Bachelor of Medicine and Surgery(MBBS)

December 23, 2008 by admin
Filed under Medical Science

Naming

The Latin names for these degrees are variously Medicinae Baccalaureus, Chirugiae Baccalaureus or Baccalaureus in Medicina et in Chirurgia, abbreviated as MB ChB, MB BCh or in other ways depending on the individual institution; the English versions are Bachelor of Medicine, Bachelor of Surgery, usually abbreviated as MB BS. The different Latin and English abbreviations may occasionally be combined by certain institutions such that BM BCh and BM BS are also seen. The specific names and abbreviations of the degrees vary with each awarding body and from region to region; this is mostly for reasons of tradition, rather than to indicate any significant difference of level or between the degrees.

The degrees are not offered in the United States, Canada and other countries. The equivalent degree in the United States is the MD or DO. In Canada the MD or MD CM are awarded.

Australia

MB BS are conferred by most Australian medical schools (undergraduate and graduate-entry).

The graduate-entry Flinders medical school confers BM BS.

The University of Newcastle offers the five-year undergraduate degree BMed. Although no degree in surgery is formally awarded by Newcastle, this degree is equivalent to the MB BS, and students may go on to a career in surgery the same as any other graduates in medicine and sugery.

Bangladesh

All medical schools in Bangladesh award MB BS.

England

Several variants of these degrees are awarded in England:

MB ChB are used at the universities of Birmingham, Bristol, Leeds, Leicester, Liverpool, Keele, Manchester, Sheffield, and Warwick.
MB BS are used at the University of East Anglia, Hull York Medical School, the University of London, and University of Newcastle-upon-Tyne.
BM BCh are used at Oxford.
BM BS are used at University of Nottingham, Peninsula Medical School and Brighton Sussex Medical School
BM is awarded at the University of Southampton. Although no degree in surgery is formally awarded by Southampton, this degree is equivalent to the MB ChB, and students may go on to a career in surgery the same as any other graduates in medicine and surgery.
MB BChir are awarded by the University of Cambridge.

At Oxford and Cambridge universities the preclinical course leads to a BA degree (upgradable after 3 tor 4 years to MA), after which most students used to go elsewhere to complete clinical training. They could take the degrees of their new university or return to their old university to take clinical examinations.

The English Triple Conjoint Diploma of LRCP, LRCS, LMSSA was a non-university qualifying examinations in medicine and surgery awarded jointly by the Royal College of Physicians of London, Royal College of Surgeons of England and Society of Apothecaries through the United Examining Board. These qualifications were registrable with the GMC until 1999. Prior to 1994, the English Conjoint diploma of LRCP, MRCS was awarded for over a century, and the LMSSA was a distinct and sometimes less-esteemed qualification.

Hong Kong

The awarding of qualifications in Hong Kong has continued to follow the British tradition despite the handover of the territory’s sovereignty from the hands of the United Kingdom to the People’s Republic of China on 30 June 1997. The dual degree is awarded as:

MB BS at University of Hong Kong; and
MB ChB at Chinese University of Hong Kong.

India

All medical schools in India award the MB BS degree under the Medical Council of India and State Medical councils’ regulations. An MB BS is an undergraduate degree, usually lasting 5½ years or more. It includes one year of a compulsory rotating internship. Completion of an MB BS degree is required in order to apply for, and join, a specialised program offering the MD / MS degree. Subsequently further specialisation can lead to DM or MCh degrees.

There used also to be Licentiate qualifications in Medicine and Surgery (LMS) in India, awarded after a shorter course, originally at a “medical school” rather than a “medical college.”

The College of Physicians and Surgeons of Bombay awarded a Licentiate at LMS level, a Membership (MCPS) at MB BS level and a Fellowship (FCPS) at MD level. The State Medical Faculty of West Bengal (previously of Bengal) also gave Licentiates and Memberships.

Ireland

The three degrees of MB BCh BAO are awarded by all medical schools in both the Republic of Ireland and Northern Ireland – namely Queen’s University Belfast, University of Dublin (Trinity College) and some constituent institutions of the National University of Ireland (Royal College of Surgeons in Ireland, University College Dublin, University College Cork and National University of Ireland, Galway).

BAO is Baccalaureus in Arte Obstetricia (Bachelor of the Obstetric Art), which the Irish Universities began to award in the 19th century after legislation insisted on a final examination in obstetrics: however this third degree was not registrable with the GMC.

LRCPI LRCSI, or simply LRCP&SI, denotes a holder of the historical non-university qualifying licenciates awarded jointly by the Royal College of Physicians of Ireland and the Royal College of Surgeons in Ireland to students of the RCSI’s medical school. Unlike the corresponding licentiates awarded by the Royal Colleges in Scotland and England (which were external qualifications), these qualifications are still registrable with the Irish Medical Council. Students at RCSI still receive these licenciates but now also receive the degrees MB BCh BAO, due to RCSI’s status as a recognised college of the National University of Ireland.

The RCSI students also received a Licence in Midwifery (LM) from each college, in the same way that the Irish Universities granted BAO degrees, so their qualifications were sometimes expressed as L & LM,RCPI, L & LM, RCSI or more misleadingly as LLM, RCP&SI.

LAH formerly denoted a licentiate of the now-defunct Apothecaries’ Hall, Dublin, and is no longer awarded.

Kenya

The two National Universities(the University of Nairobi and Moi University) with Medical Faculties in Kenya offer the ‘MBChB’ degree.

Myanmar

All medicine schools in Myanmar award the M.B.,B.S. degree.

New Zealand

The two New Zealand Medical Schools, Auckland and Otago, style their degrees as MB ChB. The New Zealand MB ChB degrees take at least 6 years after commencing university study depending upon graduate or undergraduate entry.

Pakistan

All medical schools in Pakistan award MB BS. as per the Medical and dental council of Pakistan. An MBBS is an undergraduate degree, usually lasting 5 years.

Scotland

All medical schools in Scotland award MB ChB. The University of St Andrews awarded MB ChB until the early 1970s, but since the incorporation of the medical school in the new University of Dundee, the University of St Andrews now only awards a pre-clinical BSc or BSc (Hons), and students go elsewhere to finish their training, usually to the University of Manchester for an MB ChB.

The Scottish Triple Conjoint Diploma of LRCPE, LRCSE, LRCPSG (earlier LRCPE, LRCSE, LRFPSG) is an old non-university qualifying examination in medicine and surgery awarded jointly by the Royal College of Physicians of Edinburgh, Royal College of Surgeons of Edinburgh and Royal College of Physicians and Surgeons of Glasgow, previously through a Conjoint Board and from 1994 through the United Examining Board. These qualifications were registrable with the GMC until 1999.

South Africa

The University of Pretoria, University of Cape Town, University of the Free State, University of Stellenbosch and MEDUNSA all award MB ChB, whereas the University of the Witwatersrand styles its degree as MB BCh. All South African medical degrees are awarded under the auspices of the Health Professions Council of South Africa and take at least 6 years to complete.

Singapore

The only medical school in Singapore, the Yong Loo Lin School of Medicine, confers the MBBS degree.

Wales

All medical schools in Wales award MB BCh.

West Indies

All constituent countries of the University of the West Indies confer the MBBS degree due to the historical affiliation of the University of the West Indies to the University of London.

Classification of degrees

The degrees of MB BS are rather difficult to classify. They can be received both after an undergraduate course, which lasts five or six years in addition to one year of practice as a pre-registration house officer (PRHO), or after a graduate course which lasts 4 years in addition to one year of practice as a PRHO (which now, in the UK, incorporates the first year of Foundation Training following the initiative “Modernising Medical Careers“), having previously obtained an undergraduate degree of a good class.

The degrees differ from other undergraduate degrees in that they are professional qualifications which entitle bearers to a guaranteed position upon receipt. This is not the case with other undergraduate degrees, so whilst the MB ChB are undergraduate/graduate degrees, they are perhaps more accurately conceptualised as a so-called ‘First Professional’ degree.

It is a general/ordinary degree (not an honours degree), and as such one is not awarded 1st class, 2:1 etc. as one does for honours degrees. At some institutions (for example the University of Manchester) it is possible for the degrees to be awarded with Honours, i.e. MB ChB (Hons) etc., if the board of examiners recognises exceptional performance throughout the degree course. Very few of these are awarded.

More often, it is possible to study one subject for an extra year for an honours BSc, BMedSci, BMedBiol or similar: as with the Oxford and Cambridge BAs. At a few universities most medical students obtain an ordinary degree in science as well: when the University of Edinburgh had a six year course, the third year was followed by award of an ordinary BSc (Med Sci).

Progression

Graduates of these degrees are entitled to use the title Doctor, and are eligible for membership of professional institutions (such as the Royal College of Physicians after sitting further postgraduate examinations, as well as being eligible to submit research for the awarding of the degree of MD or DM.

At some institutions it is possible to study for the degree of Master of Surgery (ChM, MCh, MChir or MS), and the possession of a medical degree is normally a prerequisite for this. There is also a similar Masters degree in Obstetrics (MAO) in Ireland.

Stylisation

The degrees of Medicine and Surgery are sometimes stylised more formally, when abbreviated as M.B., Ch.B. / M.B., B.S.

Note the punctuation:

the period (”.“) marks the level of degree and discipline
the comma (”,“) indicates a separate degree

Tags: australia, Doctor, england, ireland, MD, medical school, Medical Science, new zealand, training, uk, united kingdom

Doctor of Medicine(MD)

December 23, 2008 by admin
Filed under Medical Science

History of the medical degree

According to Sir John Bagot Glubb, Syed Farid Alatas, and S. M. Imamuddin, the first medical schools to issue academic degrees and diplomas were the teaching Bimaristan (Hospitals)of the medieval Islamic world. The first of these institutions was opened in Baghdad during the time of Harun al-Rashid. They then appeared in Egypt from 872 and then in Islamic Spain, Persia and the Maghreb thereafter. Physicians and surgeons at these hospital-universities gave lectures on Islamic medicine to medical students and then a medical diploma or degree was issued to students who were qualified to be practicing physicians.^[2]^[3]^[4]

According to Douglas Guthrie,^[5] who bases his account on L Thorndike,^[6] medical men were first called “Doctor” at the Medical School of Salerno. He states that the Emperor Frederick II decreed in 1221 that no one should practice medicine until he had been publicly examined and approved by the masters of Salerno. The course lasted 5 years, and to start one had to be 21 years old and show proof of legitimacy and of three years study of logic. The course was followed by a year of supervised practice. After the laureation ceremony the practitioners could call themselves “magister” or “doctor.”

Academic degrees for physicians by country

United States and Canada

The MB or Bachelor of Medicine was also the first type of medical degree to be granted in the United States and Canada. The first medical schools that granted the MB degree were Penn, Harvard, Toronto, Maryland, and Columbia. These first few North American medical schools that were established were (for the most part) founded by physicians and surgeons who had been trained in England and Scotland. University medical education in England culminated with the MB qualification, and in Scotland the MD, until from the mid-19th century the public bodies who regulated medical practice at the time required practitioners in Scotland as well as England to hold the two the dual Bachelor of Medicine and Bachelor of Surgery degrees (MB BS/MBChB/MB BChir/BM BCh etc). North American Medical schools switched to the tradition of the Ancient universities of Scotland and began granting the MD title rather than the MB mostly throughout the 1800s. The Columbia University College of Physicians and Surgeons in New York (which at the time was referred to as King’s College of Medicine) was the first American University to grant the MD degree instead of the MB.^[7]

Within the United States, MDs are awarded by LCME-accredited medical schools.^[8]^[9]^[10]. The Liaison Committee on Medical Education is an independent body sponsored by the Association of American Medical Colleges and the American Medical Association, the AMA.

Admissions to medical schools in the United States is highly competitive, with 17,800 of the approximately 47,000 applicants matriculating to any medical school. Before graduating from a medical school and achieving the degree of Medical Doctor, students have to pass the United States Medical Licensing Examination (USMLE) Step 1 and to take (but not necessarily pass) both the Clinical Knowledge and Clinical Skills parts of Step 2. The MD degree is typically earned in four years. Following the awarding of the MD, physicians who wish to practice in the United States are required to complete at least one internship year (PGY-1) and pass the USMLE Step 3. In order to receive Board Eligible or Board Accredited status in a specialty of medicine such as general surgery or internal medicine, then undergo additional specialized training in the form of a residency. Those who wish to further specialize in areas such as cardiology or interventional radiology then complete a fellowship. Depending upon the physician’s chosen field, residencies and fellowships involve an additional three to eight years of training after obtaining the MD. This can be lengthened with additional research years, which can last one, two, or more years.

In Canada, the MD is the basic medical degree required to practice medicine. At McGill University in Montreal, M.D., C.M. (Medicinae Doctor et Chirurgiae Magister or a Doctor of Medicine and Master of Surgery sometimes also written MDCM) degrees are awarded.

Even though the MD is a first professional degree and not a doctorate of research (ie. PhD), many holders of the MD degree conduct clinical and basic scientific research and publish in peer-reviewed journals during training and after graduation. Medical Scientist Training Programs (MSTPs) are offered at many universities which are a combined medical degree and PhD. Some MDs choose a research career and receive funding from the NIH as well as other sources such as the Howard Hughes Medical Institute. A few even go on to become Nobel Laureates.^[11]

United Kingdom, Ireland and some Commonwealth countries

In the United Kingdom and Ireland (and many Commonwealth countries) the MD is a postgraduate research degree in medicine. At some universities, this takes the form of a first doctorate, analogous to the PhD, awarded upon submission of a thesis and a successful viva. The thesis may consist of new research undertaken on a full- or part-time basis, with much less supervision (in the UK) than for a PhD, or a portfolio of previously-published work.^[12]

At some other universities (especially older institutions such as Oxford and Cambridge) the MD is a higher doctorate (similar to a DSc) awarded upon submission of a portfolio of published work representing a substantial contribution to medical research.^[1].

In the case where the MD is awarded (either as a first or higher doctorate) for previously-published research, the candidate is usually required to be either a graduate or a full-time member of staff, of several years’ standing of the university in question.^[13]

The University of Buckingham,^[14] the only private university in Great Britain, has announced an Indian-style two year full-time taught course for a “Clinical MD” in internal medicine. This is designed for non-European Union graduates, who are no longer to be allowed to take accredited training posts in UK hospitals. This degree will be awarded first in 2010.

The entry-level professional degree in these countries for the practice of medicine is that of Bachelor of Medicine and Bachelor of Surgery (MBBS or MBChB). This degree typically requires between four and six years of study and clinical training, and is equivalent to the North American MD.

India, Pakistan and Argentina

In India, an MD is a higher postgraduate degree awarded by many medical colleges to medical graduates holding the MBBS degree {MBBS degree course has a duration of five and a half years}, after three years of study and passing an examination which includes both theory and practical, in a pre-clinical or clinical subject of a non-surgical nature. The original research element is not as prominent here, as this is primarily a clinical qualification resembling the professional doctorates of the USA. In surgery, orthopaedics and gynaecology the equivalent degree is Master of Surgery (MS). DNB(Diplomate of the National Board))is considered equivalent to MD and MS.This can be obtained by passing an exam conducted by national board of examinations after completing 3 years post MBBS training in hospitals recognised by the board.After obtaining the first post graduate degree, that is MD/MS/DNB, one can go for further specialisation in medical or surgical fields. This requires three years of hard training and study and then passing an examination, both theory and practical, and the degree awarded is DM (Doctorate in Medicine, superspeciality) eg DM in Cardiology, Neurology, Nephrology, Gastroenterology etc. For surgical subspecialities the degree awarded is MCh, eg MCh (Cardiac Surgery), MCh (Neurosurgery) etc.The DM or MCh degrees are equivalent to the Fellowship training in the US and are considered “post-doctoral” degrees in India, similar to the PhD.

In Pakistan an MBBS is awarded as the basic medical qualification after completing five/six years of study. Tough entry tests are passed successfully before entering in to a medical college. Medical colleges and foreign medical qualifications are supervised by the Pakistan Medical and Dental Council (PMDC). Specialized degrees are awarded by the Pakistan College of Physicians and Surgeons.

In Argentine the medical degree Título de Médico^[15] are equivalent to the North American M. D. Degree with 6 year of intensive theoric studies followed by three years of the Residencia as a Mayor Especialidad in a particular empiric field, compounded of internships, social services and sporadic research.

Equivalent degrees in other countries

The Bachelor of Medicine and Bachelor of Surgery degrees (MB BS or MB ChB, and several variants) are equivalent to the North American MD degree.
The American osteopathic medical degree (DO) has identical training requirements and practice rights as the MD degree.^[16] (See Comparison of allopathic and osteopathic medicine.)
In Germany medical students have to complete twelve semesters of study and pass two state examinations (the first one after two years) to become physicians. A research doctorate (PhD) can only be obtained at some universities after three to five years of additional studies and research. Physicians can obtain the degree “Dr. med., Doktor der Medizin” A candidate must submit a dissertation consisting of a suitable body of original academic research. A candidate also must defend this work before a panel of expert examiners appointed by the university. The dissertation has to be published.
The Czech and Slovak title doktor medicíny, or MUDr. (Medicinae Universae doctor), are equivalent to the North American MD degree.
The Poles, instead of the North American MD, use the title of lekarz medycyny (lek. med.; compare to lekarz weterynarii – a title obtained by graduates of the veterinary degree). What may be confusing for the British is that most of the Polish medical schools, which run English-taught units of the medical degree, translate this title as “MD” and not “MBBS”. However, the Polish School of Medicine (Polish Medical Faculty) at the University of Edinburgh, which operated from 1941 to 1949, awarded both British degrees of Bachelor of Medicine and Bachelor of Surgery (MB ChB) and a Polish Dyplom Lekarza on the same bilingual Latin-Polish certificate to 227 students. Of these, 19 progressed later to Doctor of Medicine (MD). ^[17] ^[18] ^[19]
The Danish and Norwegian Candidatus medicinae or Candidata medicinae degrees (Cand.med.) are equivalent to the North American MD degree as determined by U.S. state medical boards.
In Mexico as well as most Latin American countries, schools of medicine award the “Titulo de Medico Cirujano” degree after 6 years of study (some Mexican universities award the “Titulo” after 7 years of study). The Mexican “Titulo” is equivalent to the North American MD degree according to the ECFMG. The medical curriculum in Mexico follows the European model of medical education which includes 4 years of study covering the basic and clinical sciences, an undergraduate rotating internship year, and a year of social service providing primary care to an underserved population. Physicians holding the Mexican “Titulo” degree who practice medicine in the USA or Canada use the designation “MD” after their name.
In the Netherlands finishing a medical university training does not automatically qualify to treat patients, or for that fact, to use the internationally recognised MD title. Finishing an university medical study results in a MSc or doctorandus title, locally noted as Drs. or drs. (e.g. drs. Jansen). A minimum of 2 years internship/ specialisation are required, the length in years varying with the discipline. Only after specialisation (e.g. GP medicine, cardiology), the MD title can be used. A PhD title can only be obtained after presenting a large body of original academic research, defending a resulting dissertation successfully before “a gathering of peers”, and a substantial number of peer-reviewed international publications. In the Dutch language, titles can be confusing; the Dutch “dokter” stands for a MD and literally means “physician”, while “doctor” signifies a PhD. The earlier mentioned abbreviation Drs. can also be obtained in other academic disciplines if completed succesfully, and is not medicine specific.^[20] ^[21]
IMGs (International medical graduate) or FMGs (Foreign Medical Graduates), who practice medicine in the United States may use the title MD. They can do so only if they have passed the United States Medical Licensing Examination (USMLE) exams, and satisfied any other legal requirements administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as specified under Public Law 94-484, as amended.

Overview of Medicine

December 21, 2008 by admin
Filed under Medical Science

Overview

Historically, only those with a medical degree have been considered to practice medicine. Clinicians (licensed professionals who deal with patients) can be physicians, physical therapist, physician assistants, nurses or others. The medical profession is the social and occupational structure of the group of people formally trained and authorized to apply medical knowledge. Many countries and legal jurisdictions have legal limitations on who may practice medicine.

Medicine comprises various specialized sub-branches, such as cardiology, pulmonology, neurology, or other fields such as sports medicine, research or public health.

Human societies have had various different systems of health care practice since at least the beginning of recorded history. Medicine, in the modern period, is the mainstream scientific tradition which developed in the Western world since the early Renaissance (around 1450). Many other traditions of health care are still practiced throughout the world; most of these are separate from Western medicine, which is also called biomedicine, allopathic medicine or the Hippocratic tradition. The most highly developed of these are traditional Chinese medicine, Tibetan medicine and the Ayurvedic traditions of India and Sri Lanka. Various non-mainstream traditions of health care have also developed in the Western world. These systems are sometimes considered companions to Hippocratic medicine, and sometimes are seen as competition to the Western tradition. Few of them have any scientific confirmation of their tenets, because if they did they would be brought into the fold of Western medicine.

“Medicine” is also often used amongst medical professionals as shorthand for internal medicine. Veterinary medicine is the practice of health care in animal species other than human beings.

History of medicine

The earliest type of medicine in most cultures was the use of plants (Herbalism) and animal parts. This was usually in concert with ‘magic’ of various kinds in which: animism (the notion of inanimate objects having spirits); spiritualism (here meaning an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (the supposed obtaining of truth by magic means), played a major role.

The practice of medicine developed gradually, and separately, in ancient Egypt, India, China, Greece, Persia and elsewhere. Medicine as it is practiced now developed largely in the late eighteenth century and early nineteenth century in England (William Harvey, seventeenth century), Germany (Rudolf Virchow) and France (Jean-Martin Charcot, Claude Bernard and others). The new, “scientific” medicine (where results are testable and repeatable) replaced early Western traditions of medicine, based on herbalism, the Greek “four humours” and other pre-modern theories.The focal points of development of clinical medicine shifted to the United Kingdom and the USA by the early 1900s (Canadian-born)Sir William Osler, Harvey Cushing). Possibly the major shift in medical thinking was the gradual rejection in the 1400s of what may be called the ‘traditional authority’ approach to science and medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, and anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general – see Copernicus’s rejection of Ptolemy’s theories on astronomy). People like Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past such as Galen, Hippocrates, and Avicenna/Ibn Sina, all of whose theories were in time almost totally discredited. Such new attitudes were also only made possible by the weakening of the Roman Catholic church’s power in society, especially in the Republic of Venice.

Evidence-based medicine is a recent movement to establish the most effective algorithms of practice (ways of doing things) through the use of the scientific method and modern global information science by collating all the evidence and developing standard protocols which are then disseminated to healthcare providers. One problem with this ‘best practice’ approach is that it could be seen to stifle novel approaches to treatment.

Genomics and knowledge of human genetics is already having some influence on medicine, as the causative genes of most monogenic genetic disorders have now been identified, and the development of techniques in molecular biology and genetics are influencing medical practice and decision-making.

Pharmacology has developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). The modern era really began with Robert Koch’s discoveries around 1880 of the transmission of disease by bacteria, and then the discovery of antibiotics shortly thereafter around 1900. The first major class of antibiotics was the sulfa drugs, derived originally from azo dyes. Throughout the twentieth century, major advances in the treatment of infectious diseases were observable in (Western) societies. The medical establishment is now developing drugs that are targeted towards one particular disease process. Thus drugs are being developed to minimise the side effects of prescribed drugs, to treat cancer, geriatric problems, long-term problems (such as high cholesterol), chronic diseases type 2 diabetes, lifestyle and degenerative diseases such as arthritis and Alzheimer’s disease.

Practice of medicine

The practice of medicine combines both science as the evidence base and art in the application of this medical knowledge in combination with intuition and clinical judgement to determine the treatment plan for each patient.

Central to medicine is the patient-physician relationship established when a person with a health concern seeks a physician’s help; the ‘medical encounter’. Other health professionals similarly establish a relationship with a patient and may perform various interventions, e.g. nurses,radiographers and therapists.

As part of the medical encounter, the healthcare provider needs to:

* develop a relationship with the patient

* gather data (medical history, systems enquiry, and physical examination, combined with laboratory or imaging

studies (investigations))

* analyze and synthesize that data (assessment and/or differential diagnoses), and then:

* develop a treatment plan (further testing, therapy, watchful observation, referral and follow-up)

* treat the patient accordingly

* assess the progress of treatment and alter the plan as necessary (management).

The medical encounter is documented in a medical record, which is a legal document in many jurisdictions.[1]

[edit] Health care delivery systems

Medicine is practiced within the medical system, which is a legal, credentialing and financing framework, established by a particular culture or government. The characteristics of a health care system have significant effect on the way medical care is delivered.

Financing has a great influence as it defines who pays the costs. Aside from tribal cultures, the most significant divide in developed countries is between universal health care and market-based health care (such as practiced in the U.S.). Universal health care might allow or ban a parallel private market. The latter is described as single-payor system.

Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality and pricing greatly affects the choice by patients / consumers and therefore the incentives of medical professionals. While US health care system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.

Health care delivery

Medical care delivery is classified into primary, secondary and tertiary care.

Primary care medical services are provided by physicians or other health professionals who has first contact with a patient seeking medical treatment or care. These occur in physician’s office, clinics, nursing homes, schools, home visits and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes.

Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.

Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.

Modern medical care also depends on information – still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.

Physician-patient relationship

The physician-patient relationship and interaction is a central process in the practice of medicine. There are many perspectives from which to understand and describe it.

An idealized physician’s perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning the patient’s symptoms, concerns and values; in response the physician examines the patient, interprets the symptoms, and formulates a diagnosis to explain the symptoms and their cause to the patient and to propose a treatment. The job of a physician is similar to a human biologist: that is, to know the human frame and situation in terms of normality. Once the physician knows what is normal and can measure the patient against those norms, he or she can then determine the particular departure from the normal and the degree of departure. This is called the diagnosis.

The four great cornerstones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy and physiology) and psychology (mind and behaviour). In addition, the physician should consider the patient in their ‘well’ context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient’s condition and further management. In more detail, the patient presents a set of complaints (the symptoms) to the physician, who then obtains further information about the patient’s symptoms, previous state of health, living conditions, and so forth. The physician then makes a review of systems (ROS) or systems enquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination; the findings are recorded, leading to a list of possible diagnoses. These will be in order of probability. The next task is to enlist the patient’s agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the healthcare provider educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant “teacher” in Latin. The patient-physician relationship is additionally complicated by the patient’s suffering (patient derives from the Latin patior, “suffer”) and limited ability to relieve it on his/her own. The physician’s expertise comes from his knowledge of what is healthy and normal contrasted with knowledge and experience of other people who have suffered similar symptoms (unhealthy and abnormal), and the proven ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge, although the latter may be better performed by a pharmacist.

The physician-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of healthcare providers and patients in many ways.

The quality of the patient-physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient’s disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient’s knowledge about the disease. Where such a relationship is poor the physician’s ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought.

In some settings, e.g. the hospital ward, the patient-physician relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.

Clinical skills

A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and a treatment plan.[2]

The components of the medical history are:

* Chief complaint (CC): the reason for the current medical visit. These are the ’symptoms.’ They are in the patient’s own words and are recorded along with the duration of each one. Also called ‘presenting complaint.’

* History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.

* Current activity: occupation, hobbies, what the patient actually does.

* Medications: what drugs the patient takes including over-the-counter, and home remedies, as well as herbal medicines/herbal remedies such as St. John’s Wort. Allergies are recorded.

* Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.

* Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).

* Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.

* Review of systems (ROS) or systems enquiry: an set of additional questions to ask which may be missed on HPI, generally following the body’s main organ systems (heart, lungs, digestive tract, urinary tract, etc).

The physical examination is the examination of the patient looking for signs of disease (’Symptoms’ are what the patient volunteers, ’signs’ are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:

* Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation

* General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)

* Skin

* Head, eye, ear, nose, and throat (HEENT)

* Cardiovascular (heart and blood vessels)

* Respiratory (large airways and lungs)

* Abdomen and rectum

* Genitalia (and pregnancy if the patient is or could be pregnant)

* Musculoskeletal (spine and extremities)

* Neurological (consciousness, awareness, brain, cranial nerves, spinal cord and peripheral nerves)

* Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

Laboratory and imaging studies results may be obtained, if necessary.

The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient’s problem.

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.

Branches of medicine

Working together as an interdisciplinary team, many highly trained health professionals besides medical practitioners are involved in the delivery of modern health care. Some examples include: nurses, emergency medical technicians and paramedics, laboratory scientists, pharmacists, physiotherapists, respiratory therapists, speech therapists, occupational therapists, Radiographer’s, dietitians and bioengineers.

The scope and sciences underpinning human medicine overlap many other fields. Dentistry and psychology, while separate disciplines from medicine, are considered medical fields.

Midlevel Practitioners

Nurse practitioners, midwives and physician assistants, treat patients and prescribe medication in many legal jurisdictions.

Veterinary Medicine

Veterinarians apply similar techniques as physicians to the care of animals.

Physicians have many specializations and subspecializations which are listed below. There are variations from country to country regarding which specialities certain subspecialities are in.

Diagnostic specialties

* Clinical laboratory sciences are the clinical diagnostic services which apply laboratory techniques to diagnosis and management of patients. In the United States these services are supervised by a pathologist. The personnel that work in these medical laboratory departments are technically trained staff, each of whom usually hold a medical technology degree, who actually perform the tests, assays, and procedures needed for providing the specific services.

* Pathology is the branch of medicine that deals with the study of diseases and the morphologic, physiologic changes produced by them. As a diagnostic specialty, pathology can be considered the basis of modern scientific medical knowledge and plays a large rôle in evidence-based medicine. Many modern molecular tests such as flow cytometry, polymerase chain reaction (PCR), immunohistochemistry, cytogenetics, gene rearragements studies and fluorescent in situ hybridization (FISH) fall within the territory of pathology.

* Radiology is concerned with imaging of the human body, e.g. by x-rays, x-ray computed tomography, ultrasonography, and nuclear magnetic resonance tomography.

Clinical disciplines

* Anesthesiology (AE) or anaesthesia (BE) is the clinical discipline concerned with providing anesthesia. Pain medicine is often practiced by specialised anesthesiologists.

* Dermatology is concerned with the skin and its diseases. In the UK, dermatology is a subspeciality of general medicine.

* Emergency medicine is concerned with the diagnosis and treatment of acute or life-threatening conditions, including trauma, surgical, medical, pediatric, and psychiatric emergencies.

* General practice, family practice, family medicine or primary care is, in many countries, the first port-of-call for patients with non-emergency medical problems. Family practitioners are usually able to treat over 90% of all complaints without referring to specialists.

* Hospital medicine is the general medical care of hospitalized patients. Physicians whose primary professional focus is hospital medicine are called hospitalists in the USA.

* Internal medicine is concerned with systemic diseases of adults, i.e. those diseases that affect the body as a whole (restrictive, current meaning), or with all adult non-operative somatic medicine (traditional, inclusive meaning), thus excluding pediatrics, surgery, gynecology and obstetrics, and psychiatry. There are several subdisciplines of internal medicine:

o Cardiology

o Endocrinology

o Gastroenterology

o Hematology

o Infectious Diseases

o Intensive care medicine

o Nephrology

o Oncology

o Pulmonology

o Rheumatology

* Neurology is concerned with the diagnosis and treatment of nervous system diseases. It is a subspeciality of general medicine in the UK.

* Obstetrics and gynecology (often abbreviated as Ob/Gyn) are concerned respectively with childbirth and the female reproductive and associated organs. Reproductive medicine and fertility medicine are generally practiced by gynecological specialists.

* Palliative care is a relatively modern branch of clinical medicine that deals with pain and symptom relief and emotional support in patients with terminal illnesses including cancer and heart failure.

* Pediatrics (AE) or paediatrics (BE) is devoted to the care of infants, children, and adolescents. Like internal medicine, there are many pediatric subspecialities for specific age ranges, organ systems, disease classes, and sites of care delivery. Most subspecialities of adult medicine have a pediatric equivalent such as pediatric cardiology, pediatric endocrinology, pediatric gastroenterology, pediatric hematology, pediatric oncology, pediatric ophthalmology, and neonatology.

* Physical medicine and rehabilitation (or physiatry) is concerned with functional improvement after injury, illness, or congenital disorders.

* Preventive medicine is the branch of medicine concerned with preventing disease.

* Psychiatry is the branch of medicine concerned with the bio-psycho-social study of the etiology, diagnosis, treatment and prevention of cognitive, perceptual, emotional and behavioral disorders. Related non-medical fields include psychotherapy and clinical psychology.

* Radiation therapy is concerned with the therapeutic use of ionizing radiation and high energy elementary particle beams in patient treatment.

* Radiology is concerned with the interpretation of imaging modalities including x-rays, ultrasound, radioisotopes, and MRI (Magnetic Resonance Imaging). A newer branch of radiology, interventional radiology, is concerned with using medical devices to access areas of the body with minimally invasive techniques.

* Surgical specialties employ operative treatment. These include Orthopedics, Urology, Ophthalmology, Neurosurgery, Plastic Surgery, Otolaryngology and various subspecialties such as transplant and cardiothoracic. Some disciplines are highly specialized and are often not considered subdisciplines of surgery, although their naming might suggest so.

* Urgent care focuses on delivery of unscheduled, walk-in care outside of the hospital emergency department for injuries and illnesses that are not severe enough to require care in an emergency department.

* Gender-based medicine studies the biological and physiological differences between the human sexes and how that affects differences in disease.

Interdisciplinary fields

Interdisciplinary sub-specialties of medicine are:

* Aerospace medicine deals with medical problems related to flying and space travel.

* Bioethics is a field of study which concerns the relationship between biology, science, medicine and ethics, philosophy and theology.

* Biomedical Engineering is a field dealing with the application of engineering principles to medical practice.

* Clinical pharmacology is concerned with how systems of therapeutics interact with patients.

* Conservation medicine studies the relationship between human and animal health, and environmental conditions. Also known as ecological medicine, environmental medicine, or medical geology.

* Diving medicine (or hyperbaric medicine) is the prevention and treatment of diving-related problems.

* Evolutionary medicine is a perspective on medicine derived through applying evolutionary theory.

* Forensic medicine deals with medical questions in legal context, such as determination of the time and cause of death.

* Medical humanities includes the humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice.

* eHealth, Medical informatics, and medical computer science are relatively recent fields that deal with the application of computers and information technology to medicine.

* Naturopathic medicine is concerned with primary care, natural remedies, patient education and disease prevention.

* Nosology is the classification of diseases for various purposes.

* Pharmacogenomics is a form of individualized medicine.

* PanVascular Medicine is an approach to deal with the problems of highly specialised but both, medical and economical inefficiently arranged human resources and medical equipment in today’s vascular care facilities

* Sports medicine deals with the treatment and preventive care of athletics, amateur and professional. The team includes specialty physicians and surgeons, athletic trainers, physical therapists, coaches, other personnel, and, of course, the athlete.

* Therapeutics is the field, more commonly referenced in earlier periods of history, of the various remedies that can be used to treat disease and promote health [1] [2].

* Travel medicine or emporiatrics deals with health problems of international travelers or travelers across highly different environments.

Tags: Medical Science