The practice of modern medicine

The practice of modern medicine

practitioners are not medically qualified unless they are combining such

treatments with a regular (allopathic) practice, which includes osteopathy.

In many countries the use of some forms, such as chiropractic, requires

licensing and a degree from an approved college. The treatments afforded in

these various practices are not always subjected to objective assessment,

yet they provide services that are alternative, and sometimes

complementary, to conventional practice. This group includes practitioners

of homeopathy, naturopathy, acupuncture, hypnotism, and various meditative

and quasi-religious forms. Numerous persons also seek out some form of

faith healing to cure their ills, sometimes as a means of last resort.

Religions commonly include some advents of miraculous curing within their

scriptures. The belief in such curative powers has been in part responsible

for the increasing popularity of the television, or "electronic," preacher

in the United States, a phenomenon that involves millions of viewers.

Millions of others annually visit religious shrines, such as the one at

Lourdes in France, with the hope of being miraculously healed.

SPECIAL PRACTICES AND FIELDS OF MEDICINE

Specialties in medicine. At the beginning of World War II it was possible

to recognize a number of major medical specialties, including internal

medicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology,

ophthalmology, surgery, orthopedic surgery, plastic surgery, psychiatry and

neurology, radiology, and urology. Hematology was also an important field

of study, and microbiology and biochemistry were important medically allied

specialties. Since World War II, however, there has been an almost

explosive increase of knowledge in the medical sciences as well as enormous

advances in technology as applicable to medicine. These developments have

led to more and more specialization. The knowledge of pathology has been

greatly extended, mainly by the use of the electron microscope; similarly

microbiology, which includes bacteriology, expanded with the growth of such

other subfields as virology (the study of viruses) and mycology (the study

of yeasts and fungi in medicine). Biochemistry, sometimes called clinical

chemistry or chemical pathology, has contributed to the knowledge of

disease, especially in the field of genetics where genetic engineering has

become a key to curing some of the most difficult diseases. Hematology also

expanded after World War II with the development of electron microscopy.

Contributions to medicine have come from such fields as psychology and

sociology especially in such areas as mental disorders and mental

handicaps. Clinical pharmacology has led to the development of more

effective drugs and to the identification of adverse reactions. More

recently established medical specialties are those of preventive medicine,

physical medicine and rehabilitation, family practice, and nuclear

medicine. In the United States every medical specialist must be certified

by a board composed of members of the specialty in which certification is

sought. Some type of peer certification is required in most countries.

Expansion of knowledge both in depth and in range has encouraged the

development of new forms of treatment that require high degrees of

specialization, such as organ transplantation and exchange transfusion; the

field of anesthesiology has grown increasingly complex as equipment and

anesthetics have improved. New technologies have introduced microsurgery,

laser beam surgery, and lens implantation (for cataract patients), all

requiring the specialist's skill. Precision in diagnosis has markedly

improved; advances in radiology, the use of ultrasound, computerized axial

tomography (CAT scan), and nuclear magnetic resonance imaging are examples

of the extension of technology requiring expertise in the field of

medicine.

To provide more efficient service it is not uncommon for a specialist

surgeon and a specialist physician to form a team working together in the

field of, for example, heart disease. An advantage of this arrangement is

that they can attract a highly trained group of nurses, technologists.

operating room technicians, and so on, thus greatly improving the

efficiency of the service to the patient. Such specialization is expensive,

however, and has required an increasingly large proportion of the health

budget of institutions, a situation that eventually has its financial

effect on the individual citizen. The question therefore arises as to their

cost-effectiveness. Governments of developing countries have usually found,

for instance, that it is more cost-efficient to provide more people with

basic care.

Teaching. Physicians in developed countries frequently prefer posts in

hospitals with medical schools. Newly qualified physicians want to work

there because doing so will aid their future careers, though the actual

experience may be wider and better in a hospital without a medical school.

Senior physicians seek careers in hospitals with medical schools because

consultant, specialist, or professorial posts there usually carry a high

degree of prestige. When the posts are salaried, the salaries are

sometimes, but not always, higher than in a nonteaching hospital. Usually a

consultant who works in private practice earns more when on the staff of a

medical school.

In many medical schools there are clinical professors in each of the major

specialties—such as surgery, internal medicine, obstetrics and gynecology

and psychiatry—and often of the smaller specialties as well. There are also

professors of pathology, radiology, and radiotherapy. Whether professors or

not, all doctors in teaching hospitals have the two functions of caring for

the sick and educating students. They give lectures and seminars and are

accompanied by students on ward rounds.

Industrial medicine. The Industrial Revolution greatly changed, and as a

rule worsened, the health hazards caused by industry, while the numbers at

risk vastly increased. In Britain the first small beginnings of efforts to

ameliorate the lot of the workers in factories and mines began in 1802 with

the passing of the first factory act, the Health and Morals of Apprentices

Act. The factory act of 1838, however, was the first truly effective

measure in the industrial field. It forbade night work for children and

restricted their work hours to 12 per day. Children under 13 were required

to attend School. A factory inspectorate was established, the inspectors

being given powers of entry into factories and power of prosecution of

recalcitrant owners. Thereafter there was a succession of acts with

detailed regulations for safety and health in all industries. Industrial

diseases were made notifiable, and those who developed any prescribed

industrial disease were entitled to benefits.

The situation is similar in other developed countries. Physicians are bound

by legal restrictions and must report industrial diseases. The industrial

physician's most important function, however, is to prevent industrial

diseases. Many of the measures to this end have become standard practice,

but, especially in industries working with new substances, the physician

should determine if workers are being damaged and suggest preventive

measures. The industrial physician may advise management about industrial

hygiene and the need for safety devices and protective clothing and may

become involved in building design. The physician or health worker may also

inform the worker of occupational health hazards.

Modern factories usually have arrangements for giving first aid in case of

accidents. Depending upon the size of the plant, the facilities may range

from a simple first-aid station to a large suite of lavishly equipped rooms

and may include a staff of qualified nurses and physiotherapists and one or

perhaps more full-time physicians.

Periodic medical examination. Physicians in industry carry out medical

examinations, especially on new employees and on those returning to work

after sickness or injury. In addition, those liable to health hazards may

be examined regularly in the hope of detecting evidence of incipient

damage. In some organizations every employee may be offered a regular

medical examination.

The industrial and the personal physician. When a worker also has a

persona! physician, there may be doubt. in some cases, as to which

physician bears the main responsibility for his health. When someone has an

accident

or becomes acutely ill at work, the first aid is given or directed by the

industrial physician. Subsequent treatment may be given either at the

clinic at work or by the personal physician. Because of labour-management

difficulties, workers sometimes tend not to trust the diagnosis of the

management-hired physician.

Industrial health services. During the epoch of the Soviet Union and the

Soviet bloc. industrial health service generally developed more fully in

those countries than in the capitalist countries. At the larger industrial

establishments in the Soviet Union, polyclinics were created to provide

both occupational and general can for workers and their families.

Occupational physicians were responsible for preventing occupational

diseases and injuries, health screening, immunization and health education.

In the capitalist countries, on the other hand, no fixed pattern of

industrial health service has emerged. Legislation impinges upon health in

various ways, including the provision of safety measures, the restriction

of pollution and the enforcement of minimum standards of lightning,

ventilation, and space per person. In most of these countries there is

found an infinite variety of schemes financed and run by individual firms

or equally, by huge industries. Labour unions have also done much to

enforce health codes within their respective industries. In the developing

countries there has been generally little advance in industrial medicine.

Family health care. In many societies special facilities are provided for

the health care of pregnant women mothers, and their young children. The

health care needs of these three groups, are generally recognized to be so

closely related as to require a highly integrated service that includes

prenatal care, the birth of the baby. the postnatal period, and the needs

of the infant. Such a continuum should be followed by a service attentive

to the needs of young children and then by a school health service. Family

clinics are common in countries that have state-sponsored health services,

such as those in the United Kingdom and elsewhere in Europe. Family health

care in some developed countries, such as the United States, is provided

for low-income groups by state-subsidized facilities, but other groups

defer to private physicians or privately run clinics.

Prenatal clinics provide a number of elements. There is first, the care of

the pregnant woman, especially if she is in a vulnerable group likely to

develop some complication during the last few weeks of pregnancy and

subsequent delivery. Many potential hazards, such as diabetes and high

blood pressure, can be identified and measures taken to minimize their

effects. In developing countries pregnant women are especially susceptible

to many kinds of disorders, particularly infections such as malaria. Local

conditions determine what special precautions should he taken to ensure a

healthy child. Most pregnant women, in their concern to have a healthy

child, are receptive to simple health education. The prenatal clinic

provides an excellent opportunity to teach the mother how to look after

herself during pregnancy, what to expect at delivery, and how to care for

her baby. If the clinic is attended regularly, the woman's record will he

available to the staff that will later supervise the delivery of the baby:

this is particularly important for someone who has been determined to be at

risk. The same clinical unit should he responsible for prenatal, natal, and

postnatal care as well as for the care of the newborn infants.

Most pregnant women can he safely delivered in simple circumstances without

an elaborately trained staff or sophisticated technical facilities,

provided that these can be called upon in emergencies. In developed

countries it was customary in premodern times for the delivery to take

place in the woman's home supervised by a qualified midwife or by the

family doctor. By the mid-20th century women, especially in urban areas,

usually preferred to have their babies in a hospital, either in a general

hospital or in a more specialized maternity hospital. In many developing

countries traditional birth attendants supervise the delivery. They are

women, for the most part without formal training, who have acquired skill

by working with others and from their own experience. Normally they belong

to the local community where they have the confidence of

the family, where they are content to live and serve, and where their

services are of great value. In many developing countries the better

training of him attendants has a high priority. In developed Western

countries there has been a trend toward delivery by natural childbirth,

including delivery in a hospital without anesthesia, and home delivery.

Postnatal care services are designed to supervise the return to normal of

the mother. They are usually given by the staff of the same unit that was

responsible for the delivery. Important considerations are the mailer of

breast- or artificial feeding and the care of the infant. Today the

prospects for survival of babies born prematurely or after a difficult and

complicated labour, as well as for neonates (recently born babies) with

some physical abnormality, are vastly improved. This is due to technical

advances, including those that can determine defects in the prenatal stage,

as well as to the growth of neonatology as a specialty. A vital part of the

family health-care service is the child welfare clinic, which undertakes

the care of the newbom. The first step is the thorough physical examination

of the child on one or more occasions to determine whether or not it is

normal both physically and, if possible, mentally. Later periodic

examinations serve to decide if the infant is growing satisfactorily.

Arrangements can be made for the child to be protected from major hazards

by, for example, immunization and dietary supplements. Any intercurrent

condition, such as a chest infection or skin disorder, can be detected

early and treated. Throughout the whole of this period mother and child are

together, and particular attention is paid to the education of the mother

for the care of the child.

A pan of the health service available to children in the developed

countries is that devoted to child guidance. This provides psychiatric

guidance to maladjusted children usually through the cooperative work of a

child psychiatrist, educational psychologist, and schoolteacher.

Geriatrics. Since the mid-20th century a change has occurred in the

population structure in developed countries. The proportion of elderly

people has been increasing. Since 1983, however, in most European countries

the population growth of that group has leveled off, although it is

expected to continue to grow more, rapidly than the rest of the population

in most countries through the first third of the 21st century. In the late

20fti century Japan had the fastest growing elderly population.

Geriatrics, the health care of the elderly, is therefore a considerable

burden on health services. In the United Kingdom about one-third of all

hospital beds are occupied by patients over 65; half of these are

psychiatric patients. The physician's time is being spent more and more

with the elderly, and since statistics show that women live longer than

men, geriatric practice is becoming increasingly concerned with the

treatment of women. Elderly people often have more than one disorder, many

of which are chronic and incurable, and they need more attention from

health-care services. In the United States there has been some movement

toward making geriatrics a medical specialty, but it has not generally been

recognized.

Support services for the elderly provided by private or state-subsidized

sources include domestic help, delivery of meals, day-care centres, elderly

residential homes or nursing homes, and hospital beds either in general

medical wards or in specialized geriatric units. The degree of

accessibility" of these services is uneven from country to country and

within countries. In the United States, for instance, although there are

some federal programs, each state has its own elderly programs, which vary

widely. However, as the elderly become an increasingly larger part of the

population their voting rights are providing increased leverage for

obtaining more federal and state benefits. The general practitioner or

family physician working with visiting health and social workers and in

conjunction with the patient's family often form a working team for elderly

care.

In the developing world, countries are largely spared such geriatric

problems, but not necessarily for positive reasons. A principal cause, for

instance, is that people do not live so long. Another major reason is that

in the extended family concept, still prevalent among developing countries,

most of the caretaking needs of the elderly are provided by the family.

Public health practice. The physician working in the field of public health

is mainly concerned with the environmental causes of ill health and in

their prevention. Bad drainage, polluted water and atmosphere, noise and

smells, infected food had housing, and poverty in general are all his

special concern. Perhaps the most descriptive title he can he given is that

of community physician. In Britain he has been customarily known as the

medical officer of health and. in the United Slates, as the health officer.

The spectacular improvement in the expectation of life in the affluent

countries has been due far more to public health measures than to curative

medicine. These public health measures began operation largely in the 19lh

century. At the beginning of that century, drainage and water supply

systems were all more or less primitive; nearly all the cities of that time

had poorer water and drainage systems than Rome had possessed 1,800 years

previously. Infected water supplies caused outbreaks of typhoid, cholera,

and other waterborne infections. By the end of the century, at least in the

larger cities, water supplies were usually safe. Food-home infections were

also drastically reduced by the enforcement of laws concerned with the

preparation, storage, and distribution of food. Insect-borne infections,

such as malaria and yellow fever, which were common in tropical and

semitropical climates, were eliminated by the destruction of the

responsible insects. Fundamental to this improvement in health has been the

diminution of poverty, for most public health measures are expensive. The

peoples of the developing countries fall sick and sometimes die from

infections that are virtually unknown in affluent countries.

Britain. Public health services in Britain are organized locally under the

National Health Service. The medical officer of health is employed by the

local council and is the adviser in health matters. The larger councils

employ a number of mostly full-time medical officers; in some rural areas,

a general practitioner may be employed part-time as medical officer of

health:

The medical officer has various statutory powers conferred by acts of

Parliament, regulations and orders, such as food and drugs acts, milk and

dairies regulations, and factories acts. He supervises the work of sanitary

inspectors in the control of health nuisances. The compulsorily notifiable

infectious diseases are reported to him, and he takes appropriate action.

Other concerns of the medical officer include those involved with the work

of the district nurse, who carries out nursing duties in the home, and the

health visitor, who gives advice on health matters, especially to the

mothers of small babies. He has other duties in connection with infant

welfare clinics, creches, day and residential nurseries, the examination of

schoolchildren, child guidance clinics, foster homes, factories, problem

families, and the care of the aged and the handicapped.

United States. Federal, state, county, and city governments all have public

health futtctions. Under the U.S. Department of Health end Human Services

is the Public Health Service, headed by an assistant secretary for health

and the surgeon general. State health departments are headed by a

commissioner of health, usually a physician, who is often in the governor's

cabinet. He usually has a board of health that adopts health regulations

and holds hearings on their alleged violations. A state's public health

code is the foundation on which all county and city health regulations must

be based. A city health department may be independent of its surrounding

county health department, or there may be a combined city-county health

department. The physicians of the local health departments are usually

called health officers, though occasionally people with this title are not

physicians. The larger departments may have a public health director, a

district health director, or a regional health director.

The minimal complement of a local health department is a health officer, a

public health nurse, a sanitation expert, and a clerk who is also a

registrar of vital statistics. There may also be sanitation personnel,

nutritionists, social workers, laboratory technicians, and others.

Japan. Japan's Ministry of Health and Welfare directs public health

programs at the national level, maintaining close coordination among the

fields of preventive medicine, medical care, and welfare and health

insurance. The departments of health of the prefectures and of the largest

municipalities operate health centres. The integrated community health

programs of the centres encompass maternal and child health, communicable-

disease control, health education, family planning, health statistics, food

inspection, and environmental sanitation. Private physicians, through their

local medical associations, help to formulate and execute particular public

health programs needed by their localities.

Numerous laws are administered through the ministry's bureaus and agencies,

which range from public health, environmental sanitation, and medical

affairs to the children and families bureau. The various categories of

institutions run by the ministry, in addition to the national hospitals,

include research centres for cancer and leprosy, homes for the blind,

rehabilitation centres, for the physically handicapped, and port quarantine

services.

Former Soviet Union. In the aftermath of the dissolution of the Soviet

Union, responsibility for public health fell to the governments of the

successor countries.

The public health services for the U.S.S.R. as a whole were directed by the

Ministry of Health. The ministry, through the 15 union republic ministries

of health, directed all medical institutions within its competence as well

as the public health authorities; and services throughout the country.

The administration was centralized, with little local autonomy. Each of the

15 republics had its own ministry of health, which was responsible for

carrying out the plans and decisions established by the U.S.S.R. Ministry

of Health. Each republic was divided into oblasti, or provinces, which had

departments of health directly responsible to the republic ministry of

health. Each oblast, in turn, had rayony (municipalities), which have their

own health departments accountable to the oblast health department.

Finally, each rayon was subdivided into smaller uchastoki (districts).

In most rural rayony the responsibility for public health lay with the

chief physician, who was also medical director of the central rayon

hospital. This system ensured unity of public health administration and

implementation of the principle of planned development. Other health

personnel included nurses, feldshers, and midwives.

For more information on the history, organization, and progress of public

health, see below.

Military practice. The medical services of armies, navies, and air forces

are geared to war. During campaigns the first requirement is the prevention

of sickness. In all wars before the 20th century, many more combatants died

of disease than of wounds. And even in World War II and wars thereafter,

although few died of disease, vast numbers became casualties from disease.

The main means of preventing sickness are the provision of adequate food

and pure water, thus eliminating starvation, avitaminosis, and dysentery

and other bowel infections, which used to be particular scourges of armies;

the provision of proper clothing and other means of protection from the

weather; the elimination from the service of those likely to fall sick: the

use of vaccination and suppressive drugs to prevent various infections,

such as typhoid and malaria; and education in hygiene and in the prevention

of sexually transmitted diseases, a particular problem in the services. In

addition, the maintenance of high morale has a sinking effect on casualty

rates, for, when morale is poor, soldiers are likely to suffer psychiatric

breakdowns, and malingering is more prevalent.

The medical branch may provide advice about disease prevention, but the

actual execution of this advice is through the ordinary chains of command.

It is the duty of the military, not of the medical, officer to ensure that

the troops obey orders not to drink infected water and to take tablets to

suppress malaria.

Army medical organisation. The medical doctor of first contact to the

soldier in the armies of developed countries is usually an officer in the

medical corps. In реагенте the doctor sees the sick and has functions

similar to those of the general practitioner, prescribing drugs and

dressings and there may be a sick bay where slightly sick soldiers can

remain for a few days. The doctor is usually assisted by trained nurses and

corpsmen. If a further medical opinion is required, the patient can be

referred to a specialist at a military or civilian hospital.

In a war zone, medical officers have an aid post where, with the help of

corpsmen, they apply first aid to the walking wounded and to the more

seriously wounded who are brought in. The casualties are evacuated as

quickly as possible by field ambulances or helicopters. At a company

station, medical officers and medical corpsmen may provide further

treatment before patients are evacuated to the main dressing station at the

field ambulance headquarters, where a surgeon may perform emergency

operations. Thereafter, evacuation may be to casualty clearing stations, to

advanced hospitals, or to base hospitals. Air evacuation is widely used.

In peacetime most of the intermediate medical units exist only in skeleton

form; the active units are at the battalion and hospital level. When

physicians join the medical corps, they may join with specialist

qualifications, or they may obtain such qualifications while in the army. A

feature of army medicine is promotion to administrative positions. The

commanding officer of a hospital and the medical officer at headquarters

may have no contacts with actual patients.

Although medical officers in peacetime have some choice of the kind of work

they will do, they are in a chain of command and are subject to military

discipline. When dealing with patients, however, they are in a special

position; they cannot be ordered by a superior officer to give some

treatment or take other action that they believe is wrong. Medical officers

also do not bear or use arms unless their patients are being attacked.

Naval and air force medicine. Naval medical services are run on lines

similar to those of the army. Junior medical officers are attached to ships

or to shore stations and deal with most cases of sickness in their units.

When at sea. medical officers have an exceptional degree of responsibility

in that they work alone, unless they are on a very large ship. In

peacetime, only the larger ships carry a medical officer; in wartime,

destroyers and other small craft may also carry medical officers. Serious

cases go to either a shore-based hospital or a hospital ship.

Flying has many medical repercussions. Cold, lack of oxygen, and changes of

direction at high speed all have important effects on bodily and mental

functions. Armies and air forces may share the same medical services.

A developing field is aerospace medicine. This involves medical problems

that were not experienced before space-flight, for the main reason that

humans in space are not under the influence of gravity, a condition that

has profound physiological effects.

CLINICAL RESEARCH

The remarkable developments in medicine that have been brought about in the

20th century, especially since World War II, have been based on research

either in the basic sciences related to medicine or in the clinical field.

Advances in the use of radiation, nuclear energy, and space research have

played an important part in this progress. Some laypersons often think of

research as taking place only in sophisticated laboratories or highly

specialized institutions where work is devoted to scientific advances that

may or may not be applicable to medical practice. This notion, however,

ignores the clinical research that takes place on a day-to-day basis in

hospitals and doctors' offices.

Historical notes. Although the most spectacular changes in the medical

scene during the 20lh century, and the most widely heralded, have been the

development of potent drugs and elaborate operations, another striking

change has been the abandonment of most of the remedies of the past. In the

mid-19th century, persons ill with numerous maladies were starved

(partially or completely), bled, purged, cupped (by applying a tight-

fitting vessel filled with steam to some part and then cooling the vessel),

and rested, perhaps for months or even years. Much more recently they were

prescribed various restricted diets and were routinely kept in bed for

weeks after abdominal operations, for many weeks or months when their

hearts were thought to be affected, and for many months or years with

tuberculosis. The abandonment of these measures may not be though of as

involving research, but the physician who first encouraged persons who had

peptic ulcers to eat normally (rather than to live on the customary bland

foods) and the physician who first got his patients out of bed a week or

two after they had had minor coronary thrombosis (rather than insisting on

a minimum of six weeks of strict bed rest) were as much doing research as

is the physician who first tries out a new drug on a patient. This

research, by observing what happens when remedies are abandoned, has been

of inestimable value, and the need for it has not passed.

Clinical observation. Much of the investigative clinical field work

undertaken in the present day requires only relatively simple laboratory

facilities because it is observational rather than experimental in

character. A feature of much contemporary medical research is that it

requires the collaboration of a number of persons, perhaps not all of them

doctors. Despite the advancing technology, there is much to be learned

simply from the observation and analysis of the natural history of disease

processes as they begin to affect patients, pursue their course, and end,

either in their resolution or by the death of the patient. Such studies may

be suitably undertaken by physicians working in their offices who are in a

better position than doctors working only in hospitals to observe the whole

course of an illness. Disease rarely begins in a hospital and usually does

not end there. It is notable, however, that observational research is

subject to many limitations and pitfalls of interpretation, even when it is

carefully planned and meticulously carried out.

Drug research. The administration of any medicament, especially a new drug,

to a patient is fundamentally an experiment: so is a surgical operation,

particularly if it involves a modification to an established technique or a

completely new procedure. Concern for the patient, careful observation,

accurate recording, and a detached mind are the keys to this kind of

investigation, as indeed to all forms of clinical study. Because patients

are individuals reacting to a situation in their own different ways, the

data obtained in groups of patients may well require statistical analysis

for their evaluation and validation.

One of the striking characteristics in the medical field in the 20th

century has been the development of new drugs, usually by pharmaceutical

companies. Until the end of the 19th century, the discovery of new drugs

was largely a matter of chance. It was in that period that Paul Ehrlich,

the German scientist, began to lay down the principles for modern

pharmaceutical research that made possible the development of a vast array

of safe and effective drugs. Such benefits, however, bring with them their

own disadvantages: it is estimated that as many as 30 percent of patients

in, or admitted to, hospitals suffer from the adverse effect of drugs

prescribed by a physician for their treatment. Sometimes it is extremely

difficult to determine whether a drug has been responsible for some

disorder. An example of the difficulty is provided-by the thalidomide

disaster between 1959 and 1962. Only after numerous deformed babies had

been born throughout the world did it become clear that thalidomide taken

by the mother as a sedative had been responsible.

In hospitals where clinical research is carried out, ethical committees

often consider each research project. If the committee believes that the

risks are not justified, the project is rejected.

After a potentially useful chemical compound has been identified in the

laboratory, it is extensively tested in animals, usually for a period of

months or even years. Few drugs make it beyond this point. If the tests are

satisfactory, the decision may be made for testing the drug in humans. It

is this activity that forms the basis of much clinical research. In most

countries the first step is the study of its effects in a small number of

health volunteers. The response, effect on metabolism, and possible

toxicity are carefully monitored and have to be completely satisfactory

before the drug can be passed for further studies, namely with patients who

have the disorder for which the drug is to be used. Tests are administered

at first to a limited number of these patients to determine effectiveness,

proper dosage, and possible adverse reactions. These searching studies are

scrupulously controlled under stringent conditions. Larger groups of

patients are subsequently involved to gain a wider sampling of the

information. Finally, a full-scale clinical trial is set up. If the

regulatory authority is satisfied about the drug's quality, safely, and

efficacy. it receives a license to be produced. As the drug becomes more

widely used, it eventually finds its proper place in therapeutic practice,

a process that may take years.

An important step forward in clinical research was taken in the mid-20th

century with the development of the controlled clinical trial. This sets

out to compare two groups of patients, one of which has had some form of

treatment that the other group has not. The testing of a new drug is a case

in point: one group receives the drug. the her a product identical in

appearance, but which is known to be inert—a so-called placebo. At the end

of the trial, the results of which can be assessed in various ways, it can

be determined whether or not the drug is effective and safe. By the same

technique two treatments can be compared, for example a new drug against a

more familiar one. Because individuals differ physiologically and

psychologically, the allocation of patients between the two groups must be

made in a random fashion; some method independent of human choice must be

used so that such differences are distributed equally between the two

groups.

In order to reduce bias and make the trial as objective as possible the

double-blind technique is sometimes used. In this procedure, neither the

doctor nor the patients know which of two treatments is being given.

Despite such precautions the results of such trials can be prejudiced, so

that rigorous statistical analysis is required. It is obvious that many

ethical, not to say legal, considerations arise, and it is essential that

all patients have given their informed consent to be included. Difficulties

arise when patients are unconscious, mentally confused, or otherwise unable

to give their informed consent. Children present a special difficulty

because not all laws agree that parents can legally commit a child to an

experimental procedure. Trials, and indeed all forms of clinical research

that involve patients, must often be submitted to a committee set up

locally to scrutinize each proposal.

Surgery. In drug research the essential steps are taken by the chemists who

synthesize or isolate new drugs in the laboratory; clinicians play only a

subsidiary part. In developing new surgical operations clinicians play a

more important role, though laboratory scientists and others in the

background may also contribute largely. Many new operations have been made

possible by advances in anesthesia, and these in turn depend upon engineers

who have devised machines and chemists who have produced new drugs. Other

operations are made possible by new materials, such as the alloys and

plastics that are used to make .artificial hip and knee joints.

Whenever practicable, new operations are tried on animals before they are

tried on patients. This practice is particularly relevant to organ

transplants. Surgeons themselves—not experimental

physiologists—transplanted kidneys, livers, and hearts in animals before

attempting these procedures on patients. Experiments on animals are of

limited value, however, because animals do not suffer from all of the same

maladies as do humans.

Many other developments in modem surgical treatment rest on a firm basis of

experimentation, often first in animals but also in humans; among them are

renal dialysis (the artificial kidney), arterial bypass operations, embryo

implantation, and exchange transfusions. These treatments are but a few of

the more dramatic of a large range of therapeutic measures that have not

only provided patients with new therapies but also have led to the

acquisition of new knowledge of how the body works. Among the research

projects of the late 20th century is that of gene transplantation, which

has the potential of providing cures for cancer and other diseases.

SCREENING PROCEDURES

Developments in modem medical science have made it possible to detect

morbid conditions before a person actually feels the effects of the

condition. Examples arc many: they include certain forms of cancer; high

blood pressure; heart and lung disease; various familial and congenital

conditions; disorders of metabolism, like diabetes; and acquired immune

deficiency syndrome (AIDS), the consideration to be made in screening is

whether or not such potential patients should be identified by periodic

examinations. To do so is to imply that the subjects should be made aware

of their condition and, second, that there are effective measures that can

be taken to prevent their condition, if they test positive, from worsening.

Such so-called specific screening procedures are costly since they involve

large numbers of people. Screening may lead to a change in the life-style

of many persons, but not all such moves have been shown in the long run to

be fully effective. Although screening clinics may not be run by doctors,

they are a factor of increasing importance in the, preventive health

service.

Periodic general medical examination of various sections of the population,

business executives for example, is another way of identifying risk factors

that, if not corrected, can lead to the development of overt disease.

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