSeriously Ill Hospitalized
Patients (% 0f Total Patients)At any time Severe and
Frequent
PainDyspneu
Anxiety
DepressionNausea
5149
47
4534
2323
16
146
Desbiens NA et al. J pain Manage 1999;17:248-255
8/13/2019 HUMANIORA PENGANTAR KLINIK
48/69
Patients Perspective on AGood Death
Control pain and other symptoms
Avoid inappropriate prolongation of
dying when life no longer enjoyable Relieve burden on the family
Achieve a sense of control
Strenghten relationships with lovedones
Singer PA et al. JAMA 1999; 218:163 - 168
8/13/2019 HUMANIORA PENGANTAR KLINIK
49/69
Shared bad news ?
8/13/2019 HUMANIORA PENGANTAR KLINIK
50/69
Palliative CareApproaches to providing comfort fordying persons without necessarily
modifying the underlying medicalcondition
8/13/2019 HUMANIORA PENGANTAR KLINIK
51/69
Medical Ethics
8/13/2019 HUMANIORA PENGANTAR KLINIK
52/69
Six of the values that commonly apply tomedical ethics discussions are:
1. Beneficence- a practitioner should act in the bestinterest of the patient. (Salus aegroti suprema lex.)
2. Non-maleficence- "first, do no harm" (primum nonnocere).
3. Autonomy- the patient has the right to refuse orchoose their treatment. (Voluntas aegroti suprema lex.)
4. Justice- concerns the distribution of scarce healthresources, and the decision of who gets what treatment(fairness and equality).
5. Dignity- the patient (and the person treating thepatient) have the right to dignity.
6. Truthfulnessand honesty- the concept of informedconsenthas increased in importance since the historicalevents of the Doctors' Trialof the Nuremberg trials andTuskegee Syphilis Study.
http://en.wikipedia.org/wiki/Beneficencehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wiktionary.org/wiki/autonomyhttp://en.wikipedia.org/wiki/Justicehttp://en.wikipedia.org/wiki/Dignityhttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Truthhttp://en.wikipedia.org/wiki/Honestyhttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Doctors%27_Trialhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Doctors%27_Trialhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Tuskegee_Syphilis_Studyhttp://en.wikipedia.org/wiki/Doctors%27_Trialhttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Informed_consenthttp://en.wikipedia.org/wiki/Honestyhttp://en.wikipedia.org/wiki/Truthhttp://en.wikipedia.org/wiki/Dignityhttp://en.wikipedia.org/wiki/Justicehttp://en.wiktionary.org/wiki/autonomyhttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Primum_non_nocerehttp://en.wikipedia.org/wiki/Beneficence8/13/2019 HUMANIORA PENGANTAR KLINIK
53/69
BeneficencevsAutonomy
http://en.wikipedia.org/wiki/Beneficencehttp://en.wiktionary.org/wiki/autonomyhttp://en.wiktionary.org/wiki/autonomyhttp://en.wikipedia.org/wiki/Beneficence8/13/2019 HUMANIORA PENGANTAR KLINIK
54/69
Professional ResponsibilityViolations (in general)
Conflicts of interest
Mishandling of client Disclosure of confidential information
8/13/2019 HUMANIORA PENGANTAR KLINIK
55/69
Experience, common sense, andsimply being a good person do notguarantee that physicians can
identify or resolve ethical dilemmas
8/13/2019 HUMANIORA PENGANTAR KLINIK
56/69
SOCIAL AND ECONOMIC
ISSUES IN MEDICINEMedicine is practiced in a social,economic, and political context
It takes more than excellent medical careto improve the health of the patients
Many of the determinants of the health ofindividuals and populations lie outsidetraditional clinical activity
8/13/2019 HUMANIORA PENGANTAR KLINIK
57/69
Economic Considerations
in the Practice of Medicine
health is a political issue
8/13/2019 HUMANIORA PENGANTAR KLINIK
58/69
Most illness has its origins in
social condition
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 copewith helth problems of the vast
majority
gap between health care and
medical care has become evenwider
A safe water supply
makes a major
8/13/2019 HUMANIORA PENGANTAR KLINIK
59/69
the success storiesof
better health inunderdevelopedcountries have hadmore to do withchanged economic and
political systems andimproved nutrition,water provision, andsanitationthan with
technological modern
medicine
Adequate nutrition as aprerequisite for health
Environmental condition
have major impact in
health
Agriculter and health are
two closely related
factors
makes a major
contribution to health
8/13/2019 HUMANIORA PENGANTAR KLINIK
60/69
AccessibleAppropriate to needs
Afordable
http://www.saibaba-fund.org/images/hospital.jpghttp://www.saibaba-fund.org/images/hospital.jpg8/13/2019 HUMANIORA PENGANTAR KLINIK
61/69
Conflict of Interest
Hippocratic Oath
8/13/2019 HUMANIORA PENGANTAR KLINIK
62/69
ATwelfth-century
Byzantinemanuscript ofthe Oath
Hippocratic Oath
Hipocrates OathIswear by Apollo,
Asclepius, Hygieia, and
Panacea, and I take to
witness all the gods, all thegoddesses, to keep according
to my ability and my
judgment, the following
Oath
http://en.wikipedia.org/wiki/12th_centuryhttp://en.wikipedia.org/wiki/Byzantine_empirehttp://en.wikipedia.org/wiki/Apollohttp://en.wikipedia.org/wiki/Asclepiushttp://en.wikipedia.org/wiki/Hygieiahttp://en.wikipedia.org/wiki/Panaceahttp://en.wikipedia.org/wiki/Panaceahttp://en.wikipedia.org/wiki/Hygieiahttp://en.wikipedia.org/wiki/Asclepiushttp://en.wikipedia.org/wiki/Apollohttp://en.wikipedia.org/wiki/Byzantine_empirehttp://en.wikipedia.org/wiki/12th_centuryhttp://en.wikipedia.org/wiki/12th_centuryhttp://en.wikipedia.org/wiki/12th_centuryhttp://upload.wikimedia.org/wikipedia/commons/1/1a/HippocraticOath.jpg8/13/2019 HUMANIORA PENGANTAR KLINIK
63/69
Doctor Patient Relationship
Empathy Sympathy
8/13/2019 HUMANIORA PENGANTAR KLINIK
64/69
Empathy Sympathy
Enemy
V i I
http://images.google.co.id/imgres?imgurl=http://www.digitaljournal.com/img/9/0/1/2/2/1/i/5/0/0/o/doctor-patient.jpg&imgrefurl=http://www.digitaljournal.com/image/50000&usg=__OiE55fGMknsL8saU2hZCiIj01Z8=&h=600&w=425&sz=88&hl=en&start=17&um=1&tbnid=pHtIEUbPXvT1UM:&tbnh=135&tbnw=96&prev=/images%3Fq%3Ddoctor%2Bpatient%2Brelationship%26hl%3Den%26sa%3DN%26um%3D1http://images.google.co.id/imgres?imgurl=http://www.historycooperative.org/journals/hah/9.1/images/wilde_fig01b.jpg&imgrefurl=http://www.historycooperative.org/journals/hah/9.1/wilde.html&usg=__6FylIsGgPS1e7pE-OMd10emO6a8=&h=637&w=640&sz=78&hl=en&start=11&um=1&tbnid=NlQxwVudpZj4kM:&tbnh=136&tbnw=137&prev=/images%3Fq%3Ddoctor%2Bpatient%2Brelationship%26hl%3Den%26sa%3DN%26um%3D1http://images.google.co.id/imgres?imgurl=http://www.cbc.ca/news/background/healthcare/gfx/patient-doctor-392.jpg&imgrefurl=http://www.cbc.ca/news/background/healthcare/patient-doctor-relationship.html&usg=__AwPBfJijU1Ycf_9XC7YYTHkUg0o=&h=247&w=392&sz=33&hl=en&start=6&um=1&tbnid=jJR5YAn3Z_ya_M:&tbnh=78&tbnw=123&prev=/images%3Fq%3Ddoctor%2Bpatient%2Brelationship%26hl%3Den%26sa%3DN%26um%3D18/13/2019 HUMANIORA PENGANTAR KLINIK
65/69
Various Interests
Medical Nursing
Owners
Investors Patients/Family
Insurance
PharmaceuticalIndustry
Government Medical Education
Medical Profession
Lawyer
Etc
Bargaining / Conflict
8/13/2019 HUMANIORA PENGANTAR KLINIK
66/69
8/13/2019 HUMANIORA PENGANTAR KLINIK
67/69
8/13/2019 HUMANIORA PENGANTAR KLINIK
68/69
Thank you for your attention
Batu, July 1, 2006
8/13/2019 HUMANIORA PENGANTAR KLINIK
69/69
To greater opportunity, responsibility, or obligationcan fall to the lot of a human being than to become aphysician. In the care of the suffering, [thephysician] needs technical skill, scientific knowledge,
and human understanding. . . . Tact, sympathy, andunderstanding are expected of the physician, for thepatient 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