चिकित्साशास्त्र

नेपाली विकिपीडियाबाट
यसमा जानुहोस्: परिचालन, खोज्नुहोस्


चिकित्साशास्त्र स्वास्थ्य विज्ञानको एक शाखा तथा सार्वजनिक जीवनको क्षेत्र हो| यस क्षेत्रको काम मानव स्वास्थ्य उकास्ने तथ छहिएमा त्येसको उपचार गर्ने हो| त्येसो गर्न क्रममा अध्ययन, डायग्नोसिस र उपचार गरिन्छ| यो क्षेत्र मानव शरीरको ज्ञान तथा त्यसको प्रयोग, दुवैलाइ समेट्दछ|

परिचय[सम्पादन गर्ने]

Medical care is shared between the medical profession (physicians or doctors) र other professionals such as nursespharmacists, sometimes known as allied health professionals. Historically, only those with a medical doctorate have been considered to practice medicine. Clinicians (licensed professionals who deal with patients) can be physicians, nurses, therapists or others. The medical profession is the social र occupational structure of the group of people formally trained र authorized to apply medical knowledge. Many countries र legal jurisdictions have legal limitations on who may practice medicine.

चिकित्साशास्त्रमा धेरै विषेश उप-शाखाहरू हुन्छन्, जस्तै- कार्डियोलोजी, पल्मोनोलोजी, न्युरोलोजी, वा अन्य क्षेत्र जस्तै खेलकुद चिकित्सा, शोध तथा अन्वेषण वा जनस्वास्थ्य।

Human societies have had various different systems of health care practice since at least the beginning of recorded history. Medicine, in the modern period, is the mainstream scientific tradition which developed in the Western world since the early Renaissance (around 1450). Many other traditions of health care are still practiced throughout the world; most of these are separate from Western medicine, which is also called biomedicine, allopathic medicine or the Hippocratic tradition. The most highly developed of these are traditional Chinese medicine र the Ayurvedic traditions of IndiaSri Lanka. Various non-mainstream traditions of health care have also developed in the Western world. These systems are sometimes considered companions to Hippocratic medicine, र sometimes are seen as competition to the Western tradition. Few of them have any scientific confirmation of their tenets, because if they did they would be brought into the fold of Western medicine.

"Medicine" is also often used amongst medical professionals as shorthand for internal medicine. Veterinary medicine is the practice of health care in animal species other than human beings.

चिकित्साको इतिहास[सम्पादन गर्ने]

चिकित्सक बिरामीको सेवा गर्दै लुभ् संग्रहालय, पेरिस, फ्रान्स.
मुख्य पृष्ठ : चिकित्साको इतिहास

The earliest type of medicine in most cultures was the use of plants (Herbalism) र animal parts. This was usually in concert with 'magic' of various kinds in which: animism (the notion of inanimate objects having spirits); spiritualism (here meaning an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); र divination (the supposed obtaining of truth by magic means), played a major role.

The practice of medicine developed gradually, र separately, in ancient Egypt, ancient China, ancient India, ancient Greece, Persia र elsewhere. Medicine as it is practiced now developed largely in the late eighteenth century र early nineteenth century in England (William Harvey, seventeenth century), Germany (Rudolf Virchow) र France (Jean-Martin Charcot, Claude Bernard र others). The new, "scientific" medicine (where results are testable र repeatable) replaced early Western traditions of medicine, based on herbalism, the Greek "four humours" र other pre-modern theories.[तथ्य वांछित] The focal points of development of clinical medicine shifted to the United Kingdom र the USA by the early 1900s (Canadian-born)Sir William Osler, Harvey Cushing). Possibly the major shift in medical thinking was the gradual rejection in the 1400's of what may be called the 'traditional authority' approach to science र medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, र anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general - see Copernicus's rejection of Ptolemy's theories on astronomy). People like Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past such as Galen, Hippocrates, र Avicenna/Ibn Sina, all of whose theories were in time almost totally discredited. Such new attitudes were also only made possible by the weakening of the Roman Catholic church's power in society, especially in the Republic of Venice.

Evidence-based medicine is a recent movement to establish the most effective algorithms of practice (ways of doing things) through the use of the scientific method र modern global information science by collating all the evidence र developing standard protocols which are then disseminated to doctors. One problem with this 'best practice' approach is that it could be seen to stifle novel approaches to treatment.

Genomics र knowledge of human genetics is already having some influence on medicine, as the causative genes of most monogenic genetic disorders have now been identified, र the development of techniques in molecular biology र genetics are influencing medical practice र decision-making.

औषधिशास्त्र has developed from herbalism र many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). The modern era really began with Koch's discoveries around 1880 of the transmission of disease by bacteria, र then the discovery of antibiotics shortly thereafter around 1900. The first major class of antibiotics was the sulfa drugs, derived originally from azo dyes. Throughout the twentieth century, major advances in the treatment of infectious diseases were observable in (Western) societies. The medical establishment is now developing drugs that are targeted towards one particular disease process. Thus drugs are being developed to minimise the side effects of prescribed drugs, to treat cancer, geriatric problems, long-term problems (such as high cholesterol), chronic diseases (type 2 diabetes), lifestyle र degenerative diseases such as (arthritis) र Alzheimer's disease.

Practice of medicine[सम्पादन गर्ने]

The practice of medicine combines both science as the evidence base र art in the application of this medical knowledge in combination with intuition र clinical judgement to determine the treatment plan for each patient.

Central to medicine is the patient-doctor relationship established when a person with a health concern seeks a physician's help; the 'medical encounter'. Other health professionals similarly establish a relationship with a patient र may perform various interventions, e.g. nurses, radiographers र therapists.

As part of the medical encounter, the doctor needs to:

  • develop a relationship with the patient
  • gather data (medical history, systems enquiry, र physical examination, combined with laboratory or imaging studies (investigations))
  • analyze र synthesize that data (assessment and/or differential diagnoses), र then:
  • develop a treatment plan (further testing, therapy, watchful observation, referral र follow-up)
  • treat the patient accordingly
  • assess the progress of treatment र alter the plan as necessary (management).

The medical encounter is documented in a medical record, which is a legal document in many jurisdictions.[१]

Health care delivery systems[सम्पादन गर्ने]

Medicine is practiced within the medical system, which is a legal, credentialing र financing framework, established by a particular culture or government. The characteristics of a health care system have significant effect on the way medical care is delivered.

Financing has a great influence as it defines who pays the costs. Aside from tribal cultures, the most significant divide in developed countries is between universal health caremarket-based health care (such as practiced in the U.S.). Universal health care might allow or ban a parallel private market. The latter is described as single-payor system.

Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality र pricing greatly affects the choice by patients / consumers र therefore the incentives of medical professionals. While US health care system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand र such issues as patient confidentiality र the possible exploitation of information for commercial gain on the other.

Health care delivery[सम्पादन गर्ने]

Paint of Henriette Browne

Medical care delivery is classified into primary, secondary र tertiary care.

Primary care medical services are provided by physicians or other health professionals who has first contact with a patient seeking medical treatment or care. These occur in physician's office, clinics, nursing homes, schools, home visits र other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute र chronic illnesses, preventive care र health education for all ages र both sex.

Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory careinpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor र delivery, endoscopy units, diagnostic laboratorymedical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients र deliver babies in a secondary care setting.

Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic र treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.

Modern medical care also depends on information - still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.

Doctor-patient relationship[सम्पादन गर्ने]

The doctor-patient relationship र interaction is a central process in the practice of medicine. There are many perspectives from which to understand र describe it.

An idealized physician's perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning the patient's symptoms, concerns र values; in response the physician examines the patient, interprets the symptoms, र formulates a diagnosis to explain the symptoms र their cause to the patient र to propose a treatment. The job of a doctor is essentially to be a human biologist: that is, to know the human frame र situation in terms of normality. Once the doctor knows what is normal र can measure the patient against those norms the doctor can then determine the particular departure from the normal र the degree of departure. This is called the diagnosis.

The four great cornerstones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy र physiology) र psychology (mind र behaviour). In addition, the doctor should consider the patient in their 'well' context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient's condition र further management. In more detail, the patient presents a set of complaints (the symptoms) to the doctor, who then obtains further information about the patient's symptoms, previous state of health, living conditions, र so forth. The physician then makes a review of systems (ROS) or systems enquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination; the findings are recorded, leading to a list of possible diagnoses. These will be in order of probability. The next task is to enlist the patient's agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the doctor educates the patient about the causes, progression, outcomes, र possible treatments of उनका ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant "teacher" in Latin. The patient-doctor relationship is additionally complicated by the patient's suffering (patient derives from the Latin patiens, "suffering") र limited ability to relieve it on his/her own. The doctor's expertise comes from उनका knowledge of what is healthy र normal contrasted with knowledge र experience of other people who have suffered similar symptoms (unhealthy र abnormal), र the presumed ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge.

The doctor-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, र justice are achieved. Many other values र ethical issues can be added to these. In different societies, periods, र cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship र process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status र respect over the last century, र they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power र carries both advantages र disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, र a third party (an insurance company or सरकार agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of both doctors र patients in many ways.

The quality of the patient-doctor relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values र perspectives about disease र life, र time available, the better will be the amount र quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis र increasing the patient's knowledge about the disease. Where such a relationship is poor the doctor's ability to make a full assessment is compromised र the patient is more likely to distrust the diagnosis र proposed treatment. In these circumstances र also in cases where there is genuine divergence of medical opinions, a second opinion from another doctor may be sought.

In some settings, e.g. the hospital ward, the patient-doctor relationship is much more complex, र many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers र others.

Clinical skills[सम्पादन गर्ने]

A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data र medical decision making to obtain diagnoses, र a treatment plan.[२]

The components of the medical history are:

  • Chief complaint (CC): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words र are recorded along with the duration of each one. Also called 'presenting complaint.'
  • History of present illness / complaint (HPI): the chronological order of events of symptoms र further clarification of each symptom.
  • Current activity: occupation, hobbies, what the patient actually does.
  • Medications: what drugs the patient takes including over-the-counter, र home remedies, as well as herbal medicines/herbal remedies such as St. John's Wort. Allergies are recorded.
  • Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations र operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
  • Social history (SH): birthplace, residences, marital history, social र economic status, habits (including diet, medications, tobacco, alcohol).
  • Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
  • Review of systems (ROS)or systems enquiry: an set of additional questions to ask which may be missed on HPI, generally following the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc).

The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'signs' are what the doctor detects by examination). The doctor uses उनका senses of sight, hearing, touch, र sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), र auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:

  • Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
  • General appearance of the patient र specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)
  • Skin
  • Head, eye, ear, nose, र throat (HEENT)
  • Cardiovascular (heartblood vessels)
  • Respiratory (large airways र lungs)
  • Abdomenrectum
  • Genitalia (and pregnancy if the patient is or could be pregnant)
  • Musculoskeletal (spine र extremities)
  • Neurological (consciousness, awareness, brain, cranial nerves, spinal cord र peripheral nerves)
  • Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

Laboratoryimaging studies results may be obtained, if necessary.

The medical decision-making (MDM) process involves analysis र synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

The treatment plan may include ordering additional laboratory tests र studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple र straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, र lab or imaging results or specialist consultations.

Branches of medicine[सम्पादन गर्ने]

Working together as an interdisciplinary team, many highly trained health professionals besides medical practitioners are involved in the delivery of modern health care. Some examples include: nurses, laboratory scientists, pharmacists, physiotherapists, speech therapists, occupational therapists, dietitiansbioengineers.

The scope र sciences underpinning human medicine overlap many other fields. Dentistrypsychology, while separate disciplines from medicine, are sometimes also considered medical fields. Physician assistants, nurse practitionersmidwives treat patients र prescribe medication in many legal jurisdictions. Veterinary medicine applies similar techniques to the care of animals.

Medical doctors have many specializations र subspecializations which are listed below. There are variations from country to country regarding which specialities certain subspecialities are in.

Diagnostic specialties[सम्पादन गर्ने]

  • Clinical laboratory sciences are the clinical diagnostic services which apply laboratory techniques to diagnosis र management of patients. In the United States these services are supervised by a pathologist. The personnel that work in these medical laboratory departments are technically trained staff, each of whom usually hold a medical technology degree, who actually perform the tests, assays, र procedures needed for providing the specific services.

Clinical disciplines[सम्पादन गर्ने]

Interdisciplinary fields[सम्पादन गर्ने]

Interdisciplinary sub-specialties of medicine are:

Medical education[सम्पादन गर्ने]

An image of a 1901 examination in the faculty of medicine.

Medical education is education related to the practice of being a medical practitioner, either the initial training to become a doctor or further training thereafter.

Medical education र training varies considerably across the world, however typically involves entry level education at a university medical school, followed by a period of supervised practise (Internship and/or Residency) र possibly postgraduate vocational training. Continuing medical education is a requirement of many regulatory authorities.

Various teaching methodologies have been utilised in medical education, which is an active area of educational research.

Legal restrictions[सम्पादन गर्ने]

In most countries, it is a legal requirement for medical doctors to be licensed or registered. In general, this entails a medical degree from a university र accreditation by a medical board or an equivalent national organization, which may ask the applicant to pass exams. This restricts the considerable legal authority of the medical profession to doctors that are trained र qualified by national standards. It is also intended as an assurance to patients र as a safeguard against charlatans that practice inadequate medicine for personal gain. While the laws generally require medical doctors to be trained in "evidence based", Western, or Hippocratic Medicine, they are not intended to discourage different paradigms of health र healing, such as alternative medicine or faith healing.

Criticism[सम्पादन गर्ने]

Criticism of medicine has a long history. In the Middle Ages, some people did not consider it a profession suitable for Christians, as disease was often considered God sent. God was considered to be the 'divine physician' who sent illness or healing depending on उनका will. However many monastic orders, particularly the Benedictines, considered the care of the sick as their chief work of mercy. Barber-surgeons (they had the sharpest knives) generally had a bad reputation that was not to improve until the development of academic surgery as a speciality of medicine, rather than an accessory field.[तथ्य वांछित]

Through the course of the twentieth century, doctors focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. The ensuing development of a more mechanistic, detached practice, with the perception of an attendant loss of patient-focused care, known as the medical model of health, led to further criticisms. This issue started to reach collective professional consciousness in the 1970s र the profession had begun to respond by the 1980s र 1990s.[तथ्य वांछित]

Perhaps the most devastating criticism of modern medicine came from Ivan Illich. In उनका 1976 work Medical Nemesis, Illich stated that modern medicine only medicalises disease र causes loss of health र wellness, while generally failing to restore health by eliminating disease. This medicalisation of disease forces the human to become a lifelong patient.[३] Other less radical philosophers have voiced similar views, but none were as virulent as Illich. Another example can be found in Technopoly: The Surrender of Culture to Technology by Neil Postman, 1992, which criticises overreliance on technological means in medicine.[तथ्य वांछित]

Criticism of modern medicine has led to some improvements in the curricula of medical schools, which now teach students systematically on medical ethics, holistic approaches to medicine, the biopsychosocial model र similar concepts.

The inability of modern medicine to properly address many common complaints continues to prompt many people to seek support from alternative medicine. Although most alternative approaches lack scientific validation, some may be effective in individual cases. The bioscience र alternative health care paradigms may differ to such an extent that what constitutes scientific evidence is contested.[तथ्य वांछित] Many doctors practice alternative medicine alongside "orthodox" approaches but the general body of medical practitioners is often criticised for ignoring the purported value of alternative medicine.

Medical errors are also the focus of many complaints र negative coverage. Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety, where it was long ago realized that it is dangerous to place too much responsibility on one "superhuman" individual र expect him or उनको not to make errors. Reporting systems र checking mechanisms are becoming more common in identifying sources of error र improving practice.

Radical critics of certain medical traditions may hold that whole fields or traditions of medicine are intrinsically harmful or ineffective. They would reject any use or support of practices belonging to that tradition.[तथ्य वांछित] However, generally, there is a spectrum of efficacy on which all traditions lie; some are more effective, some are less effective, but nearly all contain some harmful practices र some effective ones. Naturally, though, most individuals or groups seeking a health care practice to improve their own health would seek a tradition with the maximum degree of efficacy. There is no doubt whatsoever that Western Allopathic medicine, together with its cohorts of improved hygiene र nutrition, have been collectively responsible for most of the improvements in health worldwide over the last century or so, including: increasing longevity, decreased child mortality, increasing population numbers, better ability to monitor र halt disease spread र outbreaks, improved access to health care for all strata of society.

See also[सम्पादन गर्ने]

References[सम्पादन गर्ने]

  1. AHIMA e-HIM Work Group on the Legal Health Record. (2005), "Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes.", Journal of AHIMA 78(8): 64A–G, <http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921> 
  2. Coulehan JL, Block MR (2005), The Medical Interview: Mastering Skills for Clinical Practice (5th ed. ed.), F. A. Davis, ISBN 0-8036-1246-X 
  3. Ivan Illich (1976), Medical Nemesis, ISBN 0-394-71245-5 ISBN 0-7145-1095-5 ISBN 0-7145-1096-3 

External links[सम्पादन गर्ने]

Wikibooks
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