Talk:Medicine/Archive 3

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Criticism of medicine sections seems short and weak

The practice of modern medicine has been criticised for many other things than listed here. Its tendency to use government to establish monopoly control over procedures and chemicals. Its tendency to substitute the values of the practitions for those of patient, withholding information (more common in Japan), making decisions about what quality of life is worthwhile, discrimination against the elderly, making cost effective decisions instead of lowest risk ones, other the other hand practicing expensive "defensive" medicine, assuming patients are lying and order unnecessary tests as when ER patient with urinary tract infection reports no extra marital sexual relations, substituting their own assessment of the facts such as when Thomas Morris was denied access to anti-biotics because he suspected he had been exposed to anthrax (he had been and subsequently died) denying patients a basic right to self defense, etc.--Silverback 20:23, 11 Oct 2004 (UTC)

Please amplify in the article then. I don't think anyone considered it complete. Alteripse 20:35, 11 Oct 2004 (UTC)

I think Silverback is attempting to start a conversation about this important subject, before making the article itself a forum for the debate, which is my understanding is how this is meant to work. I agree there is enough (just in MY experience) for an entire article about this, but that does not mean as exhaustive a summary as possible does not belong here. I will try to add to the list of criticisms in this space in the near future, but for now wanted to point out there should be more support for the expansion of this section than 4 months of silence. -Jonathan Stone 2 Jan 05

You might want to consider at least 3 things. First, there are a zillion potential medical topics. No contributor has any more "obligation" or "duty" to write about any particular topic than you do. Second, remember that a general overview article such as Medicine should avoid a U.S. bias; a detailed treatment of the advantages and shortcomings of the American healthcare system probably belongs in its own separate article. Third, if you stick to generalities and complain that sometimes doctors fail to do all the things they should or sometimes do some things they shouldn't, it becomes pretty banal unless you actually want to describe and analyze the forces and influences involved. alteripse 04:28, 2 Jan 2005 (UTC)

Hey Alteripse!! happy new year!! hope all is well. I aggree that the criticism section is weak and short.. so is the section (there isn't one) on what is to be a doc... the way medicine can take over your life... the 24/24 on call... the fact you can be walking down the street and suddenly find yourself administering first aid... the family and emothional stress (confronting your own limitations, and fighting death and loosing) ... the enormous rewards (respect, $$, choice)... It'd be nice to expand this especially for the 18 year olds considering the vocation. Erich 08:12, 2 Jan 2005 (UTC)

recent removal of link

JD, that link you removed is spam in a sense, but does contain a useful collection of links. I thought about deleting it a couple weeks ago when first posted but decided to let it stay after I looked at it. I wish the poster would discuss here, but I vote for retention. (and I have no connection whatsover with the site) alteripse 13:37, 20 Feb 2005 (UTC)

Although it is spam, I find this link extremely useful and believe it should be put back. --Eleassar777 13:43, 20 Feb 2005 (UTC)

Okay, I'll put it back. Mr Spammer also removed an interlanguage link; I wonder why. Please promise me that WikiMD will get no more links in other articles. It's a messy wiki that has spammed this site numerous times. JFW | T@lk 19:51, 20 Feb 2005 (UTC)

Sure, boss. I agree it's worth nothing but the links. (smile) alteripse 20:07, 20 Feb 2005 (UTC)

BOSS? C'mon, we're not getting hierarchical on this site that runs on anarchy, are we? JFW | T@lk 21:55, 20 Feb 2005 (UTC) It just seemed the appropriate tone. Joke. alteripse 00:48, 21 Feb 2005 (UTC)

Eleassar777, please discuss and document

Why are you deleting the important information about importance of the doctor/patient relationship to the patient, and replacing it with unfounded overgeneralizations such as the relationship being "central" to medicine, and introducing a novel "teaching" role. I don't know what country you have experienced medicine in, but most doctors have little to no time to "teach", and in many cultures they jealously guard their knowledge and withhold information from patients.--Silverback 13:21, 28 Feb 2005 (UTC)

Alteripse presented the arguments very well, so read below. --Eleassar777 13:56, 28 Feb 2005 (UTC)
No she didn't, perhaps you can do better?--Silverback 15:33, 28 Feb 2005 (UTC)
Silverback, if one patient going to a doctor and saying, "Doc, I hurt. Make it better." isn't the core of medicine, please tell us all what is. "Doctor" literally means "teacher" and has been the title of physicians in English speaking societies for several centuries now--there is nothing "novel" about the physician as teacher. Furthermore, the "important information" about the doctor patient relationship you are so desperately clinging to was a poorly written paragraph that mentioned 1) a physician's relationship with his medicines, which he must compel a patient to take, and 2) a patient's relationship with his government and his insurer, but did NOT mention the physician and patient relating to each other. --Matdaddy 23:27, 1 Mar 2005 (UTC)
Well said. I hadn't realised the etymology of "doctor", but now I understand why I love teaching as well. (Is "indoctrination" an influx of physicians in a busy bar?) JFW | T@lk 13:03, 7 Mar 2005 (UTC)

patient-doctor relationship section

Silverback, a few gentle reminders.

  1. Don't you think your viewpoint might be a bit too "American-centric"? The ER phenomenon you are complaining about is a relatively contemporary American problem that still applies to a minority of the doctor-patient interactions even today in the US. Step back and take a bigger look at the process of "doctoring" across history and cultures. An intro to an article like this should be broadly applicable.
No is isn't uniquely American, ERs have always had to deal with unconscious or severely ill patients who are unable to make their own medical decisions and for whom the MD/patient relationship is irrelevant.--Silverback 15:32, 28 Feb 2005 (UTC)
  1. Please read more carefully, or at least match your reasons to the text you are editing. Your comment about the ER doesn't really contradict the description you removed. I agree it degrades the process by removing prior acquaintance (makes every interaction a first one), reducing the time, and requiring attention only to immediate problems rather than chronic ones. But if you re-read what you removed, it made no claims about any of these three issues.
It did make claims about what was "central". The ER is more central and especially in this internet and college educated age, MDs are having to deal with informed patients with strong opinions about their care.--Silverback 15:32, 28 Feb 2005 (UTC)
  1. I know you don't like it when someone suggests your assertion might be a bit POV, but this is such an example. WP has thousands of articles describing human service relationships. Nearly all start off with a description of what service gets provided in a general ideal way. We don't start the intro to an article about air travel by complaining about how expensive tickets are or how pilots make mistakes and crash the plane sometimes or how unfair it is that you have to get government approval to start a new airline. Your edit justifications might strike some as sounding like this. You might not get multiple people reverting you if you put your opinions in the criticism section of this article and label them more clearly as such, and applicable to current US healthcare system. Note I am not disputing the validity of your opinions here, just asking you to recognize that they are not quite at the level of the most fundamental indisputable fact about this topic for most of us.
Look whose talking about POV, when did you suddenly take an interest in the medical article and start deleting the previous text wholesale.--Silverback 15:32, 28 Feb 2005 (UTC)

I am open to your suggestions, but please don't revert any more. Thanks. alteripse 13:37, 28 Feb 2005 (UTC)

PS: I wrote this before you entered the note above. Thanks for elaborating your opinion. I like the intro and consider it preferable for reasons stated above. alteripse 13:45, 28 Feb 2005 (UTC)

A good compromise would be just to add this new text to the existing text rather than deleting valid information? --Silverback 15:36, 28 Feb 2005 (UTC)
PS: I didn't revert the "intro".--Silverback 15:39, 28 Feb 2005 (UTC)

First you are correct, it isn't the intro. My mistake. Second, I am generally in favor of adding rather than removing. I hadn't noticed much was removed but I will look again. I am certainly open to compromise and suggestion. I have a terribly slow connection right now and it takes several minutes to go between pages and versions. alteripse 17:17, 28 Feb 2005 (UTC)

I probably owe you at least a partial apology. There was no reason for Mattdaddy to replace what was originally there (about gatekeeper responsibility etc) and I missed that it wasn't just an addition. I responded to your edit summaries and removal and didn't understand your point about what was prev removed. Let's keep both in the same section; they are both valid points. Do you want to re-integrate or shall I? I will not try until I have a better connection later today. alteripse 17:29, 28 Feb 2005 (UTC)

My graf was attempt to describe the interaction between one patient and one doctor in an exam room which is the heart of medicine. In place of a discussion of the complicated exchange between doctor and patient, the previous graf portrays the doctor as an obstruction/intermediate between the patient and the government or an insurance company, as if healing results from an interaction between a patient and the gov't or between a patient and his insurer. There is an enormous imbalance of power and knowledge between patient and physician. A patient walks into a doctor's office apprehensive and scared because he often has little idea why he is in pain or can't get his breath or what have you, and he may not be able to tell if the cause is something benign, that will soon relent, or something that will permanently disable him. At the same time, the patient has first hand knowledge about this suffering, and only the patient can decide exactly how great a risk he will take to rid himself of it. Many educated and resourceful patients do some research on their ailments before presenting to a doctor, especially with common diseases, but few if any can present their doctor with a list of likely causes of their ailment, a check list of tests that should be performed to rule out the most dangerous and confirm the most likely, and first line therapy for more than the most common cause. And I doubt that there is anyone anywhere who has gone to his doctor having correctly diagnosed himself with myeloma and asked for his doctor's signature allowing him to treat himself with thalidomide plus dexamethasone every week for three months with bisphosphonate adjunctive therapy and prophylactic allopurinol. The doctor does not usually have first hand knowledge of the suffering the patient's disease causes, but does have experience and knowledge to consider alternate causes and suggest how likely it is that the disease will respond to conventional therapy given any modifying factors in the patient's history. Of course, some patients have researched non-conventional therapies, which the doctor hopefully then researches himself and compares with conventional means for the benefit of the patient. Anyway, I would refer anyone interested in the doctor-patient relationship to the opening chapters of Harrison's Internal Medicine, at least, or even better Ed Pellegrino's work. And think about all this yourself the next time you go see your doctor. --Matdaddy 22:15, 28 Feb 2005 (UTC)

Some patients have researched conventional therapies as well, as someone who follows the medical literature, I have educated my physicians about the latest research on ACE inhibitors, ARBs, matrix-metalloprotease inhibitors, thalidomide, beta blockers, melatonin, naltrexone the latest medical tests for novel risk factors, etc. I would not have had to go to this trouble if physicians had not lobbied the government so hard to gain and their maintain their monopoly powers. But because they are coercively in the loop with this government imposed monopoly, the patient doctor relationship is important to the patient. This fact should not be left out.--Silverback 08:54, 2 Mar 2005 (UTC)

OK, I wasn't trying to leave anything out, but I don't follow your argument here. You would have to educate your doctors far more about medicines they don't have a prescription power over. That is one ofthe complaints of patients who want all doctors to know about all manner of alternative treatments. As much more as we might like doctors to know about prescription medications, they have far less access to information about non-prescription treatments. This fact seems to directly contradict your point, unless I am misunderstanding it? alteripse 05:05, 3 Mar 2005 (UTC)

Of those I mentioned, only melatonin is non-prescription and that may change because a scientist has a use patent, and is trying to get it FDA approved. So, overall it is prescription medications I was educating the doctors about. --Silverback 05:51, 3 Mar 2005 (UTC)

Exactly. You seemed to be making the point that information would be easier to get about drugs if they were non-prescription and I think you are incorrect, because there is almost no good source of information for consumers or doctors about non-prescription drugs (melatonin being an example). In fact, I can give you some other powerful arguments against "do-it-yourself" prescribing:

  1. as imperfect as the current system is, abolishing it would make it far less possible to track rare side effects (e.g., the Vioxx & Rezulin recalls) once it was marketed;
We are protected too much from "rare" side effects, recall that Contact contained a decongestant, that was withdrawn due to increased risk of stroke. Several studies were done before one with enough statistical power showed that it increased the risk of stroke in women. The increased risk was about twice as much as from caffiene. The same study showed it was PROTECTIVE against stroke in men. It was the only decongestant the worked for my daughter, and when she was suffering should would probably have been willing to drive 20+ miles to get it rather than use pseudoephedrine HCL. Her risk of death or serious injury was probably much greater on the drive than from the medicine. patients should be allowed to make their own decisions about the risks if they want to.
  1. there is already an enormous controlled trial going on of consumer prescribing power-- the non-prescription "dietary supplement" industry, which makes drugs in all but name. Would you want Lilly and Merck acting like the companies that make non-prescription drugs-- a huge industry that provides almost zero public information about how to use them or potential risks, and wards off regulatory scrutiny in the name of "health freedom" with false and dishonest claims to consumers that someone is trying to take their vitamins away, and by contributing money to politicians (e.g., the ephedra scandal)? Think of the public knowledge about what works or doesn't work published by the NCCAM-- which was set up by public demand to provide reliable information on non-prescription treatments, and after nearly 10 years and hundreds of millions of dollars, has not reported that a SINGLE alt med treatment works or doesn't work, and has even rewritten the mission statement on their website so that people will stop expecting that type of information any time soon.
I have no problem with you using ephedra if you want.-- [User:Silverback|Silverback]] 03:54, 4 Mar 2005 (UTC)
That's generous of you. My problem with it was twofold-- first, it was a perfect example of false and incomplete advertising-- no info about risks was available to the consumer because the manufacturers were hiding behind the dietary supplement laws and (2) even as a few children and a young adults died each year a consortium of the companies was giving money to the legislators in Texas, Florida, and elsewhere to stop dead an attempt by regulatory agencies to publicly examine the risks. No honesty, no honor, just deceit and greed behind the "health freedom" movement.
  1. if you took prescribing power away from physicians, the folks who would immediately take it from you would be the insurance companies, who would quickly publish (as they try do now to some extent) lists of what drugs they would pay for and for what conditions, and would require that doctors or some other third party confirm that you had that condition.
  2. we already have problems with overuse of certain antibiotics and are trying to tighten rules on which doctors can prescribe them so we can hold on to something to which the increasingly scary bugs out there don't quickly get resistant; I wouldn't want to go the other direction and let people go to the local convenience store for over-the-counter Megastompacillin for their colds.
Historically antibiotics have also been under prescribed, it took over a decade before the medical community finally accepted that H pylori caused most stomach ulcers. There are currently bacterial theories of atherosclerosis and kidney stones and a role for fungal infections in chronic sinusitis although current antifungals damage the kidneys. Recall that postal worker Thomas Morris was denied access to Cipro by a physician before he died of anthrax. Chemical freedom should be as basic a right as self defense. Over 1,000,000 are estimate to have died as a result of FDA delays in approving beta blockers and clot busters. Most americans who unthinkingly step into voting booths an pull the lever for some politician who supports the FDA are mass murderers, I know, I was one. Makes al Qaeda look like they were playing pattycake.--Silverback 03:54, 4 Mar 2005 (UTC)
The comment on H pylori reflects a misunderstanding of the use of antibiotics in H. pylori. When the initial studies came out finding the bacteria there were no studies on whether it was causal. When the initial studies on treatment showed a benefit most patients were being treated with antibiotics. The delay in recommending antibiotics for treatment of colonization by H pylori came out after 1) the risk of allergic reactions was found be be lower than expected, 2) The initial impression that H pylori protected against gastroesophageal reflux disease was disproven, and 3) the cancer risk of H pylori was established. Kd4ttc 16:49, 30 July 2005 (UTC)
Bearing in mind the weakness of the series of one, I would point out that no one "denied" ciprofloxacin to Morris--they did fail to diagnose anthrax in him and so did not treat anthrax in him. One might as well say that you are presently being denied treatment for diseases you are not yet known to have. Along those lines, since you seem to have known for years before everyone else that H pylori caused gastric ulcers, why didn't you tell anyone else? Granted, you would have been laughed at at first, but once a few doctors became curious about the little buggers and started looking for them in the ulcers of their patients, those patients taught us all about H pylori and the pathogenesis of most ulcers. --Matdaddy 02:29, 5 Mar 2005 (UTC)
Morris informed the doctor of the white powder he had been exposed to, and that he wanted Cipro, the MD substituted his judgement and assessment of the risks for Morris. I DID tell people and doctors about the researcher in Austrailia, just not under the name "Silverback", I wasn't the first, but I was an early adopter.--Silverback 11:13, 5 Mar 2005 (UTC)
The best argument against self-prescribing is that it is no safer than performing surgery on oneself. Pseudoephedrine for nasal congestion and the like are about as safe as popping pimples (ahem, incising and draining lesions of acne vulgaris) and the risks of interventions (pharmaceutical or surgical) rise from there. --Matdaddy 01:49, 4 Mar 2005 (UTC)
That probably is the best argument, and it is wrong of course. --Silverback 03:54, 4 Mar 2005 (UTC)
On what grounds? Becuase you said so? --Matdaddy 02:29, 5 Mar 2005 (UTC)
I certainly can't think of a better argument than this wrong one. Many medicines are safer than performing surgery on oneself, although I don't think there is much about self surgery in the literature. I couple of amputations. The safety of most of the anti-hypertensives, statins, and short term use of NSAIDs are all generally safer than performing surgery on oneself.--Silverback 11:13, 5 Mar 2005 (UTC)
You are naive about self-surgery, Silverback. Look around on the internet and find all the websites about trepanning (sometimes spelled trephining). You can also find plenty of case reports in the medical literature of various self-surgery attempts, mostly castrations, but the one that sticks in my mind was the college student who tried to do an adrenalectomy on himself in his dorm room. That was, I think, in JAMA in the early 80s. Oh, and how about that murderous C-section in Missouri a couple of months ago? alteripse 17:03, 5 Mar 2005 (UTC)

Please don't accuse me of claiming doctors are perfect or there is no downside to the current system or of trying to exclude anything negative from this article. It's just that there were lots of good reasons that precribing laws were established, and they were the same reasons that clean food laws were passed: the average knowledge of consumers and prescribers about "drugs" being used a century ago was far worse than it is today, the kind of situation that brings to mind a cliche like, "those who don't know history are condemned to repeat it". I may not change your mind but it seemed worthwhile reminding people exactly why prescribing and licensing laws exist.

I have no objection to someone insisting on only FDA approved drugs, and on only taking them if they are prescribed by a physician. But those benefits could be available voluntarily. Everyone complains about the drug companies and the cost of drugs, hwoever, the largest component of the cost of obtaining drugs for most people is the cut that the physician gets. The point about the information I want retained in the article is not whether it is negative or positive, but whether it is true, and it is.--Silverback 03:54, 4 Mar 2005 (UTC)

Finally I thought I was supporting your point about power and dependence by expanding it into a paragraph. Did I make it even broader than you wanted, or less clear? How do you suggest we modify it?alteripse 12:30, 3 Mar 2005 (UTC)

Hmmm, all said, that was pretty good. Not as blunt as I would like, but pretty good.--Silverback 04:00, 4 Mar 2005 (UTC)

Silverback, Eleassar, Matdaddy, please check to see that the new "melded" version contains all the points you each thought was important. alteripse 04:05, 1 Mar 2005 (UTC)

Much has been said about the p-d relationship in these posts and the new version surely is more neutral. However, it is not evident (or at least not clearly explained) what relationships between patient and doctor prevail in different circumstances. I mean, I believe that usually this is the idealized relationship, however in some cases it is also the "ER relationship". It should be specifically written where different kinds of relationship apply. However, we could even argue that in the case of ER there is no relationship.
The other thing I wish to call attention to refers to semantics. Perhaps it would be better to use the phrase patient-doctor relationship instead of doctor-patient relationship. I mean, it is usually the patient who establishes contact with doctor so the patient should be written first. We could go even further and replace doctor with physician, because the physician is not always a doctor, according to the Latin meaning of the word. --Eleassar777 18:12, 3 Mar 2005 (UTC)
The literature in the fields of medicine and medical ethics have traditionally used the phrase doctor-patient relationship, although a quick Google search found 50k hits for "patient-doctor" relationship (compared with 300k for "doctor-patient" relationship). Beauchamp, Pellegrino, Childress, and Thomasma all use doctor-patient relationship, although in some essays Pellegrino has used physician-patient. A reviewed criticism of these authors, who began cultivating medical ethics as a field in itself and promulgated the virtue-based model of ethics (non-maleficence, beneficence, autonomy, and justice) 30-40 years ago, would be the appropriate place to challenge this terminology and suggest alternatives, not an encyclopedia entry.
The terms physician and doctor should be uniformly used thoughout the medicine section with clearly stated definitions near the beginning of this entry, or they should be used interchangeably. Some associate physician with practitioners of internal medicine and its subspecialties to the exclusion of surgeons, for example, while in other countries, only practitioners in internal medicine are called "Doctor" and surgeons are addressed as "Mister". The present day usage of the terms are very imprecise, as in most countries following the Oxbridge system, doctors do not hold a doctoral degree, making the salutation honorary or conventional but not technically accurate. And even in countries where "doctors" hold doctoral degrees, they do not research or defend theses, so their doctorate is largely titular anyway. (Law, the other profession that awards titular doctoral degrees, does not ask that holders of the Juris Doctor be addressed as "doctor.")
I agree that the terminology is imprecise and generally unsatisfactory, but an important function of reference material is to introduce the reader to a field and its idiosyncracies, so I would present the norms. --Matdaddy 01:32, 4 Mar 2005 (UTC)
That's great if you will (don't take this as being hustled, it's only that probably you can do this better than me because you know more about this topic). I mean, what is really important here is not whether we use one term or another, but that the usage of these terms is explained in the article and that it is grounded in some facts. For example, it should be explained, what is the difference between doctor and physician (it is to some degree but not at all so thoroughly as in your post here) and why it is more common to use the phrase doctor-patient relationship instead of patient-doctor relationship. Also, we should strive after consistence.
The other thing is that it should be explained in what circumstances different doctor-patient relationships develop and what influences them. It does not suffice if it is just written that some kind of it is "ideal" and "taught in school" but not said where it appears in practice.
I also see that the facts that belong together are scattered throughout the article. It will be my pleasure to correct this when you (or someone else) add the missing ones and this discussion finally ends. --Eleassar777 23:33, 4 Mar 2005 (UTC)

Silverback, the basic reason that what others have written don't include your points in the way you want to make them is that we are talking about different topics. Mattdaddy's original description of the structure of the the basic doctor-patient relationship was as unexceptionable as beginning a discussion of English sentence structure by saying, "a basic English sentence includes a subject and predicate." We all know that some meaningful utterances don't follow the paradigm, but it's still the starting point. Your point about ERs and prescription monopoly was perfectly true and perfectly irrelevant to an explanation of the structure of the basic doctor-patient interaction. Your point about it being "more important now because doctors have prescription monopoly" is a failure to understand the other points. The basic interactional structure of the relationship has not changed in 2500 years. Different aspects get distorted by local customs or circumstances (e.g., the old Chinese practice of a patient describing symptoms on a doll instead of allowing a direct visual inspection of an important person), but it is basically and usually: patient describes problem, doctor gathers info, doctor interprets info from professional knowledge perspective, doctor explains diagnosis to patient with treatment recommendation. In this context, it doesn't matter who can prescribe-- that is an irrelevant piece of local circumstance. The process is the same if the doctor is a Greek slave, shaman, chiropractor, or an ER doc.

Your 3 important points, if I recall, were that in ER interactions the doctor and patient don't know each other, that in critical care situations the doctor doesn't explain much to the patient, and that when government licenses prescription power it changes the potential advantages and disadvantages to the patient. These are perfect examples of modification of way the interaction operates by special circumstances or particular social rules but none of them replace or invalidate the basic interaction structure. Your points are both valid and deserve to be in this article, but not in the same paragraph and not as a "contradiction" or "more accurate view", which is how it seemed you were offering them.

I am sorry you thought my attempt to generalize your points into something less specific and place-bound was "namby-pamby." I wasn't trying to exclude your points, nor get into a conflict, just to put them in a context that didn't make it look so much like you just didn't get the point of the section. alteripse 18:21, 6 Mar 2005 (UTC)

It wasn't you attempt to generalize my points that I considered namby pamby, it was what was done to the whole section, it was the touchy feely bs that I generally skip over when I read looking for straight forward information content. Perhaps it is because we live in a literate age, where MDs are more in the way of the informed patient, and if they are too obstinate or insecure then we have to either cleverly work them, or feign deference, or doctor shop to get what we want.--Silverback 21:44, 6 Mar 2005 (UTC)

Silverback, the version you are pushing suggests that the patient-doctor relationship is all about power. I vehemently disagree. While there is obviously an element of power (governments have entrusted doctors with the prescription pad, not just doctors themselves), the patient-doctor relationship is primarily that of someone in need of "health", which the doctor provides as a healthcare provider (horrible term, but it's true). To paint this relationship as one of power is very much POV, and it seems consensus is against it.

Of course it should be mentioned that doctors determine access to treatment, but that is their professional judgment and should be mentioned last, not first in the paragraph on the patient-doctor relationship. JFW | T@lk 00:38, 7 Mar 2005 (UTC)

power, statistics, and lying

No my version is NOT all about power, please note that it INCLUDES your version. You also seem to be implying that power is somehow wrong, but your part is partially about paternalism and that is a more benevolent face of power, but power nonetheless. I just state the facts more boldly, and certainly in a more subdued and defensible manner than I state my opinion here. Some people don't want paternalism. NPOV is obscured by not laying out the power aspects of the relationship plainly. I've just thought of a way that your version is POV. It doesn't reflect how patients are treated like statistics. Consider an adult male seeking treatment for a UTI (urinary tract infection), most MDs will order a test for STDs even if the patient doesn't want them and assures the MD that there is no possibility of that, because the MDs have been trained that statistically a significant number of men will be lying about this. How does treating the patient like a statistic and assuming your patient is lying fit in with your version of the "relationship"?--Silverback 09:00, 7 Mar 2005 (UTC)

"My" version already makes good mention of the "power of the prescription pad" with more references. There is no need to state the facts more boldly. An intelligent reader will get the message without you shouting at him.

About paternalism: patients are treated like statistics because statistics is the only thing that really matters in the final analysis. Most heart attacks are due to atherosclerosis. Many post-MI patients undergo a coronary angiogram. Often, normal coronary arteries are found. Does that mean the doctor was wrong in requesting it? As for the male UTI patients: patients have to give consent before being tested for anything, especially STDs. Times are long past that in these matters consent was considered to be implicit.

I am very concerned about your bias. You cannot simply carry on pushing the same version now. Please address the issues. If you are willing, we can request comments from the Wikipedia user community whether your or "my" version is more POV. JFW | T@lk 13:00, 7 Mar 2005 (UTC)

No, the MD is not wrong for ordering a test that proves negative. But that is different than questioning a patient's integrity and then expecting the patient or his insurance company to pay for it. BTW, what does my "bias" have to do with the correctness of my post to the article?--Silverback 16:07, 7 Mar 2005 (UTC)

Pardon me for introducing a new section heading so it's easier to edit. I find your latest complaint interesting concerning statistics and lying: it truly indicates how little you understand what we do and what we are talking about. The ability of a doctor to help solve a patient's problem is partly based on lengthy schooling about how the body works, but in daily practice is based primarily on our experience with other patients with similar problems. We are far likely to be able to help you if we have seen a hundred other people with the same problem; otherwise all we are doing is looking something up in a book, which is something you might do as well. Statistics are a way to carry out a reality check on impressions. Impressions are a useful piece of evidence we gather for problem solving (e.g., I have the impression that treatment x works better than y for condition z), but an intelligent person has a healthy mistrust of his own impressions-- not ignoring them, but wanting to confirm them with other evidence. Statistics are how we keep our brain heuristics from misleading us. Awareness of probability statistics when treating people is more effectively done consciously than unconsciously. Trust me, you want a doctor who is aware of the probabilities. (Obviously if your use of the term "statistic" is simply a way of saying, "my doctor gives me the impression that he doesn't see me as a unique person worth making at least a brief human relationship with", then you are actually talking about an entirely different issue (caring and what you called the "touchy-feely stuff")-- I am paying you the respect of assuming you mean what you say).

So what do statistics have to do with lying? Part of the evidence we gather to solve a problem is what the patient tells us, but we are being paid to use as much information as possible to solve a problem, so we are doing you a service, not a disservice, when we wonder about what you are not telling us or when we evaluate your account the same way we do the exam, the lab report, or the textbook-- the data may be misleading in this case. In many areas of concerns about health, people find it hard to be accurate and honest about what they have done or not done. A doctor with some maturity and experience can be skeptical and still respect and care about the person--- I run into this issue on a daily basis as I take care of people with diabetes. I have been wrong both ways of course, both in trusting and in not trusting what someone told me, but many times I have solved problems other doctors couldn't because I didn't take the first account at face value. There are better and worse ways to handle this issue of course. I once heard a famous expert on sexual disorders say that he always started every visit by telling his patient he will assume that part of what he tells him is untrue. In some circumstances this level of honesty actually improves mutual confidence and communication.

It is far more dangerous to our patients if a doctor thinks that lying is something that only a few rare, "bad" people do, than if he considers it a normal part of interpersonal interaction.

At least you modified your assertion by claiming that "most" doctors check for STDs. Few of us blindly follow rules like that without making individual adjustments; most of us would not order STD screens if you were paying out of pocket and persuasively denied such risk. And we would be wrong in a few of those instances as well. As you probably know, most people do not object or complain when we check for stds and pregnancy.

You seem to have told us a lot about yourself as a patient: your insecurity at putting yourself in someone else's hands and need for reassurance that that your doctor acknowledges how much you know, your dislike of discussing emotions, your dislike of discussing a problem in terms of probabilities and uncertainties, and especially your dislike of the idea that your doctor might think of you in a way different than the persona you present. Do you call your doctor "doc" as well? If so, you are a very recognizable kind of patient (one that Osler warned about). Each of us find we are better at dealing with some personalities than others. And if you don't like my "reading" of you, perhaps it is wrong and I would get a different impression in person.

And of course, maybe you are right and you really do know more than all of us about practicing medicine. alteripse 13:29, 7 Mar 2005 (UTC)

Yes there are lots of conditions where patients perceptions can mislead them in self diagnosis if they are unaware of those situations. The danger that a lying patient gets into is the patients responsibility not the doctors. You are correct that I like to make my own decisions in areas I consider important, but wrong about discussing emotions, although they aren't the way I make decisions, I do consider their input. I have no problem with probabilities if that is the state of the science, and I agree that it is efficient to work rule out the more common or probable conditions first, but in some areas I opt for more information than is considered "cost effective". What I don't like is inconvenience and coercion, i.e., having to bother with a doctor for the routine, like renewing or adjusting prescriptions, ordering and reading blood tests, etc that unnecessarily increase the cost of medicine. The coercion is of course, the government guns that enforcement the physicians monopoly. I have no problems with physicians that act as consultants, and that don't pretend to know more than they do. What inspires my confidence is if they are willing to say what they don't know, and even look things up in front of you, or get back to you later.
I don't want to be an expert in all areas of medicine, medicine is a broad field and not all parts are equally interesting. Don't get me wrong, there are physicians I admire, and services I would employ them for. I just don't think it should be at the point of a gun. Do you think medicine could survive as it once did, without exclusive government monopolies?--Silverback 16:07, 7 Mar 2005 (UTC)

I haven't the slightest fear that we need a gov monopoly to keep our jobs. We offer a service that is so desired by people that many consider access a "social right". The only effect of dropping the licensure and presciption laws is that it would take us back a century to an even greater degree of caveat emptor. The immediate response would be some sort of certifying procedure so people could assure themselves they were getting someone with training, experience, and accountability, and the insurance companies (both health and liability) would respond by only paying for certified doctors and certified prescriptions and we would be right back where we started. alteripse 16:44, 7 Mar 2005 (UTC)

I would hope that such certification would spring up, and in fact it did exist to some extent, and was codified into law, no doubt with some physician lobbying.--Silverback 11:18, 8 Mar 2005 (UTC)
So then what would be the advantage of repealing the existing de jure licensure & prescription restrictions if the rapid result was de facto certification and prescription access restriction by private corporations? A potentially big social disadvantage would be a widening of the gap between people able to afford and not afford corporate-certified access and drugs. alteripse 13:35, 8 Mar 2005 (UTC)
An advantage would be easier access to the drugs and a reduction in costs. I would work to oppose the insurance and corporate reinstitutionalizing of physicians, in fact I advocate that my employer supply antihypertensives and statins free, and monitor the blood tests themselves as a convenience and preventive cost saving measure. Health classes in high schools should be able to teach the principles of selecting and titrating the doses of these drugs as well as reading basic blood tests for monitoring drugs. In the current system internet MDs and pharmacies should be able to wring out some of the costs this way. I also would work to have medical plans cover expensive over the counter drugs such as the non-sedating anti-histamines.--Silverback 16:37, 8 Mar 2005 (UTC)

Gentlemen, can we go back to discussing the article, instead of how Silverback would change the medical world? JFW | T@lk 17:53, 8 Mar 2005 (UTC)

Chill -- we are community building here and have strayed only about a millimeter off topic.--Silverback 18:41, 8 Mar 2005 (UTC)

We are going to teach kids in high school how to prescribe their own medicines for when they develop chronic adult diseases in 10,20,30 years?! I take care of teenagers with diabetes and other chronic diseases every day. I have been continuing this discussion under the apparently mistaken assumption that you and I belong to the same species living in the same universe. You are pulling my leg, aren't you? alteripse 03:44, 9 Mar 2005 (UTC)

I've been on anti-hypertensives since age 19. There is a consensus building that atherosclerosis begins in the young, and the increase in obesity has more teans that are pre-diabetic or with type II diabetes. I suspect that soon we will have anti-obesity drugs. I would prefer that schools just focus on scientific literacy because that is all that is really needed for someone who wants to prescribe for themselves or their families. However, since schools teach all kinds of "subjects" other than basic skills, there is no reason for them to be kept in ignorance about medical matters. I don't engage in personal attacks.--Silverback 23:52, 9 Mar 2005 (UTC)

Forgive me. I didn't intend astonishment to seem like a personal attack, although I guess if you offered that in good faith it must seem like one. Shall we say so many objections problems occurred to me that suggested that your idea of what a high school can teach a teenager about his own future health differs so radically different from my daily experience as to suggest our ideas of what is possible with the subspecies homo adulescens are incompatibly divergent? I'm not sure there is anywhere to go with this than, "we are all entitled to our opinions" I think you may have been a teenager several standard deviations from normal. I certainly admit to the same, so that conjecture is not intended as a personal attack. alteripse 01:23, 10 Mar 2005 (UTC)

Happy to forgive and forget. It was the species and universe part that seemed like an attack. I had missed your statement about treating teens with diabetes, so apologies for spouting that redundant information. --Silverback 19:20, 10 Mar 2005 (UTC)

Overall Review

I wish Wikip. had an "Article review" button for each article (maybe it does). Anyway, this article seems to be fairly comprehensive and knowledgeable, yet needs a lot of editing for style, sexist pronoun use, and a range of point-of-view issues which characterize a text lacking a degree of scientific precision when it comes to language and writing--less than satisfactory cultural context for its assertions...and style needs improvement. Hope that isn't too critical. I'll try to clean up what I can when I have time. Thanks! 70.57.141.70 02:41, 7 Mar 2005 (UTC)

I'm not sure what the purpose of "article review" would be. Be bold and start editing! If one of us doesn't like it, we'll just revert :-) JFW | T@lk 07:59, 7 Mar 2005 (UTC)
I just had a little copyedit, and the article is actually not bad at all. If you have any specific complaints, perhaps you could mention them here first so we can achieve consensus. I'm categorically against writing his/her whenever the patient or doctor is referred to. Please stick to "he". A large number of publications follows this principle for stylistic reasons, and I see no reason why we should deviate from this. JFW | T@lk 08:15, 7 Mar 2005 (UTC)

The English pronoun "he" refers to a both a male antecedent as well as to antecedents of unknown or unspecified gender; that is, when the antecedent is masculine, "he" is masculine, and when the antecedent is neutral or unspecified, so is "he." "He/she" is equivalent saying "the unspecified masculine or feminine antecedent or the feminine antecedent," which is just wasted effort. Grammar, and not sexism, should make the choice between he and she, and grammar calls for he. The writing through out the article is adequate but not inspired or artful; I think that is largely the result of so many authors.

Wikicities

Why is there the commercial link wikicities:books in the article? As it contains adds by google, it should be removed. --Eleassar777 10:42, 15 Apr 2005 (UTC)

The intro

The intro of this article was:

Medicine is a branch of health science concerned with restoring and maintaining health. Broadly, it is the practical science of preventing and curing diseases. However, medicine often refers more specifically to matters dealt with by physicians and surgeons.

I removed the third line. It suggests that medicine as practiced by physicians and surgeons is not "real medicine". I hotly contest this. Firstly, the remainder of the intro explains exactly what we want (that medicine is a science and a profession). Secondly, medicine as we know it is practiced by many more than just doctors. It is a system - medicine collapses without nurses, laboratory scientists and hospital porters. To claim that medicine is the sole jurisdiction of MDs is a strawman. I'm glad I changed it, and it should not come back. JFW | T@lk 22:08, 21 May 2005 (UTC)

JD: I think you wanted to write: "It suggests that medicine as practiced by INDIVIDUALS OTHER THAN physicians and surgeons is not "real medicine"." Kd4ttc

category

Can I suggest that the article medicine is removed from category:health as it is not consistent with the other articles listed there and can of course be accessed from its own category of category:medicine or as a subcat of category:health sciences. Any further suggestions on how we should categorise medicine and allied professions would be much appreciated as there are still a number of inconsistencies. --Vincej 16:19, 24 July 2005 (UTC)

  • I think medicine is very much a part of health. The articles in the category health are quite diverse. Much of medicine is preventive in nature. Kd4ttc 16:32, 30 July 2005 (UTC)
I agree that medicine is part of health. However if every article that is related to health was put in the parent category of health it would be huge! I am proposing that its placement in the subcategory of category:health sciences is adequate. --Vincej 12:16, 10 August 2005 (UTC)

Request

As part of the WikiProject Missing encyclopedic articles, I redirected Therapeutics here. Both the 1911 version and the 2004 version have material that to me seems exactly like what we cover here. If someone knows that it in fact is a separate discipline, can you let me know and try to create at least a stub on it? Thank you - Taxman Talk 20:33, July 29, 2005 (UTC)

Therapeutics is intrinsic to medicine, but could well refer to physiotherapy etc. Let's leave it like that for now. JFW | T@lk 14:22, 10 August 2005 (UTC)

Lead section

1) I undertook a relatively extensive revision of the lead section. Please check for appropriateness. 2) Also, does anyone think that some information should be put in the lead section about the definition of health, quality of life, and the different kinds of health (mental and physical, etc.), as these certainly bear on the field of medical knowledge and practice. Thanks ~ Dpr 07:54, 3 September 2005 (UTC)

I think an intro of more than 3 paragraphs is too much. This page is about medicine, not health, so quality of life does not need mention in the intro, nor does the distinction between mental and physical health (or their many interconnections). JFW | T@lk 07:46, 4 September 2005 (UTC)

NPOV header

Just wondering why this header was placed. The article does have a "Criticism" section for critics to have their say. Edwardian 21:07, 23 September 2005 (UTC)

See this for a clarification. Some people misunderstand NPOV, the tags and what they could do about bias without slapping tags on things all the time. JFW | T@lk 16:34, 26 September 2005 (UTC)

Hospital medicine

I removed it from clinical disciplines because it is not a clinical discipline but just a way of practice ; it encompasses all disciplines practised in a hospital setting. User:Drepanopulos

I returned the section as it is becoming a speciality in the United States; see the Hospital medicine link. The term does not encompass all disciplines in the hospital, see article for more info. I believe in the UK there are also physicians who also practice only in the hospital and others who practice only in the office. Petersam 00:09, 20 October 2005 (UTC)

In the UK many physicians have only hospital practice. The old specialty of "general medicine" is being replaced to a degree by acute physicians. There are enough "hospitalists" to justify seperate mention. 195.10.45.200 00:59, 20 October 2005 (UTC)


Emergency Medicine

The dynamic young specialty of Emergency Medicine and the emergency department has so far been neglected by Wikipedia. If you are an emergency physician or are knowledgeable about this area please contribute to the articles. I have commenced working on the Emergency Department article, but clearly these areas require an enormous quantity of work.--File Éireann 19:25, 29 October 2005 (UTC)

Specialty Section

I have edited this section to make a few changes.

Dermatology and Neurology are not generally classified as Internal medicine subspecialties. Critical care medicine, however, is. DocJohnny 09:43, 21 November 2005 (UTC)

In the UK neurology and dermatology are part of general medicine. In contrast, hematology is distinct from oncology. JFW | T@lk 00:17, 22 November 2005 (UTC)

If it is important enough, we could elaborate. :) DocJohnny 00:43, 22 November 2005 (UTC)

I will add a note that the classificaiton is a bit arbitrary. Kd4ttc 03:38, 3 January 2006 (UTC)

publication

would you like to publish this article? -- Zondor 22:24, 27 November 2005 (UTC)

What do you mean? JFW | T@lk 14:25, 1 December 2005 (UTC)

Sources

Brian0918 put an {{unsourced}} tag on the page itself. I agree that some references would be useful, but sadly most of it is simply aggregated from many sources and almost impossible to reference individually. I'd be thrilled if we could provide some good authoratitive sources, e.g. on the history of medicine or criticism of medicine. JFW | T@lk 14:25, 1 December 2005 (UTC)

H&P should be in another article

If there is no objection I am going to move the details of the H&P out of this article to another article. Kd4ttc 03:37, 3 January 2006 (UTC)

Second opinion

There were a couple of edits so far about the role of a second opinion. Most physicians are happy to have a second opinion in a case. It does not necessarily follow from a bad realationship. When there is a bad relationship it is best that the parties split. A second opinion may or may not result in having a transfer of care. Kd4ttc 19:39, 28 January 2006 (UTC)

Agree. In the lay view, "second opinion" is an expression of distrust at the diagnosis. Quod non. JFW | T@lk 03:19, 29 January 2006 (UTC)