Introduction to clinical Medicine

Clinical Medicine

Statue of Asclepius, the Greek god of medicine

 Clinical Medicine : What is it?

• is the science, art and practice of the

diagnosis, treatment, follow-up, prognosis
and prevention of diseases or exposure to
diseases.
 Clinical Medicine: Diagnosis
• Clinical tools:
History taking
Physical examination
Bedside procedures

• Medical technology ( “Investigations”):

Laboratory
Imaging: X-ray, ultrasonography, CT-scan, MRI, nuclear imaging
Pathology: Anatomic, molecular
Genetics
 Clinical Medicine: Treatment
• Pharmacotherapy
• Biologics
• Surgery
• Device based therapy
• Physical therapy
• Psychotherapy
• Radiotherapy
 Clinical Medicine: Making a diagnosis
1. Initiating the patient-doctor
interaction
2. Review medical record
3. The medical interview ( history)
4. The physical examination
5. Investigating: Do relevant
laboratory tests, pathologic
exams, imaging studies
6. Analysis and formulating
differential diagnosis
7. Diagnosis:
- Presumptive( Possible, probable,
likely) or
- Definitive
8. Informing the patient of all relevant
facts :
- Important part of the relationship and
the development of trust.
9. Recording : All medical encounters
are documented in the medical record.
The medical record is a legal document.
 Clinical Medicine: A team work
• Clinical Medicine is practiced through a collective effort
of an interdisciplinary team.
Physicians
Nurses
Paramedics
 laboratory personnel
Pharmacists
Physiotherapists
Radiographers
Dietitians
Bioengineers
…..
 Clinical Medicine
• Clinical Medicine : Science and Art

• What is the Science?

• What is the Art?

 Clinical Medicine: Science and Art

• The Science : the knowledge of complex physiologic,

pathologic processes, pharmacology, recent
evidences( data), diagnosis and treatment.

• The art: A combination of skills, intuition, experience,

judgment, decision making and communication
 Clinical Medicine: Medicine decision Making

• Medical decision-making is a fundamental responsibility of the

physician and occurs at each stage of the diagnosis/treatment.

• Whenever possible, decisions should be evidence-based.

• Evidenced based: Based on the best up-to-date available.

• Anecdotal experience is often biased.

• Despite the importance of evidence-based medicine, much

medical decision-making still relies on good clinical judgment
 Clinical decision making
• The decision-making approaches we use
1. Pattern recognition
2. Scientific method: starting with a problem, developing a
hypothesis, collecting and analyzing data.
3. Differential diagnoses/ Probabilistic approach
- Be narrower.
- Start by analyzing the diagnoses that seem most likely.
4. Analyzing lab tests and imaging
5. Treatment threshold: Depending the severity of disease and
the benefits of treatment
6. The patients' perspective: Shared decision making
7. Revaluate: Take additional history, P/E, do tests, assess
response to treatment
 Clinical Medicine: The humanistic aspect

• Trends in the delivery of health care tend to make medical care

impersonal.
(1) Patient may have little choice in selecting a physician
(2) Increasing reliance on technological advances
(3) Numerous physicians and other health professionals are
involved in the care of a patient.
 Clinical medicine: humanistic aspect

• Three main principles in physicians’ contract

with society:

 Patient welfare

 Patient autonomy

social justice
Clinical medicine: Professionalism
• Physician’s personal attributes
Integrity
 Respect
Compassion
Caring
 Clinical Medicine: Professionalism
• Availability to the patient
• Expression of sincere concern
• Willingness to take time to explain

• A nonjudgmental attitude

• Respecting patients cultures, lifestyles, attitudes, and values.

• Appreciation of the patient’s “quality of life” : a subjective

assessment of what each patient values most.
• Content and patient: to patients who evoke strongly negative or
positive emotional responses.
 Clinical Medicine: Public expectations and
accountability

• The general public’s level of knowledge regarding

health issues has grown rapidly

• Expectations have also risen.

• Physicians are held accountable : for both the

technical aspects and patients’ satisfaction.
Clinical Medicine and the internet
• The internet has had a positive effect on the
practice of medicine.

• A range of information is available to physicians

and patients almost instantaneously

• Patients, are turning to the Internet in increasing

numbers to acquire information about their
illnesses and treatment.
 Clinical Medicine and the internet
• Physicians are challenged in a positive way to keep abreast of
the latest relevant information while serving as an “editor”.

• A critically important caveat is that virtually anything can be

published on the Internet.

• Both physicians and patients who search the Internet for

medical information must be aware of this danger.

• Searching for the right evidence from the right source is a

required skill by physicians and students
 The Physician as Perpetual Student

• Graduating from medical school : is a milestone but

symbolic.

• We must embrace the role of a “perpetual student.”

• This reality is exhilarating and anxiety-provoking.

• A commitment to continued learning is an integral

part of being a physician.
Clinical medicine: Understanding health care systems

• One of the most complex systems in the World

• Health care professionals are part of the complex

system

• Understanding the system and playing the right role

to work in and improve the system is crucial.
Health care systems: The Six Health System
Building blocks (WHO 2007)

1. Health workforce
2. Service delivery
3. Information
4. Medical products, vaccines &
technologies
5. Financing
6. Leadership and governance
 Being a medical student
• “The student begins with the patient, continues with
the patient, and ends his studies with the patient,
using books and lectures as tools, as means to an
end”

• Medicine is learnt at the bedside, the library and the

internet are helpful tools.
 Being a medical student: The Osler’s way

• “He who studies medicine without books sails an uncharted sea,

but he who studies medicine without patients does not go to sea
at all.”

• “If you listen carefully to the patient they will tell you the
diagnosis”

• “Medicine is learned by the bedside and not in the class room.

Let not your conception of manifestations of disease come from
work heard in the lecture room or read from the book: See and
then research, compare and control. But see first.”
 Attributes of clinical student/ Practitioner

• Scholar ( life long learner)

• Teacher

• Patient advocate

• Communicator

• Affectionate

• Team player

• Honest
Attributes of clinical student/ Practioner

• Self motivated

• Exchange of skills and knowledge

• Manage time effectively

 Clinical skills
•History taking

•Physical examination

•Documentation

•Focused investigations

•Analysis

•Procedural skills
 Clinical skills : Ethiopian context
• Culture

• Language

• Respect

• Compassion

• Poverty
 A good clinical student
• Enthusiastic and motivated
• Proactive
• Honest
• Confident
• Prioritize information
 A good medical student
• Flexible

• Competent in basic clinical skills

• Fluent in medical terminology

• Able to communicate effectively

• Does not let exam pressure interfere with their performance during
their attachments