The practice of modern medicine

imple¬ment 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 influ¬enced a trend, especially among the developing nations to promote services that employ less highly trained pri¬mary 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 com¬plaints. 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 pro¬viding health care in the developed countries face a differ¬ent 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 con¬ditions 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 in¬crease 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 over¬whelming 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 cov¬ers 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 respon¬sible 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 gen¬eral 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 ill¬nesses, 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 combi¬nation 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 com¬promise, but in urban regions, where nearly everyone can be sent quickly to a hospital, the specialist surgeon work¬ing 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 practi¬tioners work have become common.

In Britain only a small minority of general practition¬ers 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 practition¬ers; many of these hospitals continued to function in a similar manner. All general practitioners use such hospi¬tal 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 maxi¬mum 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.