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
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