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

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. 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

practitioners, 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'

income. 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 doctors, 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 treatment of the indigent. Veterans may

receive free treatment at Veterans Administration hospitals, and the

federal government through its Indian Health Service provides medical

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, gynecologists, 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

hospital privileges, but in larger cities these privileges were more likely

to be restricted. Physicians, often sharing the same specialties, are

increasingly entering into group associations, 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. Thе cost savings 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

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