Medicine

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Medicine

I

 

INTRODUCTION

Early Amputation Tools

While the ancient Egyptians were known to perform amputations and other types of surgery, precise surgical techniques did not begin to develop until Greek physicians used surgery in diagnosis and the study of human anatomy. In the 1500s French surgeon Ambroise Paré improved on the standard method of stopping major bleeding with cautery, or searing, by using forceps and stitches. It was not until after 1865, however, when Joseph Lister introduced the use of antiseptics in the treatment of wounds, that the death rate following major amputations dropped from 50 to 12 percent. Shown here are the contents of a case of amputation instruments dating from about 1800.

John Watney/Science Source/Photo Researchers, Inc.

Medicine (Latin medicus, “physician”), the science and art of diagnosing, treating, and preventing disease and injury. Its goals are to help people live longer, happier, more active lives with less suffering and disability. Medicine goes beyond the bedside of patients. Medical scientists engage in a constant search for new drugs, effective treatments, and more advanced technology. In addition, medicine is a business. It is part of the health care industry, one of the largest industries in the United States, and among the leading employers in most communities.

Disease has been one of humanity's greatest enemies. Only during the last 100 years has medicine developed weapons to fight disease effectively. Vaccines, better drugs and surgical procedures, new instruments, and understanding of sanitation and nutrition have had a huge impact on human well-being. Like detectives, physicians and other health care professionals use clues to identify, or diagnose, a specific disease or injury. They check the patient's medical history for past symptoms or diseases, perform a physical examination, and check the results of various tests. After making a diagnosis, physicians pick the best treatment. Some treatments cure a disease. Others are palliative—that is, they relieve symptoms but do not reverse the underlying disease. Sometimes no treatment is needed because the disease will get better by itself.

While diagnosing disease and choosing the best treatment certainly require scientific knowledge and technical skills, health care professionals must apply these abilities in imaginative ways. The same disease may present very different symptoms in two patients, and a treatment that cures one patient may not work on another.

At the turn of the 20th century, many men and women were feeble by age 40. The average American born in 1900 had a life expectancy of 47.3 years. Effective treatments for disease were so scarce that doctors could carry all their drugs and instruments in a small black bag. By the end of the 20th century, medical advances had caused life expectancy to increase to 76 years. Modern health care practitioners can prevent, control, or cure hundreds of diseases. People today remain independent and physically active into their 80s and 90s. The fastest-growing age group in the population now consists of people aged 85 and over.

This medical progress has been expensive. In 1998 Americans spent $1.1 trillion on health care, an average of $4,094 per person. In the same year, health care accounted for about 13.5 percent of the gross domestic product (GDP), about one-seventh of the country's total output. Spending has grown rapidly from earlier in the century. In 1940, for instance, the United States spent $4 billion on health care.

II

 

HEALTH CARE PROFESSIONALS

Some 11.6 million people work in health care in the United States. They include about 778,000 physicians, 2.1 million registered nurses, and 160,000 dentists. Most of them work in health care services, which involve diagnosing and treating patients. Others work mainly in research, teaching, or administration of medical facilities.

A

 

Physicians

Physicians diagnose diseases and injuries, administer treatment, and advise patients on good diet and other ways to stay healthy. The United States has two kinds of physicians, the Doctor of Medicine (MD) and the Doctor of Osteopathy (DO). Both use medicines, surgery, and other standard methods of treating disease. DOs place special emphasis on problems involving the musculoskeletal system, which includes muscles, ligaments, bones, and joints.

Patients receive medical care from primary care doctors and specialists. Primary care doctors include general practitioners, family physicians, general internists, and general pediatricians. Many women also use obstetricians-gynecologists as primary care doctors. Patients usually consult a primary care doctor when they first become ill or injured. Primary care physicians can treat most common disorders, and provide comprehensive, lifelong care for individuals and families.

But medical knowledge has advanced so far that no physician can master an entire field of medicine. Primary care doctors may refer patients with unusually complicated problems to specialists with advanced training in a particular disease or field of medicine. Specialists may even concentrate in one particular area, and become subspecialists. Each specialist in internal medicine, for instance, is an expert in diagnosis and nonsurgical treatment of adult diseases. But some internists take advanced training to become subspecialists in treating adolescents, heart disease, elderly people, cancer, or arthritis. For more information about the areas that specialists treat, see the table on Medical Specialties.

B

 

Medical Education

Preparation for a career as a physician is long and demanding. It usually takes 11 years of study after high school to become a physician. The training typically includes four years of undergraduate or premedical study at a college or university; four years of medical school; and three years of advanced training in a residency. The exact length of study varies. Some colleges have a combined undergraduate and medical school program that lasts six years.

Premedical students usually major in science, or take some courses in biology, chemistry, biochemistry, mathematics, and physics. Medicine demands well-rounded individuals with knowledge of the humanities and social sciences, and courses in English, history, literature, art, music, sociology, and other fields are important. Many premedical students gain practical experience by taking summer jobs or volunteer positions in hospitals, clinics, or research laboratories.

Acceptance into a medical school requires excellent college grades, high scores on the Medical College Admission Test (MCAT), good letters of recommendation, and a personal interview with school officials. The United States has 144 medical schools. Of those, 125 award a Doctor of Medicine degree and 19 award a Doctor of Osteopathy. Students face very tough competition for admission to medical school. In 2000, more than 37,000 people applied for admission to medical school, but only 16,303 were accepted.

Education of a physician does not end with medical school graduation. New physicians must pass an examination for a state license to practice. Many then go into postgraduate education. MDs take a residency that lasts from one to seven years. DOs take an internship, which may be followed by a residency. During postgraduate education, physicians pursue advanced training and practical experience treating patients under the supervision of more experienced doctors. This postgraduate training usually takes place in a hospital or clinic.

To be recognized as a specialist in a particular field, a physician must pass a special examination and become board-certified. Physicians earn a certificate from the American Board of Medical Specialties, an organization in Atlanta, Georgia, that oversees the certification process.

Physicians who plan to go into research may obtain a doctoral degree in genetics, immunology, biochemistry, or another field. Some obtain still more training as postdoctoral fellows on the research teams of established scientists. Physicians who plan to specialize in public health may study for a master’s degree in that field.

After completing postgraduate education, physicians begin a lifetime of learning to keep current with new advances. They regularly read medical journals, take continuing education courses, and attend medical conferences.

C

 

Other Health Professionals

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

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

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

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

III

 

HEALTH CARE FACILITIES

Hospital Emergency Room

A specially trained trauma team at Bellevue Hospital in New York City treats a patient injured in a drug-related fall. Blood vessels between the membranes surrounding his brain have ruptured, causing an increase in pressure inside the skull that may kill him if not treated immediately. Teams like this one must diagnose and treat many such unconscious and critically injured patients every day. Modern hospitals include CT scanners and X-ray and emergency surgery facilities to make this possible. They may also have access to equipment such as helicopter “life flight” ambulances that increase chances of survival even more.

Hank Morgan/Science Source/Photo Researchers, Inc.

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

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

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

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

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

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

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

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