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Medical Education and Societal Needs: A Planning Report for Health Professions (1983)

Chapter: 4. The Physician's Role in a Changing Health Care System

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Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 71
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 72
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 73
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 74
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 75
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 76
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 77
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 78
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 79
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 80
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 81
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 82
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 83
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 84
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 85
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 86
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 87
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 88
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 89
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 90
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 91
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 92
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 93
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 94
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 95
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 96
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 97
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 98
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 99
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 100
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 101
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 102
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 103
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 104
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 105
Suggested Citation:"4. The Physician's Role in a Changing Health Care System." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 106

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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

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. 71

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

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

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

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'

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

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

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

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

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

Providers of Care The Hospital The most prominent institutional provider of care is, of course, the hospital. There are more than 6,500 short-stay hospitals in the United States, providing more than one million beds (Table 10~. Most hospitals are under not-for-profit ownership, often being community- owned, nongovernmental entities.21 An important trend in hospital ownership is the increasing percentage of hospitals and hospital beds owned (Table 11) or operated by for-profit organizations. Usually these are corporations that either buy or build a hospital, or enter into a management contract to operate a hospital whose ownership remains vested with another entity such as a community not-for-profie corporation, a religious order, or a unit of local government. TABLE 10 Short-stay Hospitals ant Beds by Type, United States, 1979 Community Hospitals Others Ownership Total Total General Specialty Total Psychiatric Hospitals All Ownerships 6,525 5,939 5,799 140 586 146 Government 2,222 1 ~ 812 1,795 17 410 34 Federal 325 ~ 325 -- State-local 1,897 1,812 1,795 17 85 34 Proprietary 867 767 735 32 100 70 Nonprof it 3,436 3,360 3,269 91 76 42 Beds All Ownerships 1,096,322 992,624 979,811 12,813 103,698 13,234 Government Federal State-local Proprietary Nonprof it 305,143 211,916 209,241 2,675 93,227 5,229 84,832 - ~ 84,832 220,311 211,916 209,241 2,675 8,395 92,418 86~399 84,753 1~646 6,019 69B,761 694,309 685,817 8,492 4,452 211,916 209,241 2,675 86~399 84,753 1~646 694,309 685,817 8,492 5,229 4,850 3,155 NOTE: Community hospitals include all nonfederal short-stay hospitals classif fed by the American Hospital Association according to one of the f allowing services: general medical and surgical; obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; other specialty; children's general; chiltren's eye, ear, nose, and throat; children' rehabilitation; children's orthopedic; and chiltren's other specialty . SOURCE: Division of Health Care Statistics, National Center for Health Statistics. Data from National Master Facility Inventory. 81

TABLE Ll Percentage of Hospitals and Hospital Beds Under Proprietary Ownership, United States, Selected Years 1960 to 1980 Short-staya Psychiatric Lona-term Year Hospitals Beds ~ . 1960 15% 5% -- -- 1970 12 6 8: O. 6: 1975 12 7 12 1.4 1980 12 ~ 15 2.7 aExcludes psychiatric, tuberculosis, and other respiratory disease hospitals . SOURCES: Tables 57 and 61, Reference ~ 24. The traditional proprietary hospital was of ten owned by a small group of physicians, and the lack of controls and oversight, and possibly questionable quality of care, gave the for-profit sector a bad name . However, most modern proprietaries are accredited by the Joint Commission on the Accreditation of Hospitals. Proprietary hospital corporations probably tend to purchase or build hospitals in wealthier areas and to provide only the more prof itable services, excluding services ~ such as burn or trauma treatment centers ~ that lose money. The proprietaries claim to generate a modest profit by operating facilities more efficiently, e.g., through the use of more sophisticated management techniques, group purchasing, and stricter controls on stat f ing. One study, in fact, has concluded that the modern proprietary hospital probably provides quality of care comparable to that of the not-for-prof its.22 Arguments against proprietary hospitals include objection to the "cream-skimming" notion mentioned above, the fact that lower staffing ratios lead to less patient care, and philosophical preferences that health care not be a for-profit enterprise. The management contract approach has appeal in that not-for-profit ownership is retained and the contract agency can be removes if its performance is not satisfactory or is contrary to the service and other goals of the nonprof it owners. Physicians do not seem to indicate any strong preference for either proprietary or nonprof it hospitals, since their focus is more on the support available to them in the conduct of their practices. Hospitals are facing an increasingly competitive environment. Recent proposals to promote competition, combined with the excess numbers of hospital beds in many communities, are leading hospitals to seek new ways to maintain their viability and market share. Some have resorted to such "innovations" as issuing bumper stickers and giving away f ree trips to patients through lotteries. Others are developing larger medical staffs ant improving their relationships with community 82

physicians. Many are hiring marketing experts. Others are expanding into the area of ambulatory care through the purchase or construction of medical office buildings in which offices are available to physicians at attractive rents. Still other hospitals are developing their own improved ambulatory care services--transforming traditional clinics into more appealing providers of care, or hiring physicians and opening ambulatory care group practices, either on the hospital site or in satellite locations.23 All of these efforts are designed to develop inpatient referral networks ant to encourage the use of hospital ancillary and specialty services by affiliated physicians. However, there is frequently considerable opposition on the part of medical staffs to direct hospital operation of group practices with physicians on salary . Long-Te Am Care Long-ter~ care in another area in which considerable change has occurred ~ and in which more change can be expected in the future. Primarily as a result of the availability of national entitlement programs, spending for this sector of health care (nursing homes ~ has increased dramatically, now exceeding eight percent of all health care expenditures, an compared with about two percent in 1960.24 However, there are many challenges remaining in long-term care. While the nursing home receives much exposure, both positive and negative, the United States has lagged behind many other countries in experimenting with alternative models for addressing the needs of the elderly . These include home heal th care ant a wide range of homelike situations that can serve as alternatives to institutionalization in hospitals and nursing homes for patients with some degree of independence. There are many successful examples of home health care and of intermediate types of facilities, which range from condominiums with group meals to group living situations, but the more attractice of these have f requently been available only to wealthier individuals or to those trite religious or other affiliations. Another important fac tar in considering long-term care needs is that only about f ive percent of the e lderly are resitents of nursing hones at any given t ice; many older individuals still live independently in their own homes, or even in their families' homes,15 despite the much-heralded decline of the nuclear f amity. There is a long and expensive road ahead for the nation in the area of long-eer~ care for the elderly, for physically handicapped persons, and f or mentally retarded persons. 2 In addi tion, the aging of the population--that is, the increase in the fraction of the population that is older as a result of declining fertility and increasing longevi ty-~will lead to greater polit teal and social pressures on the nation to address these needs more ef fectively. Finally, many physicians have shunned older or inf ire patients, especially among the poor and in minority groups. The glamour of medicine, the application of technology, and the potential for 83

dramatic cures are more frequently found with other patients. But the rise of geriatrics and other specialties that address the needs of these patients and the application of knowledge by all physicians to help then are clear national needs. Mental Heal th Services Mental health care is another area of health services in which the nation has not been overly successful. There has been a dramatic expansion of ef forts in mental health in recent years as a result of national initiatives with origins in the Kennedy administration. Progress in the treatment of mental illness through the use of psychotropic drugs ~ and a vastly more constructive national attitude toward mental health needs have also helped. Nevertheless, the nation Still has two systems of mental health care--one for insured and/or wealthier patients, staffed by psychiatrists and offering care in relatively more pleasant, private facilities; the other supported by governments and staffed primarily by nonphysiclans, offering care in community mental health centers and public mental health hospitals. The private care system deals more extensively with less severely impaired people, while the public system cares for the more profoundly mentally ill and those with developmental disabilities and mental re tardation. ~ 6 I: also is important to note that half . of those wi th mental illness are seen only in the ambulatory general health care sector (Chapter 6 ~ . Over the past 30 years a major movement to community-based care has led to closure or reduction in size of most state mental hospitals and to a revolving door syndrome for patients who move between institutionalization and community living. Funding for public programs in mental health is very restricted, and these programs have very limited political constituencies. Support at the community level is eroding in many communities, but the state hospitals, because of reduced size and scope of operation, are not available ro respond to many new, unmet needs . The area of mental health has at tracted physicians primarily to priorate psychiatric practice. The vast array of public services has been less popular, although undoubtedly the need is greater by most measures. Low levels of reimbursement and professional prestige further reduce the attractiveness of psychiatry in public institutions. Ambularory Care Services Wile the services discussed above are extremely important, ambulatory care services are the mainstay of health care. They are the source of continuing care in the community, especially for primary care, and serve as the initial system intake point for patients. About half of ambulatory care services are provided by solo practitioners in private practice, the traditional and philosophical home of organized a~edicine.27, 28 About 20 percent of ambulatory 84

care ts provided in group practices, and this percentage is increasing (Table 12) . Physicians are attracted to group practice f or various reasons: they can begin practice without having to expend huge initial capital outlays; they do not usually have to wait long to build up a patient clientele; they can focus on medicine rather than on administration; they can share calls, and have more flexibility in working hours, vacation time, and continuing education; they can have greater peer interaction and support; and they may achieve some economies of scale. Group practice was started to provide industrial health services in remote areas and was strongly opposed by organized medicine for years. However, the Mayo Clinic and other groups eventually provided an acceptable image for group practice. In recent years group practice has proliferated, and the trend is likely to continue. Groups may be affiliated with or owned by other organizations, such as hospi tars. Al though the large groups are most visible, most groups are small and single-specialty (Table 12~.29 TABLE 12 Number of Medical Group Practices and Physicians in Group Practice, by Type of Practice, Ignited States, Selected Years 1969 1975 1980 Type Groups Ph~slcians Groups Physicians Groups Physlcians Single Specialty 3,1b9 13,053 6,601 23,5?2 6,1S6 29,4S6 .~itispe~ialty 2,418 24, 3~9 2,976 39,3L1 3,5S2 5`,12~ Fa-. 'A Practice 784 ',691 90o 3,959 1,05- 4,712 To Cal 6, 371 40.093 8, 483 66, 84 ~ ~ 10, 762 88. 290b al9.9 percent of the 335,608 professionally active ph~rsiclans. b21. 5 percent of the 4;39, 99~ professionally active physicians. SOI;R~: American Medical association. Research Notes Vol. 4, Do. 2, Spring 1981. IQ prepaid group practice, the practice is also an insurer, or works with an insurer, and agrees to provide all needed health care ~ within the limits of a contract, in return for a prepaid monthly fee. Prepaid group practice is typified by the Kaiser health plans and by Group Health Cooperative of Puget Sound, a consumer-owned, prepaid group. These.providers reimburse physicians by salary, which is of added advantage to payers, such as employers, since physician reimbursement by salary, combined with prepayment, creates incentives that discourage unnecessary care and encourage cost containment. The attributes of prepaid groups as self-regulating, cost-conscious systems of care led to the development of federal legislation, under President Nixon, to encourage their proliferation; the rubric "health 85

maintenance organization' (HMO) was used for prepaid practice in the legislation.30 While there organizations provide a higher level of preventive care than does the fee-for-service sector, their main attribute is in somewhat reducing rates of hospitalization, the savings from which are often plowed back into a broader scope of more comprehensive servicer than is offered in moat indemnity or service insurance contracts under fee-for-service arrangements. 31 Other providers of ambulatory care services include hospitals, industrial health clinics, school health services, and public health clinics. Some of these, most notably industrial health units and possibly hospitals, are likely to expand significantly in the future, of f Bring oppo rtuni ties to physicians f or employment . Female physicians are more likely than are male physicians to be salaried--to work in a clinic, health center, local government agency, or corporate serting.28 As the number of women who are physicians continues to increase, it is likely that the trend away from solo practice (typically fee-for-service) and toward such salaried positions* will continue. Apparent reasons for this trend toward group practice and salaried employment include increased dissatisfaction with solo practice because of the long hours and the drains on personal life. Financial considerations seem to be less important .3 3 A pr i ncipal problem wi th ambulatory care in the Uni ted States has been excessive numbers of subspeciali~ts and a relative shortage of primary care physicians. However, the numbers of family practitioners trained to provide primary care has increased, as a result of Federal support for residency programs. Moreover, female physicians are more likely than male physicians to choose primary care specialities;28 if this pattern continues, as the proportion of female physicians increases,** so too will the proportion of primary care physicians. An array of midlevel practitioners also ts capable of providing selected primary care services. The ambulatory care arena is becoming increasingly competitive for both primary care and specialty services, and an increasing number of specialists probably will provide some primary care, as they vie for patients. There are still pockets of physician shortages, 34 primarily in those inner-city and rural communities that have not been attractive areas in which to live or practice. But even in many rural areas there is now an abundance of physicians and of other providers, suggesting a reevaluation of physician personnel needs and geographic d istribut ion problems .3 5, 36 *In 1978, 24.8 percent of male physicians and 39.2 percent of female physicians surveyed were salaried.28 **In 1970, 6.7 percent of physicians were women; in 1980, 10.8 percent; the percentage is expected to rice to 16 percent by 1990 and to 20 percent by 2000.32 86

Financing Health Services A principal, often overriding, determinant of the scope and structure of health services is the mechanisms through which providers are reimbursed. These mechanisms, along wi th governmental programs and taxation policy, substantially distort how, where, and by whom services are provided.37 Some solutions to health care resource problems could potentially be addressed through creative financing, but there has always been a reluctance on the part of both governmental and private insurers to experiment. An instance in which creative financing might have been applied is the following: by paying subs tantially more f or care provided in inner cities and rural areas, physician geographic disbursement might have been achieved at much lower cost than by flooding the marketplace with practitioners. Reimbursement of Individuals Re imbursement for professional services has traditionally been based on fee-for-service mechanisms, in ef feet, piecework payment for each uni t of service provided . Government programs, insurers, or patients are billed for a service based on established fee schedules. The fee schedule is itself one source of controversy, especially since there is little oversight, except for minimal claims review. Fee schedules are usually negotiated, or otherwise established, on a service-speeif ic, proviter-specif ic basis, under what amounts to pricer icing . Fees or charges are then paid at the established rate, sometimes discounted by prior contractual arrangement or governmental edict . Fee schedules are generally. based on the usual, customary, and reasonable charges for the service and geographic area and often also on a provider ' s prio r fee his tory .38 Phys icians who are employed by another organization such as a group practice or a hospital n my be paid dif ferently from the method by which the organization itself is paid by the insurer. In many f ee-f or-service groups, physicians receive a base salary plus an incentive reimbursement payment based on such factors as specialty, length of service, and productivity as measured by revenue ant ancillary services generated or by other indicators. In prepaid settings, and in hospital, industrial, school health, and certain other oraganizational situations, physicians are reimbursed on salary, sometimes supplemented by an incentive payment of some type. Not surprisingly, the type and form of payment af fects provider behavior. Incentive payment directly or indirectly based on productivity may lead to provision of more care. In prepaid settings, as compared with fee-for-service practice, there is Rome suggestion that surgery rates are lower, especially for more elective procedures such as tonsillectomies . Surgeons in prepaid se t sings generally seem to spend less time proviting care other than surgery and to perform more surgery than do surgeons in fee-for-service settings.39 Overall, there is probably relatively little dif ference in practice patterns for primary care physicians and many specialty physicians 87

regardless of setting, except perhaps for differences in use of hospital inpatient services and possibly laboratory tests. Indeed, prepaid settings are characterized by greater use of ambulatory and ancillary services and at the same t ire reduced inpatient use, especially for surgical admiesionse31 It is very difficult to gauge the potential effects of powerful economic incentives, of using specialists only to provide the types of care they are trained for and at high rates of productivity, and of otherwise forcing providers into more economically productive patterns of care. Increases in productivity would be equivalent to increases in the number of physicians in the country. The problem is one of providing appropriate settings and incentives, and at the same time avoiding incentives that will simultaneously lead to unnecessary or inappropriate case, underutilization in comparison with underlying legi timate needs, or provider and consumer dissatisfaction. Reimbursement of Institutions Reimbursement of institutional providers, and especially of the hospital, is usually based on allowable costs.38 Under cost reimbursement, hospitals have had little incentive to reduce costs or to improve operating ef f iciencies since all capital and operatln8 expenses, with a few exceptions, are pan' for by third parties. Furthermore, as a hospital increases its coses, for.example, through the acquisition of new facilities and equipment, these new costs are added onto the reimbursement basis, thus allowing for higher levels of future payment. This reimbursement spiral has persisted for years and only very recently has there been a concerted ef fort to f ind alternative, more economically sensible methods for paying institut tonal providers. The primary issues in traditional cost reimbursement involve the services that are to be paid for (usually def ined by the patient ' s insurance policy), and the costs that are allowable for laclusion in the Coat computations. Many hospitals have battles with Medicare over the determination of allowable costs, while private insurers, and especially Blue Cross, have been relatively generous in their definitions. Medicare has increasingly taken the attitude of defining allowable. costs relatively strictly so as to exclude, where possible, liability for payment for activities that do not directly contribute to the care of their benef lciaries. Many state Medicaid programs have also developed somewhat restrictive reimbursement policies and pay only a portion, perhaps 60 percent, of billed charges. The medical stat fs of most hospitals have also encouraged increases in costs by demanding the best equipment, personnel, and. physical facilities available. In the past, hospitals have been able to oblige the physicians. Hospitals also must attract physicians by competing with other community facilities, and thus each hospital a t tempts to provide a broad range of services and modern, technologically advanced facilities. The predominance of cost 88

reimbursement bat allowed, indeed facilitated, this infusion of resources that in many communities far exceeds what would be strictly needed using rigorous planning and resource allocation criteria. Re imbursement Practices The reimbursement environment is changing, however. There are many, if sometimes hesitant ~ efforts directed at limiting what in effect has been a blank check for hospitals and their medical staffs. These ef forts include the following: o prospective reimbursement under which hospitals must establish a budget in advance and adhere to that budget; o the establishment in some states of rate-setting commissions, designed to limit cost increases; o restrictions on allowable costs, which have the effect of shi f tiny costs to patients paying out of pocket or of limiting hospital expenses; o governmental regulatory ef fores to control capital. expenditures, primarily through the Cereif icate-of -Need process, the results of which are unclear; O o contracting arrangements such as the recently developed Preferred Provider Organization (PPO) concept and state contracting f or Medicaid, under which contracts, sometimes exclusive, are negotiated with presumably lower cost and more efficient providers, pa tentially including physicians; and 0 other competition-provoking approaches such as alternative delivery systems typified by the ~Os. The probable effects of these efforts are some increased attention to productivity, an increasingly dif ficult environment for marginal individual ant institutional providers, and possibly some moderation of health care costs. However, these ef forts fall far short of any dramatic and drastic change of course such as nationalization of all or parts of the health care system, or adoption of substantially reduced levels of reimbursement. Reimbursement has also af fee ted the practice of medicine by paying especially well for procedures, including surgery and diagnostic procedures, as compared with payments for counseling and other nontechnologically oriented care.41 As a result, medical practice has tended toward the use of technology, toward performance of procedures, and away from patient education, diagnosis by observation of and discussion with patients, and social and emotional counseling. The appropriateness of this shift, alternative changes in reimbursement to change priorities if advisable, and any determination of where incentives should lie, remain among the most important areas 89

for policy research. Reimbursement is only a means to an end, mechanism by which funds are allocated and distributed, and is an artifact that should be devised based on health care goals, objectives, and priorities. Health Care Personnel There are more than seven million people working in the health care f ield.42 One could argue that an important function of the system is as a source of employment (see Chapter 11), although most discussions place the health care system in the context of the goal of improving health status. Physicians are the most powerful professional group in health care; they are, however, by no means the most numerous. The number of physicians has increased substantially over the pant 15 years and is projected to increase even more in the future (Table 13~. Perceived shortages of physicians led to three initiatives to increase the quantity of this resource: the number of medical schools was increased, the number of graduates from each existing school was increased, and relatively easy entry into the country was allowed f or foreign medical graduates (FMGs ) .43 Each of these initiatives has been stopped, or reversed (see Chapters 7 and 11~. FMGs have been the subject of considerable debate, especially since the steady flow of physicians f rom many developing countries has drained those countries of physicians that they pay to Train and critically need to provide minimal levels of care. Recent restrictions on immigration will decrease but not eliminate this source of physicians. Projections of numbers of physicians indicate a rate of growth far in excess of population growth (Table 13), leading to what is now anticipated to be an overall excess of practitioners; indeed, in many locat ions the re are probably too many physicians already . This excess may feat to unnecessary services ; underutilization of skills of highly trained practitioners who are f arced to provide care outside of their area of specialty training; and other problems. The mismatch of specialties mentioned earlier is a particular source of concern, with many more surgeons per capita in the United States than in the United Kingdom, for example, and in many other countries. There is an equally Greater number of certain types of surgical procedures in this country . 4 There is a shortage of personnel in some specialties, such as occupational medicine. Issues of specialty mix need to be addressed in conjunction with decisions concerning physician supply. Finally, it remains difficult to attract physicians to certain geographic areas ant living environments where they still are needed.34 Economic and other incentives nay be required. 90

TABLE 13 Number and Population Ratios of Physicians, United States, Selected Years 1950 to 1980 and Pro jections for 1990 and 2000 Doctors of Doctors of Professionally Ac t ive Medicine Osteopathy Physicians per 10, 000 ~ D. 0. ~ Po Dulat ion Year To tal 1950 219,900 209,000 10,900 14.1 1960 251,900 239,700 12,200 13.6 1910 326,500 314,200 12,300 15.6 1980 457,500 440,400 17,100 19.7 1990 591,200 563,300 27,900 24.3 2000 704.700 665,700 39,000 27.1 SOURCE: Table 52, Reference ¢24. Among the wore than seven million people working in health care, there are about 16 other health workers for every physician.45 Nurses, of course, make up the largest category of personnel. There also are many types of therapists (physical, occupational, rehabilitation, etc. ~ ~ a growing cadre of specialist technicians (in dialysis, radiology, emergency medicine, etc. ), clinical psychologists, dentists, and others who have direct patient contact. There i s a considerable degree of controversy and competition among some of these professionals. For example, psychiatrists, psychologists, social workers, and some nurses compete for certain mental health patients. Spurred in part by the undersupply of physicians in the 1960s, many of these professionals have moved into roles that overlap in part with physicians' eradi tional roles. Procedures performed by registered nurses now include intravenous infusions, blood pressure determinations, and surgical dressing changes. Nurses of ten do physical assessments and may even initiate emergency treatments.45 In addition, new professions have been created by training and certification programs: nurse-practitioners, HE:DEX, physician assistants, nurse~midwives, and others are increasingly competing for patient care roles.45 These midlevel practitioners were intended to augment, not to replace, physicians, 46 e specially in primary care . However, turf struggles and competition for patients will likely continue. Decisions about t}~ird-party reimbursement will greatly inf luence the outcomes of such competitions. Produc t ivi ty and Ef f ic iency Pe rsonnel concerns also must consider the roles of productivity and eff iciency in health care. Health care services are not noted for high levels of productivity or efficient use of resources. For the 91

most part, there has been little incentive to promote efficiency, and priorities have been placed on patient care concerns such as the quality and quantity of care, physician practice preferences, and f inancial considerations (income) . But consider, for example, that many operating rooms are uset for perhaps one-third of the day, or that many hospitals report remarkably low (e.g., 45 to 70 percent) occupancy rates.47 Physicians and other resources are not always efficiently utilized, and efforts to increase productivity, which are likely under increased competition, may further reduce the need for physicians. Even a reduction in the annual number of physicians killed in accidents ant committing suicide would have a significant impact on physician supply. Role of Physicians Medicine is a helping profession, the primary purpose of which in Lo serve the needs of patients.48 Doctors advise, if possible cure, and certainly succor those who look to them for help.4 They skillfully use science and technology to reverse what can be reversed in a structural or metabolic defect, 50 and preserve or restore a patient 's function to the extent possible. One of the central functions of the physician in practice, whether acting as a member of a team or as an individual, is to make an accurate diagnosis by identifying the problem that the patient presents as it affects that particular patient, and to work out a relevant plan of action for that patient.* Physicians Recite which diagnostic tests to order, whether or not a patient should be hospitalized, what therapies to employ, which drugs to prescribe, if any; they also perform surgery or other procedures, and decide when to hospitalize and discharge patients. In certain contexts, for example, in the care of the developmentally disabled child, physicians function an members of teaks. But more of ten the physician alone must make sound, individual, clinical decisions. Flexner stated in 1910 that the physician's function is fast becoming social and preventive rather than individual and curative.52 While that transformation did not take place, a broadened view of the physician's role has been developing. This view sees the physician an encompassing health-promoting func~clons and emphasizing caring as well as curing (Chapter 6). A recent survey ascertained by specialty where physicians practice, what kinds of arrangements they have for practice, how many patients they see, how many office visits they hold, how often they see patients in hospitals, how many telephone calls are received, what diagnostic tests are ordered, and what types of therapies are *decisions made by physicians account for 75 to 80 percent of all health care costs, 50 although physicians flake up only about six percent of the health work force; their fees account for approximately one-f if th of health expend) Cures. S1 92

prescribed.51 Interestingly, the results show that while the total number of physician-patient encounters annually is a staggering 400 million in the hospital and 740 million in ambulatory settings, each of these physician-patient encounters is different; and the sum of patient experiences shapes any single physician's practice. But none of these statistical computations and analyses can really illuminate the doctor-patient relationship, which is the basis of the social contract between doctor and patient. Historically, the relationship between physician and patient has been a special one, with the trust of the receiver of care placed in the provider and in the institutions with which the provider in aff iliated. This traditional trust is being questioned as a result of societal changes such as the rise of the consumer movement; the changing status of various sectors of the population, particularly women; and some increase in public skepticism about the role and re levance of science and technology as the keys to social welfare and societal progress. Third-party payers' willingness to reimburse for second opinions, and publicity about physician abuses in the Medicare and Medicaid systems also raise public doubts about the reliability and credibility of individual physicians. Consumer groups, clients, and others now seek to participate in decision making in areas that in the past were lef t entirely to physicians ~ A primary physician function is to make the patient feel better; for the physican to do so effectively, a certain amount of authoritarianism, paternalism, and domination may be necessary. Ninety percent of the visits by patients to doctors are, according to McKewen, caused by conditions that are either self-lio~ited or beyond the capabilities of medicine.53 Thus, if physicians do make patients feel better most of the time, then it is chiefly because the physician can reassure the patient or give medication that is mildly palliative. Thus if physicians are to be effective in alleviating the patients' complaints by intangible means, it follows that the patients must have conf idence in the physicians themselves and in their advice, reassurance, and selection of treatment, even though the basic disorder may not be curable. The pattent's conviction must be based on the belief not only that the physician can be trusted, but also that the physician has some special knowledge that the patient does not have. The successful doctor-patient relationship requires the patient 's trust, and also acceptance of some domination. The physician must take the responsibility for the treatment of the patient, and not shift it onto the shoulders of the patient, although this does not, in some cases, preclude the physician's frankly admitting that he or she does not have all the answers. Nor does it preclude inf armed consent and responsible decision making by the patient .48 In a recent study of 1, 000 families, it was found that 64 percent were dissatisfied with their doctor-patient relationship, and that 48 percent of upper-income families and 37 percent of lower-income families had changed physicians because of dissatisfaction with the physician's personal qualities. Thus the doctor-patient relationship 93

appears to be suf fering despite our steadily advancing medical knowledge and constant improvement in therapeutic tools. Reasons for dissatisfaction include the physician's lack of warmth and friendliness, failure to consider a patient's concerns and expectations, use of unfamiliar terms, and lack of adequate explanations concerning the diagnosis ant cause of illness. The physician's success in meeting the patient's needs will depend, at Least in part, on the success of medical educators in teachlag essential psychosocial skills, and in part on the personal qualities of the individual. To repair and improve the toctor-patient relationship, physicians need to understand the impact of their personal behavior on patients. Doctor-patient rapport is the most universally applicable therapeutic tool and must be used judiciously. A more workable model than the re let ionship of omnipotent doctor and completely dependent patient is the relationship of mutual participation and cooperation in which responsibility is shared by doctor and patient. To facilitate development of physicians who can apply a biopsychosocial approach within a relationship of mutual participation between doctor and patient, medical school admissions policies need to consider the characteristics that would make the students amenable to this approach. The present tif f iculties in the doctor-patient relationship will require increased training in communication, open dialogue with public participation, and realignment of medical school admissions policies. 54 About 10 percent of physicians remain in academic medicine and spend a ma jar portion of their time in research, ranging from basic biomedical to clinical research. Research physicians should have most of the personal qualities necessary in practice--integrity, decisiveness, insight, and intellect are all crucial. Less important for research without practice are empathy, tolerance of ambiguity, community orientation, ant a sense of social responsibility. The more that patients are involved in the research, the more the qualities of the researcher must be similar to those of the practit loner. The educational function of physicians is quite different from the research function. All physicians are educators by the very nature of their work. One of the mayor functions of the physician in the doctor-patient relationship is to impart information in a useful fashion - that is, to educate. Academic physicians also teach, in the hospital, at the betelde, and in the classroom when training medical students, interns, ant residents. The problem of how to teach physicians to be good educators needs to be explored, since most of their skills as educators are self-taught, with varying degrees of succe ss . Although only few physicians become full-time administrators, most must perform at least some administrative functions, either in running of their private practices or in more formal functions within a practice, a hospital, or a medical school setting. 94

Finally, all physicians are influential citizens because of their Level of education and their status in society. The social responsibility of physicians for becoming involved in issues that are not health issues per se requires consideration. That should the physician say and/or do about public education on nuclear war, about prevention of injuries from guns and automobiles, and about matters that relate to social welfare and distribution of goods rather than to medical care itself? This raises a net of issues for study, but the ethical physician, by virtue of being such, extends his or her responsibility beyond the individual patient to the society of which the patient and the physician are both a part. A number of physician dissatisfactions have been identified. These include loss of personal satisfaction through the erosion of the doctor-patient relationship and the public's image of the profession; excessive professional demands, particularly paperwork and long hours; inadequate financial rewards; insufficient opportunities to practice where and when the physicians chose (because of oversupply of physicians ); and demanding educational requirements viewed as relentless and dehumanizing. Many present-day practitioners view themselves as excessively regulated, unappreciated, overworked, and underpaid.33 This view is not universally held, but it is of concern.55 These dissatisfactions may be based on major discrepancies between the expectations of physicians and of patients as to what the social contract between them is. In a 1973 report entitled The Future of Medical Education,56 certain predictions were made about medical education and medical practice in 1985. The report concludes: Widespread discontent throughout the society with the quality cost and availability of medical care and dissatisfaction with all the institutions involved in the medical care system have generated social, political and economic forces that will mandate signif icant changes in medical organization, f inancing and delivery by the mid-l9BOs. By 1985, not only will every American be covered by national health insurance programs, but a regionalized system of group practice, hospitals and other related resources will guarantee health care for all. Medical education, while based on science, will be f undamentally oriented toward clinical care. Admission criteria will be altered to select into medical school those who have qualities of humanity and personal and communal commitment as well as the necessary intellectual capabilities and an educational background that encompasses both the social and the biological sciences. The availability of funds to cover tuition and provide a modest living allowance will give those now excluded, the poor and the sonorities, access to the medical profession.S6 While one might wish that these predictions had come true, we are far from the mark. 95

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

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

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

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

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

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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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

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

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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