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Phylosophy of MedicalProfession
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An Overview of the Medical Care Sector
Patientsdemand fortreatment
Physician asdecisionmaker
Demand forinstitutional
setting
Prices andquantity of
services
Supply ofinstitutional
settings
The Supply SideThe Demand Side
Feldstein. Healt Care Economics, 1988
MARKET ECONOMY
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An Overview of the Medical Care Sector
Patientsdemand fortreatment
Physician asdecisionmaker
Demand forinstitutional
setting
Prices andquantity of
services
Supply ofinstitutional
settings
The Supply SideThe Demand Side
Feldstein. Healt Care Economics, 1988
MARKET ECONOMYReregulation
InsuranceCompany
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Now primarily a marketing machine to selldrugs of dubious benefit , this industry usesits wealth and power to co-opt everyinstitution that might stand in its way,
including the U.S. Congress, the Food andDrug Administration, academic medicalcenters, and the medical profession itself.
(Most of its marketing efforts are focused oninfluencing doctors, since they must write theprescription)
Marcia Angell, M.D., Former editor in chief of
The New England Journal of Medicine Winner of the Polk Award
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Professional ResponsibilityViolations (in general)
Conflicts of interest
Mishandling of client Disclosure of confidential information
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Twee koetsiers op een bok , dit gaat niet, zeiden dezegeneeshecren.Typisch symptoom van mata
doewiten " . Want, het moet gezegd worden,vele
lnlandsehe geneeskundigcnwer =den door dezedokteren gebezigd als apothekers en daardoorontbrakhen de gelegenheid er wat bij te verdienen.Het armzalig tractementvan f fo. toch maakte dat
stellig noodzakelijk.
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Six of the values that commonly apply to medicalethics 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 or choosetheir treatment. ( Voluntas aegroti suprema lex .)4. Justice - concerns the distribution of scarce health
resources, and the decision of who gets what treatment(fairness and equality).
5. Dignity - the patient (and the person treating the patient)have the right to dignity.6. Truthfulness and honesty - the concept of informed
consent has increased in importance since the historicalevents of the Doctors' Trial of 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/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/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/Beneficence8/12/2019 Phylosophy of Doctor
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No greater opportunity,
responsibility, or obligation canfall to the lot of a human beingthan to become a physician. Inthe care of the suffering, [the
physician] needs technical skill,
scientific knowledge, and humanunderstanding. . ..
Harrison's Principles of Internal Medicine , 1950
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The Doctor for the 21 st Century
Promote health, prevent and treat disease, andrehabilitate the disable in a compassionate,ethical way (within resources constrain)
Providers of primary care Communicators Critical thinkers Motivated life-long learners Information specialist Citizen of the World Practitionars of applied economics, sociology,
anthropology, epidemiology and behaviouralmedicine Health team managers Advocate for communities
World Summit on Medical Education 1993
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A 12 th centuryBysanthine manuscript
of the Oath
Hippocratic Oath
Hipocrates OathI swear by Apollo,
Asclepius, Hygieia, andPanacea, and I take to
witness all the gods, all thegoddesses, to keep according
to my ability and my judgment, the following
Oath
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PP 26/1960, LAFAL SUMPAH DOKTEROleh: PRESIDEN REPUBLIK INDONESIA
Nomor:26 TAHUN 1960 (26/1960)Tanggal:2 JUNI 1960 (JAKARTA)
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"Saya bersumpah/berjanji bahwa: Saya akan membaktikan hidup saya guna kepentingan perikekemanusiaan; Saya akan menjalankan tugas saya dengan cara yang berhormat 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 m enunaikan kewaj iban terhadap pend er i ta" saya akan ber ikh t iardengan sunggu h-sunggu h supaya saya t idak terpengaruh o lehper t imbangan Keagamaan , Kebangsaan , Kesukuan , Poli t ik Kep artaian atau Kedudu kan Sos ial ;
Saya akan memberikan kepada Guru-guru saya penghormatan dan *14128 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
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The Medical Practice
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Good Medical
Practice
Good Clinical
PracticePatient Safety
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Good Medical Practice
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Good Doctors
Good doctors make the care of theirpatients their first concern, they are
competent, keep their knowledge and skillsup to date, establish and maintain goodrelationships with patients and colleagues,
are honest and trustworthy, and act withintegrity.
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Goo d m edic al p rac t ice setsout the pr inc ip les and values
on which good practice is
founded. The guidance is add ress ed to do c to rs , but is also intended to let th e
p u b l ic k n o w what they canexpect from doctors
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The doctor-patient relationship
Explain the benefits to patients and othersof being the subject of education andrsearch, but respect their right to decline totake part in those activities
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Management Decisions about access to
medical care A responsibility to the community at
large to foster the proper use ofresources
Use resources efficiently,consistent with good patientcare
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Scholarship
Research Keeping up to date
Maintaining and improving yourperformance
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Teach ing , t ra ining , ap pr ais in g andassess ing d oc to rs and s tuden ts areimportant for the care of patients nowand in the future. This is regarded as an in tegral par t o f p rofess io nal prac t ice
If you are inv olved in teach ing youmust develop the attitudes, awarenessand knowledge, skills and practices of a competent teacher
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DOCTOR = DOCERE
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Collaboration
Working in teams Arranging cover
The central role of the general practitioner Delegation and referral Working with colleagues
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Informed Consent
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Fundamental Elements ForDisclosure To Patients
Diagnosis and prognosis Nature of proposed intervention Reseonable alternative intervention
Risk associated with each alternativeintervention Benefits associated with each alternative
intervention
Probable outcomes of each alternativeintervention
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Professionalism
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 con f l ic t o fin teres t
Brennan T et al. Ann Intern Med 2002; 1136: 243-246
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The Twenty-First-Century
Physician: Expanding FrontiersThe era of "omics": genomics,
epigenomics, proteomics,microbiomics, metagenomics,
metabolomics
Harrisons Principles of Intermal Medicine
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Logic in Medicine &Medical Decision Making
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Science (Ilmu) ?
Knowledge (Pengetahuan) ?
Scientific methode ?
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Medical knowledge is a scientificknowledge
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Doctor vs Witch doctor ?
Physician - scientist
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The Science : Diagnostic processThe Art : Clinical process
Medicine
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Methods of Finding theScientific Truth(s)
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Rasional - Empirical Deductive Inductive
Deducto hypothetico - verivicative
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Diagnostic Process is a
scientific process
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(Differential) Diagnosis, likescientific research is basedon methode of hypothesis
formulation
f h d
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Scientific Method(Rasionalism+ Empirisism)
Problem statementData collectionData classificationHypothesis formulationTesting the hypothesis
Deduction and Induction
Th S i ifi P
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The Scientific Process
Problem (illnesss)
Data collecting & dataanalysis
Hypothesis formulation &differential diagnosis
Hypothesis (diagnosis)proven or unproven(probability)
New Problems
Research Question (s)/Problem ?
Data collecting & dataanalysis
Hypothesis formulationHo/H1 Working hypoth.
Hypothesis accepted orrejected (probability)
New Research Questions
Diagnosis Research
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Medical care is often said tobe the art of making decisionwithout adequate information
Harold C. Sox
Probabvility : quantifying the uncertainty
DATA
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DATA Infinite data case sampling
Operational definition Probabilistic concept
AccuracyPrecision
Sensitivity
Specivicity
Predictive value (+/-)
Bayes theorem
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Ilness(es) vs Disease(s) ??
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Illness
The totality of signs (objectivefindings ) and symptomps ( subjectivefeelings ) that characterize a single(individuals) patient to an etiologicagent (i.e. infection)
Each such illness is unique , it happens tosingle individual over a restricted time period of time and will never happenagain in precisely the same way
Delp and Manning,1981
Ill
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Illness
Tuberculosis the illness : is the patients reaction, not merely a tissue reaction
Delp and Manning,1981
Illness is a process
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Disease
Disease do not exist in reality,they are abstraction
Tuberculosis is defined variouslyby medical scientist (clinician aswell as basic scientist) i.e. :
Delp and Manning,1981
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In pathology we study disease inclinical training we work with illness Ideally, the physician should think in
terms of both disease and illness Educational separation of disease and
illness creates obstacles that can be
overcome by conscious effort
Delp and Manning,1981
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Evidence Base Medicine
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Clinical Evidence
&Circumstances
Evidencefrom
Research
PatientsPreferences,Values, and
Rights
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in any dynamic society the onlyconstant is change .
.not all the changes are brought by thediscoveries of the sicentist and the
advances made by techologists.
Some have economic roots and somestems from aspects of man unconquerablemind from the desire for social equity, ahatred of injustice, a wish to help the sick
and disadvantage, or a simple love of
humanity .
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Medicine is advancing morerapidly than the capacity of
statemen and administratorsto deal with .
Roberts S. The Cost of Health. Turnstile PressLondon, 1958.
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health is a political issue
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Most illness has its origins insocial condition
health is a political issue and those enjoying care do notwant to share it ..
Both in the underdeveloped and thedeveloped world the medicalcontribution is largely inappropriate
to health need and does not copewith helath problems of the vastmajority
gap between health care andmedical care has become evenwider
the restricted ability of the poor to fullfill their
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the restricted ability of the poor to fullfill theirneeds for health care, for they are not in a
position, economically or politicallyexcept
possibly of the traditional type.
In South Africa , infant mortality rates are roughlysixtimes as high for blacks and coloureds as they
are for whites in other underdeveloped countries the poor and therich are not distinguished by the color of their skin
.. No recorded infant mortality rates for poor and rich, but rather rates for the population as a whole
Indonesia ?
A safe water supplymakes a major
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the success s to r ies ofbetter health in
underdeveloped countrieshave had more to do withchanged economic and political systems and
improved nutrition, water provision, and sanitation
than with technological
modern medicine
Adequate nutrition as a prerequisite for health
Environmental conditionhave major impact in
health
Agriculter and health aretwo closely related
factors
makes a majorcontribution to health
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doctors and otherprofessional health workers
playing a major and essentialrole, but not necessarily thepredominant one
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these technologicalinnovations have had onlymarginally effects, while othershave had no effect at all, andsome have had negative
ones
medical students are (usually)trained to pursue a
technological imperative, touse any available technique of
intervention
MEDICAL TECHNOLOGY
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Market imperfections and Marketfailure
In situation of natural monopoly,
competition cannot exist
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Social and Economical Context ?Integration to Health Care Services
?Interests ?
Which side ?
V i I
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Various Interensts
Medical Nursing Owners
Investors Patients/Family Insurance Pharmaceutical
Industry
Government Medical Education
Medical Profession
Lawyer
Etc
Bargaining / Conflict
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AccessibleAppropriate to needs
Afordab le
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Who is She ???
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Anak Krakatau, July 2011
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