Admitting Medical Students to the Clinic and Fundamentals of Medical Deontology

Students are admitted to the clinic for direct contact with patients in the second year of their studies. From their first day in the hospital, the students should learn the complicated and important science of association with the patient, the final purpose of which is the complete recovery of the patient. This is not only a science but also a medical talant and intuition. There are no strictly defined rules because each patient requires a special approach due to his special personality traits, pathology, mental develop­ment, education, and other special conditions (fatigue, frustration, enjoy­ment, excitation, etc.).

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General Part

The science of the duties and rights of the doctor in relation to his pa­tient is called deontology (Gk deon obligation, logos science). Deontology may also be defined as the set of rules and principles of medical ethics which govern a member of the medical profession in the exercise of his pro­fessional duties.

The concepts of morals and professional duties of practitioners have changed during the centuries, depending on the social, economic and class relationships, the political structure of the state, the level of civilization, national culture, religious traditions, and many other factors. There are many examples of selflessness in the history of the Russian medicine. The great Russian author Anton Chekhov, who was also a physician, wrote: " Being a doctor is a feat. The profession requires higher selflessness, puri­ty of thought and aspiration. Not everybody is capable of being a doctor". The profession of the doctor is hard labour, sleepless nights, doubts, tormenting experiences, patience, and self-control. At any time the doctor must be ready to render aid to the patient. A real doctor will stay with his patient after his official time is over if the situation requires. He will not spare his leisure time to help the patient without shifting his duties to

someone else.

From literature, newspapers, radio, and TV we know that in order to save his patient a doctor may travel long distances at any time of the day or season, despite the danger to his own health and sometimes even life. Many physicians do experiments on themselves to study a disease or the mechanism of its spreading, volunteer to fight epidemics of severe infec­tious diseases. The Russian physician S. Andrievsky proved the infectious nature of anthrax by experimenting on himself. D. Samoilovich infected himsefl with plague in an attempt to find a way of fighting this disease. Soviet medical workers showed their uttermost selflessness during the Civil

War and World War Two.

The profession of a physician is heroic. The student must understand this from the very start to prepare himself for a life of hard labour and anx­iety. But this life gives moral satisfaction that can hardly be given by any

other profession.

Successful therapy greatly depends on the authority of the doctor. This authority is won not only by selfless labour but also by profound knowledge, because an authoritative physician is always a competent physician. Hippocrates would emphasize that only serious study can bring success to the doctor and that only industriousness combined with knowledge may give ripe fruits. N. Chistovich emphasized that a good physician must work constantly and incessantly; only those who do everything to meet the demands of modern medicine may consider themselves to conscientiously fulfil their duties. The main deontological re

auirement is high medical skill anu a vw

knowledge and skill. A good physician should know all recent aavauvv....

medicine, follow all periodicals and other publications in his profession, attend meetings of medical societies, conferences, take active part in them, and should also be acquainted properly with the problems of the

neighbouring medical specialities.

The authority of a physician largely depends on his attitude toward the patient, his compassion and sympathy for the patient. An indifferent physician decreases the patient's confidence in him and may drastically im­pair the condition of the patient. If the patient trusts his doctor and sees he has a desire to relieve his sufferings, the treatment will often be much mqre effective with the same prescriptions. The Russian author and physician V. Veresaev wrote that the doctor may be a good diagnostician and be quite exacting in his prescriptions, but all his talents are useless if he is unable to conquer the patient's soul. Compassion for the patient is not a formal duty but a genuine sympathy for the patient and the desire to help him. And the patient should feel this compassion whenever he is in contact with medical personnel, beginning with the nurse and secondary personnel and ending with his 'saviour', the physician. Hastiness, indifference by the physician during his examinations and conversation sometimes inflict a heavy blow to a patient that may be decisive to the result of treatment.

When examining the patient, the physician should show his compassion and interest, ask the patient about his complaints, about the beginning and development of the disease, show his sympathy for the patient, so that he might feel confidence in his doctor and sometimes tell him not only his main complaints but intimate details of his life that might be helpful for the diagnosis and treatment. These requirements should be fulfilled by the medical students as well when they come for practical training at hospitals. If a student is not serious, the patient will not feel confidence in him, nor in other medical students that might come next.

As soon as the physician has gained as much information as possible about the disease from clinical findings and results of examination, he must do his best to quiet the patient, raise his spirits, and convince him that there are good signs of his recovery (fall of body temperature, better pulse, improved appetite, etc.), without dwelling on the unfavourable symptoms of the disease. It is recommended that in some cases the disease be com­pared with other more serious diseases helping the patient believe that his disease is not so grave. The patient's attention may be directed to a symp­tom absent in his case. This makes the patient forget for a time his upset-tmg thoughts. For example, if a patient with cardiac decompensation is told that his dyspnoea still persists but the cough is already absent, the pa­rent's mood may improve. If the physician is successful in suggestion, the

General Part

Chapter 1. Internal Medicine: Subject Matter, Purpose and Objectives

patient will not concentrate on the main symptoms of the disease and this in turn may remove depression and increase the patient's tone. The Russian physician G. Zakharyin indicated that, for rare exceptions, the patient's spirits are depressed. In order to successfully treat him the physician should first improve the patient's mood by giving him hope for recovery. A motivating hope can give good results immediately, e.g. patient's insomnia will be removed, which is a good remedy not only for the patient's nerves but for the entire body. At the same time, the physician's task should not be understood as reassuring his patient that the disease is not so grave but rather to convince the patient of his possible recovery (even in malignant cases).

While prescribing medicines and giving advice the physician should ex­plain the treatment schedule, its mode of administration. Improper ad­ministration of medicines will give no desirable results. For example, astr­ingent bismuth nitrate should be taken before meals so that the preparation might act on the gastric mucosa. Improper administration of preparations may harm the patient, as in the case with acetylsalicylic acid, amidopyrine or some other medicines that should be given after meals and in powdered form, rather than in tablets which might cause gastric ulcer. If the patient believes his doctor and the power of his prescriptions, the efficacy of the prescription increases. In other words, the belief in the power and skill of the doctor and his prescriptions points the way to recovery. An outstanding Russian physician V. Bekhterev wrote that a patient feels better after a talk with a true doctor. If a patient feels that his doctor is doubting, this is detrimental to his health. This is especially important in acute cases, such as myocardial infarction, cardiac asthma, or unforeseen complications during a surgical operation. The medical student should learn how to be confident without being self-conceited.

While discussing the case with his colleagues at the patient's bedside, the physician should avoid words and terms that might be unknown to the patient or might be misunderstood by him. An occasional thoughtless word from the physician may impair the mood of the patient, impair his sleep, appetite, and general condition. The student should remember that a pa­tient might ask him a question which he dares not ask the physician. The question will always concern his disease, and the student should therefore always be aware of the damage he may do to the patient by an inap­propriate answer. If the student is not sure, he must consult the doctor before answering the patient. It should be remembered that even in hopeless cases (cancer with multiple metastases, fatal heart disease, irrever­sible affections of the liver, or kidneys) the patient believes that he may recover, and the truth should therefore always be concealed from him. The

duty of the physician is to persuade the patient by all possible means that his disease may be cured.

The practical work of the physician is tightly connected with research. Diagnosis itself is research. The prescription of medicines and observation of their effects, change of preparations and selection of more efficacious means in each particular case implies an individual approach and element of research. The Russian physician V. Manassein wrote that a good doctor is always a researcher, either in the laboratory or at bedside. The student should therefore take part in scientific medical societies, where he may ac­quire the habits of a researcher. These habits will help him in his future in­dependent work, although he may only work as a practitioner.

When a student begins his practical work at clinic, he must remember that his appearance is very important for the first impression on the pa­tient. Inappropriate dress or appearance may impair the belief of the pa­tient in his power as a doctor. During breaks in studies students should not talk loudly. They should behave like real physicians and not students, avoiding loud discussions, all the more so since noise annoys the patients. Quiet and calm strengthen the nervous system of the patient and improve his condition.

It should be remembered that personal conduct of the physician is very important to the patient. For example, if the doctor insists that the patient stops smoking but smokes himself, his recommendation will not be taken seriously.

Medical deontology implies keeping medical secrets. All the physician knows about his patient should be kept secret, otherwise the patient will suffer moral and sometimes material loss. This however does not hold for cases where keeping a secret may do harm to other people. For example, if the disease is infectious, the patient should be hospitalized because his isolation arrests the spreading of the disease and provides better conditions for treatment. People close to the patient should sometimes be informed of the disease so that they might strictly follow sanitary rules and that any new cases, if any, might be treated in due time.

The problems of medical deontology are closely connected with profes­sional ethics. Some physicians try to hide their inadequate knowledge and skill behind aplomb and undue self-assurance. In order to improve their authority, some physicians may criticize their predecessors in the presence of the patient and give " new" prescriptions that actually do not differ substantially from the previous ones. Such physicians may criticize others in a way that will undermine their own authority and the patient's belief in medicine in general. The patient may speculate: " If the previous doctor gave me wrong prescriptions, why should I believe this new doctor? "

General Part

If a physician discovers an error in the prescriptions and methods of his predecessor, he must correct it tactfully so that the patient does not lose his belief in medicine and in his recovery. Medical ethics should be learned by the students from the very start of their education, because the medical students of today are physicians of tomorrow.

Once a person decides to become a physician he must obey the medical laws and fulfil his duties properly in accordance with this oath: " Having received the high calling of being a doctor and upon entering the medical profession, I solemnly swear that I shall commit all my knowledge and strength to the protection and improvement of man's health, to the treat­ment and prevention of his diseases. I swear to be ready to render medical assistance at any time of my life and carefully, attentively help my patients, and keep their confidence. I swear that I shall always continue to improve my medical knowledge and skill so that my work might advance medical science and practical medicine. I swear that I shall consult colleagues if I may require medical advice, and shall give such advice to my colleagues whenever they need it. I swear that I shall keep sacred, and further develop the noble traditions of the Fatherland's medicine and always remember my duties to mankind. Being aware of the danger of nuclear weapons for mankind, I shall fight indefatiguably for prevention of nuclear war. I swear that I shall be true to this oath for the whole of my life".

Chapter 2 HISTORY OF DIAGNOSIS