The practice of modern medicine

The practice of modern medicine

Contens:

1. Health care and its delivery

2. ORGANIZATION OF HEALTH SERVICES

3. Levels of health care.

4. Costs of health care.

5. ADMINISTRATION OF PRIMARY HEALTH CARE

6. MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

7. Britain.

8. United Stales.

9. Russia.

10. Japan.

11. Other developed countries.

12. MEDICAL PRACTICE IN DEVELOPING COUNTRIES

13. China

14. India.

15. ALTERNATIVE OR COMPLEMENTARY MEDICINE

16. SPECIAL PRACTICES AND FIELDS OF MEDICINE

17. Specialties in medicine.

18. Teaching.

19. Industrial medicine.

20. Family health care.

21. Geriatrics.

22. Public health practice.

23. Military practice.

24. CLINICAL RESEARCH

25. Historical notes.

26. Clinical observation.

27. Drug research.

28. Surgery.

29. SCREENING PROCEDURES

THE PRACTICE OF MODERN MEDICINE

Health care and its delivery

The World Health Organization at its 1978 international, conference held in

the Soviet Union produced the Alma-Ata Health Declaration, which was

designed to serve governments as a basis for planning health care that

would reach people at all levels of society. The declaration reaffirmed

that "health, which is a state of complete physical, mental and social well-

being, and not merely the absence of disease or infirmity, is a fundamental

human rit.nl and that the attainment of the highest possible level of

health is a most important world-wide social goal whose realization

requires the action of many other social and economic sectors in addition

to the health sector." In its widest form the practice of medicine, that is

to say the promotion and care of health, is concerned with this ideal.

ORGANIZATION OF HEALTH SERVICES

"It is generally the goal of most countries to have their health services

organized in such a way to ensure that individuals, families, and

communities obtain the maximum benefit from current knowledge and

technology available for the promotion, maintenance, and restoration of

health. In order to play their part in this process, governments and other

agencies are faced with numerous tasks, including the following: (1) They

must obtain as much information as is possible on the size, extent, and

urgency of their needs; without accurate information, planning can be

misdirected. (2) These needs must then be revised against the resources

likely to be available in terms of money, manpower, and materials;

developing countries may well require external aid to supplement their own

resources. (3) Based on their assessments, countries then need to determine

realistic objectives and draw up plans. (4) Finally, a process of

evaluation needs to be built into the program; the lack of reliable

information and accurate assessment can lead to confusion, waste, and

inefficiency.

Health services of any nature reflect a number "I interrelated

characteristics, among which the most obvious but not necessarily the most

important from a national point of view, is the curative function; that is

to say caring for those already ill. Others include special services that

deal with particular groups (such as children or pregnant women) and with

specific needs such as nutrition or immunization; preventive services, the

protection of the health both of individuals and of communities; health

education; and, as mentioned above, the collection and analysis of

information.

Levels of health care.

In the curative domain there are various forms оf medical practice. They

may be thought of generally as forming a pyramidal structure, with three

tiers representing increasing degrees of specialization and technical

sophistication but catering to diminishing numbers of patients as they are

filtered out of the system at a lower level. Only those patients who

require special attention or treatment should reach the second (advisory)

or third (specialized treatment) tiers where the cost per item of service

becomes increasingly higher. The first level represents primary health

care, or first contact care, or which patients have their initial contact

with the health-care system.

Primary health care is an integral part of a country's health maintenance

system, of which it forms the largest and most important part. As described

in the declaration of Alma-Ata, primary health care should be "based on

practical scientifically sound and socially acceptable methods and

technology made universally accessible to individuals in the community

through their full participation and at a cost that the community and

country can afford to maintain at every stage of then development." Primary

health care in the developed countries is usually the province of a

medically qualified physician; in the developing countries first contact

care is often provided by nonmedically qualified personnel.

The vast majority of patients can be fully dealt with at the primary level.

Those who cannot are referred to the second tier (secondary health care, or

the referral services) for the opinion of a consultant with specialized

knowledge or for X-ray examinations and special tests. Secondary health

care often requires the technology offered by a local or regional hospital.

Increasingly, however, the radiological and laboratory services provided by

hospitals are available directly to the family doctor, thus improving his

service to palings and increasing its range. The third tier of health care

employing specialist services, is offered by institutions such as leaching

hospitals and units devoted to the care of particular groups—women,

children, patients with mental disorders, and so on. The dramatic

differences in the cost of treatment at the various levels is a matter of

particular importance in developing countries, where the cost of treatment

for patients at the primary health-care level is usually only a small

fraction of that at the third level- medical costs at any level in such

countries, however, are usually borne by the government.

Ideally, provision of health care at all levels will be available to all

patients; such health care may be said to be universal. The well-off, both

in relatively wealthy industrialized countries and in the poorer developing

world, may be able to get medical attention from sources they prefer and

can pay for in the private sector. The vast majority of people in most

countries, however, are dependent in various ways upon health services

provided by the state, to which they may contribute comparatively little

or, in the case of poor countries, nothing at all.

Costs of health care. The costs to national economics of providing health

care are considerable and have been growing at a rapidly increasing rate,

especially in countries such as the United States, Germany, and Sweden; the

rise in Britain has been less rapid. This trend has been the cause of major

concerns in both developed and developing countries. Some of this concern

is based upon the lack of any consistent evidence to show that more

spending on health care produces better health. There is a movement in

developing countries to replace the type of organization of health-care

services that evolved during European colonial times with some less

expensive, and for them, more appropriate, health-care system.

In the industrialized world the growing cost of health services has caused

both private and public health-care delivery systems to question current

policies and to seek more economical methods of achieving their goals.

Despite expenditures, health services are not always used effectively by

those who need them, and results can vary widely from community to

community. In Britain, for example, between 1951 and 1971 the death rate

fell by 24 percent in the wealthier sections of the population but by only

half that in the most underprivileged sections of society. The achievement

of good health is reliant upon more than just the quality of health care.

Health entails such factors as good education, safe working conditions, a

favourable environment, amenities in the home, well-integrated social

services, and reasonable standards of living.

In the developing countries. The developing countries differ from one

another culturally, socially, and economically, but what they have in

common is a low average income per person, with large percentages of their

populations living at or below the poverty level. Although most have a

small elite class, living mainly in the cities, the largest part of their

populations live in rural areas. Urban regions in developing and some

developed countries in the mid- and late 20th century have developed

pockets of slums, which are growing because of an influx of rural peoples.

For lack of even the simplest measures, vast numbers of urban and rural

poor die each year of preventable and curable diseases, often associated

with poor hygiene and sanitation, impure water supplies, malnutrition,

vitamin deficiencies, and chronic preventable infections. The effect of

these and other deprivations is reflected by the finding that in the 1980s

the life expectancy at birth for men and women was about one-third less in

Africa than it was in Europe; similarly, infant mortality in Africa was

about eight times greater than in Europe. The extension of primary health-

care services is therefore a high priority in the developing countries.

The developing countries themselves, lacking the proper resources, have

often been unable to generate or implement the plans necessary to provide

required services at the village or urban poor level. It has, however,

become clear that the system of health care that is appropriate for one

country is often unsuitable for another. Research has established that

effective health care is related to the special circumstances of the

individual country, its people, culture, ideology, and economic and natural

resources.

The rising costs of providing health care have influenced a trend,

especially among the developing nations to promote services that employ

less highly trained primary health-care personnel who can be distributed

more widely in order to reach the largest possible proportion of the

community. The principal medical problems to be dealt with in the

developing world include undernutrition, infection, gastrointestinal

disorders, and respiratory complaints. which themselves may be the result

of poverty, ignorance, and poor hygiene. For the most part, these are easy

to identity and to treat. Furthermore, preventive measures are usually

simple and cheap. Neither treatment nor prevention requires extensive

professional training: in most cases they can be dealt with adequately by

the "primary health worker," a term that includes all nonprofessional

health personnel.

In the developed countries. Those concerned with providing health care in

the developed countries face a different set of problems. The diseases so

prevalent in the Third World have, for the most part, been eliminated or

are readily treatable. Many of the adverse environmental conditions and

public health hazards have been conquered. Social services of varying

degrees of adequacy have been provided. Public funds can be called upon to

support the cost of medical care, and there are a variety of private

insurance plans available to the consumer. Nevertheless, the funds that a

government can devote to health care are limited and the cost of modern

medicine continues to increase thus putting adequate medical services

beyond the reach of many. Adding to the expense of modern medical practices

is the increasing demand for greater funding of health education and

preventive measures specifically directed toward the poor.

ADMINISTRATION OF PRIMARY HEALTH CARE

In many parts of the world, particularly in developing countries, people

get their primary health care, or first-contact care, where available at

all, from nonmedically qualified personnel; these cadres of medical

auxiliaries are being trained in increasing numbers to meet overwhelming

needs among rapidly growing populations. Even among the comparatively

wealthy countries of the world, containing in all a much smaller percentage

of the world's population, escalation in the costs of health services and

in the cost of training a physician has precipitated some movement toward

reappraisal of the role of the medical doctor in the delivery of first-

contact care.

In advanced industrial countries, however, it is usually a trained

physician who is called upon to provide the first-contact care. The patient

seeking first-contact care can go either to a general practitioner or turn

directly to a specialist. Which is the wisest choice has become a subject

of some controversy. The general practitioner, however, is becoming rather

rare in some developed countries. In countries where he does still exist,

he is being increasingly observed as an obsolescent figure, because

medicine covers an immense, rapidly changing, and complex field of which no

physician can possibly master more than a small fraction. The very concept

of the general practitioner, it is thus argued, may be absurd.

The obvious alternative to general practice is the direct access of a

patient to a specialist. If a patient has problems with vision, he goes to

an eye specialist, and if he has a pain in his chest (which he fears is due

to his heart), he goes to a heart specialist. One objection to this plan is

that the patient often cannot know which organ is responsible for his

symptoms, and the most careful physician, after doing many investigations,

may remain uncertain as to the cause. Breathlessness—a common symptom—may

be due to heart disease, to lung disease, to anemia, or to emotional upset.

Another common symptom is general malaise—feeling run-down or always tired;

others are headache, chronic low backache, rheumatism, abdominal

discomfort, poor appetite, and constipation. Some patients may also be

overtly anxious or depressed. Among the most subtle medical skills is the

ability to assess people with such symptoms and to distinguish between

symptoms that are caused predominantly by emotional upset and those that

are predominantly of bodily origin. A specialist may be capable of such a

general assessment, but, often, with emphasis on his own subject, he fails

at this point. The generalist with his broader training is often the better

choice for a first diagnosis, with referral to a specialist as the next

option,

It is often felt that there are also practical advantages for the patient

in having his own doctor, who knows about his background, who has seen him

through various illnesses, and who has often looked after his family as

well. This personal physician, often a generalist, is in the best position

to decide when the patient should be referred to a consultant.

The advantages of general practice and specialization are combined when the

physician of first contact is a pediatrician. Although he sees only

children and thus acquires a special knowledge of childhood maladies, he

remains a generalist who looks at the whole patient. Another combination of

general practice and specialization is represented by group practice, the

members of which partially or fully specialize. One or more may be general

practitioners, and one may be a surgeon, a second an obstetrician, a third

a pediatrician, and a fourth an internist. In isolated communities group

practice may be a satisfactory compromise, but in urban regions, where

nearly everyone can be sent quickly to a hospital, the specialist surgeon

working in a fully equipped hospital can usually provide better treatment

than a general practitioner surgeon in a small clinic hospital.

MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

Britain. Before 1948, general practitioners in Britain settled where they

could make a living. Patients fell into two main groups: weekly wage

earners, who were compulsorily insured, were on a doctor's "panel" and were

given free medical attention (for which the doctor was paid quarterly by

the government); most of the remainder paid the doctor a fee for service at

the time of the illness. In 1948 the National Health Service began

operation. Under its provisions, everyone is entitled to free medical

attention with a general practitioner with whom he is registered. Though

general practitioners in the National Health Service are not debarred from

also having private patients, these must be people who are not registered

with them under the National Health Service. Any physician is free to work

as a general practitioner entirely independent of the National Health

Service, though there are few who do so. Almost the entire population is

registered with a National Health Service general practitioner, and the

vast majority automatically sees this physician, or one of his partners,

when they require medical attention. A few people, mostly wealthy, while

registered with a National Health Service general practitioner, regularly

see another physician privately; and a few may occasionally seek a private

consultation because they are dissatisfied with their National Health

Service physician.

A general practitioner under the National Health Service remains an

independent contractor, paid by a capitation fee; that is, according to the

number of people registered with him. He may work entirely from his own

office, and he provides and pays his own receptionist, secretary, and other

ancillary staff. Most general practitioners have one or more partners and

work more and more in premises built for the purpose. Some of these

structures are erected by the physicians themselves, but many are provided

by the local 'authority, me physicians paying rent for using them. Health

centres, in which groups of general practitioners work have become common.

In Britain only a small minority of general practitioners can admit

patients to a hospital and look after them personally. Most of this

minority are in country districts, where, before the days of the National

Health Service, there were cottage hospitals run by general practitioners;

many of these hospitals continued to function in a similar manner. All

general practitioners use such hospital facilities as X-ray departments and

laboratories, and many general practitioners work in hospitals in emergency

rooms (casualty departments) or as clinical assistants to consultants, or

specialists.

General practitioners are spread more evenly over the country than

formerly, when there were many in the richer areas and few in the

industrial towns. The maximum allowed list of National Health Service

patients per doctor is 3.500; the average is about 2.500. Patients have

free choice of the physician with whom they register, with the proviso that

they cannot be accepted by one who already has a full list and that a

physician can refuse to accept them (though such refusals are rare). In

remote rural places there may be only one physician within a reasonable

distance.

Until the mid-20th century it was not unusual for the doctor in Britain to

visit patients in their own homes. A general practitioner might make 15 or

20 such house calls in a day. as well as seeing patients in his office or

"surgery," often in the evenings. This enabled him to become a family

doctor in fact as well as in name. In modern practice, however, a home

visit is quite exceptional and is paid only to the severely disabled or

seriously ill when other recourses are ruled out. All patients are normally

required to go to the doctor.

It has also become unusual for a personal doctor to be available during

weekends or holidays. His place may be taken by one of his partners in a

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