Diagnostics as a process of medical knowledge. Diagnostic examination methods - diagnosis and diagnosis in clinical medicine

In general theoretical terms, there are two approaches to analyzing and evaluating diagnostics. One of them considers diagnosis as a recognition-recognition, algorithmic process, carried out according to previously known rules. Supporters of this view essentially understand diagnostics as the recognition of what is already known and does not contain new knowledge about an object. Recognition is a complex mental process that involves penetration, to a certain extent, into the essence of what is being studied. By reducing diagnosis to recognition, they emphasize the special distance between recognition as such and scientific knowledge and research.

In fact, diagnosis is not a normal recognition process, i.e. identification of the disease being studied with the knowledge contained in textbooks and monographs. Known knowledge about the desired, suspected disease is only a guideline on the complex path of searching for a true individualized diagnosis of the disease.

The recognition process in medical diagnostics has some atypical features, presenting itself as a unique form of cognition of the unknown or little-known and individual in the known. In particular, this is the identification of an atypically developing disease.

In general, scientific knowledge, regardless of the profile of science, cannot but rely on the known. Often new scientific discoveries are a kind of hybrid of what is already known and what is new. Likewise, in diagnostics, recognizing what is already known and discovering something new is a single process. Relying on the known, the doctor strives to understand the unknown and specific when diagnosing a disease. Recognizing the typological characteristics of a particular patient, the doctor is often faced with the individual characteristics of the disease. An individualized diagnosis is not only a consequence of recognition, but also a discovery, cognition of something new, not previously encountered or a significant change in the typical one. A typological, nosological diagnosis is mainly the result of recognition, and a specific, individualized diagnosis (the diagnosis of a given patient) is largely a consequence of cognition, i.e. acquisition of new knowledge. Thus, we can conclude that diagnosis is not just a recognition process. Based on the basic principles of the theory of knowledge, diagnosis should be considered as a specific form of knowledge, in which at the same time its general laws are manifested.

The diagnostic process has neither chronological nor spatial demarcation lines separating sensory and logical cognition. Taking anamnesis, laboratory and instrumental examinations most of all gravitate towards the sensory stage of cognition. But even when collecting anamnesis, the doctor is guided by certain theoretical principles and clinical principles, thereby, as it were, grouping and classifying “sensory material.” The specificity of diagnosis as a form of cognition enhances the significance of sensory contemplation. In diagnostic work, the doctor constantly has to deal with objective and subjective data and indications. The accuracy and adequacy of the diagnosis depend on one or another understanding of the relationship between the objective and the subjective, their role and share in the development and course of pathological processes. In the so-called subjective examination of the patient, i.e. When familiarizing yourself with the patient’s complaints about his condition, his pain sensations, the doctor, to one degree or another, knows the objective state of the patient, the pathological basis of the disease. In addition, objective research is not limited to laboratory and instrumental methods. Objective methods include the usual classical physical methods: palpation, percussion, auscultation. And when using the latter, the possibility of subjective assessment and interpretation of certain objective evidence is very high. Thus, any type of patient cognition can be both objective in its content and subjective in form. This happens because the information obtained using instrumental methods is deciphered and explained by specialists with different levels of professional training, often not directly familiar with the patient’s painful condition.

When starting to study diagnostics, doctors approach a sick person for the first time and thus enter the field of practical medicine. This is a very difficult and unique activity. " Medicine as a science ", according to S. P. Botkin, " provides a certain amount of knowledge, but knowledge itself does not yet provide the ability to apply it in practical life" This skill is acquired only by experience.

Practical, or clinical, medicine must be considered as a special science, with special methods inherent in it. Diagnostics as a special discipline deals with the methodological side of clinical medicine.

Observation, assessment of observed phenomena and inference - these are the three mandatory stages on the path to recognizing diseases and making a diagnosis. According to these three stages, the entire content of diagnostics can be divided into three, to a certain extent, independent sections:

1) a department that includes methods of observation or research - medical technology or diagnostics in the narrow sense of the word;

2) a department devoted to the study of symptoms revealed by research - semiology or semiotics;

3) the department in which the peculiarities of thinking are clarified when constructing diagnostic conclusions based on observation data - medical or clinical logic.

The first two sections have now been developed in detail and constitute the main content of all diagnostic manuals and courses. The third department - medical logic - has not yet been theoretically developed in detail: usually in textbooks, in chapters devoted to the particular diagnosis of individual diseases, one can find only simple comparisons or listings of symptoms, only external milestones of medical logic. The assimilation of this essential and necessary aspect of the matter occurs in the clinic, in the very process of medical practice.

In order to fully appreciate and understand the current state of diagnostics, it is necessary to trace, at least in the most general terms, the course of its historical development in connection with the history of medicine in general.

We will dwell only on a few of the most important stages of this historical path.

It has become a well-known tradition to begin the history of medical issues with the “father of medicine” Hippocrates. This tradition has both objective and subjective justification. Objectively in the works of Hippocrates in the V-IV centuries. BC, humanity for the first time received a systematization of its centuries-old experience in the matter of healing. Subjectively, to this day, 2500 years later, one can be amazed at the greatness of this man as a thinker and doctor. Having gathered together contemporary medical knowledge and experience, Hippocrates treated them critically and discarded everything that corresponded to direct observations, for example, all religious medicine of that time. Careful observation and facts were laid by Hippocrates as the foundation of medicine, and on this solid ground we see the further progressive development of medicine over the course of the 7th and 8th centuries until the 4th century. ad.

Diagnosis in the era of Hippocrates and his followers, in accordance with the general direction of medical thought, was based on careful observation of the patient. Great attention was paid to the patient's complaints and previous history of the disease; an accurate and detailed examination of the patient’s body was required, paying attention to the general appearance, facial expression, body position, chest shape, condition of the abdomen, skin and mucous membranes, tongue, body temperature (by palpating with the hand); sleep, breathing, digestion, pulse and various types of secretions (sweat, urine, feces, sputum, etc.) were assessed.

As for the methods of objective examination of the patient, even then, apparently, all those methods were used that still form the basis of the practical doctor’s methodology, namely: palpation, for example, of the liver and spleen, changes in which were monitored even day by day; tapping - at least when determining the tympanic sound; auscultation (at least Hippocrates already speaks about the friction noise during pleurisy, comparing it with the sound of skin rubbing, and about sounds reminiscent of “boiling vinegar”, probably corresponding to fine wheezing, and the doctor Aretaeus in the 1st century AD absolutely definitely refers to a heart murmur); finally, shaking, the famous succussio Hyppocratis, which, along with fades Hyppocratis, is included in all diagnostic manuals. Thus, Hippocratic diagnosis, based on questioning the patient and on a detailed study of him using various senses, seems to be basically no different from modern diagnosis, but the difference between them, due to the subsequent improvement of research techniques, the development of semiotics and understanding of the essence of symptoms, of course, colossal.

In the II-III century. AD, a revolution took place in the field of medical thought, which had a tremendous impact on the entire further development of medicine. The reason for this revolution can be considered the scarcity of accurate natural historical knowledge of that time, the already revealed inconsistency with the requirements of practical medicine and the inability for them to give more or less satisfactory answers to questions arising at the patient’s bedside. The searching thought, not finding explanations in observations and facts, took a different path - along the path of speculative reasoning. And Galen - the second monumental figure in the history of medicine after Hippocrates, who, as it were, concentrated in himself all the knowledge of his contemporary era and presented it in 434 trends - went towards this new direction of medical thought. He brought all the medical knowledge of that time into one complete system, in which all the gaps of factual knowledge were filled with abstract reasoning so that there was no room for any doubts or searches.

Diagnostics at this time still remained fundamentally Hippocratic and was enriched by a detailed study of the pulse and the invention of mirrors to illuminate some of the more accessible body cavities (rectum, vagina). At the same time, thanks to Galen, the foundation of topical diagnostics is laid, i.e., recognition of local foci of diseases. Before that, according to the pathogenetic ideas of the ancients, disease was considered as a general suffering, as diathesis or dyscrasia, depending on changes in the basic juices of the body.

Next comes the era of the Middle Ages. In the field of medical thought, this is the era of the undivided dominance of Galen's ideas. His teaching, as a dogma, is not subject to doubt or challenge. For more than 1000 years, free creative thought has died down, stagnation sets in and the regression inevitably associated with it. Diagnosis in this dark and sad era has lost its vital reality and has been reduced almost exclusively to examining the pulse and examining urine.

The Renaissance gives impetus to the liberation of human thought from the oppression of metaphysics. In the 16th and 17th centuries. the inductive, natural-scientific method of thinking and research lays the foundation for modern scientific medicine (Vesalius is the “Luther of anatomy”; Harvey is the founder of circulatory physiology; Morgagni is the founder of the organo-localistic trend in pathological anatomy and medicine). But the deductive method of thinking did not give up its positions without a fight, the struggle with varying success continued until the first third of the 19th century, when natural philosophy - the last medical speculative system - had to finally give way to modern medicine, which had stood on the solid ground of natural science.

In diagnostics during this period of time, until the beginning of the 19th century, there was no noticeable movement forward; even if we take into account some advances in the recognition of heart diseases (palpation of the cardiac region, examination of the jugular veins and carotid veins) and the introduction of chemical testing of urine.

G early 19th century Medicine has entered a period of its development, which we are witnessing. An unshakable natural scientific foundation provides the opportunity and guarantee of continuous movement forward, and this movement occurs at an ever-increasing speed, changing the entire face of medicine beyond recognition almost before our eyes.

The scientific foundations of modern diagnostic methods, based mainly on the development of physics and chemistry, began to be laid at the beginning of the 18th century, but the thermometer (Fahrenheit - 1723, Celsius - 1744), ear mirror (artificial illumination of the eardrum - 1741) and percussion were invented then (Auenbrugijer,. 1761) did not find suitable soil for spreading and did not meet with sympathy. And only from the beginning of the 19th century. diagnostics began to flourish rapidly: in 1808, almost half a century after the invention of percussion by Auenbrugger, a French translation of his work appeared, which had already attracted everyone's attention; in 1818 Corvisart published his observations on percussion; in 1819 Laennec published his work on auscultation; in 1839 Skoda gives scientific justification for these methods of physical diagnosis. Chemical and microscopic research methods are being developed. In the middle of the 19th century. Clinical thermometry is being developed.

Great contribution to the diagnosis of internal diseases contributed by Russian and Soviet doctors and scientists. The activities of the founders and reformers of the modern Russian therapeutic clinic - S. P. Botkin, G. A. Zakharyin and A. A. Ostroumov (second half of the 19th century), who paved those main paths and pointed out that functional-physiological direction, along which to a large extent the development of the Soviet clinic is still going on. In particular, Botkin, having raised the methodology of clinical research to a greater scientific height, substantiated individualizing diagnostics - diagnosing not the disease, but the patient. Zakharyin developed and brought anamnesis, as a method of examining a patient, to the level of real art. Ostroumov, relying on the evolutionary principle and the laws of heredity, developed essentially constitutional clinical diagnostics. If percussion and auscultation were adopted by us, one might say, in a ready-made form, then palpation, as a research method, was subject to the most detailed development and received its most complete form in our country from V.P. Obraztsov (Kiev) and his school (the so-called systematic methodical deep sliding palpation). In Russian and Soviet clinics, many different and important methods and methods of private diagnostics have been developed. Some of them have received worldwide recognition and widespread distribution. These are, for example, the Korotkov auscultatory method for determining arterial blood pressure and the Arinkin method of sternal puncture of bone marrow.

Extensive pathological and anatomical control of the diagnosis (Rokitansky, Virchow) gives the diagnosis of internal diseases the opportunity for further confident development. In our Union, this was especially facilitated by the method of comprehensive examination of organs during autopsy of corpses (mainly the method of complete evisceration developed by G.V. Shor), the mandatory autopsy of all dead in medical institutions and the widespread dissemination of clinical-anatomical conferences over the last 15-20 years ( A. I. Abrikosov, I. V. Davydovsky, S. S. Weil, V. G. Garshi, the development of medicine over the past 50 years has not taken on a particularly rapid pace and wide scope.It is based on the colossal successes of natural science in general, physics, and chemistry and biology in particular.During this time, new scientific disciplines arose, developed and differentiated, such as bacteriology, serology, the study of immunity, protozoology, epidemiology, physical and colloid chemistry, enzymology, radiology, hematology and many others.

Diagnostics, widely using and adapting for its purposes the latest research methods in the field of natural science, currently has a large number of microscopic, physical, chemical, physicochemical, bacteriological and biological laboratory research methods.

The microscopic (or histological) method, thanks to the improvement of the microscope and staining methods, has reached a high degree of perfection and makes it possible to study the morphological composition of various compartments and secretions, physiological and pathological, body fluids, as well as study various tissues by biopsy. Blood microscopy has developed into a special hematological research method, playing a prominent role in the diagnosis of a number of different diseases. The study of cellular elements of body fluids has developed into a cytological method or cytodiagnostics. The introduction of dark-field microscopy, called ultramicroscopy, allows us to look beyond microscopic visibility.

Physical methods in modern diagnostics are very widely represented by various kinds of measuring, recording, optical and electrical instruments. I will point out only some areas of application of these methods: measurement of blood pressure, graphic recordings of heart contractions, arterial and venous pulses, photographic recordings of heart sounds and noises - the so-called phonography - and electrical currents of the heart - electrocardiography.

Over the 50 years of its existence, the X-ray method of research has developed into an independent discipline, and X-ray diagnostics in the form of fluoroscopy, radiography, and X-ray cinematography has miraculously enhanced our vision, and we now see with our own eyes the true size of the heart and its movements, the condition of the blood vessels, the activity of the stomach, the relief its mucosa, stones in the kidneys or gall bladder, the location and nature of pathological changes in the lungs, tumors in the brain, etc.

Chemical methods, when applied to the study of urine, the contents of the gastrointestinal canal, blood, etc., reveal to us the secrets of intracellular metabolism and allow us to monitor the function of various organs.

Physicochemical methods based on the molecular and colloidal properties of body fluids are becoming increasingly important in connection with the development of physical chemistry.

The bacteriological method in the form of bacterioscopy and the culture method plays an extremely important role for the etiological diagnosis of infectious diseases.
Biological methods in the form of various immune reactions (immunodiagnostics) are widely used: the agglutination reaction (Gruber-Widal) for the recognition of typhoid fever, paratyphoid fever, typhus, cholera, dysentery, etc.; complement fixation reaction (Bordet - Gengou) - for syphilis (Wassermann), echinococcus (Weinberg), tuberculosis (Bezredka); tuberculin reactions - subcutaneous, skin, ocular, etc. This also includes the isohemoagglutination reaction (determination of blood groups), which is of great practical importance, etc.

This, in the most general terms, is the modern diagnostic equipment using scientific laboratory research methods.

All these methods are characterized by the fact that they are based on visual perceptions, as in other exact sciences. However, the main feature of medical diagnosis is that it is not limited to methods based only on visual perceptions, but also uses all other senses, increasingly equipping them with instrumental technology.

The persistent desire to use all our senses for research purposes is the first characteristic feature of diagnostics and is explained by the extreme complexity of its object - a sick person: this is the most complex biological organism, which is also in a period of illness in particularly difficult living conditions.

However, not all of our senses are equally good analyzers of external phenomena. The thinner the analyzer, the more reliable the data obtained through it, the more correct the conclusion based on it, the closer, therefore, to reality is our diagnosis. And vice versa, the rougher the analyzer, the less reliable the observation, the greater the possibility of error. Therefore, diagnostics, forced by necessity to use all methods of observation available to it, thereby weakens the power of its conclusions.

Two factors determine the dignity of our senses as analyzers of the external world:

1) the lowest threshold of irritation, i.e. that minimal external irritation that is already capable of causing sensation, and

2) the difference threshold of irritation, i.e. that minimal change in the degree of irritation, which we have already noted as a difference. The lower both thresholds of irritation are, the more accurate the analyzer is. From this point of view, our senses are arranged in the following descending order: vision, touch (in connection with active motor sensations), hearing, smell and taste.

Thus, the data we obtain using vision is the most accurate and reliable. Palpation, which is a combination of touch and active motor sensations, is the second most accurate method of research, since the difference threshold here can reach a very small value. The organ of hearing as an analyzer is much lower than the first two. Therefore, percussion and auscultation as research methods are far inferior to inspection and palpation, and the data obtained with their help leaves much to be desired in terms of clarity and accuracy. This ambiguity of perception is a constant source of error. Hence the desire to replace auditory perceptions with visual ones whenever possible is understandable. And diagnostics in this regard has already achieved relatively much.

Of extremely important practical importance is the fact that all our senses are capable of training, of a certain education and improvement through systematic exercise.

A characteristic feature of medical diagnosis from a methodological point of view is a unique, exclusively characteristic way of research by questioning the patient (history): In this way, we strive to find out the patient’s complaints, his past, his mental state and his individuality. This method in practice presents a number of difficulties, and the ability to collect an anamnesis must be learned no less than the ability to objectively examine, especially since the correct collection of an anamnesis is undoubtedly more difficult to learn than the method of objective examination.

Further, a characteristic property of diagnosis is the need to individualize each patient, that is, to capture, understand and evaluate the unique combination of physical and mental, physiological and pathological characteristics that a given patient currently represents.

Modern diagnostics, fully armed with all its research methods, has powerful analytical power, but it also faces tasks of a synthetic order: assessing the condition and activity of individual organs, their systems and the entire organism as a whole. To do this, it is necessary to combine a number of individual symptoms into one general picture. Functional diagnostics strives for this task, which, however, in relation to most organs and systems is still in the development period; it is most developed in relation to the gastrointestinal tract and kidneys, less - to the cardiovascular system and liver and is almost only outlined in relation to other body systems (hematopoietic organs, autonomic nervous system, endocrine glands).

Finally, in recent times, diagnosis has been faced with more and more urgency and in a new, broader light, by the task of recognizing and assessing the mental state and inner life of each patient. For at present there is no longer any doubt that the neuropsychic factor, especially affective-emotional experiences of a depressive nature, are of great importance for the occurrence, course and outcome of almost all diseases. Consequently, there is a need to develop methods of elementary psychological and psychopathological analysis for the needs of everyday medical research in all areas of practical medicine. Thus, a new and important component is outlined in the general course of the recognition process - the diagnosis of the patient’s personality and the assessment of her reaction.

These are the past, present and possibly the near future of diagnostics, these are its features as the methodological basis of practical medicine. Medicine is closely related to other areas of scientific knowledge. The total amount of knowledge is growing at an enormous rate. Research methods are multiplying and becoming more complex. Almost each of them, taken in its entirety, is able to absorb all the attention and time of the person studying it, and yet all diagnostics with all its many methods is only one of the stages of a doctor’s activity at the patient’s bedside and only one of the many disciplines of the course of medical Sci.

The abundance of the actual stock of scientific knowledge necessary for a doctor, the ever-increasing speed of its accumulation, the constant enrichment and complication of research methods and techniques and the peculiar difficulties of their practical application at the patient’s bedside - all this makes us seriously think about the task of studying and mastering all this material in general and diagnosing in in particular.

The demands placed on medical school today are extremely high. A Soviet doctor must be fully armed with advanced medical theory and modern medical technology, because nowhere and never has the task of providing every citizen with highly qualified medical care been posed and resolved as it is now in the USSR. The task of a medical school should be seen as providing the future doctor with the necessary general medical training, good medical technique, modern scientific methods and strong skills for independent work, with the help of which he could further specialize and improve in any field of medicine and keep up from its constant forward movement.

Diagnostics - the subject is purely methodological; its content consists of various research methods. Not even the most detailed and clear presentation of research methods from the department can fully teach diagnostics. All methods are based on the perceptions of one or another of the sense organs, and in diagnosis, as already mentioned, almost all senses at the same time. This circumstance explains the difficulties that diagnosis presents. Only through repeated, long-term and independent exercises can one properly educate one’s senses and one can master the ability to observe and explore. This explains why an experienced doctor sees, hears and touches what an inexperienced doctor does not notice at all. But the same is true for medical thinking, which is also developed through constant exercise, through active independent work. The law according to which the development of the individual repeats the development of the species has a general meaning: it also applies to education. To become a scientist or a doctor, you need to go through the entire path of human thought and experience in this regard in an abbreviated form and at an accelerated pace: you need to learn to observe, notice the general in the particular, generally grasp the individual, see the pattern in the change of phenomena, etc. Active and independent work in one area and with one method, like any training in a certain direction, makes it extremely easier in the future to master other methods and work in other areas.

So, practical medicine in general, and diagnostics as its methodological basis in particular, due to their inherent characteristics, require a special approach to their study and assimilation. Here, more than anywhere else, the proposition is true that the essence of education always lies in self-education.

Only through truly independent work, through constant education of your organs of perception, through persistent active thinking can you master the technique, but once you master it, it is no longer difficult to acquire the necessary knowledge and experience.

Of course, the most important and decisive prerequisite for the most successful and skillful use of modern methods of medical diagnosis is mastery of the basic method of understanding life as a dialectical process - dialectical materialism. Only with the help of this method is that in-depth analysis and subsequent synthesis of the complex interaction of biological and social factors possible, which makes it possible to establish a correct individual diagnosis and apply effective therapy.

Introduction

Philosophy of medicine and its historical development

The essence and structure of the cognitive process

Contemporary interaction between philosophy and medicine

Diagnostics as a specific cognitive process

Conclusion

Bibliography

Introduction

Philosophy and medicine are equally ancient cultural phenomena in origin; their close connection is manifested in the proximity of the subjects of research (the study of man, his personality and the influence of society on the individual), the similarity of goals and objectives, the unity of methodology, and value orientation. Despite different directions of activity and different ways of searching for truth (medicine chooses at the dawn of its existence the path of practical action, philosophy - the path of theoretical generalization and reflection), both of them solve the same problem - the problem of the survival of humanity on Earth, the problem of self-determination of man as a natural and cultural being. In this matter, philosophy and medicine cannot help but combine their efforts, since separately they are devoid of integrity - philosophy moves away from empiricism, “has its head in the clouds,” while medicine, immersed in the study of the body, forgets about the individual, “drowns” in details and particulars.

Throughout its centuries-long history of development, medicine has gone hand in hand with philosophy. “A doctor who is also a philosopher is like a god,” said Hippocrates. “There is a need for a true and valid natural philosophy, on which the whole edifice of medical science must be built,” wrote Francis Bacon.

The problem of cognition is one of the most important in philosophy and medicine. Cognition is the process of acquiring and developing knowledge, conditioned primarily by social and historical practice, its constant deepening, expansion and improvement.

Knowledge and its study is not something immutable, given once and for all, but is “something dialectical”, developing according to certain laws.

In the work of any doctor, the most difficult section is diagnosis - a section of clinical medicine that includes the content, methods and means of recognizing diseases and the patient’s condition in order to take appropriate therapeutic and preventive measures. The object of cognition in clinical medicine is a person, but the patient is not only an object, but also a subject of cognition, therefore, in diagnosis, the objective and subjective are closely intertwined, and this combination is more complex than in any other area of ​​cognition.

Modern medicine at the turn of the XX-XXI centuries. has achieved enormous success: it is enough to note the impressive achievements in the field of cardiac surgery, transplantology, medical technologies, prevention and treatment of many infectious diseases, as well as in the field of fundamental medicine. Preserving and improving people's health by improving the diagnostic process and introducing new treatment technologies are the most relevant in the development of modern medicine.

The purpose of this work is to study the problems of diagnosing human diseases as a specific process of cognition that exists throughout the development of philosophical thought.

In connection with this goal, the following research objectives can be formulated:

what is the philosophy of medicine and its historical development;

determine the essence of the cognitive process;

- identify features modern interaction between philosophy and medicine ;

Identify the features of the philosophical problem of diagnosis as a specific cognitive process.

The abstract consists of an introduction, four chapters, a conclusion and a list of references.

Philosophy of medicine and its historical development

Throughout the history of culture, the ideas of uniting philosophical and medical knowledge for the sake of comprehending the mystery of life and the mystery of man were implemented in the works of the most famous philosophers, physicians, and natural scientists. As a result, a special branch of knowledge has emerged - the philosophy of medicine, which is designed to generalize the existing practical knowledge about man as a biological and social, material and spiritual being and to find adequate ways to adapt a person to the surrounding living conditions.

The symbiosis of philosophical and medical ideas represents ancient Eastern wisdom, contained in the Egyptian book of the dead, Indian Vedas, in the teachings of Chinese Taoists (the doctrine of immortality), as well as in the works of doctors and philosophers of the East (for example, Avicenna). The basis of Eastern philosophy of medicine has always remained the principle of systematicity in the study of the micro- and macrocosm, the peculiarity is the consideration of the human body as a self-sufficient entity in which spirit and body are inextricably linked; illnesses of the body are considered here primarily as illnesses of the spirit; accordingly, the treatment of an illness is, first of all, the restoration of mental balance and spiritual health. In Ancient Greece - the cradle of philosophical knowledge - philosophy and medicine also closely cooperate and mutually enrich. They are united by the desire to understand the human psyche, an attempt to answer the question of what a person is, what is the (personal and social) value of human health, whether a person is a biological or social being (these questions are discussed in the works of such famous ancient Greek doctors and philosophers as Empedocles, Aristotle , Hippocrates, etc.)

In the medieval European tradition, philosophical and medical research continue to intersect. A new branch of knowledge is actively developing, located at the intersection of philosophy, medicine and natural science research (primarily chemistry), which also includes elements of divination and witchcraft - alchemy. Despite the unrealistic goals (the search for the elixir of life or the philosopher's stone), alchemy played a positive role both in the study of the human being (G. Fracasto) and in the development of some laboratory techniques, especially necessary for developing practical medicine (for example, distillation, sublimation, etc. .). European physician-philosophers of the Middle Ages (F. Rabelais, R. Bacon, Paracelsus, etc.) anticipated many subsequent medical discoveries and developments, methods of treating diseases; they also studied the impact of society (social status of the individual) on the development of pathological processes in the body. Overcoming and revising many of the foundations of ancient medicine and human philosophy, medieval scientists and naturalists contributed to the introduction of chemicals into medicine, and also laid the foundations for the theory of human adaptation in the environment.

The relationship between philosophy and medicine in the era of New Time is dictated by interest in man, his new interpretations. Thus, in the philosophy of French materialism (the ideas of doctors Locke, La Mettrie), a person is understood as a machine that acts by analogy with the macrocosm (according to the laws of classical Newtonian mechanics). In the philosophy of the 19th century, the problems of man as a social being, the problems of the influence of the psyche on the development of pathological processes in the human body are comprehended. Ideas of the 19th century (Freud, Gestalt psychology, etc.) contributed to the emergence of psychosomatic medicine at the beginning of the 20th century<#"justify">The main content of human consciousness is knowledge. Knowledge is the result of cognitive activity. The problem of knowledge is recognized as one of the main philosophical problems. Cognition is an activity aimed at obtaining new knowledge. Humanity has always strived to acquire new knowledge. The theory of knowledge explores the nature of human knowledge, the forms and patterns of transition from a superficial idea of ​​things (opinions) to comprehension of their essence (true knowledge), and in connection with this it considers the question of ways to achieve truth, its criteria.

But a person could not know the truth as true if he did not make mistakes, therefore the theory of knowledge also examines how a person falls into errors and how he overcomes them. Finally, the most pressing question for all epistemology has been and remains the question of what practical, vital meaning reliable knowledge about the world, about man himself and human society has. All these numerous questions, as well as those that arise in the field of other sciences and in social practice, contribute to the formulation of the extensive problems of the theory of knowledge. The human mind, in the process of cognition, each time tries to answer the question: is the world knowable, is man himself and his body knowable?

In an attempt to answer it, three main lines can be identified: optimism, skepticism and agnosticism. Optimists affirm the fundamental knowability of the world; agnostics, on the contrary, deny it. Skeptics do not deny the fundamental knowability of the world, but express doubt about the reliability of knowledge.

The main problem that leads to agnosticism is the following: in the process of cognition, an object is inevitably refracted through the prism of our senses and thinking. We receive information about him only in the form in which he acquired as a result of such refraction. And if so, then how possible is it for the human mind to comprehend the essence of the universe? It turns out that we are limited in our ways of knowing, and are unable to say anything reliable about the world, about ourselves.

One of the sources of agnosticism is epistemological relativism - the absolutization of variability, fluidity of phenomena, events of existence and knowledge. Supporters of relativism proceed from the principle that everything in the world is fleeting, and what was considered true yesterday is today recognized as a fallacy. Value judgments are subject to even greater instability.

Skeptical thought goes back in part to the reasoning of ancient philosophers: “Whoever wants to know clearly must first doubt thoroughly.”

Agnosticism is an exaggerated form of skepticism. Skepticism, while recognizing the fundamental possibility of knowledge, expresses doubt about the reliability of knowledge. A person driven by the desire for knowledge says: “I don’t know what it is, but I hope to find out.” The agnostic says: “I don’t know what it is, and I never will.” However, to a reasonable extent, skepticism is useful and even necessary, especially in medicine. As a cognitive technique, skepticism appears in the form of doubt, and this is the path to truth. Ignorance affirms and denies; knowledge is doubtful. Speaking about knowledge, we should pay attention to the extreme diversity of types or characters of knowledge.

Everyday knowledge and everyday knowledge is based, first of all, on observation and ingenuity; it is empirical in nature and is better consistent with life experience than with abstract scientific constructs. The significance of everyday knowledge as a precursor to other forms of knowledge should not be underestimated: common sense often turns out to be subtler and more insightful than the mind of another scientist.

Scientific knowledge presupposes an explanation of facts, their comprehension in the entire system of concepts of a given science. Scientific knowledge answers the questions not only how, but also why it proceeds in this particular way. Scientific knowledge does not tolerate lack of evidence: this or that statement becomes scientific only when it is substantiated. The essence of scientific knowledge lies in understanding reality, in a reliable generalization of facts, in the fact that behind the random it finds the necessary, natural, behind the individual - the general.

Cognition presupposes a bifurcation of the world into an object and a subject. The subject is a complex hierarchy, the foundation of which is the entire social whole. Ultimately, the ultimate producer of knowledge and wisdom is all of humanity. In society, historically there are groups of individuals whose special purpose and occupation is the production of knowledge that has a special vital value. Such, in particular, is scientific knowledge, the subject of which is the community of scientists. In this community, individuals stand out whose abilities, talent and genius determine their particularly high cognitive achievements. History preserves the names of these people as symbols of outstanding milestones in the evolution of scientific ideas.

A fragment of being that finds itself in the focus of cognition constitutes the object of cognition and becomes, in a certain sense, the “property” of the subject, having entered into a subject-object relationship with it. In modern epistemology, it is customary to distinguish between the object and the subject of knowledge. By object of knowledge we mean real fragments of existence that are being studied. The object of knowledge is the specific aspects to which the edge of the seeking thought is directed. Thus, a person is the object of study of many sciences - biology, medicine, psychology, sociology, philosophy, etc. However, each of them “sees” a person from its own point of view: for example, psychology studies the psyche, the spiritual world of a person, his behavior, medicine - his ailments and methods of treating them, etc.

It is known that man is a creator, a subject of history, and he himself creates the necessary conditions and prerequisites for his historical existence. Consequently, the object of socio-historical knowledge is not only cognized, but also created by people: before becoming an object, it must first be created and shaped by them.

In man's knowledge of the essence of the pathological process in the body, man deals with organisms of his own kind. Being the subject of knowledge, he is at the same time its object. Because of this, the interaction between subject and object in such cognition becomes especially complicated.

Contemporary interaction between philosophy and medicine

All basic theories of modern medicine are, in one way or another, connected with the philosophy of medicine, which determines the fundamental postulates and positions of general theoretical systems. Thus, modern philosophical research (philosophical anthropology, philosophy of consciousness, social philosophy) underlies:

medical theory of adaptive response (the theory of adaptation is a general biological theory of medicine, but medicine deals not only with biological adaptations, but also with social adaptation, i.e. a person’s adaptation to social life),

theory of determinism (causality and connection of pathological processes occurring in the body),

as well as the theory of normal (optimal) self-regulation and the theory of general pathology.

The so-called “philosophy of healing” becomes the philosophical foundations of clinical medicine, i.e. theory of diagnosis, treatment, rehabilitation, etc., built in accordance with the understanding of the essence of man as a psycho-bio-social being. As a philosophical basis for preventive medicine, one can consider research in the field of the theory of hygiene as the optimal state of man and the environment. The philosophical theory of values ​​forms the philosophical foundation of medical ethics, deontology, and clinical practice.

Modern philosophy acts as a methodological foundation of medical knowledge, which is intended to unite disparate individual studies and systematically apply them to the study of a qualitatively unique living system - man. The dialectical method comes to the fore in the work of a modern doctor, since only it provides a comprehensive, systematic approach to the issues of the disease, its treatment, prevention, and the rehabilitation period.

The dialectical approach is based on holistic systems thinking, which unites, rather than dismembers, opposites, and also takes into account the relationship between the general and the local (even ancient doctors noticed that the body is whole, and if any element (part) is broken in it, then to a certain extent the whole organism changes to a degree, its vital activity as an integral system is disrupted.).

The task of the philosophy of medicine, of course, does not boil down to simply citing certain provisions of dialectics in connection with medical knowledge; its main goal is to teach students and clinicians to apply dialectics to the analysis of specific natural scientific and clinical factors, and then from knowledge to move on to the ability to apply dialectics in practice. A doctor who does not master the dialectical method, no matter how good a specialist he is, will not be able to correctly assess the intersecting and contradictory pathological processes in the body and, at best, will intuitively be able to come to the right conclusions - correctly diagnose and prescribe treatment.

The dialectical method, used today in various fields of knowledge and naturally in modern medicine, is based primarily on systems thinking. A systematic approach, characteristic of modern science in general, is especially important in medicine, because she works with an extremely complex living system - a person, whose essence is by no means reduced to the simple interaction of the organs of the human body. In fact, the theory of treatment itself is a specific theory of control of a living system, since treatment is a system of measures aimed at psychosomatic optimization of a person’s condition.

Delving into the study of complex interconnected systems of the human body, a modern doctor must be guided by the basic principles of systems theory, developed in the philosophy of natural science since the mid-nineteenth century. Thus, the philosophy of medicine calls for considering the phenomenon of disease as a structural-functional systemic process. The principles of structure in medicine are implemented as the principles of the unity of morphology and physiology in the theory of pathology. Biological structure combines a dynamic substrate (object of morphology) with a “formed” process (object of physiology). Until now in medicine, the theoretical recognition of the unity of structure and function has peacefully coexisted with the confidence that at the onset of the disease, changes in organs and systems do not go beyond the framework of so-called functional disorders. The achievements of modern biology and medicine, especially molecular biology, biophysics, and genetics, make it possible to confidently deny the existence of functional diseases and make it possible to find a morphological substrate that is adequate to any dysfunction. Thus, the systemic-functional approach in medicine allows both to study the details, parts, processes of the individual organism, to consider the functions of its systems, and not to forget about integrity, studying a person not as a mechanical conglomerate of “parts and details”, but as a living system, organically integrated into natural and social reality

Armed with a systematic method, a modern doctor has no right to forget that it is not an organism, but a person who lies on a clinical bed: the doctor in this case must take into account not only the state of his soma, but also his mental state, personal and individual characteristics. The same can be said about the problem of making a diagnosis, which includes an analysis of epistemological diagnostic problems, an analysis of the subjective and objective causes of diagnostic errors, and taking into account the socio-cultural “background” of the disease.

In the twentieth century, synergetics was created as a complex interdisciplinary direction in science and a method of scientific activity. Synergetics studies open, nonlinear, stable systems, a typical example of which is humans. Combining the efforts of synergetics and medicine is one of the important tasks of modern philosophy of medicine. Synergetics opens up new approaches to human health, where treatment takes on the image of self-discovery. Treatment and cure appear as synergistic processes in which hidden attitudes toward a healthy future are revealed in the person himself.

Using the scientific apparatus of synergetics, it is proposed to study the body as an integral open system, characterized by a special type of interaction of its parts. Obviously, any pathological change in an organ, tissue, etc. serves as a source of disturbance not only of this organ, but also of others, in this case there is a disruption of the usual connections of systems and organs of the human body and the formation of new pathological connections, the development of which is difficult to predict and, accordingly, to predict the forms of progression of the disease.

A typical example of the use of synergetic ideas in medicine is the study of the processes of interaction of parts of the human body with geocosmic factors. Both geocosmic systems and humans are dissipative systems (open, i.e. interacting and exchanging matter and energy with the external environment). A complex of geocosmic factors can influence the system of the human body: the average monthly correlation amounts of leukeograms, electrolyte balance, blood enzyme status are synergistic (corresponding, connected) with the average monthly dynamics of cosmic rays. Research has shown that biological systems have the properties of emergency self-organization and dynamic adaptability to changes in environmental factors. The resulting chaos is compensated by the process of self-organization, which brings order to the system.

Thus, synergetics becomes a way not only of knowledge, but also, in a particular case, of understanding and treating a person as a psychosomatic being. Synergetics entails a new dialogue between man and nature, the creation of a new eco-reality. It should be recognized that synergetics is closely related to dialectics and systems theory, and largely uses their categorical apparatus, considering the problems of evolution, systematicity, interaction, as well as factors of chance, necessity and reality.

Unfortunately, the current state of theoretical medicine (the doctrine of disease, compensatory-adaptive processes, mechanisms for compensating for impaired functions, connections and relationships of parts in the body, etc.) allows us to state the fact that theoretical medicine today is not yet comprehensive knowledge and is not yet is still presented in the form of separate fragments, but not a complete system. G. Selye in his work “At the Level of the Whole Organism” wrote: “Life is not a simple sum of its component parts... The further you dismember...living complexes, the further you move away from biology and in the end you are left with only majestic, eternal and comprehensive laws inanimate nature..." In the knowledge of living nature in general, a contradiction constantly arises - from elementarism to integrity and from the latter again to elementary dismemberment. The thought of researchers inevitably encounters a cognitive paradox, noted by Schelling: how to know the whole before the parts, if this presupposes knowledge of the parts before the whole... The meticulous study of particulars and details, so characteristic of medical science, certainly contributes to the progress of medical knowledge, however, the almost complete absence of generalizations private knowledge of various branches of medicine into a logically and experimentally substantiated theoretical system, the so-called general pathology, hinders the development of modern medicine.

Diagnostics as a specific cognitive process

philosophy medicine disease knowledge

A diagnosis in clinical medicine is a brief conclusion about the essence of the disease and the patient’s condition.

Diagnostics consists of three main sections: a) semiology - the study of symptoms; b) methods of diagnostic examination; c) methodological foundations defining the theory and methods of diagnosis (Postovit V.A., 1991)

Diagnosis is the main, core essence of clinical medicine. The diagnosis must be correct, detailed and early. The diagnosis is based on a nosological principle, including the name of a specific disease in accordance with the existing nomenclature. According to the method of constructing and justifying the diagnosis, two types are distinguished - direct and differential. The essence of the first (direct) is that the doctor, having collected all its typical, or pathognomonic, signs, considers them from the point of view of only one alleged disease. The essence of a differential diagnosis is that from a number of different diseases that have many common symptoms, after establishing the differences, one or another disease is excluded. Differential diagnosis consists of comparing this particular clinical picture with a number of other clinical pictures in order to identify one of them and exclude the rest.

A sign in the diagnosis of diseases can be “symptom”, “syndrome”, “symptom complex”, “clinical picture”. These signs vary in their specificity and degree of generality. A symptom is a single (specific or nonspecific) sign. Symptoms can be divided into obvious and hidden. The former are detected directly by the doctor’s senses, the latter - with the help of laboratory and instrumental research methods. A symptom complex is a nonspecific combination, a simple sum of symptoms. A syndrome is a specific combination of internally interrelated several symptoms. A specific symptom, symptom complex, syndrome refers to special signs. The clinical picture - the entire set of symptoms and symptom complexes - is a universal (classical) sign of the disease. However, signs of the disease in the classical general form, when all the symptoms and symptom complexes are present, are rarely found in reality. Therefore, a universal characteristic is revealed through individual characteristics and their special combinations.

Only in relatively rare cases, when a pathognomonic or highly specific symptom (symptom complex) is identified, is it possible to make a reliable nosological diagnosis. Much more often, the doctor deals with a patient’s totality of general, nonspecific symptoms and must spend significant effort analyzing them. At the same time, in diagnosis, symptoms should not be mechanically summed up, but interrelated, taking into account the significance of each of them.

Clinical experience shows that of the three sections of diagnosis, medical logic is the most important, since the constantly developing semiology and medical technology are of subordinate importance. For example, one type of inference is an analogy - about the similarities and differences between the symptoms of a particular patient with the symptoms of known diseases. More complex methods in the epistemological process are induction and deduction.

Induction is a research method that consists in the movement of thought from studying the particular to the formulation of general provisions, that is, diagnostic thinking moves from individual symptoms to establishing a nosological diagnosis. Deduction is an inference moving from knowledge of a greater degree of generality to knowledge of a lesser degree of generality. The logical structure of a clinical diagnosis is the key way to solve any diagnostic problem with a high degree of efficiency or get as close as possible to solving it. Even with insufficient erudition in matters of a related specialty, the doctor, using the logic of clinical thinking, will not pass by an unclear phenomenon, but will try, using the techniques of diagnostic logic and attracting the necessary information at each logical stage, to find out the pathological essence of the disease and the extent of its danger for the patient.

The movement of knowledge in the diagnostic process goes through a number of stages, reflecting the analytical and synthetic activities of the doctor. Thus, according to V.P. Kaznachayev and A.D. Kuimov, the entire logical structure of making a clinical diagnosis after direct (empirical) perception of the patient as a specific identity can be divided into 5 stages:

The first stage (first degree of abstraction): clarification of the anatomical substrate of the disease, that is, its localization in the body.

Second stage (second degree of abstraction): clarification of the pathoanatomical and pathophysiological nature of the pathological process.

Third stage (highest degree of abstraction): formation of a working diagnostic (nosological, less often syndromic) hypothesis.

Fourth stage: determining the degree of probability of the diagnostic hypothesis through differential diagnosis.

The fifth stage (synthetic, return from an abstract diagnosis to a concrete one): clarification of etiology and pathogenesis, formulation of a clinical diagnosis taking into account all the features of the disease, drawing up a treatment plan, determining the prognosis of the disease, subsequent testing of the diagnostic hypothesis during the examination, observation and treatment of the patient.

In V.A. Postovit’s diagram of the diagnostic process, three phases are identified:

Identification of all symptoms of the disease, including negative symptoms, during clinical and laboratory examination. This is the phase of collecting information about the morbidity of a particular patient;

Understanding the detected symptoms, “sorting” them, assessing them according to their degree of importance and specificity, and comparing them with the symptoms of known diseases. This is the phase of analysis and differentiation;

Formulating a disease diagnosis based on identified signs and combining them into a logical whole is the phase of integration and synthesis.

However, the division of the diagnostic process into separate stages is conditional, because in real diagnostics it is impossible to draw a line between the stages of this process, to determine exactly where one ends and the second begins. In real life, the diagnostic process is continuous, strictly limited in time, and there are no clearly defined periods or sequential transitions of the thought process in it, so the doctor classifies symptoms continuously, during the examination of the patient.

Clinical thinking is a specific mental conscious and subconscious activity of a doctor, which makes it possible to most effectively use the data of science, logic and experience to solve diagnostic and therapeutic problems in relation to a particular patient. The main forms of clinical thinking are carried out through analysis and synthesis.

In diagnostic work there are a lot of guesses - so-called hypotheses, so the doctor is obliged to constantly think and reflect, taking into account not only indisputable, but also difficult-to-explain phenomena. A preliminary diagnosis is almost always a more or less probable hypothesis.

According to E.I. Chazov, the success of a doctor’s professional diagnostic activity is ultimately determined by the logical and methodological capabilities of his medical thinking.

The need for doctors to know logic is especially increasing today, because it is becoming obvious that a significant part of diagnostic errors are not so much the result of insufficient medical qualifications, but rather an almost inevitable consequence of ignorance and violation of the most elementary laws of logic. These laws for any type of thinking, including medical thinking, have a normative nature, since they reflect the objective certainty, differences and conditionality of the phenomena of the material world.

The basic rules of logically coherent medical thinking are revealed in the four laws of logic - the laws of inferential knowledge. The law of identity characterizes the certainty of thinking.

The consistency of thinking is determined by the law of non-contradiction and the law of excluded middle. Evidence-based thinking is characterized by the law of sufficient reason.

The requirements of the logical law - the law of identity - are that the concept of the subject of research (for example, a symptom, nosological unit, etc.) must be precisely defined and maintain its uniqueness at all stages of the thought process. The law of identity is expressed by the formula: “ And there is A.” At the same time, any dynamic or relatively stable object (process, sign of a process) can be thought of as A, as long as during reflection, the once taken content of the thought about the object remains constant. In diagnostic practice, compliance with the law of identity requires, first of all, specificity and definiteness of concepts. The substitution of a concept, a thesis that reflects the phenomenon under discussion in its essential principles is a frequent cause of fruitless discussions among specialists in various fields. The importance of the law of identity in diagnostic work is constantly increasing. With the development of medical science, not only the names of many diseases are clarified, their varieties are discovered, new means of examining the patient appear, and, along with them, additional diagnostic signs. The content of concepts used in diagnosis (symptoms, syndromes, nosological units) often changes significantly. Changes in environmental conditions and the pace of human activity give rise to diseases that were not previously encountered. The law of identity requires constant updating and clarification of the international and national nomenclature of nosological forms, classifications of diseases and their use in everyday diagnostic work by a doctor of any specialty.

The law of non-contradiction requires consistency in reasoning, the elimination of contradictory, mutually exclusive concepts and assessments of phenomena. This law is expressed by the formula: “the propositions A is B” and “A is not B” cannot be simultaneously true. A violation of the law of contradiction is manifested in the fact that a true thought is affirmed simultaneously and on an equal basis with the thought opposite to it. More often, this occurs when the conclusion about the essence of the disease is based on an analysis of nonspecific symptoms and the doctor has not taken proper measures to identify the pathognomonic signs of the nosological form. A similar situation arises in cases where the diagnostic hypothesis is based on part of the clinical symptoms and other signs of the disease that contradict the expressed judgment are not taken into account. Formal-logical contradictions cannot be confused with dialectical contradictions in objective reality and knowledge.

The law of exclusion of the third, which follows from the law of non-contradiction, is expressed by the formula: “A is either B or not B.” This law states that two contradictory statements about the same subject at the same time and relative to each other cannot be true and false together. In this case, out of two judgments, one is chosen - the true one, since there is no third intermediate judgment, which must also be true. For example, pneumonia in certain conditions can be either the main disease that led the patient to death, or only a complication of other diseases.

The logical law of sufficient reason is expressed in the formula: “if there is B, that is, as its basis A.” The law states that every reason must have a sufficient reason to be true. The validity of the diagnosis is based on the establishment of symptoms and syndromes specific to a given nosological form, which in turn must also be justified. To substantiate the diagnosis, the practice-tested truths of modern medical science are used. The most reliable diagnosis will be made by a doctor who constantly uses the latest achievements of practical and theoretical medicine. Violation of the law of sufficient reason continues to be a source of contradictions in some modern ideas about the pathogenesis of a number of diseases, as well as difficulties associated with the reproducibility of the same clinical and pathological diagnosis by different specialists.

Practical verification of the truth of the diagnosis is a difficult problem at present. In this regard, judgment about the correctness of the diagnosis based on the effectiveness of treatment of patients is of relative importance, since treatment may be independent of the diagnosis in cases where the disease is recognized but poorly treated, or the condition of patients worsens due to an unclear diagnosis. In addition, pathogenetic therapy may be effective at certain stages of a large group of diseases that have different etiologies, but some common mechanisms of development. Nevertheless, in terms of observations even now, this method of verifying the truth of the diagnosis can have a positive effect.

Much more often, the following two methods are used to identify diagnostic errors (the truth of a clinical diagnosis):

) study of the degree of agreement between the diagnoses of some medical institutions (clinics) and the diagnoses of other institutions (inpatient departments of hospitals) - an indirect verification of the truth of the diagnosis;

) comparison of clinical and pathological diagnoses according to a number of parameters determined by relevant methodological developments - direct verification of the truth of the diagnosis.

However, it should be taken into account that the effectiveness of clinical and pathological comparisons (not only in autopsies and subsequent clinical and anatomical conferences, but also on surgical and biopsy materials) depends on a number of objective and subjective factors, primarily determined by the material and technical equipment of the departments of the pathological service , the professionalism of the pathologist and the attending physician, the degree of their cooperation in the complex work of identifying the essence of suffering, the cause and mechanism of death of the patient.

Nosological form (nosological unit) is a specific disease that is distinguished as an independent disease, as a rule, on the basis of established causes, development mechanisms and characteristic clinical and morphological manifestations.

Also, in modern medicine, antinosology is widespread, claiming that there are only sick people, but there are no diseases.

Thus, we can conclude that an important supporting part of a clinical diagnosis is knowledge of semiology and the ability to think logically. At the same time, the supporting parts of the diagnosis are the conscious clinical experience of the doctor, as well as his intuitive, specific thinking.

Conclusion

The study and synthesis of literary sources on the problem of diagnostics in medicine showed:

Philosophy and medicine, over the course of many centuries of their development, mutually enrich each other and intersect; As an independent branch of knowledge, the philosophy of medicine becomes especially relevant and developed in the twentieth century, when a huge number of research programs appear at the intersection of philosophy and medicine: the practice and technique of treatment, self-healing, self-improvement are developed, taking into account the internal capabilities of the body, the reserves of the human spirit, analyzing and recycling the best ideas of philosophers and doctors.

The problem of knowledge is recognized as one of the main philosophical problems. Cognition is an activity aimed at obtaining new knowledge. Humanity has always strived to acquire new knowledge.

The essence of scientific knowledge lies in understanding reality, in a reliable generalization of facts, in the fact that behind the random it finds the necessary, natural, behind the individual - the general.

Practical knowledge is also closely related to scientific knowledge. The difference between them lies mainly in the target setting. The goal of scientific knowledge is the discovery of patterns. The goal of the practice is to create a new thing (device, device, medicine, industrial technology, etc.) based on already fully known knowledge. By transforming the world, practice transforms a person.

3. Modern philosophy acts as a methodological foundation of medical knowledge, which is intended to unite disparate private studies and systematically apply them to the study of a qualitatively unique living system - man.

The task of the philosophy of medicine, of course, does not boil down to simply citing certain provisions of dialectics in connection with medical knowledge; its main goal is to teach students and clinicians to apply dialectics to the analysis of specific natural scientific and clinical factors, and then move on from knowledge to the ability to apply dialectics in practice.

4. Diagnostics is a specific creative process in which not only conscious but also subconscious thinking is involved, in which intuition has played and will play a certain role, requiring, however, a fairly critical attitude towards oneself and testing in practice.

A systematic approach, characteristic of modern science in general, is especially important in medicine, because she works with an extremely complex living system - a person, whose essence is by no means reduced to the simple interaction of the organs of the human body. In fact, the theory of treatment itself is a specific theory of control of a living system, since treatment is a system of measures aimed at psychosomatic optimization of a person’s condition.

Medical diagnosis is not recognition “in general”, but recognition of the Disease, its Name.

The development of modern medical technology has a pronounced tendency to “deepen” the systemic-structural level of diagnostics. But no matter how deeply we penetrate to the cellular, subcellular, molecular and so on structural levels, we can only draw conclusions and conclusions at the organismal level. Deepening knowledge about the specific mechanism of pathological changes at the molecular-cellular level does not at all lead to knowledge of the causes of pathology in the body.

Medical diagnostic thinking is not exhausted by the laws of formal logic: the laws of identity, exclusion of the third, non-contradiction and sufficient reason are quite conditionally feasible in medicine.

Cause-and-effect relationships in medicine are established rather conditionally, and the connections themselves are ambiguous: the same cause can cause different consequences, and the same consequence can occur due to different reasons. No factor by itself can cause the disease.

Thus, diagnosis is a specific cognitive process, and without constant reliance on philosophical doctrine - the general methodology of science - it is almost impossible to create a single, coherent theoretical base of modern medicine from disparate facts.

Bibliography

1. Alekseev P.V., Panin A.V. Philosophy. - M., 1998.

Volodin N.N., Shukhov V.S. // Attending doctor. - 2000. - No. 4. - P.68-70.

Kozachenko V.I., Petlenko V.P., History of philosophy and medicine. - St. Petersburg, 1994.

Lisitsyn Yu.P., Petlenko V.P. Determination theory of medicine. - St. Petersburg, 1992.

Paltsev M.A. // Doctor. - 2000. - No. 5. - P.39-41.

Petlenko V.P. Philosophy and worldview of a doctor. - L., 1991.

Poryadin G.V., Frolov V.A., Volozhin A.I. // Pathol. physiology and experimental therapy. - 2005. - No. 4. - P.2-5.

Selye G. From dream to discovery: How to become a scientist / trans. from English - M.: Progress, 1987.

Philosophy of Medicine / ed. Yu.L. Shevchenko. - M., 2004.

Philosophical encyclopedic dictionary. - M.: Sov. encyclopedia, 1983.

Chikin S.Ya. Physician-philosophers. - M., 1990.

Fundamentals of philosophy in questions and answers. Textbook for higher educational institutions. M.: - Phoenix Publishing House, 1997.

Philosophy: Textbook for higher educational institutions. - Rostov n/d.: “Phoenix”, 1995

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Features of observation and experiment in medicine

Observation– a method of empirical knowledge, which has the goal of collecting, accumulating and describing scientific facts. It supplies primary material for scientific research. Observation is a systematic, purposeful and planned study of reality. Observation uses various techniques such as comparison, measurement, etc. If ordinary observation gives us information about the qualitative characteristics of an object, then measurement gives us more accurate knowledge and characterizes the object in terms of quantity. Observation with the help of devices and technical means (microscope, telescope, X-ray machine, etc.) makes it possible to significantly expand the range of sensory perception. At the same time, observation as a method of cognition is limited; the researcher states only what is happening in objective reality, without interfering in the natural course of processes.

Until the 17th century, clinical observation was the only method of knowledge in medicine. K. Bernard calls this period of medicine observational, for the first time shows the limited nature of this method and becomes a pioneer of experimental medicine. Since the advent of the experimental approach to the study of diseases, medicine has become scientific.

In some professions (medicine, criminology, etc.), a sense of observation is very important. Features of observation in medicine are determined by its role and consequences. If at the observation level the doctor misses some symptoms or changes, then this will necessarily lead to errors in diagnosis and treatment.

Experiment(Latin experimentum - test, experience) - a means of cognition of objective reality through active influence on it by creating new conditions that correspond to the goals of the study or by changing the processes themselves in the required direction. An experiment is a research method when the researcher actively influences an object, creating artificial conditions to identify certain properties, or when the object itself is artificially reproduced. The experiment allows you to study a subject in pure conditions (when minor factors are excluded) and in extreme situations. If in real conditions (for example, during observation) we depend on the natural course of phenomena and processes, then in an experiment we have the opportunity to repeat them an unlimited number of times.

The development of modern science is impossible without the use of experiment. The experiment is used for educational purposes, to solve certain scientific problems, to test certain hypotheses and for educational purposes. In other words, they distinguish research, testing and demonstration experiments. According to the mode of action they are distinguished physical, chemical, biological, psychological, medical, social and etc.
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experiments. Depending on the flow conditions, experiments are distinguished natural and laboratory. A laboratory experiment is carried out on material models (animals, plants, microorganisms, etc.) or mental, ideal ones (mathematical, informational, etc.).

In medicine, an experiment involves active intervention in the human body, which leads to a change in physiological or pathological processes for a scientific or therapeutic purpose. In a narrow sense, a medical experiment is the application for the first time of certain methods of influencing the human body for therapeutic or research purposes. But what is used for the first time is not always an experiment. Therefore, it is necessary to distinguish an experiment (which is carried out systematically and for the purpose of knowledge) from forced treatment tactics.

Features of observation and experiment in medicine - concept and types. Classification and features of the category "Peculiarities of observation and experiment in medicine" 2015, 2017-2018.

Diagnostics is the main form of cognitive activity of a doctor. “Establishing a diagnosis is a complex cognitive process, the essence of which is the reflection of objectively existing patterns in the doctor’s mind. He faces essentially the same task as any other researcher - establishing objective truth,” noted medical theorists and philosophers G.I. Tsaregorodtsev. and Erokhin V.G.

The diagnostic process consists of the following stages: examination of the patient, analysis of the obtained facts and creation of a synthetic picture of the disease in this patient, construction of a diagnosis, verification of the truth of the diagnosis and its clarification during the treatment of the patient, prognosis of the disease and its outcomes.

Before the start of diagnostic measures, the doctor, based on the patient’s interview data (history) and his own observations, correlated with professional knowledge, forms a diagnosis hypothesis, in which elements of objective and subjective knowledge are closely intertwined. Further diagnostic measures are aimed at bringing the hypothetical knowledge of the diagnosis as close as possible to true knowledge based on objective data.

The doctor, “beginning to examine and objectively examine the patient, prescribing additional laboratory tests and studies, essentially already has in his head a certain examination plan and a certain set of hypotheses regarding the possible diagnosis of the disease. ...At the stage of understanding the received data, in the process of differential diagnosis, the doctor does not act as a “pure” theorist. He constantly compares his own train of thought with objective indicators of the development of the disease, analyzes the dynamics of changes in the symptoms of the disease, and looks for new empirical evidence of his hypothesis.”

At each of these stages, there is a close interaction between the sensory and rational sides of cognition, the objective and subjective are manifested in the picture of the disease of a particular patient.

“The diagnostic process has some specific features that distinguish it from other types of cognitive activity. First of all, diagnosis, as follows from the very meaning of the term “diagnosis,” is a process of recognition,” i.e. This is the process of establishing a particular manifestation of a pathological process of a certain type. In the individual picture of the disease, both general and specific features of a particular disease, specific to a given person, are manifested.

The same disease occurs in different people with different combinations of characteristic and uncharacteristic symptoms. For each patient, a specific disease does not proceed “strictly according to the rules,” but takes into account the individual characteristics of his body, his personality. In medical practice, “atypical” cases are often encountered. This is the manifestation of the general in the individual, specific. The difficulty of diagnosis is manifested primarily in seeing the general in the individual and applying the necessary methods and means, taking into account both the general and the individual. “Essentially... the “art” of diagnosis is the individualization of diagnosis of the nosological form of the disease, taking into account the characteristics of the patient and other specific circumstances.”

“The interweaving of a variety of external and internal, sometimes random, circumstances turns diagnostic activity into a truly creative act.”

The established diagnosis may have varying degrees of truth, i.e. knowledge about a person’s disease may have varying degrees of completeness and correspondence to objective reality. This problem of medical knowledge is directly related to the problem of medical errors.

The problem of medical errors is a designation of the problem of errors made in the course of their professional activities by medical workers.

Currently, it is customary to distinguish between errors caused by objective and subjective reasons. This division is based on the differences between delusion and one’s own mistake. For example, if a doctor encounters a new disease unknown to science in his practice and, without knowing this, tries to explain it using his existing knowledge and ideas, then he is mistaken. The reasons for the error in this case do not depend on him or anyone else. When a doctor acts incorrectly due to gaps in his education or inability to correctly assess an objectively complex situation, then they speak of a medical error.

All sources of diagnostic errors are associated with the process of interaction of the cognizing subject (medical worker) with a certain object of medical cognition. Therefore, “the division of errors into objective and subjective entirely relates to the activity of the subject of knowledge – the individual doctor.”

There are no professions whose specialists would not make mistakes in their practical activities. Even the ancient Romans formulated their observation about errors in the form of an axiom: “It is common for every person to make mistakes” (Errare humanym est). Of course, medical workers are also mistaken. But a distinctive feature of medical errors is that their consequence is damage to the health, and in a broad sense, the life of another person.

Subjective sources of professional errors of medical workers include: insufficient professional training, gaps in professional knowledge, exaggeration of the importance of the readings of one’s own senses, inability to think logically, unlawful generalizations and conclusions, preconceived beliefs, pressure from other people’s opinions, dishonest attitude towards one’s professional duties, etc. .

Objective reasons for medical errors, including diagnostic errors, include everything that is associated with the general level of development of medical knowledge, with the real possibilities of making a diagnosis, i.e. all those conditions that do not depend on the will and knowledge of individual people.

Highly qualified specialists also make mistakes, and here the reasons are of a different nature: the complexity of the course of the disease, the lack of knowledge on this issue in medical science itself. And in these cases, a creative approach to solving an existing problem and a specialist’s professional intuition become of great importance.

In medical ethics there is the concept of “medical error”. It is still largely debatable, and in the conditions of modern medicine it is filled with new ethical, philosophical and legal content.

Negligence, negligence, lack of professional knowledge and skills, resulting in damage to the patient’s health (and in extreme cases, death) in different historical periods of the existence of medicine had different consequences for the doctor (or other medical worker).

The laws of King Hammurabi, who ruled in the mid-2nd millennium BC, list punishments for erroneous treatment. For example, if as a result of an unsuccessful operation the patient lost his sight, then the doctor lost his hands. Thus, society cultivated the responsibility of a physician for his professional actions.

In the early stages of the formation of domestic medicine, the actions of a doctor were equated to witchcraft, to “witchcraft - sorcery.” During the period of Peter the Great's reforms, a Decree was issued, which introduced the obligatory autopsy of corpses in cases of human death into the duty of doctors. This was the first step towards a scientific understanding of the correctness of diagnosis and treatment of patients, identifying and analyzing doctors’ mistakes.

In the last decades of the 20th century. In connection with the expansion of the rights of citizens and the increase in the value of human life, the system of legal punishment of medical workers for causing damage to the patient’s health is becoming increasingly widespread.

Many people consider the attitude of the outstanding doctor and scientist N.I. Pirogov to be an example of a doctor’s attitude towards his professional mistakes. He believed that doctors should extract as much learning as possible from their professional mistakes, enriching both their own experience and the cumulative experience of medicine. Only such a path meets the requirements of professional medical ethics, and only such a life position can compensate for the “evil of medical errors.”

The outstanding domestic doctor I.A. Kassirsky rightly noted: “...Medical errors are a serious and always urgent problem in healing. It must be admitted that no matter how well the medical case is handled, it is impossible to imagine a doctor who already has extensive scientific and practical experience behind him, with an excellent clinical school, is very attentive and serious, who in his work could accurately determine any disease and so “To treat him without fail, to perform the operation perfectly.”

A kind of milestone in the history of the formation of modern ideas about medical errors were the works of I.V. Davydovsky. New accents in the content of the concept of “medical errors” by I.V. Davydovsky come down to the following:

1. “Medical errors are an unfortunate defect in medical practice.” Unfortunately, it is impossible to imagine a doctor who would not make diagnostic and other professional errors. The point is the extraordinary complexity of the object.

2. The relevance of the problem of medical errors has objective prerequisites. First of all, it should be noted the sharply increased “activity” of modern methods of treatment and diagnosis, as well as the negative aspects of progressive specialization in medicine.

3.Registration, systematization and study of medical errors should be carried out systematically and everywhere. The main goal of such activities within each clinical institution should be pedagogical concern for the growth of professionalism of hospital doctors.

4. It is fundamentally important when analyzing medical errors to differentiate ignorance from ignorance, in other words: a doctor is just a person; the measure of his responsibility for professional errors (not only in legal, but also in moral and ethical terms) must have some objective criteria. If a doctor does not know the basic basics of anatomy, physiology and clinical practice, he should be removed from work.

A narrower meaning of the term “medical error” was subsequently acquired in forensic medicine. She divides all unfavorable treatment outcomes causally related to the actions of a doctor into criminal offenses, medical errors and accidents. Indeed, human life and health are protected by criminal law. To be consistent, every case of unfavorable treatment outcome should be subject to criminal proceedings. Obviously, this is not socially advisable, practically impossible, and finally, meaningless. “Medical errors” are excusable due to some objective and subjective circumstances, conditions inherent in medical practice itself.

The thesis about the “doctor’s right to make a mistake” is untenable both from a logical and ideological point of view.

From a logical point of view: one cannot take things for granted; professional conflicts between doctors - “unfortunate marriages” - happen due to circumstances beyond the control of the doctor, and not by right.

From an ideological point of view: if the professional activity of a doctor is deliberately guided by mistakes, then it loses its humanistic nature. The idea of ​​“the right to make mistakes” demoralizes the doctor.

Complications of drug treatment deserve exceptional attention from clinicians, pharmacologists, and all medical workers.

The concept of “medical error” emphasizes the more subjective side of the professional activity of a medical worker, his ability to apply the general provisions of medical science to individual cases of disease, and the assessment of erroneous professional actions from the standpoint of responsibility (moral, legal).

The concept of “iatrogeny” is largely related to the concept of “medical error”. Currently, this concept means …………………….

Iatrogenesis is caused by professional errors of medical workers.

Professional errors of medical workers, due to their extreme significance for other people, should be a negative experience that should be comprehensively analyzed in order to prevent its repetition in the future. Each mistake must be assessed by the specialist’s own conscience. This is the professional duty of a medical worker. L.N. Tolstoy wrote: “Try to fulfill your duty, and you will immediately find out what you are worth.”