The practice of modern medicine

group practice, a provision that is reasonably satisfactory. General

practitioners, however, may now use one of several commercial deputizing

services that employs young doctors to he on call. Although some of these

young doctors may he well experienced, patients do not generally appreciate

this kind of arrangement.

United Stales. Whereas in Britain the doctor of first contact is regularly

a general practitioner, in the United States the nature of first-contact

care is less consistent. General practice in the United States has been in

a slate of decline in the second half of the 20th century especially in

metropolitan areas. The general practitioner, however, is being replaced to

some degree by the growing field of family practice. In 1969 family

practice was recognized as a medical specialty after the American Academy

of General Practice (now the American Academy of Family Physicians) and the

American Medical Association created the American Board of General (now

Family) Practice. Since that time the field has become one of the larger

medical specialties in the United States. The family physicians were the

first group of medical specialists in the

United States for whom recertification was required.

Theie is no national health service, as such, in the United Stales. Most

physicians in the country have traditionally been in some form of private

practice, whether seeing patients in their own offices. clinics, medical

centres, or another type of facility and regardless of the patients'

income. Doctors are usually compensated by such state and federally

supported agencies as Medicaid (for treating the poor) and Medicare (for

treating the elderly); not all doctors, however, accept poor patients.

There are also some state-supported clinics and hospitals where the poor

and elderly may receive free or low-cost treatment, and some doctors devote

a small percentage of their time to treatment of the indigent. Veterans may

receive free treatment at Veterans Administration hospitals, and the

federal government through its Indian Health Service provides medical

services to American Indians and Alaskan natives, sometimes using trained

auxiliaries for first-contact care.

In the rural United States first-contact care is likely to come from a

generalist I he middle- and upper-income groups living in urban areas,

however, have access to a larger number of primary medical care options.

Children are often taken to pediatricians, who may oversee the child's

health needs until adulthood. Adults frequently make their initial contact

with an internist, whose field is mainly that of medical (as opposed to

surgical) illnesses; the internist often becomes the family physician.

Other adults choose to go directly to physicians with narrower specialties,

including dermatologists, allergists, gynecologists, orthopedists, and

ophthalmologists.

Patients in the United States may also choose to be treated by doctors of

osteopathy. These doctors are fully qualified, but they make up only a

small percentage of the country's physicians. They may also branch off into

specialties, hut general practice is much more common in their group than

among M.D.'s.

It used to be more common in the United States for physicians providing

primary care to work independently, providing their own equipment and

paying their own ancillary staff. In smaller cities they mostly had full

hospital privileges, but in larger cities these privileges were more likely

to be restricted. Physicians, often sharing the same specialties, are

increasingly entering into group associations, where the expenses of office

space, staff, and equipment may be shared; such associations may work out

of suites of offices, clinics, or medical centres. The increasing

competition and risks of private practice have caused many physicians to

join Health Maintenance Organizations (HMOs), which provide comprehensive

medical. care and hospital care on a prepaid basis. Thе cost savings to

patient's are considerable, but they must use only the HMO doctors and

facilities. HMOs stress preventive medicine and out-patient treatment as

opposed to hospitalization as a means of reducing costs, a policy that has

caused an increased number of empty hospital beds in the United States.

While the number of doctors per 100,000 population in the United States has

been steadily increasing, there has been a trend among physicians toward

the use of trained medical personnel to handle some of the basic services

normally performed by the doctor. So-called physician extender services are

commonly divided into nurse practitioners and physician's assistants, both

of whom provide similar ancillary services for the general practitioner or

specialist. Such personnel do not replace the doctor. Almost all American

physicians have systems for taking each other's calls when they become

unavailable. House calls in the United Stales, as in Britain, have become

exceedingly rare.

Russia. In Russia general practitioners are prevalent in the thinly

populated rural areas. Pediatricians deal with children up to about age 15.

Internists look after the medical ills of adults, and occupational

physicians deal with the workers, sharing care with internists.

Teams of physicians with experience in varying specialties work from

polyclinics or outpatient units, where many types of diseases are treated.

Small towns usually have one polyclinic to serve all purposes. Large cities

commonly have separate polyclinics for children and adults, as well as

clinics with specializations such as women's health care, mental illnesses,

and sexually transmitted diseases. Polyclinics usually have X-ray apparatus

and facilities for examination of tissue specimens, facilities associated

with the departments of the district hospital. Beginning in the late 1970s

was a trend toward the development of more large, multipurpose treatment

centres, first-aid hospitals, and specialized medicine and health care

centres.

Home visits have traditionally been common, and much of the physician's

time is spent in performing routine checkups for preventive purposes. Some

patients in sparsely populated rural areas may be seen first by feldshers

(auxiliary health workers), nurses, or midwives who work under the

supervision of a polyclinic or hospital physician. The feldsher was once a

lower-grade physician in the army or peasant communities, but feldshers are

now regarded as paramedical workers.

Japan. In Japan, with less rigid legal restriction of the sale of

pharmaceuticals than in the West, there was formerly a strong tradition of

self-medication and self-treatment. This was modified in 1961 by the

institution of health insurance programs that covered a large proportion of

the population; there was then a great increase in visits to the outpatient

clinics of hospitals and to private clinics and individual physicians.

When Japan shifted from traditional Chinese medicine with the adoption of

Western medical practices in the 1870s. Germany became the chief model. As

a result of German influence and of their own traditions, Japanese

physicians tended to prefer professorial status and scholarly research

opportunities at the universities or positions in the national or

prefectural hospitals to private practice. There were some pioneering

physicians, however, who brought medical care to the ordinary people.

Physicians in Japan have tended to cluster in the urban areas. The Medical

Service Law of 1963 was amended to empower the Ministry of Health and

Welfare to control the planning and distribution of future public and

nonprofit medical facilities, partly to redress the urban-rural imbalance.

Meanwhile, mobile services were expanded.

The influx of patients into hospitals and private clinics after the passage

of the national health insurance acts of 1961 had, as one effect, a severe

reduction in the amount of time available for any one patient. Perhaps in

reaction to this situation, there has been a modest resurgence in the

popularity of traditional Chinese medicine, with its leisurely interview,

its dependence on herbal and other "natural" medicines, and its other

traditional diagnostic and therapeutic practices. The rapid aging of the

Japanese population as a result of the sharply decreasing death rate and

birth rate has created an urgent need for expanded health care services /or

the elderly. There has also been an increasing need for centres to treat

health problems resulting from environmental causes.

Other developed countries. On the continent of Europe there are great

differences both within single countries and between countries in the kinds

of first-contact medical care. General practice, while declining in Europe

as elsewhere, is still rather common even in some large cities, as well as

in remote country areas.

In The Netherlands, departments of general practice are administered by

general practitioners in all the medical schools—an exceptional state of

affairs—and general practice flourishes. In the larger cities of Denmark,

general practice on an individual basis is usual and popular, because the

physician works only during office hours. In addition, there is a duty

doctor service for nights and weekends. In the cities of Sweden, primary

care is given by specialists. In the remote regions of northern Sweden,

district doctors act as general practitioners to patients spread over huge

areas; the district doctors delegate much of their home visiting to nurses.

In France there are still general practitioners, but their number is

declining. Many medical practitioners advertise themselves directly to the

public as specialists in internal medicine, ophthalmologists,

gynecologists, and other kinds of specialists. Even when patients have a

general practitioner, they may still go directly to a specialist. Attempts

to stem the decline in general practice are being made hy the development

of group practice and of small rural hospitals equipped to deal with less

serious illnesses, where general practitioners can look after their

patients.

Although Israel has a high ratio of physicians to population, there is a

shortage of general practitioners, and only in rural areas is general

practice common. In the towns many people go directly to pediatricians,

gynecologists, and other specialists, but there has been a reaction against

this direct access to the specialist. More general practitioners have been

trained, and the Israel Medical Association has recommended that no patient

should be referred to a specialist except by the family physician or on

instructions given by the family nurse. At Tel Aviv University there is a

department of family medicine. In some newly developing areas, where the

doctor shortage is greatest, there are medical centres at which all

patients are initially interviewed by a nurse. The nurse may deal with many

minor ailments, thus freeing the physician to treat the more seriously ill.

Nearly half the medical doctors in Australia are general practitioners—a

far higher proportion than in most other advanced countries—though, as

elsewhere, their numbers are declining. They tend to do far more for their

patients than in Britain, many performing such operations as removal of the

appendix, gallbladder, or uterus, operations that elsewhere would be

carried out by a specialist surgeon. Group practices are common.

MEDICAL PRACTICE IN DEVELOPING COUNTRIES

China. Health services in China since the Cultural Revolution have been

characterized by decentralization and dependence on personnel chosen

locally and trained for short periods. Emphasis is given to selfless

motivation, self-reliance, and to the involvement of everyone in the

community. Campaigns stressing the importance of preventive measures and

their implementation have served to create new social attitudes as well as

to break down divisions between different categories of health workers.

Health care is regarded as a local matter that should not require the

intervention of any higher authority; it is based upon a highly organized

and well-disciplined system that is egalitarian rather than hierarchical,

as in Western societies, and which is well suited to the rural areas where

about two-thirds of the population live. In the large and crowded cities an

important constituent of the health-care system is the residents'

committees, each for a population of 1,000 to 5,000 people. Care is

provided by part-time personnel with periodic visits by a doctor. A number

of residents' committees are grouped together into neighbourhoods of some

50,000 people where there are clinics and general hospitals staffed by

doctors as well as health auxiliaries trained in both traditional and

Westernized medicine. Specialized care is provided at the district level

(over 100,000 people), in district hospitals and in epidemic and preventive

medicine centres. In many rural districts people's communes have organized

cooperative medical services that provide primary care for a small annual

fee.

Throughout China the value of traditional medicine is stressed, especially

in the rural areas. All medical schools are encouraged to teach traditional

medicine as part of their curriculum, and efforts are made to link colleges

of Chinese medicine with Western-type medical schools. Medical education is

of shorter duration than it is in Europe, and there is greater emphasis on

practical work. Students spend part of their time away from the medical

school working in factories or in communes; they are encouraged to question

what they are taught and to participate in the educational process at all

stages. One well-known form of traditional medicine is acupuncture, which

is used as a therapeutic and pain-relieving technique; requiring the

insertion of brass-handled needles at various points on the body,

acupuncture has become quite prominent as a form of anesthesia.

The vast number of nonmedically qualified health staff, upon whom the

health-care system greatly depends, includes both full-time and part-time

workers. The latter include so-called barefoot doctors, who work mainly in

rural areas, worker doctors in factories, and medical workers in

residential communities. None of these groups is medically qualified. They

have had only a three-month period of formal training, part of which is

done in a hospital, fairly evenly divided between theoretical and practical

work. This is followed by a varying period of on-the-job experience under

supervision.

India. Ayurvedic medicine is an example of a well-organized system of

traditional health care, both preventive and curative, that is widely

practiced in parts of Asia. Ayurvedic medicine has a long tradition behind

it, having originated in India perhaps as long as 3.000 years ago. It is

still a favoured form of health care in large parts of the Eastern world,

especially in India, where a large percentage of the population use this

system exclusively or combined with modern medicine. The Indian Medical

Council was set up in 1971 by the Indian government to establish

maintenance of standards for undergraduate and postgraduate education. It

establishes suitable qualifications in Indian medicine and recognizes

various forms of traditional practice including Ayurvedic. Unani. and

Siddha. Projects have been undertaken to integrate the indigenous Indian

and Western forms of medicine. Most Ayurvedic practitioners work in rural

areas, providing health care to at least 500,000.000 people in India alone.

They therefore represent a major force for primary health care, and their

training and deployment are important to the government of India.

Like scientific medicine, Ayurvedic medicine has both preventive and

curative aspects. The preventive component emphasizes the need for a strict

code of personal and social hygiene, the details of which depend upon

individual, climatic, and environmental needs. Rodilv exercises, the use of

herbal preparations, and Yoga form a part of the remedial measures. The

curative aspects of Avurvcdic medicine involves the use of herbal

medicines, 'external preparations, physiotherapy, and diet. It is a

principle of Ayurvedic medicini. that the preventive and therapeutic

measures be adapted to the personal requirements of each patient.

Other developing countries. A main goal of the World Health Organization

(WHO), as expressed in the Alma-Ata Declaration of 1978, is to provide to

all the citizens of the world a level of health that will allow them to

lead socially and economically productive lives by the year 2000. By the

late 1980s, however, vast disparities in health care still existed between

the rich and poor countries of the world. In developing countries such as

Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in the

late 1980s spent less than $5 per person per year on public health, while

in most western European countries several hundred dollars per year was

spent on each person. The disproportion of the number of physicians

available between developing and developed countries is similarly wide.

Along with the shortage of physicians, there is a shortage of everything

else needed to provide medical care—of equipment, drugs, and suitable

buildings, and of nurses, technicians, and all other grades of staff, whose

presence is taken for granted in the affluent societies. Yet there are

greater percentages of sick in the poor countries than in the rich

countries. In the poor countries a high proportion of people are young, and

all are liable to many infections, including tuberculosis, syphilis,

typhon). and cholera (which, with the possible exception of syphilis, are

now rare in the rich countries), and also malaria, yaws. worm infestations,

and many other conditions occurring primarily in the warmer climates.

Nearly all of these infections respond to the antibiotics and other drugs

that have been discovered since the 1920s. There is also much malnutrition

and anemia, which can be cured if funding is available. There is a

prevalence of disorders remediable by surgery. Preventive medicine can

ensure clean water supplies, destroy insects that carry infections, teach

hygiene, and show how to make the best use of resources.

In most poor countries there are a few people, usually living in the

cities, who can afford to pay for medical care and in a free market system

the physicians lend to go where they can make the best living; this

situation causes the doctor-patient ratio to be much higher in the towns

than in country districts. A physician in Bombay or in Rio de Janeiro, for

example, may have equipment as lavish as that of a physician in the United

States and can earn an excellent income. The poor, however, both in the

cities and in the country, can gel medical attention only if it is paid for

by the state, by some supranational body, or by a mission or other

charitable organization. Moreover, the quality of the care they receive is

often poor, and in remote regions it may be lacking altogether. In

practice, hospitals run by a mission may cooperate closely with stale-run

health centres.

Because physicians are scarce, their skills must be used to best advantage,

and much of the work normally done by physicians in the rich countries has

to be delegated to auxiliaries or nurses, who have to diagnose the common

conditions, give treatment, take blood samples, help with operations,

supply simple posters containing health advice, and carry out other tasks.

In such places the doctor has lime only to perform major operations and

deal with the more difficult medical problems. People are treated as far as

possible on an outpatient basis from health centres housed in simple

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