The practice of modern medicine
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
8. United Stales.
11. Other developed countries.
12. MEDICAL PRACTICE IN DEVELOPING COUNTRIES
15. ALTERNATIVE OR COMPLEMENTARY MEDICINE
16. SPECIAL PRACTICES AND FIELDS OF MEDICINE
17. Specialties in medicine.
19. Industrial medicine.
20. Family health care.
22. Public health practice.
23. Military practice.
24. CLINICAL RESEARCH
25. Historical notes.
26. Clinical observation.
27. Drug research.
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
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
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, in the 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
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
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-
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
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
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