Good medical practice

Dr Dharmakanta Kumbhakar

(The writer can be reached at drkdharmakanta@yahoo.com)

Medicine bridges the gap between science and society. Indeed, the appli cation of scientific knowledge to human health is a crucial aspect of clinical practice. Doctors are one important agent through which scientific understanding is expressed. The role of the doctor has changed drastically since the 1930s and 1940s when practitioners struggled with unbelievably large numbers of patients in their districts. Today the numbers of patients are much smaller, but their qualitative demands are much higher. Every patient wants to look for caring doctors. The patient expects that the doctor examines him/her properly, comes to a correct diagnosis and offers treatment with the aim of curing the patient. It is good medical practice that as a set of values, behaviours, and relationships that underpin the trust the public has in doctors. Good medical practice has several components like medical professionalism (competence), doctor-patient relationship, good communication, judicious use of investigations, good prescribing and practising within medical ethics.

Medicine is more than the sum of our knowledge about the disease. Medicine concerns the experiences, feelings, and interpretations of human beings in often extraordinary moments of fear, anxiety, and doubt. In this extremely vulnerable position, it is medical professionalism that underpins the trust the public has in doctors. Medical professionalism includes how to provide the patient, and their family, with relevant but complex information, discussing management options, and reaching appropriate ethical decisions that are commensurate with the available resources. Medical professionalism lies at the heart of being a good doctor. Patients certainly understand the meaning of poor professionalism and associate it with poor medical care. The public is well aware that an absence of professionalism is harmful to their interests. Medical professionalism has roots in almost every aspect of modern healthcare. High-quality care depends on both effective health teams and efficient health organizations. Healthcare is increasingly provided by a multi-disciplinary team. The doctor usually takes the lead in determining the overall direction of care but must also guide the patient through the unfamiliar landscape, language and customs of clinical care; interpret, synthesize and convey complex information; and help the patient and their family to participate fully in thinking about their care and in the decision- making process. Professionalism, therefore. implies multiple commitments—to the patient, to fellow professionals, and to the institution or system within which healthcare is provided, to the extent that the system supports patients collectively.

Continuous professional development (CPD) with up-to-date knowledge of the subject to maintain competence and expertise is another component of medical professionalism. Good doctors never stop learning and continue to develop their knowledge, skills and attributes throughout their working lives, to the benefit of their patients and themselves. Personal and professional development (PPD) requires a reflective and self-directed approach to the study and practice of medicine and will maximize both life-long effectiveness and personal satisfaction. PPD begins in the first days at medical college and continues through postgraduate training and subsequent professional practice.

The doctor-patient relationship is one of the important components of good medical practice. Patients (and doctors) differ in their beliefs, attitudes and expectations. Good medical practice, or the art of medicine, hinges on the ability to recognize and respect these differences and to treat every patient as an individual. A doctor-patient relationship is in itself therapeutic; a successful consultation with a trusted and respected practitioner will therefore have beneficial effects irrespective of any other therapy given. Trust is the single vital ingredient in the relationship between patient and doctor where lives are at stake. The doctor-patient relationship is also multi-layered, dynamic and bilateral. The physician must make the care of their patient their first concern, patient health must be the priority, to have love and empathy for the patient who is a fellow human being in pain, must treat every patient politely and considerately, must respect the patient's dignity and privacy, must listen to the patient and respect their views, should give patients information in a way that

they can understand, should respect the rights of patients to be fully involved in decisions about their care, should keep professional knowledge and skills up to date, should recognize the limitations of their professional competence, be honest and trustworthy, to not resort to unfair practices, should respect and protect confidential information, make sure that their personal beliefs do not prejudice patient's care, act quickly to protect the patient from risk if the doctor has good reason to believe that the doctor or a colleague may not be fit to practice, avoid abusing your position as a doctor and work with colleagues in the ways that best serve patient's interest.

Good communication is one of the most important components of good medical practice because it identifies problems quickly and clearly, defines expectations, and helps to establish trust between the clinician and patient. Failure in communication leads to poor health outcomes, strained working relations, widespread dissatisfaction among patients, their families and health professionals, anger and litigation. Sadly, poor communication is commonplace in the most healthcare system and has become the root cause of most complaints. At the beginning of a medical consultation, many patients feel ill and most will be apprehensive. Their distress will be enhanced and effective communication will be impossible if the clinician appears indifferent, unsympathetic and short of time. The first impression is critical and it is essential that the patient be put at ease by appropriate introductions and friendly greetings and look at the patient. The clinician must ensure that the patient feels that he or she is the centre of interest and should begin each interview by outlining the objectives of the consultation. The doctor must also ensure that dignity is preserved and that the patient feels comfortable throughout the examination; this may entail the presence of a chaperon and always requires explanation in advance of whatever examination is to be performed. Listening and talking to the patient with care and skill usually lead to a provisional diagnosis, establishing rapport, and determining which investigations are likely to be most productive.

Modern medical practice has become dominated by sophisticated and often expensive investigations. Judicious use of investigations is another component of good medical practice. It is easy to forget that the judicious use of these tools and the interpretation of the data they provide; is crucially dependent on good basic clinical skills. Indeed, a test should only be ordered if it is clear that the result will influence the patient's management and the perceived value of the resulting information exceeds the anticipated discomfort, risk and cost of the procedure. Clinicians should therefore analyse their patient's condition carefully and draw up a provisional management plan before requesting any investigations.

Good prescribing is another component of good medical practice. Prescribe only when necessary, assess the balance of benefit to harm, choose medicines and dosage that are appropriate to the pathophysiology of the disease, continue therapy for an appropriate time and alter it only when necessary.

The physician must practice within medical ethics. Medical ethics is concerned both with the standards of the medical profession and with the study of ethical problems raised by the practice of medicine. Clinical ethics which deal with the relationship between a doctor and an individual patient and public health ethics which deal with a health issue of the community are prime concerns in good medical practice than research ethics. There should not have any nexus between doctors, hospitals, diagnostic sets up and pharmaceutical companies. The best possible good medical practice is that where compassionate healthcare can be provided to patients or the community within the available resources in a specific setting, doing justice to the profession within ethics respecting persons and their autonomy, telling truth with informed consent, keeping confidentiality and giving maximum beneficence to the patient with non-maleficence.