April 21, 2015

What clinicians do and why they do it

The Nature of Clinical Medicine. The return of the clinician

Nowadays, technology pervades media and our live. This is a good moment to rethink the basics, the foundations of medicine, its values and goals. Eric Cassell contributes decisively to this aim with his new book, a must read at least for physicians and all professionals related with medicine.
Health economists should be aware of better understanding  about the goals of medicine and purposes of physicians. They reflect the true "production function".
Here is a brief summary of the book and afterwards its goals and purposes:

Clinical medicine, as a thinking discipline, is concerned not only with what clinicians do, but why. When physicians act in medicine they have some purpose or goal in mind. What they actually do and how they go about it is in the service of their purposes and their goals. Such goals cover a wide range of topics centering on patients, the doctor-patient relationship, the acts of doctoring patients, and the goals involved in being a physician among other physicians working within the institutions of medicine.

The Nature of Clinical Medicine takes its direction from a catalog of goals of medicine that range from the expected diagnosis and treatment of diseases to wider concerns for patients, for physicians, and for medicine itself. The chapters are specific in teaching the kinds of knowledge that clinicians require in order to be able to achieve these goals. The central focus of the clinician and of this book is the patient. According to Eric Cassell, everything else, including the disease, is secondary.
Summary of the Goals of Medicine

A. Patient-centered goals

1. Save life.
2. Prolong life.
3. Cure disease.
4. Prevent suffering.
5. Relieve suffering.
6. Do no harm.
7. Protect the patient from danger.
8. Do not frighten the patient.
9. Relieve the patient’s fears.
10. Make the patient better in the patient’s terms.
11. Do nothing unnecessary (or more than necessary). B. Goals related to the physician–patient relationship
12. Develop and maintain a good relationship.
13. Be trustworthy.
14. Tell the truth.
15. Be reliable.
16. Be constant.
17. Be there when needed.
18. Make a difference.

C. Goals related directly to doctoring the patient

19. Make a diagnosis (where pertinent make a tissue diagnosis).
20. Decide what the problem is.
21. Obtain the necessary information.
22. Make sense of the case (in pathophysiological, anatomical, psychological, and social terms).
23. Decide the correct treatment and its timing.

D. Goals related to being a physician among other physicians

24. Seek and maintain comprehensive knowledge.
25. Maintain the standards of medicine.
26. See that things are done right.
27. Protect the patient from bad medicine and incompetent physicians.
28. Behave in a proper, doctorly manner.
29. Look good to other physicians and the patient and family.
30. Avoid error.
31. Avoid blame.
32. Maintain relationships with peers.
33. Stay alive in the institution (hospital or medical school) and community

The relationship between purposes or goals and values (p.166). Five kind of goals:
  1. Specific obligations to other people or institutions—patients, other caregivers, or the hospital
  2. Responses to rights that everybody has, for example, the right to refuse treatment, or to freedom from assault or coercion.
  3. Purposes based in what might be called utility. Things pursued because of the benefit to the patient, or the avoidance of injury. Also purposes directed at general benefit, like the advance of medical knowledge.
  4. Purposes related to what might be called self-development values. Here, there is intrinsic value in acquiring a particular piece of knowledge or skill because it is believed to be part of the general good if even one person has special knowledge. The goal of acquiring a particular knowledge or ability lies in this arena of values.
  5. Purposes related to one’s own project in life, like becoming a good clinician apart from, for example, the acquisition of a specific skill  or the general advance of medical knowledge