The practice of modern medicine

name. In modern practice, however, a home visit is quite exceptional and is paid only to the severely disabled or seriously ill when other recourses are ruled out. All patients are normally required to go to the doctor.

It has also become unusual for a personal doctor to be available during weekends or holidays. His place may be taken by one of his partners in a group practice, a provision that is reasonably satisfactory. General practi¬tioners, however, may now use one of several commercial deputizing services that employs young doctors to he on call. Although some of these young doctors may he well experienced, patients do not generally appreciate this kind of arrangement.

United Stales. Whereas in Britain the doctor of first contact is regularly a general practitioner, in the United States the nature of first-contact care is less consistent. General practice in the United States has been in a slate of decline in the second half of the 20th century especially in metropolitan areas. The general practitioner, however, is being replaced to some degree by the growing field of family practice. In 1969 family practice was recognized as a medical specialty after the American Academy of General Practice (now the American Academy of Family Physicians) and the American Medical Association created the American Board of General (now Family) Practice. Since that time the field has become one of the larger medical specialties in the United States. The family physicians were the first group of medical specialists in the

United States for whom recertification was required.

Theie is no national health service, as such, in the United Stales. Most physicians in the country have traditionally been in some form of private practice, whether seeing patients in their own offices. clinics, medical centres, or another type of facility and regardless of the patients' in¬come. Doctors are usually compensated by such state and federally supported agencies as Medicaid (for treating the poor) and Medicare (for treating the elderly); not all doc¬tors, however, accept poor patients. There are also some state-supported clinics and hospitals where the poor and elderly may receive free or low-cost treatment, and some doctors devote a small percentage of their time to treat¬ment of the indigent. Veterans may receive free treatment at Veterans Administration hospitals, and the federal gov¬ernment through its Indian Health Service provides med¬ical services to American Indians and Alaskan natives, sometimes using trained auxiliaries for first-contact care.

In the rural United States first-contact care is likely to come from a generalist I he middle- and upper-income groups living in urban areas, however, have access to a larger number of primary medical care options. Children are often taken to pediatricians, who may oversee the child's health needs until adulthood. Adults frequently make their initial contact with an internist, whose field is mainly that of medical (as opposed to surgical) illnesses; the internist often becomes the family physician. Other adults choose to go directly to physicians with narrower specialties, including dermatologists, allergists, gynecolo¬gists, orthopedists, and ophthalmologists.

Patients in the United States may also choose to be treated by doctors of osteopathy. These doctors are fully qualified, but they make up only a small percentage of the country's physicians. They may also branch off into specialties, hut general practice is much more common in their group than among M.D.'s.

It used to be more common in the United States for physicians providing primary care to work independently, providing their own equipment and paying their own ancillary staff. In smaller cities they mostly had full hos¬pital privileges, but in larger cities these privileges were more likely to be restricted. Physicians, often sharing the same specialties, are increasingly entering into group as¬sociations, where the expenses of office space, staff, and equipment may be shared; such associations may work out of suites of offices, clinics, or medical centres. The increasing competition and risks of private practice have caused many physicians to join Health Maintenance Organizations (HMOs), which provide comprehensive medical. care and hospital care on a prepaid basis. Thå cost sav¬ings to patient's are considerable, but they must use only the HMO doctors and facilities. HMOs stress preventive medicine and out-patient treatment as opposed to hospitalization as a means of reducing costs, a policy that has caused an increased number of empty hospital beds in the United States.

While the number of doctors per 100,000 population in the United States has been steadily increasing, there has been a trend among physicians toward the use of trained medical personnel to handle some of the basic services normally performed by the doctor. So-called physician extender services are commonly divided into nurse prac¬titioners and physician's assistants, both of whom provide similar ancillary services for the general practitioner or specialist. Such personnel do not replace the doctor. Al¬most all American physicians have systems for taking each other's calls when they become unavailable. House calls in the United Stales, as in Britain, have become exceedingly rare.

Russia. In Russia general practitioners are prevalent in the thinly populated rural areas. Pediatricians deal with children up to about age 15. Internists look after the med¬ical ills of adults, and occupational physicians deal with the workers, sharing care with internists.

Teams of physicians with experience in varying specialties work from polyclinics or outpatient units, where many types of diseases are treated. Small towns usually have one polyclinic to serve all purposes. Large cities commonly have separate polyclinics for children and adults, as well as clinics with specializations such as women's health care, mental illnesses, and sexually transmitted diseases. Polyclinics usually have X-ray apparatus and facilities for examination of tissue specimens, facilities associated with the departments of the district hospital. Beginning in the late 1970s was a trend toward the development of more large, multipurpose treatment centres, first-aid hospitals, and specialized medicine and health care centres.

Home visits have traditionally been common, and much of the physician's time is spent in performing rou¬tine checkups for preventive purposes. Some patients in sparsely populated rural areas may be seen first by feldshers (auxiliary health workers), nurses, or midwives who work under the supervision of a polyclinic or hospital physician. The feldsher was once a lower-grade physician in the army or peasant communities, but feldshers are now regarded as paramedical workers.

Japan. In Japan, with less rigid legal restriction of the sale of pharmaceuticals than in the West, there was formerly a strong tradition of self-medication and self-treatment. This was modified in 1961 by the institution of health insurance programs that covered a large proportion of the population; there was then a great increase in visits to the outpatient clinics of hospitals and to private clinics and individual physicians.

When Japan shifted from traditional Chinese medicine with the adoption of Western medical practices in the 1870s. Germany became the chief model. As a result of German influence and of their own traditions, Japanese physicians tended to prefer professorial status and schol¬arly research opportunities at the universities or positions in the national or prefectural hospitals to private practice. There were some pioneering physicians, however, who brought medical care to the ordinary people.

Physicians in Japan have tended to cluster in the urban areas. The Medical Service Law of 1963 was amended to empower the Ministry of Health and Welfare to control the planning and distribution of future public and non¬profit medical facilities, partly to redress the urban-rural imbalance. Meanwhile, mobile services were expanded.

The influx of patients into hospitals and private clinics after the passage of the national health insurance acts of 1961 had, as one effect, a severe reduction in the amount of time available for any one patient. Perhaps in reaction to this situation, there has been a modest resurgence in the popularity of traditional Chinese medicine, with its leisurely interview, its dependence on herbal and other "natural" medicines, and its other traditional diagnostic and therapeutic practices. The rapid aging of the Japanese population as a result of the sharply decreasing death rate and birth rate has created an urgent need for expanded health care services /or the elderly. There has also been an increasing need for centres to treat health problems resulting from environmental causes.

Other developed countries. On the continent of Europe there are great differences both within single countries and between countries in the kinds of first-contact medical care. General practice, while declining in Europe as else¬where, is still rather common even in some large cities, as well as in remote country areas.

In The Netherlands, departments of general practice are administered by general practitioners in all the medical schools—an exceptional state of affairs—and general prac¬tice flourishes. In the larger cities of Denmark, general practice on an individual basis is usual and popular, be¬cause the physician works only during office hours. In addition, there is a duty doctor service for nights and weekends. In the cities of Sweden, primary care is given by specialists. In the remote regions of northern Sweden, district doctors act as general practitioners to patients spread