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,inthe 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


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