Medicine

C

Other Health Professionals

Medicine is not restricted to physicians. A wide variety of health care practitioners work in this exciting field. By far the largest professional group is nurses. Registered nurses help physicians during examinations, treatment, and surgery. They observe, evaluate, and record patients’ symptoms, administer medications, and provide other care (see Nursing). Nurse practitioners perform basic duties once reserved for physicians, such as diagnosing and treating common illnesses and prescribing medication. Certified nurse-midwives care for mothers during pregnancy and deliver babies (see Midwifery). Nurse-anesthetists administer anesthesia to patients during surgery. Licensed practical nurses provide basic bedside care for sick patients under the supervision of registered nurses and physicians.

Physician assistants deliver basic health services under the general supervision of a physician. They examine patients, order X rays and laboratory tests, and prescribe drugs or other treatment. In some rural areas, physician assistants provide all basic health care for patients, consulting with a supervising physician by telephone or electronic mail.

Dentists diagnose, treat, and help prevent diseases of the teeth, gums, and other tissues in the mouth and jaws (see Dentistry). Most are general practitioners, but many specialize in a particular area of dental health. Orthodontists treat teeth that are poorly aligned; oral surgeons operate on the jaw and mouth; periodontists specialize in gum disease; pediatric dentists care for children; endodontists perform root canals; prosthodontists make and insert artificial teeth and dentures. Other dental professionals include dental hygienists who assist dentists in surgery, clean teeth, and provide fluoride treatments. They advise patients on proper oral hygiene techniques to prevent tooth and gum disease.

For more information about other health care practitioners, see the table on Allied Health Professionals.

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III

Health Care Facilities

A sick or injured person can obtain medical care in several different places. These include provider practices such as medical offices and clinics, hospitals, nursing homes, and home care.

There are about 200,000 medical offices, clinics, and other provider practices in the United States. Earlier in the 20th century most physicians were solo practitioners working in their own offices or in partnership with another doctor. Patients visited the office, received an examination or other service, and paid a fee. This traditional solo, fee-for-service medicine has been declining. Many physicians now practice in groups where they share the same offices and equipment with other doctors. Group practices may combine primary care physicians, several kinds of specialists, laboratories, and equipment for diagnosing disease. Physicians who practice in a group reduce their own expenses and provide patients with a wider range of services.

Many doctors are joining with hospitals, insurance companies, and industrial employers to provide managed care for groups of patients. Physicians may work as employees of health maintenance organizations (HMOs) or other health care alliances. These plans oversee, or manage, care for patients, to avoid unnecessary services and reduce costs. Rather than taking a fee from each patient, managed care physicians may receive an annual salary from the HMO or a fixed sum for each patient.

Patients who are too sick for care in a doctor's office go to a hospital. Hospitals offer patients 24-hour care from a staff of health professionals. They provide services not available elsewhere, such as major surgery, child birth, and intensive care for the critically ill. The United States has about 6,020 hospitals including more than 1 million beds. Several kinds of hospitals exist, including general hospitals, specialized hospitals that care for specific diseases, small community hospitals, and large academic medical centers that train new doctors. Hospitals also provide many outpatient services to patients being treated in doctors' offices and clinics. These include laboratory tests, computerized imaging scans, X rays, and other diagnostic tests for people who do not require admission to the hospital.

Hospital care is the most expensive form of health care. Efforts to control health care costs have emphasized reducing the number of patients admitted to hospitals and their length of stay. During the 1980s and 1990s, these efforts led to the closing of more than 600 hospitals, which eliminated almost 200,000 beds. Physicians also try to treat more people on a nonhospital, or outpatient, basis, and these cost-control efforts have led to fast growth in outpatient treatment centers. These include ambulatory surgery centers, where patients undergo operations once available only in hospitals and return home the same day.

Patients who need long-term medical care because of advanced age or chronic illness may stay in a nursing home. The United States has about 17,000 nursing homes with about 1.8 million patients. The number of nursing homes has doubled since 1960 because there are more older people in the population. Changing lifestyles, in which adult children and parents often live far apart, also contributed to the need for more nursing homes. About 85 percent of nursing home patients are age 65 and over. Many stay for a few weeks while recovering from an acute illness. They receive medical care and help with everyday activities like eating, bathing, and using the bathroom. Then they return home and care for themselves, often with the help of family or other caregivers. Other patients stay longer.

Some patients need regular medical care and other assistance, but are not sick enough for a hospital or nursing home. Home health care allows them to receive skilled nursing and other care in their own homes. Home care services are the fastest-growing sector of the health care industry, increasing about 30 percent per year in the 1990s. This growth is largely because home care is less expensive than hospital or nursing home care. Home care also is very popular with patients because most people prefer staying at home, rather than entering a hospital or nursing home. About 15,000 home health agencies provide most home care services in the United States. Many agencies are privately owned. Hospitals, public health departments, and other organizations also offer home care.

Hospices are special health care facilities that provide care for dying patients in the final stages of a terminal illness. A hospice staff is focused on making the last days of a dying patient pain free and comfortable. Many patients choose hospice services in their homes.

IV

Health Care Around the World

The quality of care in other developed countries is comparable with that in the United States—patients have access to similar drugs, diagnostic tests, and other technology for preventing, diagnosing, and treating disease. Patients in Canada, the United Kingdom, Western Europe, and Japan use primary care physicians for most health problems. Patients are sent to specialists for more serious conditions, and may receive care in hospitals and nursing homes.

The major difference is in the way other developed countries pay for health care. Private health insurance pays for most care in the United States. About 90 percent of Americans have private health insurance. Employers usually pay a portion of the premium, or cost, as part of the benefits provided to employees besides their salaries.

Most European countries have a national health insurance plan that provides free care. Taxes paid by citizens pay the cost. In Canada, the central government and the provinces share costs for medical care. Individuals usually contribute a certain amount through payroll deductions. The central government does not own most health care facilities in these countries.

China and other countries have a completely socialized health care system. The government owns all health care facilities. Physicians and other health care personnel are government employees. The former Soviet Union established the world's first socialized medical system in the 1920s. But Russia and other independent republics, formed when the Soviet Union broke up in 1990, are experimenting with private health insurance and other financing methods.

Billions of people in developing countries suffer greatly because medical care is not readily available and is poor in quality. Governments in many poor countries in sub-Saharan Africa and Asia spend only a few dollars per person on health care each year. Trained people, equipment, and medicines needed to provide the most basic medical care are in grave shortage. Families in these countries typically earn only a few hundred dollars each year. They must rely on the government, international aid organizations, missions, or charities for health care.

Health care personnel and facilities are not evenly distributed among the world’s population. Wealthy industrialized countries have more physicians and hospital beds per person than poorer developing countries. In the mid-1990s, the United States had one physician for every 400 people and Canada one per 454 persons. In comparison, the African country of Malawi had one physician per 45,736 people; Nigeria had one per 5,207 people; and India had one physician per 2,459 people. Hospital facilities are also distributed unequally. The United States has one hospital bed for every 244 people compared with one per 196 in Canada; one per 949 in Honduras; one per 1,252 in Haiti; and one per 1,270 in India. Major imbalances in the amount of money spent on health care also exist. The poorest developing countries spent less than $10 per person per year on health, compared to several thousand per person in developed countries.

V

Medical Research

Research is one of the most important fields of medicine. It provides health care professionals with new knowledge and technology for better diagnosis, treatment, and prevention of disease.

Medical research often combines medicine with related fields of biology, and is called biomedical research. Research can be basic or applied. Basic, or fundamental, research has no immediate practical application. Basic cancer research, for instance, may try to identify gene mutations that turn a healthy cell malignant. While this information does not have immediate clinical value, it generates knowledge that often leads to better care for patients. Applied research has a specific practical goal, such as development of a better drug for breast cancer. The early stages of biomedical research usually occur in a laboratory. As scientists gain more knowledge in a particular area, they begin studies on humans. These studies often take place in hospitals or clinics and are called clinical research.

Clinical research usually is performed by multidisciplinary teams, rather than by individual scientists working alone. These groups of men and women have knowledge and skills in different areas, or disciplines, of science. A multidisciplinary biomedical research team may include biochemists, geneticists, physiologists, and physicians. Each team member approaches the problem from a different side and shares knowledge with the group. This multidisciplinary approach increases the chances of solving a problem or developing a new treatment.

A

Clinical Trials

One of the greatest advances in medicine was the introduction of a new research technique in the mid-1950s called the controlled clinical trial, which is used to determine if new drugs and other treatments are safe and effective. In the controlled clinical trial, one group of patients, the treatment group, receives the new drug or new treatment. Another group, the control group, is given an inactive pill (a placebo) or the best standard treatment. Researchers then compare the two groups over a period of time. The data collected is put through rigorous statistical techniques to determine whether the new treatment is safer and more effective than standard therapy or no treatment.

Most clinical trials are conducted on a blind or double-blind basis. In a blind trial, patients do not know whether they receive the new drug or a placebo. In a double-blind trial, neither patients nor physicians know who is receiving the new treatment. This secrecy is important because patients who know they are taking a powerful new drug may expect to feel better and report improvement to doctors. Researchers who know that a patient is receiving the test treatment may also see improvements that really do not exist.

Clinical trials usually are randomized. Researchers put patients into the treatment group or control group at random. This helps to assure that neither group contains an excess of patients with severe disease. A drug may appear more effective if the treatment group were packed with patients who had only mild symptoms.

The results of clinical trials are subjected to peer review. Researchers publish their results in scientific journals or present them to an audience of other scientists, who are their peers. This gives scientists not involved in the research a chance to spot potential errors.