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The practice of medicine

The medical encounter or patient-doctor relationship is what medicine is about. A person with a health problem or concern sees a doctor for help. The practice of medicine combines both science and art. Science and technology are the evidence base for many clinical problems for the general population at large. The art of medicine is the application of this medical knowledge in combination with intuition and clinical judgment to determine the proper diagnoses and treatment plan for this unique patient.

The doctor needs to:

  • develop a relationship with the patient
  • gather data (medical history and physical examination combined with laboratory or imaging studies)
  • analyze and synthesize that data (assessment and/or differential diagnosis), and then
  • develop a treatment plan (more testing, therapy, watchful observation, referral and follow-up).

The medical encounter is documented in a medical record. One method that is used is called the problem-oriented medical record (POMR), which includes a problem list of diagnoses and a "SOAP" method of documentation for each visit:

  • S - Subjective, the medical history of the problem from the point-of-view of the patient.
  • O - Objective, the physical examination and any laboratory or imaging studies.
  • A - Assessment, is the medical decision-making process including the differential diagnoses and most probable diagnoses.
  • P - Plan, the way resolve the problem and monitor progress

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