Phylosophy of (Modern Era)

Doctor
 Phylosophy :
"love of wisdom" Greek
 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. . ..

Harrison's Principles of Internal Medicine, 1950

DECLARATION OF ALMA ATA 1978

Health for all by the year 2000

… health is a basic human
entitlement, to which all should
have equal access and equal right
…
Paine and Tjam. WHO 1988
Appropriate to needs Accessible

Afordable
DOCTOR = DOCERE
Doctor-Patient Relationship

patient derives from the Latin patior, "suffer"

… in any dynamic society the only constant is
change ….

Advances in:
genetics
biochemistry
imaging technology
laboratory technology
therapeutic maneuvers and modalities

does not make a Good Physician

Good Medical Practice
Patients are entitled to good
doctors…..

Patients must be able to trust

doctors with their lives and
wellbeing…..
 Good Doctors
Good doctors make the care of their
patients their first concern: they are
competent, keep their knowledge and
skills up to date, establish and
maintain good relationships with
patients and colleagues, are honest
and trustworthy, and act with
integrity.
 Justice forbids discrimination in
health care (education ?) based on
race, religion, or gender and
supports a moral right to health care,
with access based on medical need
rather than ability to pay….
 The Doctor-patient Relationship
• Relationships based on openness, trust and
good communication will enable you to work in
partnership with your patients to address their
individual needs
• To establish and maintain trust you must:
listen to patients, ask for and respect their
views about their health, and respond to their
concerns and preferences
 The Doctor-patient relationship
• Respect patients’ privacy and dignity, treat
information about patients as confidential
• In exceptional circumstances, you should be
prepared to justify your decision
• Respect the right of patients to be fully involved in
decisions about their care
• Respect the right of patients to a second opinion
 The Doctor-patient relationship
• The doctor’s cultural and belief systems
influence his or her interactions with parents
and accept this may impact on the doctor-
patient relationship
• A positive outcome is achieved when a doctor
and patient have mutual respect and
understanding
 Professional Responsibilities
• 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

 Professional Responsibility
Violations (in general)
• Conflicts of interest
• Mishandling of client
• Disclosure of confidential information
 Fundamental Elements For Disclosure To
Patients
• Diagnosis and prognosis
• Nature of proposed intervention
• Reasonable alternative intervention
• Risk associated with each alternative intervention
• Benefits associated with each alternative
intervention
• Probable otcomes of each alternative intervention
There is nothing new on the
horizon..
Hippocratic Oath
A twelfth-century Byzantine
manuscript of the Oath in the
form of a cross.

Hipocrates Oath
I swear by Apollo, Asclepius,
Hygieia, and Panacea, and I
take to witness all the gods,
all the goddesses, to keep
according to my ability and
my judgment, the following
Oath…..
 Six of the Values
that commonly apply to medical ethics discussions
• Beneficence - a practitioner should act in the best interest of
the patient (Salus aegroti suprema lex).
• Non-maleficence - "first, do no harm" (primum non nocere).
• Autonomy - the patient has the right to refuse or choose their
treatment (Voluntas aegroti suprema lex).
• Justice - concerns the distribution of scarce health resources,
and the decision of who gets what treatment (fairness and
equality).
• Dignity - the patient (and the person treating the patient) have
the right to dignity.
• Truthfulness and honesty - the concept of informed consent
has increased in importance since the historical events of the
Doctors' Trial of the Nuremberg trials and
Tuskegee Syphilis Study.
 Lafal Sumpah Dokter Indonesia

PP 26/1960, LAFAL SUMPAH DOKTER

Ditetapkan di Jakarta oleh PEJABAT PRESIDEN REPUBLIK INDONESIA Ir. H Djuanda
Diundangkan di Jakarta pada tanggal 2 Juni 1960. Menteri Kehakiman, SAHARDJO
 "Saya bersumpah/berjanji bahwa:
• Saya akan membaktikan hidup saya guna kepentingan perikekemanusiaan;
• Saya akan menjalankan tugas saya dengan cara yang terhormat dan bersusila, sesuai
dengan martabat pekerjaan saya;
• Saya akan memelihara dengan sekuat tenaga martabat dan tradisi luhur jabatan
kedokteran;
• Saya akan merahasiakan segala sesuatu yang saya ketahui karena pekerjaan saya dan
karena keilmuan saya sebagai Dokter;
• Kesehatan penderita senantiasa akan saya utamakan;
• Dalam menunaikan kewajiban terhadap penderita" saya akan berikhtiar dengan
sungguh-sungguh supaya saya tidak terpengaruh oleh pertimbangan Keagamaan,
Kebangsaan, Kesukuan, Politik Kepartaian atau Kedudukan Sosial;
• Saya akan memberikan kepada Guru-guru saya penghormatan dan pernyataan terima
kasih yang selayaknya;
• Teman-sejawat saya akan saya perlakukan sebagai saudara kandung;
• Saya akan menghormati setiap hidup insani mulai dari saat pembuahan;
• Sekalipun diancam, saya tidak akan mempergunakan pengetahuan Kedokteran saya
untuk sesuatu yang bertentangan dengan hukum perikemanusiaan;
• Saya ikrarkan sumpah ini dengan sungguh sungguh dan dengan mempertaruhkan
kehormatan diri saya"

Ditetapkan di Jakarta pada tanggal 2 Juni 1960. Pejabat Presiden Republik, Indonesia, DJUANDA
Diundangkan di Jakarta pada tanggal 2 Juni 1960. Menteri Kehakiman, SAHARDJO
Good Medical Practice
 g ”
pi n
o p
S h
“

Patient
Historical Perspectives of Health Care

Charity Health Care Re-

Industry regulation

Provided by
Non-profit For-profit
goverment ?
 The Demand Side
The Supply Side
Patients Physician
demand as
for decision
treatment maker

Market Economy
Demand for
institutional
setting

Prices and
Supply of
quantity of
institutional
services
settings

An Overview of the Medical Care Sector

Feldstein. Health Care Economics, 1988
...Now primarily a marketing machine to sell
drugs of dubious benefit, this industry uses its
wealth and power to co-opt every institution
that might stand in its way, including the U.S.
Congress, the Food and Drug Administration,
academic medical centers, and the medical
profession itself. (Most of its marketing efforts
are focused on influencing doctors, since they
must write the prescription)...

Marcia Angell, M.D., Former editor in chief of

The New England Journal of Medicine Winner of the Polk Award
Market imperfections and Market failure

In situation of natural monopoly,

competition cannot exist
Historical Perspectives of Health Care

Health Care Re-

Charity
Industry regulation

Provided by
Non-profit For-profit
goverment
 The Demand Side The Supply Side
Patients Physician
demand as
for decision
treatment maker

Market Economy
Insurance Demand for
Company institutional
setting

Prices and
Supply of
quantity of
institutional
services
settings

An Overview of the Medical Care Sector

Feldstein. Health Care Economics,
Feldstein, 1988
 Various Interests
• Medical • Government
• Nursing • Medical Education
• Owners
• Medical Profession
• Investors
• Lawyer
• Patients/Family
• Insurance • Etc
• Pharmaceutical
Industry
Bargaining / Conflict
Which side ???
 Kesejahateraan Dokter ?
Dokter termasuk pegawai golongan 3B, gaji
pokok Rp 2.2 juta plus tunjangan fungsional
Rp 300 ribu, total Rp 2.6 juta....
Negara Gaji dokter/tahun
USA $80.000 – 120, 000/tahun
Canada $120, 000/tahum
Eropa $110.000/tahun
Jepang $100. 000 – 150.000’tahun
Singapore $60.000 – 70.000/tahun
Malaysia RM 10.000/bulan
(Rp 180.000 – 360 juta/tahun)
India $ 10.000 – 25.000/tahun
Thailand Rp 90 juta/tahun

Sumber: m.kaskus.co.id
… health (and education) is a political issue
and those enjoying care do not want to share it
… ..

Health care and Education should be decided

as “Human Investment” NOT just a
Government Spending
Twee koetsiers op een bok, dit gaat
niet, zeiden deze geneesheren.
Typisch symptoom van „mata
doewiten". Dokter Indonesia sekatang pasti tetap
idialis dan lebih baik dari dokter Raden
Goeteng
… in any dynamic society the only constant is
change ….

….not all the changes are brought by the

discoveries of the sicentist and the advances
made by techologists….

…Some have economic roots and some stems

from aspects of man unconquerable mind –
from the desire for social equity, a hatred of
injustice, a wish to help the sick and
disadvantage, or a simple love of humanity….
 Logic in Medicine &
Medical Decision Making
WHO ARE YOU ?
Medicine (Kedokteran)
The Science & The Art
 Science (Ilmu) ?

Knowledge (Pengetahuan) ?

Scientific methode ?
Medical knowledge is a scientific
knowledge
Doctor vs Witch doctor ?

Physician - scientist
 Medicine

The Science : Diagnostic process

The Art : Clinical process
Methods of Finding the
Scientific Truth(s)
• Rasional - Empirical
• Deductive – Inductive
• Deducto – hypothetico - verivicative
Diagnostic Process is a scientific process
(Differential) Diagnosis, like
scientific research is based
on methode of hypothesis
formulation
 The Scientific Process
Diagnosis
• Problem (illnesss)
• Data collecting & data
analysis
• Hypothesis formulation &
differential diagnosis
• Hypothesis (diagnosis)
proven or unproven
(probability)
• New Problems
Research
• Research Question (s)
/Problem ?
• Data collecting & data
analysis
• Hypothesis formulation
Ho/H1 Working hypoth.
• Hypothesis accepted or
rejected (probability)
• New Research Questions
 Various Interensts
• Medical • Government
• Nursing • Medical Education
• Owners
• Medical Profession
• Investors
• Lawyer
• Patients/Family
• Insurance • Etc
• Pharmaceutical
Industry
Bargaining / Conflict
Evidence Base Medicine
 Clinical Evidence
&
Circumstances

Patients’
Evidence
Preferences,
from
Values, and
Research
Rights
… in any dynamic society the only constant is
change ….

….not all the changes are brought by the

discoveries of the sicentist and the advances
made by techologists….

…Some have economic roots and some stems

from aspects of man unconquerable mind –
from the desire for social equity, a hatred of
injustice, a wish to help the sick and
disadvantage, or a simple love of humanity….
WHO ARE YOU ?

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t i f ul tr
b ea u n t es t
m o st 9 9 co
. Th e n y 1 9
M A N . T i f f a
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 nti o n
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Malang, 10 September 2015