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OCR for page 70
Chapter 4
THE PHYSICIAN ' S ROLE IN A CHANGING
HEALTH CARE SYSTEM
Stephen J. Williams
Elena O. Nightingale
Barbara Filner
The health care sys tem in this country has experienced
unprecedented change ant growth since World War II, but especially
during the past twenty years.1 These changes ref. lect a multitude of
developments, including fundamental shif ts in the political and
philosophical underpinnings of American life, dramatic advances in the
technology of medicine, evolving expectations on the part of the
consumer toward physicians, and dif ferent characteristics of the
popular ion and the heal th care problems they experience . The nature
of these changes, their projected future course, ant the implications
for the physician, the consumer, and the health care system are the
subject of this chapter. The analysis is oriented toward an
examinat ion of the role of the physician on the assumption that future
general ions of physicians should be trained to f it into the health
care system and not to mold the system to f it their own preconcep-
tions and personal desires.
Underlying the pro jections made in the chapter is the dual
recognition that the projections may turn out to be wrong, but that
planning requires using assumpt ions based on current knowledge . The
potential for fundamental changes in health and health care is very
real. That potential bears an important message: f legibility and
adaptation to change will be essential in medical education in the
future ~ and will also be valuable personality traits in the practicing
physician.
The Provision of Health Care--An Overview
The heal th care Says tem nerves an expanding populat ion of consumers
whose characteristics have changed dramatically in the years since
World War II. These characteristics are expected to continue to
change in a number of important ways.
Demographic Trends
The demographic characteristics of the population are of
fundamental importance, since they define who receiver care.
Demographic trends point toward continued moderate growth in the U. S.
population, which is expected to level off eventually at about 300
million; a substantial portion of pro jec ted growth is attributed to
immigration (Table 1~. Fertility rates are unlikely to increase very
substantially from their relatively low (by historical standards
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TABLE 1 Past and Pro jec ted United States Population, Selected Yeare,
1930-2000
Population
at Start Net Increase Net Civilian
Year or of Period Total Per- Births Deaths Immigration
Period (1,000) (1,000) cent (1,000) (1,000) (1,000)
1930 122,487 1,128 0.9 2,618 1,419 113
1935 L26, 874 853 0. 7 2, 37 7 1, 421 -2
1940 132, 054 1, 221 0.9 2 ~ 570 1 ~ 432 77
1945 139,767 1,462 1.1 2,873 1~549 162
1950 151,135 2,486 1.7 3,645 1,468 299
1955 164,588 2,925 1.8 4,128 1,S37 337
1960 179,386 2,901 1.6 4,307 1,708 327
1965 193, 223 2, 315 1.2 3, 801 1, 830 373
1970 203,849 2,617 1.3 3,739 1,927 438
1975 214,931 2,165 1.0 3,144 1,894 449
1976 217,095 2,084 1.0 3,168 1,910 353
1977 219,179 2,298 1.0 3,327 1,900 394
1978 221,477 2,403 1.1 3,328 1,925 427
1979 223,880 2,564 1.1 3,468 1,908 460
1980a 226, 444 2, 586 1.1 3, 589 1, 984 654
Pro jec t ions
Series I
1980-1985 224, 066 2, 962 1.3 4, 714 2, 152 400
1985-1990 238,878 3,167 1.3 5,067 2,299 400
1990-1995 254, 715 2,934 1.2 4,975 2,441 40Q
1995-2000 269,384 2,691 1.0 4,866 2,575 400
Series II
1980-1985 222 ~ 159 2 ~ 144 1.0 3, 882 2 ~ 138 400
1985-1990 232, 880 2 ~ 126 0 ~ 9 4 ~ 008 2, 281 400
1990-1995 243~513 1~847 0@8 3~868 2~421 400
1995—2000 252 ~ 750 1, 562 Oe 6 3, 676 2 ~ 551 400
Series III
1980—1985 220~732 1~629 Oe7 3~359 2~129 400
1985—1990 228~879 1~477 Oe6 3~347 2~270 400
1990—1995 236 ~ 264 1 ,142 0 e 5 3 ~ 149 2 ~ 408 400
1995-2000 241 ~ 973 781 0 ~ 3 2 ~ 916 2 ~ S35 400
aEs timate .
SOURCE: Reference #3.
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current levels (Table 2), and mortality rates in the United States
wil .~ undoubtedly decline further, but slowly (Table 3 ~ . Average
lend oh of life will likely increase further (Table 4~. Thus, all
other things being equal, population growth would lead to continued
need for additional health care resources ~ although the absorption of
existing inventories (or their deterioration) will still take come
t ire in many communities . 3-11
TABLE 2 Live Births and Age Specific Birth Rates, United States,
Selected Years, 1950 to 1979
1950 1960 1970 1980
.
Live birthea 3.63 4.26 3.73 3.49
Bi rth rateb 24.1 23. 7 18.4 15.9
Age-specif ic birth rate
10-14 1.0 0.8 1.2 1.2
15-19 81.6 89.1 68.3 53.4
20-24 196.6 258.1 167.8 115.7
25-29 166. 1 191.4 145.1 115.6
30-34 103. 7 112.7 73.7 61.8
35-39 52 .9 56.2 31.7 19.4
40-44 15. 1 15 . 5 ~ .1 3.9
45-49 1.2 0.9 0.5 0.2
aMillions ~
bLive births per thousand women.
SOURCE: Table 1, Reference #24.
Of course, total populat ion is only one aspect of the demographic
characteristics. She nation experienced, after World War II, a shift
in population from rural and farm communities to urban areas,
initially to cities and subsequently to the suburba.12 The shif ts
f row the Midwest ant Northeast to the South and West1 have led to a
mismatch of population and health care resources. Recent shif ts have
been out of large cities to smaller cities and towns. 3 Future
changes are dif f icult to predict .
The largest group of immigrants in recent years has been Hispanic,
ant following the Vietnam era there was a substantial inf flux of
Southeast Asians to a number of population centers. This migration
places additional new demands, resulting from language and cultural
dif f erences, on the health care system.
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TABLE 3 Age-adjusteda Death Ratesb by Cause, United States,
Selected Years, 1950 to 1979
19 50 L960
.
Total 841.5 760.9 714.3 588.8
White men 963.1 917.7 893.4 751.1
Whi te women 645.0 S. 55.0 501. 7 412 . 2
Black men 1,373.1 1,264.1 1, 318.6 1,090.4
Black women 1,106.7 916.9 814.4 636.1
Heart disease 307.6 286.2 253.6 203. 5
Cerebrovascular disease 88.8 79.7 66.3 42.5
CancerC 125.4 125. ~ 129.9 133.2
Pneumonia and inf luenza 26.2 28.0 22 .1 11.4
Chronic liver disease 8.5 10.5 14.7 12.2
Diabetes melli tus 14.3 13. 6 14.1 10.0
Accidents 57~5 49~9 53~7 43~7
Suicide 11.0 10.6 11.S 11.9
Homicide 5.4 5.2 9.1 10. 4
aAge adjusted to the total population of the United States in 1940,
using 11 age groups.
breaths per 100, 000 resident population.
Between 1950 and 1979 respiratory system cancer death rates almost
tripled, digestive system cancer death rates decreased by 29 percent,
and breast cancer death rates among women remained constant.
SOURCE: Tables 9 and 15, Reference #24.
TABLE 4 Life Expectancy at Birth and at Age 65, United States,
Selected Years 1950 to 1980
-
Year
Lif e Expec fancy in Years
At Birth At Age 65
l95oa 68.2 13.9
1960a 69.7 14.3
1970 70.8 15.2
1975 72.5 16.0
1980b 73.6 16.4
alocludes deaths of non-re~ident~ of the united States.
bProvisional data.
SOURCE: Table 10, Reference #24.
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The aging of the U. S. population also has been much noted in
recent years. 13 Those over 65 represent a steadily increasing
proportion of the total {J. S . population; 11 percent in 1980, wi th
pro ject ions of 13, 17, and 20 percent in the years 2000, 2020, and
2040, respectively.14 Furthermore, the elderly themselves are
getting older on average. Those over 75 accounted for 40 percent of
the elderly in L980; pro jections are for increases to 49, 43, and
56 percent in the yearn 2000, 2020, and 2040, respectively.l4 This
suggests an increased demand on health care resources--the number of
short-stay hospital days per person, for example, increases with age,
as do limitations in activity resulting from chronic conditions (Table
5 ~ . Perhaps of greater consequence than the quantitative impact is
the qualitative impact of these changes. Because the elderly often
have multiple chronic diseases and they may present with atypical
symptoms, diagnosis and treatment are complicated ~ Chapter 6 ~ .
Maintenance of f unction, rather than cure, oust of ten be the
phys ician ' s goal . 1 ~
TABLE 5 Limitation of Activity and Use of Health Care Resources by
Selected Age Groups, United States, 1980 and Pro jections for 2000
Percent
1980 2, 000 Increase
(millions) (millions) 1980-2000
To Cal Popula t ion
Number 232.7 273.9 18
Limitation-chronica 25.6 34.2 34
Physician visits llOL.8 1314.1 19
Short-stay hospital days 264.0 345.3 31
Nursing home residents 1.5 2.5 67
Personal health care expendituresb $219, 400 $273, 400 25
Age 6 5 and Older
Number 25.9 36.3 40
Limitation-chronica. 10.2 14.9 46
Physician visits 165.7 231.1 39
Short-stay hospital days 89.9 133.0 48
Nursing home residents 1.3 2.3 77
Personal health care expendituresb $64, 500 S90, 300 40
Age 75 and Older
Number 10.3 17.9 74
Limitation-chronica 4.7 8.4 79
Physician visits 66.1 114.6 73
Sho rt-s tay hospi tal days 4 5 . ~ 7 9 . 7 7 4
Nursing home residents 1.1 2.1 91
Personal health care expendituresb
aLimitation of activity due to chronic conditions.
bConstant 1980 dollars.
SOURCE: Tables 1, 3, 5, 6, 7, ant 8, Ref erence #14 .
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Mo reality and Morbidity
The most important change in causes of death in the United States
has been the decline in serious infectious disease and the increase in
chronic conditions .1 This shift has been caused by a number of
factors, including control of communicable disease through public
health measures, immunization programs, improved medical care and drug
therapy, and especially the introduction of antibiotics; and the
additional years of life that accompany the reduction in death rater
of infants and children. 16 It is important to recognize that
mortality data are inexact, that data recorded on death cereif icates
in the early l900s were based on less scientific evidence than is
common today, and that mortality alone does not fully define the
health services needed by a population since most health care is
provided for problems that are not likely to lead to death.
Morbidity is more difficult to define, study, and monitor than is
mortality. Illnesses associated with well-clef ined diseases, such as
reportable communicable diseases, are the easiest to monitor. But
many problems are not clinically well def ined . They may involve
social and emotional components that may be far more signif leant and
debilitat ing than the somatic complaints, or may be only one of
multiple problems affecting an individual. Furthermore, especially in
ambulatory care, formal categories for disease def inition are
inadequate or difficult to apply. Finally, many problems are
self-limiting, or are outs ide the scope of tradi t tonal medical
practice.17 Today 's measures of morbidity have ~ n increased
emphasis on the patient's ability to function, reflecting the nature
of chronic diseases; on social and emotional illnesses, ranging from
accidents to psychiatric problems and reflecting the broader scope of
problems treated within the system; and on more fundamental health
care needs, including those related to prevention, reflecting a more
aggressive and comprehensive approach to health care.
A high percentage of ambulatory care is attributable to primary
care, some of which can be provided by nurse-practitioners and other
midlevel personnel, 18 and a significant fraction of visits are for
nonsomatic reasons (Table 6 ~ . Data on hospitalizations (Table 7
partially ref lect the high fraction of all surgery that court be
performed on an ambulatory care basin, estimated to be as much an
40 percent; the proliferat ion of ambulatory surgery centers both
within and independent of hospitals is changing the nature of both
surgery and the hospital.
The data also hint at the need for continuing specialization by
physicians and for the services of providers who can respond to needs
that are not necessarily amenable to technological intervention, that
of ten require more caring than curing, and that exist on the border
between health and social services. The role physicians should assume
in dealing with these problems and the training they should have to do
so remain unclear.
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TABLE 6 Number and Percentage of Of f ice Visits, by the 20 Most Common
Principal Diagnoses, United States, 1980
Number of
Utility in
Rank Principal Diagnosis Thousands Percent
1 Normal pregnancy 26, 256 4.6
2 Essential hypertension 25 ,137 4.4
3 Health supervision of infant or child 17, 496 3.0
4 General medical examination 16, 078 2.
5 Acute upper respiratory infections of
multiple or unspecif fed sites 15, 050 2.6
6 Suppurative and unspecified otitis media 11, 748 2.0
7 Neurotic disorders 11, 251 2.0
8 Diseases of sebaceous glands 10, 578 1.8
9 Follow-up examinat ions 9, 682 1. 7
10 Diabe tes mellitus 9, 5S1 1.7
11 Special investigations and examinations 9, 530 1.7
12 Acute pharyagitis 9, 361 1.6
13 Allergic rhinitis 8, 439 1.5
14 Obesity and other hyperalimentation 8,081 1.4
15 Other forms of chronic ischemic heart
disease 6,958 1.2
16 Disorders of refraction and accommodation 6, 271 1.1
L7 Bronchitis, not specified as acute or
chronic 6, 024 1.0
18 Asthma 5,921 1.0
19 Contact dermatitis ant other eczema S. 720 - 1.0
20 Other diseases due to Intrudes and
Chlamydiae 5, 093 O ~ 9
All ocher diagnoses 351, 522 61.1
SOURCE: National Center for Health Statistics 1980 Summery. National
Ambulatory Metical Care Survey. Advance Data, No. 77, Feb. 22 ~ 1982,
Hyattsville, Md., ITS. Department of Health and H Man Services.
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TABLE 7 Discharges and Days of Care, Nonfederal Short-stay Hospitals,
Accor~nosis, United States ~ 1979
Discharges Days of Care
Age, Sex, and Diagnosis Categories (Number per 1, 000 population)
Bo th Sexes
Total 162.8 1~158.2
Diseases of the heart 13.0 122.
Malignant neoplasms 7 .9 94.1
Fracture 5~3 54.0
Neuroses and nonpsychotic disorders 5.2 49.4
Pneumonia 3 .6 27.7
Male
under IS years 80.3 3S2.4
Pneumonia S.9 30.6
Frac ture 4 .0 22.0
Congenital anomalies 3.8 22.0
Inguinal hernia 2.7 6.0
Bronchitis, emphysema, asthma 3.7 14.9
Intercranial in jury 2.3 5.8
15-44 years 97 .1 616.5
Fracture 6.6 51.4
Neuroses and nonpsychoeic disorders 7 .4 69. 2
Lacerations 3.8 17.8
Sprains and strains 3.7 21.0
Diseases of the heart 3.1 22.0
Intercranial in jury 2.3 11 .1
45-64 years 193.2 1, 562.7
Diseases o f the heart 33.2 279.6
Malignant neoplasms 14.0 161.3
Neuroses and nonpsychotic disorders 9.6 82.
Inguinal hernia 6.3 34.3
Fracture 5 .2 S1. 0
Ulcer 3 .6 27 .3
65 years and over 410. 5 4, 287.1
Diseases of the heart 77.9 792.1
Malignant neoplasms 48.6 621. 2
Cerebrovascular disease 24.4 307.6
Hyperplasia of prostate 16.5 172.4
Pneumonia 13. S 146.0
~ Continued
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TABLE 7 ~ cant inued ~
Age, Sex' ant Diagnosis Categories
Discharges Days of Care
(Number per 1, 000 population)
~ , , _
Female
Under 15 years 64.7 275.5
Pneumonia 4.3 22.0
Fracture 2.1 11.2
Congenital anomalies 2.5 13.1
Bronchitis, emphysema, asthma 2.3 8.4
Eye diseases and conditions 1.6 3 .4
15-44 years 213.0 1,009.0
Delivery 71.1 266.3
Disorders of menstruation 7.3 24.0
Benign neoplasms 4 .2 22 . 5
Neuroses and nonpsychotic disorders 6.2 56 .1
Malignant neoplasms 2.7 21. 7
Cholelithiasis (gallstones ~ 2.6 20. 6
4 5-64 years 199 .0 1, 642 . 3
Diseases of the heart 17.5 151.8
Malignant neoplasms 16 .3 188.2
Benign neoplasms 5.7 36.6
Disorders of menstruation 6.9 22.2
Neuroses and nonpsychotic disorders 6.3 57.8
65 years and over 373.6 4,109.1
Diseases of the heart 65.1 695.1
Malignant neopLasms 31.1 429.4
Fracture 21.3 348.8
Cerebrovascular disease 23.2 299.2
Eye diseases and conditions 17 . L 70.7
Rheumatoid arthritis and osteoarthritis 8.8 112.1
SOURCE: Division of Health Care Statistics, National Center for Health
Statistics. Data from National Hospital Discharge Survey.
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Ut i lization of Services
The dynamics of population, the changes in patterns of disease,
and the political and economic environment of the nation have deeply
affected the health care system. In many respects the nation has
substantially expanded its commitment to providing more, and perhaps
better, quality health care.
An increasing percentage of net tonal consumption has been
allocated to health care in successive years, and especially since
196S (Table 8) . This growth ref. lects an increase in the quantity of
services provided ~ that is, more services to each person and more
people served), an increase in both complexity and cost for many
typesof service provided (such as a hospital day of care) and a
greater increase in the cost of health services due to inf lationary
and other pressures than was experienced in most other sectors of the
economy .19
TABLE 8 Gross National Product and National Health Expenditures,
United States, Selected Years
Year
Gross
National
Product Billions of As percent Dollars
(billions ~ dollars of . GNP per capita
Na t tonal Healt h Expend i ture s
.
1940 ~ 100.0 4.0 4.0 30
1950 286. 5 12. 7 4.4 82
1960 506.5 26.9 5.3 146
1970 992.7 74.7 . 7.5 358
1980 2,628.8 249.0 9.5 1,075
1981 2,925.5 286.6 9.8 1,225
SOURCE: Table 64, Reference #24.
The recent contraction in services provided by entitlement
programs, in coverage included among employee benef its, and in the
number of employed benef iciaries of insurance plans is a mild setback
in the overall trend toward more universal coverage . And, although
the political environment may preclude universal entitlement through
some form of national health insurance in the near future, the overall
trend toward more coverage for more people is unlikely to be
s ignif icantly reversed .20
Most outpatient care (physician ViSitB) occurs in physician
of f ices or clinics, but hospital ambulatory care services ant
telephones also provide access ~ Table 9 ~ .
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TABLE 9 Per Capita Physician itisits, by Source of Care and Patient
Characteristics, United States, 1980
Doctor's Office, Hospital
Clluic, or Outpatient
Group Practice Department Telephone
~ _
Charac teri ~ tic
All Sources
or Places
Totala 4.7 3.1 0.6 0.6
Age
Sex
Race
Under 17 4.4 2.8 0.6 0.8
17-44 4.4 2.9 0.6 0.5
45-64 5.1 3.6 0.6 O. 5
65 and over 6.4 4.8 0.7 0.6
Male 4.1 2.7 0.6 0.5
Female 5.3 3.6 0.6 0.7
White 4.8 3.3 0.5 0.7
Black 4 . 6 2.6 1.2 0.3
Family income
Less then $7, 000 5. ~ 3.2 1.1 O. 5
t7,000-$9,999 4.4 2.7 0.7 0.6
$10,000-S14,999 4.9 3.2 0.7 0.6
$15,000-$24,999 4.7 3.2 0.5 0.6
$25,000 or more 4.6 3.2 0.4 0.7
Geographic region
Northeast 4.7 3.0 0.7 0.6
North Central 4. 1 3.3 0.5 0.7
South 4.6 3.} 0.6 0.5
West 4.9 3.4 0.6 0.6
revisits per person.
SOURCE: Table 35, Reference #24.
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Obviously, it is very dif f icult to make pro jections about the
future role of physicians. Since it is expected that in 1990 about 40
percent of the greatly expanded supply of physicians in this country
will have graduated from medical school in the 1980s, these
individuals need to be trained now for the future, however difficult
it is to project that future. The clinical practitioner of the future
will undoubtedly need to be able to manage much more information than
the practitioner of today, and will probably need to master computer
techniques for this purpose. The future physician will continue to
need a deep appreciation of the scientific basis of medicine, but the
scientific basis will be increasingly complex, and the technologies
that will be available will also be expanded in number and in
complexity. Therefore, it will be even more important to have the
capacity to evaluate new interventions ant to make sound decisions
about when to use them and when not to use them.
It also appears that ethical dilemmas in medicine will increase an
our eechnologic capability increases. As an example, the application
of gene tic engines ring techniques to humans will certainly provide
benef its in the diagnosis and treatment of genetic disorders, but will
also create quandaries: Should we tamper with the human genome ? What
about making changes not related to disease, but to desirability of
traits? Where are the limits to be set and by whom? Difficult
questions will involve life-sustaining measures, organ replacements,
and so on.
Because of the size of the industry ant its impact on the economy,
the physician of the f uture should understand the health care system
much better before becoming a member of it and will need to understand
the government's participation in decisions affecting the health of
the individual ant of the public as a whole. There probably will be a
larger role for physicians to contribute to the elucidation of health
policy issues ant to the implementation of health policies than there
has been in the page. The physician will probably also have an
increasing role in nonmedical issues ~ relating to the environment, to
aggression, and to violence, that impact very directly on survival and
on the quality of survival. Physicians in the future will also
probably need to work increasingly with other health professionals and
with other sectors of society in designing and implementing policies
related to health care costs and their containment in the context of
continuously improving the quality and equi ty of access to quality care
for the whole population.
Conclusion
Each of the changes in health services identif fed above affects
the need for and the role of physicians. The multiplicity of changes
and trends in health care ant the interrelationships of these trends
severely complicate any pro jections of future requirements for medical
education. Technological advancements alone have the potential of
throwing into total disarray any current pro jections. The direct
relationship between reimbursement policies, economic conditions, and
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other f inancial factors, independent of actual need for health care
servicer, vitally af fects the quantity, type, and location of services
that patients seek. These caveats duly repeat those at the beginning
of the chapter to emphasize the dif f iculties of suggesting future
courses of action. lathe response to the perceived, ant possibly very
real, doctor shortage, and subsequent events leading to totay's
possible doctor Surplus, illustrate the dif f iclllties of formulating
public policy in this area (Chapter 11) .57
Socioeconomic and demographic trends suggest continued growth in
the United States population, but with an increasing fraction of the
population being recent immigrants, minorities, and probably lower
income. These expanding population groups have a tendency to use
health care services at rates equal to, or exceeding, those of the
general population, provided that adequate reimbursement is available,
especially f rom governmental entitlement programs. Constrictions on
f unding f or public programs, reduced access to care because of
inadequate facilities and providers, and the unique problems of
immigrants, especially of undocumented or non-English-speaking people,
all will constrict the quantity of services that might otherwise be
sought . However, on balance, there is likely to be a net increase in
the quantity of services sought in the years ahead, all other factors
constant, at least until the population reaches demographic
equilibrium, an event nearly 70 or more years away and beyond any
reasonable planning period for medical education.
Changes in mortality and morbidity are difficult to project, but
there is little likelihood of ma jor deviations f row current trends
over the short term. Advances in medical knowledge and applications
of technology may lead to more fundamental change in the long run.
For the next 20 years there will be need for continued focus on
chronic diseases, on prevention, on the inf irmities of aging, and on
the more prevalent causes of morbidity. Some changes in the
technologies of disease detection and innovative therapeutic
approaches are likely, but there is little to suggest that these
advances will be so revolutionary that they will radically alter
current patterns of medical practice. Of greater concern is the
increasing shift in delivery of current technologies. For example,
the rapid rise in the use of ambulatory surgery, with the potential
for shif tiny a very signif leant fraction of all surgery out of the
lapatient arena, may result in lower procedure costs, lower levels of
surgeon reimbursement, but possibly greater surgeon productivity
(along with a need for fewer surgeons ), and higher average costs for
the care that remains in the hospital because of the removal of
relatively low-cost and profitable procedures.
Other examples of changes in patterns of providing care that can
radically influence the health care system without any fundamental
changes in medical knowledge or technology include the following:
0 increased use of noninvasive diagnostic procedures, such as
Computerized Axial Tomography, which may lead to fewer costly
invas ive procedures;
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o use of chemotherapeutic and radiological treatments to
substitute far surgery, and adoption of less radical surgical
approaches;
increased use of the telephone for caregiving, and especially
for followup care;
o changes in the use of midlevel practitioners;
o continued deinstitutionalization of patients in mental health
and long-term care settings;
increased reliance on patients to contribute to their own
health by habit modification, health-promoting practices, and
self-care;S~ and
o continued increaser in the numbers of women who are physicians,
and maintenance of their pattern of fewer hours of practice,
greater likelihood of choosing primary care specialties, lower
income per hour practiced, and greater likelihood of being
salaried, compared to male physicians .28
Many o ther changes could lead to either greater or lesser neet and
demand f or heal th care . Of course, there are ma jor areas of iline~s
intervention that, through concerted ant successful national efforts,
could lead to lower levels of need for health care.59 These
include, as a sampling,
o reduct ion in the number of accidents, and especially of
vehicular accident a;
o reduction or elimination of drinking, drugs, ant smoking as
mayor contributory causes of illness;
reduction in rates of violent death and injury, and especially
of homicide and ocher criminal acts;
o increased psychosocial support through resurgence of the
extended family and of f riendshipe; and
o reductions of social pressures and tensions leading to lower
levels of mental, psychosomatic ~ and somatic health problems.
There are many judgmental factors associated with the definition
of illness in thin country. These are functions of both the patient 's
perceptions and reactions, and of profeselonal decisions and
e~raluseions, especially on the part of the physician. Not all care
currently provided would be Justified on the basis of rigorous .
assessments. 60 Patients seek care for social support, for
reassurance, for treatment for self-resolving problems, and for other
situations that are not purely in the domain of scientific knowledge,
as reflected in part by the data from the National Ambulatory Medical
Care Survey, and from other studies of primary care.
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Professional judgments may also be muddied by economic
considerations, a too limited or outdated knowledge base, or simply
poor practice patterns. As a result, some care provided by
professionals or initiated at their suggestion ~ the powers of which
are very strong ~ may not be warranted ~ Such care includes repeat
visits for problems thee are self-resolving or for problems that the
patient is capable of ~elf-monitoring; unnecessary surgery, however
def ined, as ref lected in differential surgical rates especially for
more elective or sub jective diagnosis, in the United States as
compared with the United Kingdom, in prepaid versus fee-for-~ervice
insurance plans or health care systems ~ and in better-insured versus
poorly insured populations; and care that is generated due to medical
malpractice concerns and other aspects of defensive medicine.
This discussion suggests that even if the denominator of patients
is known, there are many variables, even exclusive of insurance
coverage, that will affect the numerator of use of resources, thereby
affecting total utilization rates. The addition of financing
variables f urther complicates the analysis . These considerations
include, but are not limited to, the following:
o extent, level, and types of health insurance coverage among the
population;
o levels of employment and hence eligibility for benefits;
scope of coverage of services and eligibility for governmental
entitlement programs; ~
effects of cost containment initiatives such an Preferred
Provider Organizations, Health Haintenance Organizations,
institutional prospective reimbursement, competitive bidding,
utilization review, and restrictions on supply due to
Certificate-of-Need and other regulatory ef forts;
prevalence and effect on utilization of deductibles,
co-insurance, and other fonts of risk sharing involving both
consumers and providers;
patient abilities to pay out of pocket, especially for
uncovered services under entitlement programs like Medicare,
insurance programs, especially indemnity plane ~ and for
elective uninsured care;
the effect of overall economic conditions including employment
and unemployment, female labor force participation, ant
employer sponsorship of benefit programs in health; and
issues of taxation including the deductibility of health care
costs on individual returns and of health care benefit costs on
corporate returns, and on the taxation of benef it payments made
on behalf of employees .
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Many of these issues involve complex political trade-offs that are
likely to be more affected by national, social, and political
sentiments than by rigorous public policy analysis or health care
needs assessments.
The net effect of all of the trends, topics, and influences
discussed above is not easy to project in terms of utilization of
health care services. Ideally, the number and type of physicians
needed should follow directly, and in many respects rather easily,
f rom pro Section of utilization by type of service . But the water is
muddied by all of the f ac tore discussed throughout this chapter,
leading to immense cliff iculty in conducting the type of planning that
would yield specif ic and implementable guidelines on physician needs.
Parenthetically, these difficulties have severely hampered the
methodological and political success of health planning in the
regulatory environment represented by the health systems agencies.
There are, unfortunately, still further complications. There is
no reason to assume that the care currently provided accurately
reflects the underlying physiological and psychological needs of the
population. Aside from excess and inappropriate care that may be
provided, as discussed above, other care may be needed but not
provided as a result of barriers that patients face , both internal
(such as fear of symptoms or lack of truse of medicine) ant external
(resulting from system-originated factors such as lack of financing or
facilities). For example, the mental health needs of the nation, at
least according to the President's Commission on Mental Health,
are far from being met.
There are also other issues, in some ways more philosophical. The
role of the physician, in particular, has never really been
clarified. Is the physician merely a provider of technical services,
or a confidant, adviser, and arranger of all care? What is ache
physician' s obligation to assure the continuity and comprehensiveness
of care for patients? In an organizational setting such as a hospital
or group practice, how does the physician share patient care
responsibilities with the organization? The relationship between
physicians and other providers, especially nurses and midlevel
personnel, has remained in limbo for years, each part making new
assumptions and changing the relationship here and there, never fully
certain of how things should be; these relationships need
clarif ication.
Finally, health care serves many interests beyond the socially
popular goal of improving the health of the American people . The re
a re political f ights, turf ~ truggles, egos, unreasonable demands by
patients ant providers alike, social ant economic goals, union
demands, tax policies, problems in motivating people to be aware of
their own health care needs, many self-destructive ant costly
behaviors, fears, hopes, and wants. To satisfy everyone would be a
near impossibility.
Medical education itself has been subject to many stressful
situations. How much science training should the physician possess?
How much training in the social sciences, and in the economic and
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political processes of society and of health care are needed? Is the
physician's role defined by medical education at all? Is the current
prototypical four years each of college, medical school, and often
residency, appropriate (many other countries follow far different and
frequently accelerated approaches) ?
How many physicians do we need and how should they be trained?
This is the fundamental question for medical education, yet any
attempt at an answer must address a far-ranging and exceedingly
complex set of questions. Assumptions can radically affect the
resulting pro Sections, an is well illustrated by the possibility of
substantially increasing the productivity of existing health care
services. We clearly have too many surgeons ~ based on many sources of
data and analysis, but paradoxically we do not know how many we really
need. Many of our decisions are based on political and economic
considerations rather than on the types of rigorous analysis that
policy analysts and health care planners prefer. Many decisions are
not loaned on analysis at all. Implementation of suggestions for
change may consider political factors more than analytical ones; and
implementation can take a long time, leading to a vastly different
world by the time the changes have been accomplished, and risking that
those changes are outdated or inappropriate by the time they become
ef Elective .
The future of medical education is inextricably intertwined with
the past, present, and future of not only health and health care, but
of all aspects of our society. Rigorous analysis alone, no Hatter how
elegant, will not provide the necessary answers to formulate a
long-term and lasting strategy for medical- education. The changing
nature of health care services, and of our nation' s reliance on health
care to solve many diverse needs, and the limits of medicine, Which
are very real, mandate a broad, sweeping assessment.62
Only by looking broadly can the issues of medical education be
adequately addressed. Even then, the task is awesome. The trends ant
issues presented in this chapter only begin to set the stage, ant only
raise some of the questions that must be answered. The future will
hold many more important changes and, hopefully, greater prospects
than has the recent past. We must keep in mind that the underlying
societal goal of health care services is to improve the nation's
heal th; but reaching that goal involves moving through a very
intricate maze.
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Representative terms from entire chapter:
care services
