Basics of Medical Informatics - summary
Week 1: Basics of Medicine
Patient and doctor journey
Thoughts of a patient/person
A good doctor understands what the complaint means for the patient's daily life, makes a
diagnosis, chooses the right treatment, and tries to promote adherence to therapy and satisfy
patients.
The World Health Organization’s (WHO) definition of health is ‘‘a state of complete physical,
psychological and social well being”. The quality of life depends on physical symptoms
experienced day by day, and having satisfactory possibilities to care symptoms. Some
day-to-day symptoms may be related to chronic diseases, however most symptoms can be
categorized as 'everyday illness': coughing, headaches, fatigue, fever, heartburn, back pain e.g.,
people often check the severity of symptoms online with sites such as www.gpinfo.nl.
There are symptoms that ask for immediate attention, for example if a severe accident causes
injurys or severe wounds, there is little ambiguity about the needed action. Nevertheless, for the
majority of symptoms the interpretation is ambiguous. It is uncertain whether a symptom is
harmless or a sign of an illness. The interpretation of symptoms is very
much influenced by a patients believes and experience.
Concepts such as disease, illness, sickness, health, healing and
wholeness can be difficult to define precisely. Part of the reason for this is
that they embody value judgments and are rooted in metaphor. We have
dictionary, medical and popular/literary definitions.
● Disease: a pathological process, most often physical as in throat
infection, or cancer of the bronchus, sometimes undetermined in
origin, as in schizophrenia. The quality which identifies disease is some deviation from a
biological norm.
○ Some diseases, clearly, are less respectable than others → Munchenausen’s
syndrome (psychological condition where someone pretends to be ill or
deliberately produces symptoms of illness in themselves)
● Illness: a feeling, an experience of unhealth which is entirely personal, interior to the
person of the patient. Often it accompanies disease, but the disease may be undeclared,
as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists
where no disease can be found.
○ Illness is the patient’s experience of ill health, sometimes when no disease can
be found
● Sickness: the external and public mode of unhealth. Sickness is a social role, a status, a
negotiated position in the world, a bargain struck between the person henceforward
called ‘sick’, and a society which is prepared to recognise and sustain him. The security
of this role depends on a number of factors, not least the possession of that much
treasured gift, the disease. Sickness based on illness alone is a most uncertain status.
But even the possession of disease does not guarantee equity in sickness.
○ Sickness is the role negotiated with society
1
,Basics of Medical Informatics - summary
● Health: definition above, to try to define health as simply the absence of disease or
infirmity leads you into difficulties: ill health can’t be defined simply in terms of disease,
for example, because people can have a disease (especially one with minor symptoms)
without feeling ill, and they can have unwanted symptoms (nausea, faintness,
headaches and so on) when no disease or disorder seems to be present. Nor is the fact
that a condition is unwanted enough to describe it as ill health.
● Healing and wholeness: Healing is understood by religion not only as the natural
process of tissue regeneration sometimes assisted by medical means, but also as
whatever process results in the experience of greater wholeness of the human spirit.
Healing in the latter sense need not be religious in form (nature, music or friendship as
well as religious rites may be agents of healing), nor accompanied by “cures” or
“miracles”. other signs of hope, when attested, may be seen as traces of a transcendent
or encompassing wholeness, in which human wholeness is grounded. But wholeness is
always imperfectly realised in the fragmentariness of human experience; and while for
religion the encompassing wholeness is not reducible to a psychological projection, it is
discovered most commonly in the mode of expectancy, both in the midst of life and in the
face of death
Next to the wide variety in (perception of) symptoms, there is much diversity in reasons and how
often a person seeks help of a physician. One could argue that the reason for seeking medical
attention is often more influenced by these patients believes ("is it serious? Is it harmfull??),
more than it's influenced by the severity. For example, if a patient has a cough he's more likely
to seek medical attention if he's afraid the cough is caused by lungcancer, then if he thinks it's
caused by an innocent viral infection (flu)
About 70% of people visit their GP at least once a year. Immigrants, women, the elderly and
people with a low social status visit their GP more often. As mentioned above, not only the
severity of the 'disease' but also other factors influence the decision to go to a physician. These
include demographic factors (age, sex, and ethinic minority groups), socialeconomic factors
(social class, unemployment, housing tenure), family factors, psychological factors (perceived
sustainability, perceived severity, perceived benefits and costs, knowledge about illness, belief
in effectiveness of self care, stressful life events), consultation patterns (distance from surgery,
appointment systems, access to A&E emergency service)
Once someone has decided to go to a physician, or arrives at the GP/hospital in acute
situations, the clinical process begins.
Thoughts of a physician
Physicians make dozens of clinical decisions every day: some are made easily, almost reflective
and require little thinking, others require considerable knowledge and gathering lots of data. A
doctor has to consider the emotional, social, and personal aspects of the patient’s life and
family. He/she may consult colleagues about difficult cases. Some decisions can be made with a
high degree of confidence but others with uncertainty.
2
,Basics of Medical Informatics - summary
There are major differences between decision-making and problem-solving. The two entities
differ in discrete and subtle ways and should be resolved at different levels within teams or
organizations. Decision-making usually involves more experienced higher-order,
process-dependent, and non-linear skills. The impact of decision-making is usually more global,
long-term, and less quantifiable and qualifiable.
Differences between problem-solving and decision-making
● Problem-solving is a more analytical process than decision-making
● Problem-solving is more process-related, while decision-making is more contextual
● Problem-solving is directed at a specific goal or discrete answer
● Both may have consequences that are not always predictable or sequential
● Problems, once solved, may require no further action for that problem, while issues that
require decision-making are more likely to carry long-term or unintended consequences
or follow-on responsibilities or physician involvement
● Decision-making requires a more global or inclusive understanding of the domain
● Decision-making relies mre on experience and judgement than problem-solving
● Decision-making provides a course of action or final opinion–not the directions or steps
to get there
● Problem-solving can be pushed down to more junior decision-makers and, indeed, helps
them develop their decision-making skills. Decision-making is usually relegated to the
more senior members of a team.
Clinical decision-making does not follow vague or ill-defined
principles. It is not just about finding the right diagnosis or
prescribing the correct treatment. Decision-making must
observe principles and guidelines that can be simply stated
and formally discussed. Decision-making can be considered
as a series of steps that form a cycle to be repeated over
and over until the problem is resolved. Decision-making is
cyclical–we may make a decision but rarely walk away from
the patient–therefore our decision-making is evolving and
always being refined.
In healthcare, ethical decisions are inevitable. Medical ethics used to concern only doctors,
nowadays it's a subject of everyone's interest. The medical-ethical topics are also discussed in
politics, and laws and regulations for established. Typical subjects are the relationship between
doctor and patient, professional secrecy, discontinuing or forgoing treatment, waiting lists,
dealing with patients who are unable to express their will, the end of life, stem cell research,
embryo selection and organ transplantation. Some of these topics are as old as medicine,
others are new and the result of medical developments. Moreover, not only healthcare has
changed, society as well. Consider, for example, the aging population and increased ethnic
diversity.
3
, Basics of Medical Informatics - summary
Physicians may deal with a great variety of perplexing ethical problems even in a small medical
practice, physicians may held different opinions about prescribing a placebo, breaching patient
confidentiality due to a health risk or 'upcoding' to get treatment covered. The standards for
physicians are a way to provide some guidance on ethical problems, but they cannot address
every issue, and may not fit each particular case. In case of a ethical issue, a physician relies
basic values explained below:
1. Autonomy: it is required that a patient can determine their own healthcare. In order to
make a fully informed decision, the patient must understand all risks and benefits of a
procedure and the likelihood of success.
2. Justice: to be fair and treat like cases alike as a physician, and the benefits and burdens
of care (for example a new treatment) must be distributed equally among all groups in
society.
3. Beneficence: all procedures are with the intent of doing good for the patient.
4. Non malfeasance: a procedure does not harm the patient involved or others in society.
However, it is not limited to just these four principles, the physician should respect the values
and attitudes of patients and has to consider many other important values.
In general, a doctor follows these steps to diagnose:
1. Find out what the reason for consulting is
2. Ask about the medical history (be aware of the difficulty of this question)
3. Physical examination if needed
4. Differential Diagnosis
5. Additional testing (if necessary; Lab testing, X-ray etc)
6. Diagnosis
Problem of the patient and reason for medical consultation
At the general practitioner the consultation starts the moment the physician sees the patient
(how does the patient makes contact, what is the physical state? How do they walk?).
Subsequently, the patient explains his or her symptoms in the office. It seems logical that the
problem is clear after hearing the patient's story, but the reality is far from this. Patients who visit
a general practitioner or medical specialist have expectations and wishes. Some patients may
seek for a physician because they just need someone to listen to them. Or a patient may tell
about symptoms as the problem, whilst the underlying problem is something different. Or it can
be that the person is not aware of the underlying problem themselves.
Excessively high expectations of patients (almost anything is possible, everyone is entitled to
the most advanced care, making mistakes is not allowed, a super specialist is best) lead to a
disproportionately large demand for care and thus to high costs, without much improvement in
quality of life (QoL). It is important for the practitioner to map out the patient's wishes (the
reason for medical consultation) and at the same time to ensure that the patient receives the
care he needs. This requires consultation and cooperation, but also negotiation. The closer a
physician can come to an understanding of the patient’s illness experience, the better he can
fulfill to deliver care in every unique patient context.
4
Week 1: Basics of Medicine
Patient and doctor journey
Thoughts of a patient/person
A good doctor understands what the complaint means for the patient's daily life, makes a
diagnosis, chooses the right treatment, and tries to promote adherence to therapy and satisfy
patients.
The World Health Organization’s (WHO) definition of health is ‘‘a state of complete physical,
psychological and social well being”. The quality of life depends on physical symptoms
experienced day by day, and having satisfactory possibilities to care symptoms. Some
day-to-day symptoms may be related to chronic diseases, however most symptoms can be
categorized as 'everyday illness': coughing, headaches, fatigue, fever, heartburn, back pain e.g.,
people often check the severity of symptoms online with sites such as www.gpinfo.nl.
There are symptoms that ask for immediate attention, for example if a severe accident causes
injurys or severe wounds, there is little ambiguity about the needed action. Nevertheless, for the
majority of symptoms the interpretation is ambiguous. It is uncertain whether a symptom is
harmless or a sign of an illness. The interpretation of symptoms is very
much influenced by a patients believes and experience.
Concepts such as disease, illness, sickness, health, healing and
wholeness can be difficult to define precisely. Part of the reason for this is
that they embody value judgments and are rooted in metaphor. We have
dictionary, medical and popular/literary definitions.
● Disease: a pathological process, most often physical as in throat
infection, or cancer of the bronchus, sometimes undetermined in
origin, as in schizophrenia. The quality which identifies disease is some deviation from a
biological norm.
○ Some diseases, clearly, are less respectable than others → Munchenausen’s
syndrome (psychological condition where someone pretends to be ill or
deliberately produces symptoms of illness in themselves)
● Illness: a feeling, an experience of unhealth which is entirely personal, interior to the
person of the patient. Often it accompanies disease, but the disease may be undeclared,
as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists
where no disease can be found.
○ Illness is the patient’s experience of ill health, sometimes when no disease can
be found
● Sickness: the external and public mode of unhealth. Sickness is a social role, a status, a
negotiated position in the world, a bargain struck between the person henceforward
called ‘sick’, and a society which is prepared to recognise and sustain him. The security
of this role depends on a number of factors, not least the possession of that much
treasured gift, the disease. Sickness based on illness alone is a most uncertain status.
But even the possession of disease does not guarantee equity in sickness.
○ Sickness is the role negotiated with society
1
,Basics of Medical Informatics - summary
● Health: definition above, to try to define health as simply the absence of disease or
infirmity leads you into difficulties: ill health can’t be defined simply in terms of disease,
for example, because people can have a disease (especially one with minor symptoms)
without feeling ill, and they can have unwanted symptoms (nausea, faintness,
headaches and so on) when no disease or disorder seems to be present. Nor is the fact
that a condition is unwanted enough to describe it as ill health.
● Healing and wholeness: Healing is understood by religion not only as the natural
process of tissue regeneration sometimes assisted by medical means, but also as
whatever process results in the experience of greater wholeness of the human spirit.
Healing in the latter sense need not be religious in form (nature, music or friendship as
well as religious rites may be agents of healing), nor accompanied by “cures” or
“miracles”. other signs of hope, when attested, may be seen as traces of a transcendent
or encompassing wholeness, in which human wholeness is grounded. But wholeness is
always imperfectly realised in the fragmentariness of human experience; and while for
religion the encompassing wholeness is not reducible to a psychological projection, it is
discovered most commonly in the mode of expectancy, both in the midst of life and in the
face of death
Next to the wide variety in (perception of) symptoms, there is much diversity in reasons and how
often a person seeks help of a physician. One could argue that the reason for seeking medical
attention is often more influenced by these patients believes ("is it serious? Is it harmfull??),
more than it's influenced by the severity. For example, if a patient has a cough he's more likely
to seek medical attention if he's afraid the cough is caused by lungcancer, then if he thinks it's
caused by an innocent viral infection (flu)
About 70% of people visit their GP at least once a year. Immigrants, women, the elderly and
people with a low social status visit their GP more often. As mentioned above, not only the
severity of the 'disease' but also other factors influence the decision to go to a physician. These
include demographic factors (age, sex, and ethinic minority groups), socialeconomic factors
(social class, unemployment, housing tenure), family factors, psychological factors (perceived
sustainability, perceived severity, perceived benefits and costs, knowledge about illness, belief
in effectiveness of self care, stressful life events), consultation patterns (distance from surgery,
appointment systems, access to A&E emergency service)
Once someone has decided to go to a physician, or arrives at the GP/hospital in acute
situations, the clinical process begins.
Thoughts of a physician
Physicians make dozens of clinical decisions every day: some are made easily, almost reflective
and require little thinking, others require considerable knowledge and gathering lots of data. A
doctor has to consider the emotional, social, and personal aspects of the patient’s life and
family. He/she may consult colleagues about difficult cases. Some decisions can be made with a
high degree of confidence but others with uncertainty.
2
,Basics of Medical Informatics - summary
There are major differences between decision-making and problem-solving. The two entities
differ in discrete and subtle ways and should be resolved at different levels within teams or
organizations. Decision-making usually involves more experienced higher-order,
process-dependent, and non-linear skills. The impact of decision-making is usually more global,
long-term, and less quantifiable and qualifiable.
Differences between problem-solving and decision-making
● Problem-solving is a more analytical process than decision-making
● Problem-solving is more process-related, while decision-making is more contextual
● Problem-solving is directed at a specific goal or discrete answer
● Both may have consequences that are not always predictable or sequential
● Problems, once solved, may require no further action for that problem, while issues that
require decision-making are more likely to carry long-term or unintended consequences
or follow-on responsibilities or physician involvement
● Decision-making requires a more global or inclusive understanding of the domain
● Decision-making relies mre on experience and judgement than problem-solving
● Decision-making provides a course of action or final opinion–not the directions or steps
to get there
● Problem-solving can be pushed down to more junior decision-makers and, indeed, helps
them develop their decision-making skills. Decision-making is usually relegated to the
more senior members of a team.
Clinical decision-making does not follow vague or ill-defined
principles. It is not just about finding the right diagnosis or
prescribing the correct treatment. Decision-making must
observe principles and guidelines that can be simply stated
and formally discussed. Decision-making can be considered
as a series of steps that form a cycle to be repeated over
and over until the problem is resolved. Decision-making is
cyclical–we may make a decision but rarely walk away from
the patient–therefore our decision-making is evolving and
always being refined.
In healthcare, ethical decisions are inevitable. Medical ethics used to concern only doctors,
nowadays it's a subject of everyone's interest. The medical-ethical topics are also discussed in
politics, and laws and regulations for established. Typical subjects are the relationship between
doctor and patient, professional secrecy, discontinuing or forgoing treatment, waiting lists,
dealing with patients who are unable to express their will, the end of life, stem cell research,
embryo selection and organ transplantation. Some of these topics are as old as medicine,
others are new and the result of medical developments. Moreover, not only healthcare has
changed, society as well. Consider, for example, the aging population and increased ethnic
diversity.
3
, Basics of Medical Informatics - summary
Physicians may deal with a great variety of perplexing ethical problems even in a small medical
practice, physicians may held different opinions about prescribing a placebo, breaching patient
confidentiality due to a health risk or 'upcoding' to get treatment covered. The standards for
physicians are a way to provide some guidance on ethical problems, but they cannot address
every issue, and may not fit each particular case. In case of a ethical issue, a physician relies
basic values explained below:
1. Autonomy: it is required that a patient can determine their own healthcare. In order to
make a fully informed decision, the patient must understand all risks and benefits of a
procedure and the likelihood of success.
2. Justice: to be fair and treat like cases alike as a physician, and the benefits and burdens
of care (for example a new treatment) must be distributed equally among all groups in
society.
3. Beneficence: all procedures are with the intent of doing good for the patient.
4. Non malfeasance: a procedure does not harm the patient involved or others in society.
However, it is not limited to just these four principles, the physician should respect the values
and attitudes of patients and has to consider many other important values.
In general, a doctor follows these steps to diagnose:
1. Find out what the reason for consulting is
2. Ask about the medical history (be aware of the difficulty of this question)
3. Physical examination if needed
4. Differential Diagnosis
5. Additional testing (if necessary; Lab testing, X-ray etc)
6. Diagnosis
Problem of the patient and reason for medical consultation
At the general practitioner the consultation starts the moment the physician sees the patient
(how does the patient makes contact, what is the physical state? How do they walk?).
Subsequently, the patient explains his or her symptoms in the office. It seems logical that the
problem is clear after hearing the patient's story, but the reality is far from this. Patients who visit
a general practitioner or medical specialist have expectations and wishes. Some patients may
seek for a physician because they just need someone to listen to them. Or a patient may tell
about symptoms as the problem, whilst the underlying problem is something different. Or it can
be that the person is not aware of the underlying problem themselves.
Excessively high expectations of patients (almost anything is possible, everyone is entitled to
the most advanced care, making mistakes is not allowed, a super specialist is best) lead to a
disproportionately large demand for care and thus to high costs, without much improvement in
quality of life (QoL). It is important for the practitioner to map out the patient's wishes (the
reason for medical consultation) and at the same time to ensure that the patient receives the
care he needs. This requires consultation and cooperation, but also negotiation. The closer a
physician can come to an understanding of the patient’s illness experience, the better he can
fulfill to deliver care in every unique patient context.
4
