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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 70

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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 19952000 252 ~ 750 1, 562 Oe 6 3, 676 2 ~ 551 400 Series III 19801985 220~732 1~629 Oe7 3~359 2~129 400 19851990 228~879 1~477 Oe6 3~347 2~270 400 19901995 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. 71

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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. 72

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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. 73

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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 . 74

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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. 7'

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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. 76

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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 77

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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. 78

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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 ~ . 79

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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. 80

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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 96

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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; 97

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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. 98

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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 . 99

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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 100

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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. 101

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REFERENCES 1. Torrent, P. R. The American Health Care System. St . Louis: C. V. Mosby, 1978. . Rushmer, R. Health care technology. In Williams, S.J. and Torrens, P.R., Introduction to Health Services, 2nd ed. New Yo rk: John Wiley and Sons, 1983 . Bureau of the Census. Statistical Abstract of the United States, 1981. Washington, D.C.: U.S. Government Printing Office, 1981. Spiegel, A. D. and Hyman, H. lI. Basic Health Planning Methods . Germantown, Md.: Aspen Systems Corporation, 1978. Keyfitz, N. Mathematical Demography. New York: John Wiley ant Sons, 1977. '. Anderson, R., et al. Access to medical care among the Hispanic population of the Southwestern United States. Journal of Health and Social Behavior 22: 78-89, 1981. 7. Weeks, J. R. Population, 2nd ed. Belmont, Calif .: Wadsworth Publishing, 1981. National Center for Health Statistics. Lawrence, L. and McLemore, T. 1981 summary: National ambulatory medical care survey. Advance Data from Vital and Health Statistice' No. 88. DHHS - Publication No. (PHS) 83-1250. Hyattsville, Hd.: Public Health Se rvice, 1983 . National Center for Health Statistics. Annual summary of births, deaths, marriages, ant divorces: United States, 1981. Monthly Vital Statistics Report, Vol. 30, No. 13. DHHS Publication No. (PHS) 83-1120. Hyattsville, Md.: Public Health Service, 1982. 10. Knox, E.G. Epidemiology in Health Care Planning. New York: Oxford University Press, 1979. Institute of Medicine. Controlling the Supply of Hospital Beds. Washington, D. C.: National Academy of Sciences, 1976. 12. Smith, T. L. and Zopf, P.E. Demography. Port Washington, New York: Alf ret Publishing, 1976. 13. Somers, A. R. The geriatric imperative: A major challenge to the health professions. In Somers, A. R. and Fabian, 13. R. ~ ets. The Geriatric ImDerative. New York: Appleton-Century-Crofts, 1981. 14. Rice, D. P. and Feldman, J. R. Tables and Charts for Demographic Changes and the Health Needs of the Elderly. Handout. Institute of Medicine Annual Meeting, October 20, 1982, Washington, D.C. 102

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15. Filner, B. and Williams, S. F. Health promotion for the elderly: Reducing functional. dependency. In lathe Geriatric Imperative, see Ref erence 14 . 16. Hanlon, J. J. and Pickett, G. Public Health Administration and Practice, 7th ed. St. Louis: C.V. Hobby, 1979. , 17 . Noble, J. Primary Care and the Practice of Hedicine. Boston: Little, Brown, 1976. 18. Scheffler, R., et al. Physicians and new health practitlonere: Issues for the 1930~. Inquiry 16 :195-229, 1979. 19. Shortell, S. M. Factors associated with the utillsation of health services. In Introduction to Health Services, see Reference #2. 20 . Richardson, W. C. Health care f inancing . In Introduct ion to Health Services, see Ref erence #2. 21. Dowling, W. L. The hospital. In Introduction to Health Services, see Ref e rence 92 . . Kushman, J. E. and Nuckton, C. F. Further evidence on the relative performance of proprietary and nonprofit hospitals. Medical Care 15: 189-204, 197 7. 23. Williams, S. J., et al. Hospital sponsored primary care group practices: A developing modality of care. Health and Medical Care Services Review 1 :1-13, 1978. _ 24. U. S. Department of Health and Human Services, Public Health Service. [Iealeh,. United Seater, 1982. Table 73. DHNS Publication No . (PHS )83-1232. Washington, 1). C.: U. S. Government Printing Office, 1982. 25. Kane, R. L. and Kane, R.A. Care of the aged: Old problems in need of new solutions. Science 200: 913-919, 1978. 26. Redlich, F. and K~llert, S. R. Trends in American mental health. American Journal of Psychiatry L35: 22-2S, 1978. 27. Rower, M. From poor beginnings, the growth of primary care . Hospitals 49:38-43, 1975. 28. Bobula, J.D. Income differences between male and female physicians. In Glandon, G. L. and Shapiro, R. J., eta. Profile of Medical; Practice 1980. Chicago: American Medical Association, An_ 1980 e 29. Williams, S. J. Ambulatory care. In Introduction to Health Services ~ see Reference #2. 30. Bauman, P. The formulation and evolution of the Health Maintenance Organization policy, 1970-1973 . Social Science and Medicine 10 :129-142, 197 5. 103

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31. Luft, [1. Health Maintenance Organizations. New York: John Wiley and Sons, 1981. 32. U. S. Department of Health and Human Services, Public Health Service, Health Resources Administration, Bureau of Health Professions. Third Report to Congress on the Status of Health Prof essions Personnel in the Uni ted States . OHHS Publication No . (HRA) 82-2, 1982. 33. Louis Harris and Associates. Medical Practice in the 1980~: Physicians Look at their Changing Professions. Study No. 8041S. Report to the Henry J. Kaiser Family Foundation. Menlo Park, California, 1981. 34. U. S. Department of Health ant Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Office of Data Analyale and Management. Selected Statistics on Health Manpower Shortage Areas (As of September 30, 1982~. Harch 3, 1983. 35. Rosenblatt, R. and Moscovice, I. Rural Health Care. New York: John Wiley and Sons, 1982. 36. Newhouse, J. P., Williams, A. P., Bennett, B. W., ant Schwartz, W. B. Where have all the doctors gone? Journal of the American Medical Association 247: 2392-2396, 1982. 37. Krizav. J. and Wilson. A. The Patient as Consumer. Lexington, Mass.: D.C. Heath, 1974. 38. Klarman, H. E.. The financing of health care. In Knowles, J., ed. Doing Better and Feeling Worse. New York: W. W. Norton, 1977. 39. Hughes ~ F. Surgical workloads in a community practice . Surgery 71: 315, 1912. 40. Salkever, D. S. and Bice, T.W. Hospital Certificate-of-Need Controls. Washington, D. C.: American Enterprise Institute , 1979. 41. Rushmer, R. F. National Priorities for Health. New York: John Wiley and Sons, 1981. 42. Table 51, Reference #24. 43. Stevens, R. et al. The Alien Doctors. New York: John Wiley and Sons, 1978. 44. Bunker, J. P. Surgical manpower: a comparison of operations and surgeons in the United States and in England and Wales. New England Journal of Medicine 282:135, 1970. ~ , 45. Roemer, M. I. An Introduction to the U. S. }lealth Care System. New York: Springer Publishing ~ 1983. 104

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46. Lippard, V. W. and Purcell, E. F. Intermediate Level Health Practitioners. New York: Josiah Racy, Jr . Foundation, 1973. 47. American Hospital Association. Hospital Statistics. Chicago: AHA, 1979. 48. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Haking Health Care Decisions. The Ethical and Legal Implications of Informed D.C.: U. S. Government Printing Office, 1982. . Black, D. The aims of a health service. Lancet 1: 952-954, 1982. 50. McDermott, W. Education and general medical care. Annals of Internal Medicine 96: 512-S17, 1982. 51. The Robert Wood Johnson Foundation. Medical Practice in the United States. Princeton, N.J.: Robert Wood Johnson Foundation, 1981. 52. Flexner, A. The Flexner Report on Medical Education in the United States. A Report to the Carnegie Foundation for the Advancement of Teaching. Washington, D.C.: Science and Health Publications, 1960. (Original printing, 1910. ~ S3. McKeown, T. The direction of medical research. Lancet 2: 1281-1284, 1979. S4. Jenson, P. S. The doctor-patient relationship headed for impass or improvement . Annals of Internal Medicine 95: 769-771, 1981. 55. Pe terson, M. L. Physicians ' forecasts of medical practice, why is the glass half empty? Annals of Internal Medicine 97: 778-780, 1982. 56. Anlyan, W.G., et al. The Future of Medical Education. Durham, N. C.: Duke University Press , 1973. 57. Fein, R. The Doctor Shortage. Washington, D.C.: Brookings Insti tution, 1965 . 58. U. S. Department of Health and Human Services. Healthy People. Washington, D.C.: U. S. Government Printing Office, 1979. 59. Institute of Medicine. Healthy People. The Surgeon General's Report on Health Promotion and Disease Prevention. Background Papers. DREW (PHS) Publication No. 79-55071A. Washington, D.C. U. S. Government Printing Of f ice, 1979. . 60. LoGerf o, J. P., et al . Tonsillectomies, adenoidectomles, audits: have surgical indications been met? Hetical Care 16:950-955, 1978. 105

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61. President's Commission on Mental Health. Final Report. Washington, D.C.: U. S. Government Printing Of f ice , 1978. 62. Dubos, R. Mirage of Health. 106 New York: Harper and Row, 1959.