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The Doctor Luke Fildes crop.jpg
"The Doctor" by Luke Fildes (detail)[1]
Names Physician, medical practitioner, doctor of medicine, medical doctor or simply doctor
Type Profession
Activity sectors Medicine, Health care
Competencies the ethics, art and science of Medicine, Analytical skills, Critical thinking
Education required see Medical education
Fields of employment Clinics, Hospitals
Related jobs General practitioner or Family physician, Surgeon, other Medical specialists

A physician'also known as doctor of medicine, medical doctor, or simply doctor'practices the ancient profession of medicine, which is concerned with maintaining or restoring human health through the study, diagnosis, and treatment of disease or injury. This properly requires both a detailed knowledge of the academic disciplines (such as anatomy and physiology) underlying diseases and their treatment'the science of medicine'and also a decent competence in its applied practice'the art or craft of medicine.

Both the role of the physician and the meaning of the word itself vary significantly around the world, but as generally understood, the ethics of medicine require that physicians show consideration, compassion and benevolence for their patients.

Life is short, and Art long;
the crisis fleeting; experience perilous, and decision difficult.
The physician must not only be prepared to do what is right himself,
but also to make the patient, the attendants, and externals cooperate.
'First aphorism of Hippocrates, c. 400 BCE, from the Hippocratic Corpus online (translated by Francis Adams)


[edit] Modern meanings

A doctor performing a typhoid vaccination, 1943

In modern English, the term physician is used in two main ways, with relatively broad and narrow meanings respectively. This is the result of history and is often confusing. These meanings and variations are explained below.

[edit] North America

In the United States and Canada, the term physician usually describes all medical practitioners holding the degrees of Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO). Within North America, the title physician, in this broad sense, also describes the holders of medical degrees from other countries that are equivalent to the North American Doctor of Medicine degrees; typical examples of such degrees from non-North American countries are MB BChir, BM BCh, MB BCh, MB ChB, MBBS, BM, M.B.B.S. etc.. In the US, only those graduating from faculties listed in the WHO Directory of Medical Schools [2] are able to apply for medical licensure in the relevant US jurisdiction, via the ECFMG.[3]

The American Medical Association, established in 1847, currently uses physician in this broad sense to describe all its members. However, the American College of Physicians, established in 1915, does not: its title uses physician in an older, narrower sense, as discussed next.

[edit] Specialist in internal medicine

Physician is still widely used in its older, more narrow sense, especially outside North America. In this usage, a physician is a specialist in internal medicine or one of its many sub-specialties (especially as opposed to a specialist in surgery). This traditional meaning of physician conveys a sense of expertise in treatment by drugs or medications, rather than by the procedures of surgeons.[4]

This older usage is at least six hundred years old in English: physicians and surgeons were once members of separate professions, and traditionally were rivals. The Shorter Oxford English Dictionary, third edition, gives a Middle English quotation making this contrast, from as early as 1400:

O Lord, whi is it so greet difference betwixe a cirugian and a physician.[5]

Henry VIII granted a charter to the London Royal College of Physicians in 1518. It was not until 1540 that he granted the Company of Barber/Surgeons (ancestor of the Royal College of Surgeons) its separate charter. In the same year, the English monarch established the Regius Professorship of Physic at the University of Cambridge.[6] Newer universities would probably describe such an academic as a professor of internal medicine. Hence, in the 16th century, physic meant roughly what internal medicine does now.

Currently, a specialist physician in this older, narrower sense would probably be described in the United States as an internist. Another term, hospitalist, was introduced in 1996,[7] to describe US specialists in internal medicine who work largely or exclusively in hospitals. Such 'hospitalists' now make up about 19% of all US general internists,[8] who are often called general physicians in Commonwealth countries.

The older, more narrow usage of physician as an internist is common in the United Kingdom and other Commonwealth countries (such as Australia, Bangladesh, India, New Zealand, Pakistan, South Africa, Sri Lanka, Zimbabwe), as well as in places as diverse as Brazil, Hong Kong, Indonesia, Japan, Ireland, and Taiwan. In such places, the more general English terms doctor or medical practitioner are prevalent, describing any practitioner of medicine (whom an American would likely call a physician, in the newer, broad sense).[9] In Commonwealth countries, specialist pediatricians and geriatricians are also described as specialist physicians who have sub-specialized by age of patient rather than by organ system.

[edit] "Physician and surgeon"

Around the world, the combined term "Physician and Surgeon" is a venerable way to describe either a general practitioner, or else any medical practitioner irrespective of specialty.[5][4] This usage still shows the older, narrower meaning of physician and preserves the old difference between a physician, as a practitioner of physic, and a surgeon. The term may be used by state medical boards in the United States of America, and by equivalent bodies in provinces of Canada, to describe any medical practitioner.

[edit] Other designations

Osteopaths as a generic term in the European and Commonwealth nations have a very limited alternative care role and should not be confused with a physician who is a Doctor of Osteopathic Medicine. Physicians and surgeons (medical doctors) who are graduates of osteopathic medical schools, and have the degree of D.O. (Doctor of Osteopathic Medicine), have unlimited practicing rights in all specialties and subspecialties of medicine just as their allopathic M.D.(Doctor of Medicine) counterparts. In the US, osteopathic medical schools (DO) have a curriculum almost identical to allopathic (MD) schools with the exception of osteopathic manipulative medicine, which focuses on extra instruction in the musculoskeletal system. Internationally, there are variations in the DO degree; osteopathic education includes teaching manipulative medicine.[10] In the U.S.A. the American Podiatric Medical Associaiton (APMA) defines podiatrists as physicians and surgeons that fall under the department of surgery in hospitals.[11]

In India and many other countries, BHMS (homeopathic) and BAMS (ayurvedic) degree holders like MBBS (allopathic) holders, are treated equally as a registered medical practitioner. They have the right to practice medicine of their systems. They are referred to as physicians. They have to undergo further specialization post-graduate degree to become a specialist in a particular field of medicine/surgery.

Nurse practitioners (NPs) are not described as physicians; the American College of Nurse Practitioners do not describe themselves this way. They are classified as advance practice registered nurses/clinicians, and are also known as mid-level (healthcare) practitioners in US government regulations.[12] Nurse practitioners may perform work similar to that of physicians, especially within the realm of primary care, but use advanced nursing models instead of medical models. The scope of practice for a Nurse Practitioner in the United States is defined by individual state boards of registration in nursing, as opposed to state boards of registration in medicine. Physician Assistants are also classified as midlevel advance practice clinicians, have a similar scope of practice as nurse practitoners, but are regulated by state boards of registration in medicine as they are educated in the medical model like physicians.

[edit] Social role and world view

[edit] Biomedicine

Within Western culture and over recent centuries, conventional Western medicine has become increasingly based on scientific reductionism and materialism. This style of medicine is now dominant throughout the industrialized world, and is often termed Biomedicine by medical anthropologists.[13] Biomedicine "formulates the human body and disease in a culturally distinctive pattern",[14] and is a world view learnt by medical students. Within this tradition, the medical model is a term for the complete "set of procedures in which all doctors are trained" (R. D. Laing, 1972),[15] including mental attitudes. A particularly clear expression of this world view, currently dominant among conventional physicians, is evidence-based medicine. Within conventional Western medicine, most physicians still pay heed to their ancient traditions:

The critical sense and sceptical attitude of the Hippocratic school laid the foundations of modern medicine on broad lines, and we owe to it: first, the emancipation of medicine from the shackles of priestcraft and of caste; secondly, the conception of medicine as an art based on accurate observation, and as a science, an integral part of the science of man and of nature; thirdly, the high moral ideals, expressed in that most "memorable of human documents" (Gomperz), the Hippocratic oath; and fourthly, the conception and realization of medicine as the profession of a cultivated gentleman.
' Sir William Osler, Chauvanism in Medicine (1902)[16]

In this Western tradition, physicians are considered to be members of a learned profession, and enjoy high social status, often combined with expectations of a high and stable income and job security. However, medical practitioners often work long and inflexible hours, with shifts at unsociable times. Their high status is partly from their extensive training requirements, and also because of their occupation's special ethical and legal duties. The term traditionally used by physicians to describe a person seeking their help is the word patient (although one who visits a physician for a routine check-up may also be so described). This word patient is an ancient reminder of medical duty, as it originally meant 'one who suffers'. The English noun comes from the Latin word patiens, the present participle of the deponent verb, patior, meaning 'I am suffering,' and akin to the Greek verb πî�σχî�î�î� (= paskhein, to suffer) and its cognate noun πî�î�î¿ς (= pathos).[5][17]

Physicians in the narrow sense (specialist physicians or internists'see above) are commonly members or fellows of professional organizations, such as the American College of Physicians or the Royal College of Physicians in the United Kingdom, and such hard-won membership is itself a mark of status.

[edit] Complementary and alternative medicine

While contemporary biomedicine has distanced itself from its ancient roots in religion and magic, many forms of traditional medicine[18] and complementary and alternative medicine (CAM) continue to espouse vitalism in various guises: 'As long as life had its own secret properties, it was possible to have sciences and medicines based on those properties' (Grossinger 1980). [19] The US National Center for Complementary and Alternative Medicine (NCCAM) classifies CAM therapies into five categories or domains, including:[20] alternative medical systems, or complete systems of therapy and practice;mind-body interventions, or techniques designed to facilitate the mind's effect on bodily functions and symptoms;biologically based systems, including herbalism; and manipulative and body-based methods, such as chiropractic and massage therapy.

In considering these alternate traditions that differ from biomedicine (see above), medical anthropologists emphasize that all ways of thinking about health and disease have a significant cultural content, including conventional western medicine.[13][14][21][22]

Homeopathy is a popular complementary system of medicine. Homeopathy is included in national system of medicine in many countries including India and neighbouring countries. The practitioners of homeopathic medicine in these countries are generally referred to as homeopathic doctor/homeopath/homeopathic physician on par with conventional medical physicians.

[edit] Physicians' own health

Some commentators have argued that physicians have duties to serve as role models for the general public in matters of health, for example by not smoking cigarettes.[23] Indeed, in most western nations relatively few physicians smoke, and their professional knowledge does appear to have a beneficial effect on their health and lifestyle. According to a study of male physicians,[24] life expectancy is slightly higher for physicians (73.0 years for white and 68.7 for black) than lawyers or many other highly educated professionals. Causes of death less likely in physicians than the general population include respiratory disease (including pneumonia, pneumoconioses, COPD, but excluding emphysema and other chronic airway obstruction), alcohol-related deaths, rectosigmoidal and anal cancers, and bacterial diseases.[24]

However ... "By medicine life may be prolong'd, yet death will seize the Doctor too" (Cymbeline).[25] Physicians are exposed to occupational hazards and temptations, and there is a well-known aphorism that "doctors make the worst patients".[26] Causes of death that may be higher in physicians than in the general population include suicide and self-inflicted injury, drug-related causes, traffic accidents, and cerebrovascular and ischaemic heart disease.[24]

[edit] Desired behaviour

Interviews with patients have indicated that the ideal physician would be confident, empathetic, humane, personal, forthright, respectful, and thorough. Incorporating clues to such behaviors may create a better doctor-patient relationship.[27]

Undesired behaviors are essentially the opposites, specially being insensitive or disrespectful, e.g. arrogance in dismissing the patient's input, disinterest in the patient as an individual, impatience in answering a patient's questions or callousness in discussing the patient's prognosis. Another undesired behavior is seemingly providing excellent service in the original visit but then failing to meet the created expectations about the speed or quality of follow-up service.[27]

Still, when having to choose between high technical quality and high interpersonal quality, two thirds of patients choose high technical quality.[28] Nevertheless, the level of technical quality may be hard for a non-professional to assess, which in reality results in a tendency of patients to primarily judge physicians on behavior.[27]

[edit] Education and training

Medical education and career pathways for doctors vary considerably across the world.

[edit] All medical practitioners

In all developed countries, entry-level medical education programs are tertiary-level courses, undertaken at a medical school attached to a university. Depending on jurisdiction and university, entry may follow directly from secondary school or require pre-requisite undergraduate education. The former commonly take five or six years to complete. Programs that require previous undergraduate education (typically a three or four year degree, often in Science) are usually four or five years in length. Hence, gaining a basic medical degree may typically take from five to eight years, depending on jurisdiction and university.

Following completion of entry-level training, newly graduated medical practitioners are often required to undertake a period of supervised practice before full registration is granted, typically one or two years. This may be referred to as "internship" or "conditional registration". Some jurisdictions, including the United States, require residencies for practice.

Medical practitioners hold a medical degree specific to the university from which they graduated. This degree qualifies the medical practitioner to become licensed or registered under the laws of that particular country, and sometimes of several countries, subject to requirements for internship or conditional registration.

[edit] Specialists in internal medicine

After graduation, medical practitioners often undertake further training in a particular field, to become a medical specialist. In North America, this is often referred to as residency training; in Commonwealth countries, such trainees are often called registrars.

This further training typically takes from three to six years, but can be longer depending on specialty and jurisdiction. Primary care is increasingly recognized as a specialty, and residency programmes in this field are becoming common. A medical practitioner who completes specialist training in internal medicine (or in one of its sub-specialties) is an internist, or a physician in the older, narrower sense.

In some jurisdictions, specialty training is begun immediately following completion of entry-level training, or even before. In other jurisdictions, junior medical doctors must undertake generalist (un-streamed) training for one or more years before commencing specialization. Hence, depending on jurisdiction, a specialist physician (internist) often does not achieve recognition as a specialist until twelve or more years after commencing basic medical training'five to eight years at university to obtain a basic medical qualification, and up to another nine years to become a specialist.

[edit] Regulation

In most jurisdictions, physicians (in either sense of the word) need government permission to practice. Such permission is intended to promote public safety, and often to protect the public purse, as medical care is commonly subsidized by national governments.

[edit] All medical practitioners

Among the English-speaking countries, this process is known either as licensure as in the United States, or as registration in the United Kingdom, other Commonwealth countries, and Ireland. Synonyms in use elsewhere include colegiación in Spain, ishi menkyo in Japan, autorisasjon in Norway, Approbation in Germany, and "î�î�î�î�î� î�ρî�î�σî�î�ς" in Greece. In France, Italy and Portugal, civilian physicians must be members of the Order of Physicians to practise medicine.

In some countries, including the United Kingdom and Ireland, the profession largely regulates itself, with the government affirming the regulating body's authority. The best known example of this is probably the General Medical Council of Britain. In all countries, the regulating authorities will revoke permission to practice in cases of malpractice or serious misconduct.

In the large English-speaking federations (United States, Canada, Australia), the licensing or registration of medical practitioners is done at a state or provincial level or nationally as in New Zealand. Australian states usually have a "Medical Board," while Canadian provinces usually have a "College of Physicians and Surgeons." All American states have an agency which is usually called the "Medical Board", although there are alternate names such as "Board of Medicine," "Board of Medical Examiners", "Board of Medical Licensure", "Board of Healing Arts" or some other variation.[29] After graduating from a first-professional school, physicians who wish to practice in the U.S. usually take standardized exams, such as the USMLE for MDs and DOs or the COMLEX-USA for DOs, which is not available to MDs.

[edit] Specialists in internal medicine

Most countries have some method of officially recognizing specialist qualifications in all branches of medicine, including internal medicine. Sometimes, this aims to promote public safety by restricting the use of hazardous treatments. Other reasons for regulating specialists may include standardization of recognition for hospital employment and restriction on which practitioners are entitled to receive higher insurance payments for specialist services.

[edit] Performance and professionalism supervision

The issue of medical errors, drug abuse, and other issues in physician professional behavior received significant attention across the world,[30] particularly following a critical 2000 report[31] which "arguably launched" the patient-safety movement.[32] In the U.S., as of 2006 there were few organizations which systematically monitored performance. In the U.S. only the Department of Veterans Affairs randomly drug tests, in contrast to drug testing practices for other professions which have a major impact on public welfare. Licensing boards at the U.S. state level depend upon continuing education to maintain competence.[33] In Europe, as of 2009 the health systems are governed according to various national laws, and can also vary according to regional differences similar to the United States.[34]

[edit] See also

[edit] References

  1. ^ In 1949, Fildes' painting The Doctor was used by the American Medical Association in a campaign against a proposal for nationalized medical care put forth by President Harry S. Truman. The image was used in posters and brochures along with the slogan, "Keep Politics Out of this Picture" implying that involvement of the government in medical care would negatively affect the quality of care. 65,000 posters of The Doctor were displayed, which helped to raise public skepticism for the nationalized health care campaign.|http://correspondents.theatlantic.com/abraham_verghese/2009/06/the_ama_conflicted_in_its_interests.ph>
  2. ^ [1]
  3. ^ [2]
  4. ^ a b H.W. Fowler. (1994). A Dictionary of Modern English Usage (Wordsworth Collection). NTC/Contemporary Publishing Company. ISBN 1853263184. 
  5. ^ a b c Brown, Lesley (2002). The New shorter Oxford English dictionary on historical principles. Oxford [Eng.]: Clarendon. ISBN 0198612710. 
  6. ^ "University of Cambridge: History of the School of Clinical Medicine". University of Cambridge. http://www.medschl.cam.ac.uk/about/history.html. Retrieved 2008-02-05. 
  7. ^ Wachter R, Goldman L (1996). "The emerging role of "hospitalists" in the American health care system". N Engl J Med 335 (7): 514'7. doi:10.1056/NEJM199608153350713. PMID 8672160. 
  8. ^ Kuo, YF; Sharma, G; Freeman, JL; Goodwin, JS (2009). "Growth in the care of older patients by hospitalists in the United States". N Engl J Med 360 (11): 1102'1112. doi:10.1056/NEJMsa0802381. PMID 19279342. 
  9. ^ "The Royal Australasian College of Physicians: What are Physicians?". Royal Australasian College of Physicians. Archived from the original on 2008-03-06. http://web.archive.org/web/20080306053048/http://www.racp.edu.au/index.cfm?objectid=49EF1EB5-2A57-5487-D74DBAFBAE9143A3. Retrieved 2008-02-05. 
  10. ^ "JAOA Letters". http://www.jaoa.org/cgi/reprint/107/1/6.pdf. Retrieved 2008-03-01. 
  11. ^ http://www.apma.org/MainMenu/AboutPodiatry.aspx
  12. ^ http://www.deadiversion.usdoj.gov/21cfr/cfr/1300/1300_01.htm#b28
  13. ^ a b A. D. Gaines, R.A. Hahn, ed (1985). "Chapter 1: Introduction (by editors)". Physicians of western medicine. Dordrecht (Netherlands): D. Reidel. pp. 3'22. ISBN 90-277-1790-7. 
  14. ^ a b Good, Byron J (1994). "Chapter 3". Medicine, rationality, and experience: an anthropological perspective (based on the Lewis Henry Morgan Lectures, at the University of Rochester, NY, in March 1990). Cambridge, UK: Cambridge University Press. pp. 65, 65'87. ISBN 0-521-42576-X (pbk). 
  15. ^ Laing, R.D. (1971). The politics of the family and other essays. London: Tavistock Publications. 
  16. ^ Osler, Sir William (1902). "Chauvanism in medicine: address to the Canadian Medical Association, Montreal (17 September 1902)". The Montreal Medical Journal XXXI. 
  17. ^ Partridge, Eric (1966). Origins: a short etymological dictionary of modern English. New York: Macmillan. ISBN 0025948407. 
  18. ^ Galdston, Iago, ed (1963). "Part 1: Medicine and primitive man (five chapters); Part 2: Medical man and medicine man in three North American Indian societies (three chapters)". Man's image in medicine and anthropology: Monograph IV, Institute of social and historical medicine, New York Academy of Medicine. New York: International Universities Press. pp. 43'334. 
  19. ^ Grossinger, Richard (1980, 1982 (revised edition)). Planet medicine: from stone age shamanism to post-industrial healing. Berkeley, CA, US: North Atlantic Books. pp. 116'131. ISBN 978-1-55643-369-6. 
  20. ^ "Complementary and Alternative Medicine ' U.S. National Library of Medicine Collection Development Manual". http://www.nlm.nih.gov/tsd/acquisitions/cdm/subjects24.html. Retrieved 2008-03-31. 
  21. ^ Galdston, Iago, ed (1963). "Part V: Culture and the practice of modern medicine (two chapters)". Man's image in medicine and anthropology: Monograph IV, Institute of social and historical medicine, New York Academy of Medicine. New York: International Universities Press. pp. 477'520. 
  22. ^ Joralemon, DonaldJ (1999). "chapter 1: What's so cultural about disease?". Exploring medical anthropology. Needham Heights, MA, US: Allyn and Bacon. pp. 1'15. ISBN 0-205-27006-9 (pbk). 
  23. ^ Appel JM (2009). "Smoke and mirrors: one case for ethical obligations of the physician as public role model". Camb Q Healthc Ethics 18 (1): 95'100. doi:10.1017/S0963180108090142. PMID 19149049. 
  24. ^ a b c Frank E, Biola H, Burnett CA (October 2000). "Mortality rates and causes among U.S. physicians". Am J Prev Med 19 (3): 155'9. doi:10.1016/S0749-3797(00)00201-4. PMID 11020591. 
  25. ^ Shakespeare, William (~1609, publ. 1623). Cymbeline (play): Act 5, Scene 5. London[Eng.]. 
  26. ^ Schneck SA (December 1998). "'Doctoring' doctors and their families". JAMA 280 (23): 2039'42. doi:10.1001/jama.280.23.2039. PMID 9863860. 
  27. ^ a b c Bendapudi NM, Berry LL, Frey KA, Parish JT, Rayburn WL (March 2006). "Patients' perspectives on ideal physician behaviors". Mayo Clin. Proc. 81 (3): 338'44. doi:10.4065/'81.3.338 (inactive 2009-12-01). PMID 16529138. 
  28. ^ Fung CH, Elliott MN, Hays RD, et al. (August 2005). "Patients' preferences for technical versus interpersonal quality when selecting a primary care physician". Health Serv Res 40 (4): 957'77. doi:10.1111/j.1475-6773.2005.00395.x. PMID 16033487. 
  29. ^ "AMA Links to state medical boards". http://www.ama-assn.org/ama/pub/category/2645.html. Retrieved 2008-03-01. 
  30. ^ Lim MK (February 2004). "Quest for quality care and patient safety: the case of Singapore". Qual Saf Health Care 13 (1): 71'5. doi:10.1136/qshc.2002.004994. PMID 14757804. 
  31. ^ Committee on Quality of Health Care in America, Institute of Medicine. (2000). To Err is Human: Building A Safer Health System. National Academies Press. Free full-text.
  32. ^ Wachter RM (2010). "Patient safety at ten: unmistakable progress, troubling gaps". Health Aff (Millwood) 29 (1): 165'73. doi:10.1377/hlthaff.2009.0785. PMID 19952010. 
  33. ^ Leape LL, Fromson JA (January 2006). "Problem doctors: is there a system-level solution?". Ann. Intern. Med. 144 (2): 107'15. PMID 16418410. 
  34. ^ Suñol R, Garel P, Jacquerye A (February 2009). "Cross-border care and healthcare quality improvement in Europe: the MARQuIS research project". Qual Saf Health Care 18 Suppl 1: i3'7. doi:10.1136/qshc.2008.029678. PMID 19188459. 

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