THE PRACTICE OF MODERN MEDICINE, страница 4

Specialties in medicine. At the beginning of World War II it was possible to recognize a number of major medi­cal specialties, including internal medicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology, ophthal­mology, surgery, orthopedic surgery, plastic surgery, psy­chiatry and neurology, radiology, and urology. Hematology was also an important field of study, and microbiology and biochemistry were important medically allied specialties. Since World War II, however, there has been an almost explosive increase of knowledge in the medical sciences as well as enormous advances in technology as applica­ble to medicine. These developments have led to more and more specialization. The knowledge of pathology has been greatly extended, mainly by the use of the electron microscope; similarly microbiology, which includes bacte­riology, expanded with the growth of such other subfields as virology (the study of viruses) and mycology (the study of yeasts and fungi in medicine). Biochemistry, sometimes called clinical chemistry or chemical pathology, has con­tributed to the knowledge of disease, especially in the field of genetics where genetic engineering has become a key to curing some of the most difficult diseases. Hematology also expanded after World War II with the development of electron microscopy. Contributions to medicine have come from such fields as psychology and sociology espe­cially in such areas as mental disorders and mental hand­icaps. Clinical pharmacology has led to the development of more effective drugs and to the identification of adverse reactions. More recently established medical specialties are those of preventive medicine, physical medicine and re­habilitation, family practice, and nuclear medicine. In the United States every medical specialist must be certified by a board composed of members of the specialty in which certification is sought. Some type of peer certification is required in most countries.

Expansion of knowledge both in depth and in range has encouraged the development of new forms of treat­ment that require high degrees of specialization, such as organ transplantation and exchange transfusion; the field of anesthesiology has grown increasingly complex as equipment and anesthetics have improved. New technolo­gies have introduced microsurgery, laser beam surgery, and lens implantation (for cataract patients), all requiring the specialist's skill. Precision in diagnosis has markedly improved; advances in radiology, the use of ultrasound, computerized axial tomography (CAT scan), and nuclear magnetic resonance imaging are examples of the extension of technology requiring expertise in the field of medicine.

To provide more efficient service it is not uncommon for a specialist surgeon and a specialist physician to form a team working together in the field of, for example, heart disease. An advantage of this arrangement is that they can attract a highly trained group of nurses, technologists. operating room technicians, and so on, thus greatly im­proving the efficiency of the service to the patient. Such specialization is expensive, however, and has required an increasingly large proportion of the health budget of insti­tutions, a situation that eventually has its financial effect on the individual citizen. The question therefore arises as to their cost-effectiveness. Governments of developing countries have usually found, for instance, that it is more cost-efficient to provide more people with basic care.

Teaching. Physicians in developed countries frequently prefer posts in hospitals with medical schools. Newly qualified physicians want to work there because doing so will aid their future careers, though the actual experience may be wider and better in a hospital without a medical school. Senior physicians seek careers in hospitals with medical schools because consultant, specialist, or professorial posts there usually carry a high degree of prestige. When the posts are salaried, the salaries are sometimes, but not always, higher than in a nonteaching hospital. Usually a consultant who works in private practice earns more when on the staff of a medical school.

In many medical schools there are clinical professors in each of the major specialties—such as surgery, internal medicine, obstetrics and gynecology and psychiatry—and often of the smaller specialties as well. There are also pro­fessors of pathology, radiology, and radiotherapy. Whether professors or not, all doctors in teaching hospitals have the two functions of caring for the sick and educating students. They give lectures and seminars and are accom­panied by students on ward rounds.

Industrial medicine. The Industrial Revolution greatly changed, and as a rule worsened, the health hazards caused by industry, while the numbers at risk vastly increased. In Britain the first small beginnings of efforts to ameliorate the lot of the workers in factories and mines began in 1802 with the passing of the first factory act, the Health and Morals of Apprentices Act. The factory act of 1838, however, was the first truly effective measure in the indus­trial field. It forbade night work for children and restricted their work hours to 12 per day. Children under 13 were required to attend School. A factory inspectorate was es­tablished, the inspectors being given powers of entry into factories and power of prosecution of recalcitrant owners. Thereafter there was a succession of acts with detailed reg­ulations for safety and health in all industries. Industrial diseases were made notifiable, and those who developed any prescribed industrial disease were entitled to benefits.

The situation is similar in other developed countries. Physicians are bound by legal restrictions and must report industrial diseases. The industrial physician's most impor­tant function, however, is to prevent industrial diseases. Many of the measures to this end have become stan­dard practice, but, especially in industries working with new substances, the physician should determine if work­ers are being damaged and suggest preventive measures. The industrial physician may advise management about industrial hygiene and the need for safety devices and protective clothing and may become involved in building design. The physician or health worker may also inform the worker of occupational health hazards.

Modern factories usually have arrangements for giving first aid in case of accidents. Depending upon the size of the plant, the facilities may range from a simple first-aid station to a large suite of lavishly equipped rooms and may include a staff of qualified nurses and physiothera­pists and one or perhaps more full-time physicians.

Periodic medical examination. Physicians in industry carry out medical examinations, especially on new em­ployees and on those returning to work after sickness or injury. In addition, those liable to health hazards may be examined regularly in the hope of detecting evidence of incipient damage. In some organizations every employee may be offered a regular medical examination.

The industrial and the personal physician. When a worker also has a persona! physician, there may be doubt. in some cases, as to which physician bears the main re­sponsibility for his health. When someone has an accident

or becomes acutely ill at work, the first aid is given or directed by the industrial physician. Subsequent treatment may be given either at the clinic at work or by the personal physician. Because of labour-management difficulties, workers sometimes tend not to trust the diagnosis of the management-hired physician.

Industrial health services. During the epoch of the So­viet Union and the Soviet bloc. industrial health service generally developed more fully in those countries than in the capitalist countries. At the larger industrial establish­ments in the Soviet Union, polyclinics were created to provide both occupational and general can for workers and their families. Occupational physicians were responsible for preventing occupational diseases and injuries, health screening, immunization and health education.

In the capitalist countries, on the other hand, no fixed pattern of industrial health service has emerged. Legisla­tion impinges upon health in various ways, including the provision of safety measures, the restriction of pollution and the enforcement of minimum standards of lightning, ventilation, and space per person. In most of these countries there is found an infinite variety of schemes financed and run by individual firms or equally, by huge industries. Labour unions have also done much to enforce health codes within their respective industries. In the de­veloping countries there has been generally little advance in industrial medicine.

Family health care. In many societies special facilities are provided for the health care of pregnant women mothers, and their young children. The health care needs of these three groups, are generally recognized to be so closely related as to require a highly integrated service that includes prenatal care, the birth of the baby. the postnatal period, and the needs of the infant. Such a continuum should be followed by a service attentive to the needs of young children and then by a school health service. Family clinics are common in countries that have state-sponsored health services, such as those in the United Kingdom and elsewhere in Europe. Family health care in some devel­oped countries, such as the United States, is provided for low-income groups by state-subsidized facilities, but other groups defer to private physicians or privately run clinics.

Prenatal clinics provide a number of elements. There is first, the care of the pregnant woman, especially if she is in a vulnerable group likely to develop some complication during the last few weeks of pregnancy and subsequent delivery. Many potential hazards, such as diabetes and high blood pressure, can be identified and measures taken to minimize their effects. In developing countries preg­nant women are especially susceptible to many kinds of disorders, particularly infections such as malaria. Local conditions determine what special precautions should he taken to ensure a healthy child. Most pregnant women, in their concern to have a healthy child, are receptive to simple health education. The prenatal clinic provides an excellent opportunity to teach the mother how to look after herself during pregnancy, what to expect at delivery, and how to care for her baby. If the clinic is attended regularly, the woman's record will he available to the staff that will later supervise the delivery of the baby: this is particularly important for someone who has been determined to be at risk. The same clinical unit should he responsible for prenatal, natal, and postnatal care as well as for the care of the newborn infants.

Most pregnant women can he safely delivered in sim­ple circumstances without an elaborately trained staff or sophisticated technical facilities, provided that these can be called upon in emergencies. In developed countries it was customary in premodern times for the delivery to take place in the woman's home supervised by a qualified midwife or by the family doctor. By the mid-20th century women, especially in urban areas, usually preferred to have their babies in a hospital, either in a general hospital or in a more specialized maternity hospital. In many developing countries traditional birth attendants supervise the deliv­ery. They are women, for the most part without formal training, who have acquired skill by working with others and from their own experience. Normally they belong to the local community where they have the confidence of

the family, where they are content to live and serve, and where their services are of great value. In many developing countries the better training of him attendants has a high priority. In developed Western countries there has been a trend toward delivery by natural childbirth, including de­livery in a hospital without anesthesia, and home delivery.

Postnatal care services are designed to supervise the return to normal of the mother. They are usually given by the staff of the same unit that was responsible for the delivery. Im­portant considerations are the mailer of breast- or artificial feeding and the care of the infant. Today the prospects for survival of babies born prematurely or after a difficult and complicated labour, as well as for neonates (recently born babies) with some physical abnormality, are vastly im­proved. This is due to technical advances, including those that can determine defects in the prenatal stage, as well as to the growth of neonatology as a specialty. A vital part of the family health-care service is the child welfare clinic, which undertakes the care of the newbom. The first step is the thorough physical examination of the child on one or more occasions to determine whether or not it is normal both physically and, if possible, mentally. Later periodic examinations serve to decide if the infant is growing sat­isfactorily. Arrangements can be made for the child to be protected from major hazards by, for example, immuniza­tion and dietary supplements. Any intercurrent condition, such as a chest infection or skin disorder, can be detected early and treated. Throughout the whole of this period mother and child are together, and particular attention is paid to the education of the mother for the care of the child.

A pan of the health service available to children in the developed countries is that devoted to child guidance. This provides psychiatric guidance to maladjusted children usu­ally through the cooperative work of a child psychiatrist, educational psychologist, and schoolteacher.

Geriatrics. Since the mid-20th century a change has oc­curred in the population structure in developed countries. The proportion of elderly people has been increasing. Since 1983, however, in most European countries the population growth of that group has leveled off, although it is expected to continue to grow more, rapidly than the rest of the population in most countries through the first third of the 21st century. In the late 20fti century Japan had the fastest growing elderly population.

Geriatrics, the health care of the elderly, is therefore a considerable burden on health services. In the United Kingdom about one-third of all hospital beds are occupied by patients over 65; half of these are psychiatric patients. The physician's time is being spent more and more with the elderly, and since statistics show that women live longer than men, geriatric practice is becoming increas­ingly concerned with the treatment of women. Elderly people often have more than one disorder, many of which are chronic and incurable, and they need more attention from health-care services. In the United States there has been some movement toward making geriatrics a medical specialty, but it has not generally been recognized.