THE PRACTICE OF MODERN MEDICINE, страница 2

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 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.