Practice of medicine
The medical encounter or patient-doctor relationship is central
to medicine. A person with a health problem or concern sees a doctor
for help. The practice of medicine combines both science and art.
Science and technology are the evidence base for many clinical problems
for the general population at large. The art of medicine is the
application of this medical knowledge in combination with intuition
and clinical judgment to determine the proper diagnoses and treatment
plan for this unique patient and to treat the patient accordingly.
Other health professionals similarly establish a relationship with
a patient and may perform interventions from their perspective,
e.g. nurses, radiographers and therapists.
As part of the medical encounter, the doctor
needs to:
develop a relationship with the patient
gather data (medical history and physical examination
combined with laboratory or imaging studies)
analyze and synthesize that data (assessment and/or
differential diagnosis), 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.
The medical encounter is documented in a medical record, which is
a legal document in many jurisdictions. One method that is used
is called the problem-oriented medical record (POMR), which includes
a problem list of diagnoses and a "SOAP" method of documentation
for each visit:
S - Subjective, the medical history of the problem
from the point-of-view of the patient.
O - Objective, the physical examination and any laboratory
or imaging studies.
A - Assessment, is the medical decision-making process
including the differential diagnoses and most probable
diagnoses.
P - Plan, the way resolve the problem and monitor progress
Medical systems
Medicine is practiced within the medical system of a particular
culture or government. Leaving aside tribal cultures, the most significant
divide in developed countries is that between universal health care
and the market based health care (such as practiced in the U.S.).
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