129
FALSE STARTS AND LESSER ALTERNATIVES* MILTON TERRIS, M.D. Professor and Chairman, Department of Community and Preventive Medicine New York Medical College New York, N.Y.
E face a serious crisis in primary care. The number of general practitioners in office practice per 100,000 population fell from 83 in 1940 to 24 in 1972. During the same period pediatricians and internists in office practice increased from 6 to 17 per 100,000 population, but the total number of primary physicians fell from 89 to 41 per 100,000, a decline of 54%.1 2 The shortage of primary physicians is one of the most important components of the general crisis in health care. Felt most acutely in rural areas and working-class districts of cities, it has come to affect almost all sections of the population as people find it increasingly difficult to obtain primary care. From 1955 to 1970 hospital outpatient visits per 100 persons in the United States increased by 85% but emergency visits rose by 250% ;3 the poor no longer are alone in using emergency rooms for nonemergency care. A variety of proposals have been made and in part implemented to solve the problem of providing primary care. A number of these may be categorized as "feldsherism," an approach which calls for the training and use of physician's substitutes such as physician's assistants and nurse-practitioners.
FELDSHERISM IN THE U.S.S.R. One of the milestones on the American road to feldsherism was Victor Sidel's paper on "Feldshers and 'Feldsherism' in the U.S.S.R. " 5 Sidel differentiated between the urban feldsher, who works in polyclinics and elsewhere under the direct supervision of a physician, and the rural feldsher who "usually works in a feldsher-midwife station located in a village or on a collective farm and practices relatively independently of physicians except for regular supervisory visits." Sidel reported that the independent clinical role of the rural feldsher was * Presented in a panel, Strategies for Primary Care, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
130
130
M. M. TERRIS TERRIS~~~~~~~~~~~~~~~
being restricted and eliminated increasingly in the Soviet Union, and that the feldsher-midwife stations were "being replaced as rapidly as possible by centralized physician-run stations." Yet, instead of applauding this policy of eliminating inferior medical care for the rural population, Sidel seemed to question its validity, stating that he believed it was probably based more on the "legacy of the old image of the feldsher as a 'second-class' doctor for peasants," and on "emulation of the Western-type goal of primary-physician care for each individual" than on "careful evaluation of health needs and medical resources in the Soviet Union." Sidel ended his paper with the thought that "the Soviet and American societies have much to learn from each other, in this as in many other fields." I agree, and I suggest that the evidence he presents on the experience with the rural feldsher in the Soviet Union indicates that we should be extremely cautious about introducing physician's assistants or nurse-practitioners in the United States. In pre-Soviet Russia, the place of the feldsher was the subject of much controversy in the Zemstvos or district assemblies. "Whereas progressive and democratically inclined Zemstvo physicians strove to provide the peasantry with easily accessible, fully qualified medical assistance, assigning the feldshers only an auxiliary role, the landowners who headed the Zemstva were in favor of independent feldsher services as being a cheaper form of medical assistance."6 Apparently, the nobility and gentry felt that "The peasant is not accustomed and does not need scientific medical assistance, his diseases are 'simple' and for this a feldsher is enough-a physician treats the masters, and a peasant is treated by a feldsher."5 Sidel appears to have been mistaken in stating that urban feldshers in the U.S.S. R. work in polyclinics. Patrick Storey has since emphasized that "the feldshers do not work in the polyclinics, which are the source of general medical care for the population, or in the general or specialized hospitals."7 This is confirmed by the Ministry of Health of the U.S.S.R. in its list of the urban organizations which utilize feldshers: Industrial establishments, schools, the emergency-care service, and sanitation and epidemiological centers are included, but polyclinics and hospitals are not.8 John Cooper, president of the Association of American Medical Colleges and a member of an official exchange mission to the U.S. S. R. in 1970 stated that There is a general misconception in the United States about the role of the feldsher. He or she does not serve as a surrogate physician or Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
131
even as a physician's assistant of the type being trained in this country, except in remote outposts. Even here, there are plans to replace them with physicians as rapidly as possible. Feldshers have defined roles to play in the overall health care system and do not have a position between the physician and nurse. Many serve technical roles in operating complex equipment or carrying out laboratory procedures. Some are sanitary workers with responsibilities like those of some public health workers in the United States. Others man medical stations in industrial establishments and provide first aid and give follow-up treatment to patients under the direction of a physician. In contrast to the plans to increase substantially the number of physicians educated, there is no similar plan for an increase in the education and training of feldshers.9 Relatively independent rural feldshers were a valuable medical-care resource in 1913, when in all of Russia there were about 28,000 physicians, or one per 5,700 population, and about 46,000 middle medical workers,10 29,000 of whom were feldshers .6 Today, when the U.S.S.R. boasts a total of 830,000 physicians or one physician for 308 persons,11 the highest physician-population ratio in the world, the independent rural feldsher has become a medical-care anachronism. As Sidel reports, the feldshers are "being replaced as rapidly as possible by centralized physician-run stations.' THE BAREFOOT DOCTORS" OF CHINA
A poor cousin of the feldsher is the Chinese "barefoot doctor," who has been overly romanticized in many quarters. A balanced evaluation has been made by Robert Hsu, who states that " Given the severe shortage of qualified physicians, the barefoot doctors have had a very useful role in providing basic medical-health care in the rural areas." 12 However, he indicates a number of serious deficiencies. The quality of the barefoot doctors is limited by their brief training period, usually three to six months, and by their educational background, which may be as little as two years of primary school. "There is no national or regional professional standard for selection, training and certification. Consequently, the quality of the barefoot doctors is uneven.... As long as they recognize their own limitations and conscientiously refer more serious cases to physicians and hospitals, no harm will be done. If they are overly self-confident or misjudge serious cases, they will prevent or delay patients from obtaining proper care."
Vol. 53, No. 1, January-February 1977
132
M. TERRIS
There is considerable danger from barefoot doctors who have a penchant for experimentation. Among other things, they are encouraged to experiment with herbs and develop their own herbal medicines. Hsu comments that "This kind of highly decentralized, professionally unsupervised, and ideologically inspired 'research and development' in herbal medicines is inefficient and potentially dangerous." He concludes that "The program has not been a panacea; the usefulness of the barefoot doctors lies in their being a stopgap measure rather than a long-term solution to the shortage of physicians." Whatever its practical values, the Chinese program is based on an antiintellectual ideology, often rationalized as a crusade against medical and other elitism. Mao Tse-tung's statement in June 1965, criticizing the policies of the Ministry of Public Health and declaring that "In health and medical work, put the stress on the rural areas,' '13-16 also contains the following: Medical education should be reformed, because there is no need to read so many books. How many years had Hua T'o* studied? How many had Li Shih-chen of the Ming dynasty studied? Medical schools do not have to admit only senior middle-school graduates; it is quite proper to take in third-year children from junior schools. The main point is to raise their standard during practice. The physicians trained in this way may not be very competent, but far better than fake doctors and witch doctors. Furthermore, villages can afford them. More study only makes them stupid.17
The anti-intellectualism of this statement is difficult to believe. Yet it is consistent with the entire course of the Cultural Revolution since 1966 which, as E. Grey Dimond notes, ".. . .continued as a nationwide disruption for three years. The targets were essentially all individuals that we would identify in management, academic, professional, intellectual, or cultural roles. The students were the primary arm of the government in this attack, functioning in a quasi-military manner, and university activity essentially stopped.'"18 All medical schools were closed, and all students were graduated whether or not they had completed the full curriculum. Starting in 1970, many of the schools reopened, but with a three-year curriculum instead of the previous five or six years. '415" 18,19 Furthermore, the requirements for premedical education have been reduced.15"19 Prior to 1966 the People's Republic of China had rapidly increased the *
A famous surgeon of the third century.
Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
133
number of physicians, from less than 40,000 in 1950 to 150,000 in 1967. By then China had one physician for every 5,000 persons, a ratio more favorable than had existed in Russia in 1913, plus 172,000 feldshers trained on the Soviet model, 186,000 nurses, 42,000 midwives, and 100,000 pharmacists.13 By 1976 China could easily have doubled the number of physicians and at least tripled the number of feldshers, nurses, midwives, and pharmacists. But most of these potential increases were halted by the Cultural Revolution; instead, there occurred an abrupt lowering of standards. The feldsher with two and a half years of training has now been replaced by a barefoot doctor trained in three to six months. The physician with five or six years of training is being succeeded by one trained in a three-year school. Indeed, if one deducts the time allotted for manual labor, military training, and physical education, the difference in the length of training of the Chinese doctor and the Russian feldsher almost disappears. l8 The narrowly practical orientation of the new Chinese medical curriculum and its mandated inclusion of traditional and herbal medicine suggest not only that the Chinese feldsher has become a barefoot doctor, but that the Chinese doctor may well have become little more than a feldsher.
FELDSHERISM
IN
INDUSTRIAL COUNTRIES
In contrast, the more industrialized socialist countries of Eastern Europe have not taken the route of training feldshers, but have concentrated instead on achieving a rapid increase in the number of physicians. This also is true of Cuba, which lost about 40% of its 6,000 physicians in the first half of the 1960s, and then proceeded to increase the number of physicians to a total of 9,000 in 1976, providing one physician for every 950 persons.20 In none of the industrial nations of Western Europe is there any significant movement toward feldshers, physician's assistants or nurse-practitioners. The question naturally arises: why is it that only the United States among the industrial countries is embracing feldsherism, a phenomenon closely associated with developing countries? After all, the United States of 1976 is not the Russia of 1920 or the China of 1950. We shall return to this question later, since any effective remedies for the deficits in primary care must be based on understanding the causes of our difficulties. At this point, however, it should be emphasized that in the United States, just as in the Soviet Union and China, feldsherism establishes two classes of care. In the U.S.S.R. and China the discrimination in quality of care favors urban over rural areas, and this also will be true in the United States. But here, Vol. 53, No. 1, January-February 1977
134 134
M. TERRIS
in addition, it will magnify the disparities in the two-class medical care system in the cities, providing physicians for those who can afford them and physician's assistants and nurse-practitioners, practicing independently or with token supervision, for those who cannot. Feldsherism often is championed as an attack on medical elitism and the establishment. The truth is that medical elitists and the establishment find feldsherism increasingly congenial to their views and interests: physicians will not have to bother with patients who cannot pay their way, leaving their care to less expensive talents, while the establishment, just as in prerevolutionary Russia, will have secured a cheaper form of medical care for the poor. Like the Russian nobility and gentry who wanted a physician to treat the master and a feldsher to treat the peasant, there are many among our business and professional elites who consider it entirely reasonable to have pediatricians and internists for the affluent and nurse-practitioners for the poor. Despite all the disclaimers, feldsherism in the United States is profoundly undemocratic; it is the epitome of class discrimination. THE FAMILY PRACTITIONER
Another alternative which is being proposed and implemented is the resurrection and transformation of the general practitioner into a more highly trained physician who can provide primary care for the entire family. In evaluating this alternative, one must decide whether the interests of family care are served better by a single primary physician or by the internistpediatrician combination. Despite the rhetorical and sentimental value of family practice, there is little evidence to indicate that one physician is better than two in dealing with family problems. Further, each of the two will know more than the family physician about the care of children or the care of adults. The fundamental difficulty of the family practitioner concept, however, is that it is a throwback to 19th century methods of providing medical care. It attempts to train a competent general physician for solo practice at a time when the scientific and technological revolution in medicine makes solo practice obsolete. TEAM PRACTICE IN HEALTH CENTERS
If the great scientific advances of this period are to be brought fully into play for the benefit of the ordinary citizen, medicine must be organized as team practice. This method of providing care goes beyond what we ordinarily Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
135
call group practice, in which general and specialized physicians work together. In team practice these general and specialist physicians work in community health centers with dentists, pharmacists, laboratory workers, clinical and public-health nurses, nutritionists, health educators, social workers, and other health personnel required to meet the specific needs of the population being served. The model for primary care that makes sense in the United States of 1976 is the community or neighborhood health center, an institution which has been operative for many years in the U.S.S.R. and other socialist countries and which provides a sounder model for study and emulation than that of the feldsher. Its value now has been demonstrated successfully in the United States in that most unfavorable of all community laboratories-the povertystricken ghettos of our cities. The neighborhood health center belongs in every neighborhood and community, regardless of economic level; all of us need it if we are to obtain the best that medicine can offer. The health center, however, cannot stand alone. If it is to make our scientific capability available to everyone, then it has to be an integral part of a regional network of hospitals and other institutions with the resources of a medical school at its center. Where the resources of the regional medical school are inadequate, specialized resources at the national level have to be made accessible to the individual who needs them, no matter where he lives. These additional resources are essential complements to the team providing primary care in the community health center. The moment we move from stating that primary care should be given by the internist and pediatrician, family practitioner, physician's assistant, or nurse-practitioner to the position that primary care should be given by team practice in community health centers, we gain enormously in flexibility of approach. We can now experiment with teams of differing composition and organization of work, and reexamine traditional allocations of functions. Many procedures which physicians perform are a legacy of the institution of solo practice, in which the physician had to do everything himself. In team practice such procedures can be done-and probably done better-by other health workers. What we need is simple, but difficult to achieve: a spirit of inquiry, experimentation, and willingness to get out of the rut of past habits and traditions. We also need to make certain that changes actually improve the quality of care and serve the interest of patients rather than those of physicians or administrators. An impressive example of initiative in this area is Sidney Garfield's recent Vol. 53, No. 1, January-February 1977
136 136
M. TERRIS
M.
TERRIS
paper on "Evaluation of an Ambulatory Medical-Care Delivery System."21 His approach is to use a health-testing service for new patients, with referral to either a health-care service, preventive maintenance service, or sick-care service, as defined below. In his controlled experiment at the KaiserPermanente Medical Center, the new patients randomly assigned to this system were referred by the health-testing service as follows: 55% for health care (health education; immunization; posture and exercise training; psychosocial and drug-abuse counseling; and clinics for nutrition, adolescents, family planning, prenatal, and well-baby care); 19% for preventive maintenance (obesity, diabetes, hypertension, arthritis, back, mental health, geriatric, and rehabilitation clinics); and 26% for sick care (doctors' group practice in integrated facilities: clinics and hospitals, special laboratories, radiotherapy, intensive and acute care, and extended care). As Garfield and his colleagues point out, an important feature of this approach is that Paramedical personnel are used extensively in the health evaluation, health-care and preventive-maintenance services of the new system, but they are used there in a highly organized way. In health evaluation, supported by multiphasic health testing, on-line data processing, protocols, and 'advice' rules, nurse practitioners need not diagnose or treat patients but rather record normal (or abnormal) measurements and findings and decide (as a team) with the supervising physician whether the patient is well or sick and the appropriate services for referral. In health care and preventive maintenance they strictly follow physician-prepared-protocols. The new system, with its clear division of user demand into health-status groups and its matching services with tasks defined by protocol, favors the safe and effective use of paramedical personnel as compared to their use in the relatively unsystematized heterogeneous demand of the traditional medical-care system. The results indicate that the new system provided access to new patients within 24 to 48 hours, as compared to six or eight weeks of waiting for an appointment in the traditional system. For every 1,000 entrants to the new system, 940 physician hours were used for all services provided during a 12-month period, as compared with 1,635 physician hours per 1,000 entrants for the control group assigned to the traditional system. The saving in physician time is 43%, and in total costs 25%. There is some question as to whether supervision by physicians in the Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER
ALTERNATIVES
137
health-testing, health-care, and preventive maintenance services of the new system is adequate, especially since Garfield and his colleagues put so much emphasis on the savings in costs. There is need for information about the effects on the quality of diagnostic, health-care, preventive maintenance, and sick-care services. We look forward to further reports on these and other parameters of evaluation of this salient innovation in medical care organization. Perhaps one of the most significant features of the new system is its explicit recognition of the importance of health care and preventive maintenance, areas which tend to be neglected in traditional medical care. One is reminded of the strong emphasis given to prevention in the U.S.S. R. and China, where curative and preventive services are integrated in the work of physicians and other health workers. In China, as Sidel points out, the barefoot doctors are responsible for environmental sanitation, health education, and immunization. 13 In the U.S.S.R. the feldsher must take action for early detection of acute infectious diseases and major nonepidemic diseases, participate in follow-up surveillance of the local population, take sanitary measures for the prevention of disease, and provide health education.8 In urban areas the district nurse not only helps the district physician in the polyclinic but "carries out his instructions in people's homes, investigates the living and housing conditions of people attending the follow-up clinics, trains such people and the members of their families in measures of individual prophylaxis, carries out health education work among the public, organizes voluntary health workers, gives prophylactic inoculations, and checks on the fulfillment of the physician's recommendations with regard to treatment, diet and hygiene.' '6 These activities are more community oriented than those described in the Kaiser- Permanente system, which appear to be confined within the four walls of the medical center. It will not be easy for the Kaiser- Permanente system to change completely from the traditional model of group practice by physicians to the community-oriented model of team practice by physicians and other health workers based in neighborhood centers. CAUSES OF THE PRIMARY CARE CRISIS
Let us return to the question which was raised earlier in this paper: Why is it that among the industrial countries only the United States is embracing feldsherism, a phenomenon closely associated with developing countries? Probably all industrial nations have fewer physicians, either general or Vol. 53, No. 1, January-February 1977
138
138
M. M. TERRIS
TERRIS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
specialized, in rural areas. This is a problem which will not be fully resolved until agriculture becomes industrialized and urbanized to the point of reaching parity in economic and cultural resources. Only the United States, however, has such a startling disparity in the supply of primary and other physicians among the neighborhoods of its cities. These great disparities do not occur in urban areas of the socialist countries, because their national health services are part of a planned economy in which the supply of health-center and hospital personnel is planned and distributed in a rational way for every region, district, and neighborhood. In the industrial capitalist countries other than the United States two factors mitigate differences in primary care. In many of these countries specialists work primarily as salaried employees in government hospitals, and the growth of specialization thereby is controlled effectively. These countries all have national health insurance in one form or another and, thus, the social class differences in purchasing power for primary medical care are reduced or eliminated. There are differences in the availability of primary physicians, but these are considerably reduced by this relative or absolute equalization of medical purchasing power. In the United States, on the other hand, the system of voluntary health insurance generally excludes ambulatory care, so that the difference in the purchasing power of rich and poor is reflected fully in the medical marketplace. The results are well known: a glut of physicians in the wealthy neighborhoods and suburbs and the virtual disappearance of physicians from the poorest areas of the cities. The difficulties are intensified by the fact that most specialists in the United States are in private practice outside the hospitals, with no restrictions on their proliferation. This situation, further, forces hospitals to develop residency-training programs in order to have full-time physicians to care for patients; such programs inevitably emphasize training in inpatient care and specialty areas rather than in primary care. As a result, the number of approved hospital residencies has been inflated beyond all reasonable criteria of need for specialists or quality of training. In 1941 there were about 5,000 residencies, all of which were filled by North American graduates. In 1973 there were almost 54,000 residencies, 9% of which were unfilled. In 1974 more than 65,000 residencies were available.22
Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
139
EFFECTIVE SOLUTIONS What should be done? The most effective solution would be to establish a national health service with a rationally planned and regionally integrated system of health centers and hospitals providing equitable services to communities and neighborhoods. If this is politically unfeasible, then a national health-insurance system should be established which approaches the characteristics of a national health service, including 100% coverage of both services and population. The services should be provided primarily by group and team practice in health centers organized in accordance with federal standards. This can be achieved by substituting capitation for fee-for-service payment, establishing financial and other inducements to practitioners to work in health centers, and making higher capitation payments to centers in rural areas and poor neighborhoods. Federal standards should include requirements for 1) the regionalization of health centers and hospitals, 2) correcting the imbalance in residency-training programs, realigning them to meet the needs of the public, 3) emphasis on primary care and preventive services, 4) reasonable staffing patterns and salary structures, and 5) mandatory periods of postgraduate education for physicians and other health personnel, with the costs included in the capitation payment. Finally, to make certain that the national health-insurance system is oriented toward health service rather than payment, administration should be the responsibility of a federal department of health, its regional offices, and state and area health departments. These should have sufficient professional resources to provide competent administration and supervision of the healthcare program and its integration with preventive services in the community. Not until such measures are taken will the crisis in primary care be resolved. REFERENCES 1. Overpeck, M. D.: Physicians in family Economics, University of Michigan practice 1931-67. Public Health Rep. School of Public Health, 1972. 85:485-494, 1970. 4. Jacobs, A. R., Gavett, J. W., and Wer2. Roback, G. A.: Distribution of Physisinger, R.: Emergency department utilicians in the U.S., 1972, Regional, State, zation in an urban community. County. Chicago, Amer. Med. Assoc., J.A.M.A. 216:307-12, 1971. 1973, vol. 1. 5. Sidel, V. W.: Feldshers and "feld3. Donabedian, A., Axelrod, S. J., sherism." The role and training of the Swearingen, C., and Jameson, J.: Medfeldsher in the U.S.S.R. N. Engl. J. ical Care Chart Book, fifth ed. Ann ArMed. 278:934-40, 981-92, 1968. bor, Mich., Bureau of Public Health
Vol. 53, No. 1, January-February 1977
140
M. TERRIS
6. Ashurkov, E. D., Zhuk, A., and Lisitsin, Y.: The Work and Training of Feldshers and Nurses in the U.S.S.R. In: Aspects of Public Health Nursing. Public Health Papers No. 4. Geneva, World Health Organization, 1961. 7. Storey, P. B.: The Soviet Feldsher as a Physician's Assistant. DHEW Publication No. (NIH) 72-58. Washington, D.C., Govt. Print. Off., 1972. 8. Ministry of Health of the U. S. S. R.: The Training and Utilization of Feldshers in the U.S.S.R. Public Health Papers No. 56. Geneva, World Health Organization, 1974. 9. Cooper, J. A. D.: Education for the health professions in the Soviet Union. J. Med. Educ. 46:412-18, 1971. 10. Lisitsin, Y.: Health Protection in the U.S.S.R. Moscow, Progress Publishers, 1972. 11. Pustovoy, I. V.: Health Care Planning in the U.S.S.R. Chicago, The Center for Studies, Administration Health Graduate School of Business, the University of Chicago, 1975. 12. Hsu, R. C.: The barefoot doctors of the People's Republic of China-Some problems. N. Engl. J. Med. 291:12427, 1974. 13. Sidel, V. W.: The barefoot doctors of the People's Republic of China. N. Engl. J. Med. 286:1292-1300, 1972.
14. Sidel, V. W.: Medical education in the People's Republic of China. New Phys. 21:284-91, 1972. 15. Wen, C.-P. and Hays, C. W.: Medical education in China in the postcultural revolution era. N. Engl. J. Med. 292:998-1005, 1975. 16. Lampton, D. M.: Public health and politics in China's past two decades. Health Serv. Rep. 87:895-904, 1972. 17. Ch'en, J.: Mao Papers: Anthology and Bibliography. London, Oxford University Press, 1970, pp. 100-01. 18. Dimond, E. G.: Medical education and care in People's Republic of China. J.A.M.A. 218:1552-57. 1971. 19. Walls, P. D., Walls, L. H., and Langsley, D. G.: Medical education in the People's Republic of China. J. Med. Educ. 50:371-83. 1975. 20. Ferrer Gracia, H. (National Director of Epidemiology, Ministry of Public Health, Republic of Cuba). Personal communication. 21. Garfield, S. R., Collen, M. F., Feldman, R., et al.: Evaluation of an ambulatory medical-care delivery system. N. Engl. J. Med. 294:426-31.
1976. 22. Directory of Approved Residencies, 1974-75. Chicago, Amer. Med. Assoc., 1975.
Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES* MILTON TERRIS, M.D. Professor and Chairman, Department of Community and Preventive Medicine New York Medical College New York, N.Y.
E face a serious crisis in primary care. The number of general practitioners in office practice per 100,000 population fell from 83 in 1940 to 24 in 1972. During the same period pediatricians and internists in office practice increased from 6 to 17 per 100,000 population, but the total number of primary physicians fell from 89 to 41 per 100,000, a decline of 54%.1 2 The shortage of primary physicians is one of the most important components of the general crisis in health care. Felt most acutely in rural areas and working-class districts of cities, it has come to affect almost all sections of the population as people find it increasingly difficult to obtain primary care. From 1955 to 1970 hospital outpatient visits per 100 persons in the United States increased by 85% but emergency visits rose by 250% ;3 the poor no longer are alone in using emergency rooms for nonemergency care. A variety of proposals have been made and in part implemented to solve the problem of providing primary care. A number of these may be categorized as "feldsherism," an approach which calls for the training and use of physician's substitutes such as physician's assistants and nurse-practitioners.
FELDSHERISM IN THE U.S.S.R. One of the milestones on the American road to feldsherism was Victor Sidel's paper on "Feldshers and 'Feldsherism' in the U.S.S.R. " 5 Sidel differentiated between the urban feldsher, who works in polyclinics and elsewhere under the direct supervision of a physician, and the rural feldsher who "usually works in a feldsher-midwife station located in a village or on a collective farm and practices relatively independently of physicians except for regular supervisory visits." Sidel reported that the independent clinical role of the rural feldsher was * Presented in a panel, Strategies for Primary Care, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
130
130
M. M. TERRIS TERRIS~~~~~~~~~~~~~~~
being restricted and eliminated increasingly in the Soviet Union, and that the feldsher-midwife stations were "being replaced as rapidly as possible by centralized physician-run stations." Yet, instead of applauding this policy of eliminating inferior medical care for the rural population, Sidel seemed to question its validity, stating that he believed it was probably based more on the "legacy of the old image of the feldsher as a 'second-class' doctor for peasants," and on "emulation of the Western-type goal of primary-physician care for each individual" than on "careful evaluation of health needs and medical resources in the Soviet Union." Sidel ended his paper with the thought that "the Soviet and American societies have much to learn from each other, in this as in many other fields." I agree, and I suggest that the evidence he presents on the experience with the rural feldsher in the Soviet Union indicates that we should be extremely cautious about introducing physician's assistants or nurse-practitioners in the United States. In pre-Soviet Russia, the place of the feldsher was the subject of much controversy in the Zemstvos or district assemblies. "Whereas progressive and democratically inclined Zemstvo physicians strove to provide the peasantry with easily accessible, fully qualified medical assistance, assigning the feldshers only an auxiliary role, the landowners who headed the Zemstva were in favor of independent feldsher services as being a cheaper form of medical assistance."6 Apparently, the nobility and gentry felt that "The peasant is not accustomed and does not need scientific medical assistance, his diseases are 'simple' and for this a feldsher is enough-a physician treats the masters, and a peasant is treated by a feldsher."5 Sidel appears to have been mistaken in stating that urban feldshers in the U.S.S. R. work in polyclinics. Patrick Storey has since emphasized that "the feldshers do not work in the polyclinics, which are the source of general medical care for the population, or in the general or specialized hospitals."7 This is confirmed by the Ministry of Health of the U.S.S.R. in its list of the urban organizations which utilize feldshers: Industrial establishments, schools, the emergency-care service, and sanitation and epidemiological centers are included, but polyclinics and hospitals are not.8 John Cooper, president of the Association of American Medical Colleges and a member of an official exchange mission to the U.S. S. R. in 1970 stated that There is a general misconception in the United States about the role of the feldsher. He or she does not serve as a surrogate physician or Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
131
even as a physician's assistant of the type being trained in this country, except in remote outposts. Even here, there are plans to replace them with physicians as rapidly as possible. Feldshers have defined roles to play in the overall health care system and do not have a position between the physician and nurse. Many serve technical roles in operating complex equipment or carrying out laboratory procedures. Some are sanitary workers with responsibilities like those of some public health workers in the United States. Others man medical stations in industrial establishments and provide first aid and give follow-up treatment to patients under the direction of a physician. In contrast to the plans to increase substantially the number of physicians educated, there is no similar plan for an increase in the education and training of feldshers.9 Relatively independent rural feldshers were a valuable medical-care resource in 1913, when in all of Russia there were about 28,000 physicians, or one per 5,700 population, and about 46,000 middle medical workers,10 29,000 of whom were feldshers .6 Today, when the U.S.S.R. boasts a total of 830,000 physicians or one physician for 308 persons,11 the highest physician-population ratio in the world, the independent rural feldsher has become a medical-care anachronism. As Sidel reports, the feldshers are "being replaced as rapidly as possible by centralized physician-run stations.' THE BAREFOOT DOCTORS" OF CHINA
A poor cousin of the feldsher is the Chinese "barefoot doctor," who has been overly romanticized in many quarters. A balanced evaluation has been made by Robert Hsu, who states that " Given the severe shortage of qualified physicians, the barefoot doctors have had a very useful role in providing basic medical-health care in the rural areas." 12 However, he indicates a number of serious deficiencies. The quality of the barefoot doctors is limited by their brief training period, usually three to six months, and by their educational background, which may be as little as two years of primary school. "There is no national or regional professional standard for selection, training and certification. Consequently, the quality of the barefoot doctors is uneven.... As long as they recognize their own limitations and conscientiously refer more serious cases to physicians and hospitals, no harm will be done. If they are overly self-confident or misjudge serious cases, they will prevent or delay patients from obtaining proper care."
Vol. 53, No. 1, January-February 1977
132
M. TERRIS
There is considerable danger from barefoot doctors who have a penchant for experimentation. Among other things, they are encouraged to experiment with herbs and develop their own herbal medicines. Hsu comments that "This kind of highly decentralized, professionally unsupervised, and ideologically inspired 'research and development' in herbal medicines is inefficient and potentially dangerous." He concludes that "The program has not been a panacea; the usefulness of the barefoot doctors lies in their being a stopgap measure rather than a long-term solution to the shortage of physicians." Whatever its practical values, the Chinese program is based on an antiintellectual ideology, often rationalized as a crusade against medical and other elitism. Mao Tse-tung's statement in June 1965, criticizing the policies of the Ministry of Public Health and declaring that "In health and medical work, put the stress on the rural areas,' '13-16 also contains the following: Medical education should be reformed, because there is no need to read so many books. How many years had Hua T'o* studied? How many had Li Shih-chen of the Ming dynasty studied? Medical schools do not have to admit only senior middle-school graduates; it is quite proper to take in third-year children from junior schools. The main point is to raise their standard during practice. The physicians trained in this way may not be very competent, but far better than fake doctors and witch doctors. Furthermore, villages can afford them. More study only makes them stupid.17
The anti-intellectualism of this statement is difficult to believe. Yet it is consistent with the entire course of the Cultural Revolution since 1966 which, as E. Grey Dimond notes, ".. . .continued as a nationwide disruption for three years. The targets were essentially all individuals that we would identify in management, academic, professional, intellectual, or cultural roles. The students were the primary arm of the government in this attack, functioning in a quasi-military manner, and university activity essentially stopped.'"18 All medical schools were closed, and all students were graduated whether or not they had completed the full curriculum. Starting in 1970, many of the schools reopened, but with a three-year curriculum instead of the previous five or six years. '415" 18,19 Furthermore, the requirements for premedical education have been reduced.15"19 Prior to 1966 the People's Republic of China had rapidly increased the *
A famous surgeon of the third century.
Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
133
number of physicians, from less than 40,000 in 1950 to 150,000 in 1967. By then China had one physician for every 5,000 persons, a ratio more favorable than had existed in Russia in 1913, plus 172,000 feldshers trained on the Soviet model, 186,000 nurses, 42,000 midwives, and 100,000 pharmacists.13 By 1976 China could easily have doubled the number of physicians and at least tripled the number of feldshers, nurses, midwives, and pharmacists. But most of these potential increases were halted by the Cultural Revolution; instead, there occurred an abrupt lowering of standards. The feldsher with two and a half years of training has now been replaced by a barefoot doctor trained in three to six months. The physician with five or six years of training is being succeeded by one trained in a three-year school. Indeed, if one deducts the time allotted for manual labor, military training, and physical education, the difference in the length of training of the Chinese doctor and the Russian feldsher almost disappears. l8 The narrowly practical orientation of the new Chinese medical curriculum and its mandated inclusion of traditional and herbal medicine suggest not only that the Chinese feldsher has become a barefoot doctor, but that the Chinese doctor may well have become little more than a feldsher.
FELDSHERISM
IN
INDUSTRIAL COUNTRIES
In contrast, the more industrialized socialist countries of Eastern Europe have not taken the route of training feldshers, but have concentrated instead on achieving a rapid increase in the number of physicians. This also is true of Cuba, which lost about 40% of its 6,000 physicians in the first half of the 1960s, and then proceeded to increase the number of physicians to a total of 9,000 in 1976, providing one physician for every 950 persons.20 In none of the industrial nations of Western Europe is there any significant movement toward feldshers, physician's assistants or nurse-practitioners. The question naturally arises: why is it that only the United States among the industrial countries is embracing feldsherism, a phenomenon closely associated with developing countries? After all, the United States of 1976 is not the Russia of 1920 or the China of 1950. We shall return to this question later, since any effective remedies for the deficits in primary care must be based on understanding the causes of our difficulties. At this point, however, it should be emphasized that in the United States, just as in the Soviet Union and China, feldsherism establishes two classes of care. In the U.S.S.R. and China the discrimination in quality of care favors urban over rural areas, and this also will be true in the United States. But here, Vol. 53, No. 1, January-February 1977
134 134
M. TERRIS
in addition, it will magnify the disparities in the two-class medical care system in the cities, providing physicians for those who can afford them and physician's assistants and nurse-practitioners, practicing independently or with token supervision, for those who cannot. Feldsherism often is championed as an attack on medical elitism and the establishment. The truth is that medical elitists and the establishment find feldsherism increasingly congenial to their views and interests: physicians will not have to bother with patients who cannot pay their way, leaving their care to less expensive talents, while the establishment, just as in prerevolutionary Russia, will have secured a cheaper form of medical care for the poor. Like the Russian nobility and gentry who wanted a physician to treat the master and a feldsher to treat the peasant, there are many among our business and professional elites who consider it entirely reasonable to have pediatricians and internists for the affluent and nurse-practitioners for the poor. Despite all the disclaimers, feldsherism in the United States is profoundly undemocratic; it is the epitome of class discrimination. THE FAMILY PRACTITIONER
Another alternative which is being proposed and implemented is the resurrection and transformation of the general practitioner into a more highly trained physician who can provide primary care for the entire family. In evaluating this alternative, one must decide whether the interests of family care are served better by a single primary physician or by the internistpediatrician combination. Despite the rhetorical and sentimental value of family practice, there is little evidence to indicate that one physician is better than two in dealing with family problems. Further, each of the two will know more than the family physician about the care of children or the care of adults. The fundamental difficulty of the family practitioner concept, however, is that it is a throwback to 19th century methods of providing medical care. It attempts to train a competent general physician for solo practice at a time when the scientific and technological revolution in medicine makes solo practice obsolete. TEAM PRACTICE IN HEALTH CENTERS
If the great scientific advances of this period are to be brought fully into play for the benefit of the ordinary citizen, medicine must be organized as team practice. This method of providing care goes beyond what we ordinarily Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
135
call group practice, in which general and specialized physicians work together. In team practice these general and specialist physicians work in community health centers with dentists, pharmacists, laboratory workers, clinical and public-health nurses, nutritionists, health educators, social workers, and other health personnel required to meet the specific needs of the population being served. The model for primary care that makes sense in the United States of 1976 is the community or neighborhood health center, an institution which has been operative for many years in the U.S.S.R. and other socialist countries and which provides a sounder model for study and emulation than that of the feldsher. Its value now has been demonstrated successfully in the United States in that most unfavorable of all community laboratories-the povertystricken ghettos of our cities. The neighborhood health center belongs in every neighborhood and community, regardless of economic level; all of us need it if we are to obtain the best that medicine can offer. The health center, however, cannot stand alone. If it is to make our scientific capability available to everyone, then it has to be an integral part of a regional network of hospitals and other institutions with the resources of a medical school at its center. Where the resources of the regional medical school are inadequate, specialized resources at the national level have to be made accessible to the individual who needs them, no matter where he lives. These additional resources are essential complements to the team providing primary care in the community health center. The moment we move from stating that primary care should be given by the internist and pediatrician, family practitioner, physician's assistant, or nurse-practitioner to the position that primary care should be given by team practice in community health centers, we gain enormously in flexibility of approach. We can now experiment with teams of differing composition and organization of work, and reexamine traditional allocations of functions. Many procedures which physicians perform are a legacy of the institution of solo practice, in which the physician had to do everything himself. In team practice such procedures can be done-and probably done better-by other health workers. What we need is simple, but difficult to achieve: a spirit of inquiry, experimentation, and willingness to get out of the rut of past habits and traditions. We also need to make certain that changes actually improve the quality of care and serve the interest of patients rather than those of physicians or administrators. An impressive example of initiative in this area is Sidney Garfield's recent Vol. 53, No. 1, January-February 1977
136 136
M. TERRIS
M.
TERRIS
paper on "Evaluation of an Ambulatory Medical-Care Delivery System."21 His approach is to use a health-testing service for new patients, with referral to either a health-care service, preventive maintenance service, or sick-care service, as defined below. In his controlled experiment at the KaiserPermanente Medical Center, the new patients randomly assigned to this system were referred by the health-testing service as follows: 55% for health care (health education; immunization; posture and exercise training; psychosocial and drug-abuse counseling; and clinics for nutrition, adolescents, family planning, prenatal, and well-baby care); 19% for preventive maintenance (obesity, diabetes, hypertension, arthritis, back, mental health, geriatric, and rehabilitation clinics); and 26% for sick care (doctors' group practice in integrated facilities: clinics and hospitals, special laboratories, radiotherapy, intensive and acute care, and extended care). As Garfield and his colleagues point out, an important feature of this approach is that Paramedical personnel are used extensively in the health evaluation, health-care and preventive-maintenance services of the new system, but they are used there in a highly organized way. In health evaluation, supported by multiphasic health testing, on-line data processing, protocols, and 'advice' rules, nurse practitioners need not diagnose or treat patients but rather record normal (or abnormal) measurements and findings and decide (as a team) with the supervising physician whether the patient is well or sick and the appropriate services for referral. In health care and preventive maintenance they strictly follow physician-prepared-protocols. The new system, with its clear division of user demand into health-status groups and its matching services with tasks defined by protocol, favors the safe and effective use of paramedical personnel as compared to their use in the relatively unsystematized heterogeneous demand of the traditional medical-care system. The results indicate that the new system provided access to new patients within 24 to 48 hours, as compared to six or eight weeks of waiting for an appointment in the traditional system. For every 1,000 entrants to the new system, 940 physician hours were used for all services provided during a 12-month period, as compared with 1,635 physician hours per 1,000 entrants for the control group assigned to the traditional system. The saving in physician time is 43%, and in total costs 25%. There is some question as to whether supervision by physicians in the Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER
ALTERNATIVES
137
health-testing, health-care, and preventive maintenance services of the new system is adequate, especially since Garfield and his colleagues put so much emphasis on the savings in costs. There is need for information about the effects on the quality of diagnostic, health-care, preventive maintenance, and sick-care services. We look forward to further reports on these and other parameters of evaluation of this salient innovation in medical care organization. Perhaps one of the most significant features of the new system is its explicit recognition of the importance of health care and preventive maintenance, areas which tend to be neglected in traditional medical care. One is reminded of the strong emphasis given to prevention in the U.S.S. R. and China, where curative and preventive services are integrated in the work of physicians and other health workers. In China, as Sidel points out, the barefoot doctors are responsible for environmental sanitation, health education, and immunization. 13 In the U.S.S.R. the feldsher must take action for early detection of acute infectious diseases and major nonepidemic diseases, participate in follow-up surveillance of the local population, take sanitary measures for the prevention of disease, and provide health education.8 In urban areas the district nurse not only helps the district physician in the polyclinic but "carries out his instructions in people's homes, investigates the living and housing conditions of people attending the follow-up clinics, trains such people and the members of their families in measures of individual prophylaxis, carries out health education work among the public, organizes voluntary health workers, gives prophylactic inoculations, and checks on the fulfillment of the physician's recommendations with regard to treatment, diet and hygiene.' '6 These activities are more community oriented than those described in the Kaiser- Permanente system, which appear to be confined within the four walls of the medical center. It will not be easy for the Kaiser- Permanente system to change completely from the traditional model of group practice by physicians to the community-oriented model of team practice by physicians and other health workers based in neighborhood centers. CAUSES OF THE PRIMARY CARE CRISIS
Let us return to the question which was raised earlier in this paper: Why is it that among the industrial countries only the United States is embracing feldsherism, a phenomenon closely associated with developing countries? Probably all industrial nations have fewer physicians, either general or Vol. 53, No. 1, January-February 1977
138
138
M. M. TERRIS
TERRIS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
specialized, in rural areas. This is a problem which will not be fully resolved until agriculture becomes industrialized and urbanized to the point of reaching parity in economic and cultural resources. Only the United States, however, has such a startling disparity in the supply of primary and other physicians among the neighborhoods of its cities. These great disparities do not occur in urban areas of the socialist countries, because their national health services are part of a planned economy in which the supply of health-center and hospital personnel is planned and distributed in a rational way for every region, district, and neighborhood. In the industrial capitalist countries other than the United States two factors mitigate differences in primary care. In many of these countries specialists work primarily as salaried employees in government hospitals, and the growth of specialization thereby is controlled effectively. These countries all have national health insurance in one form or another and, thus, the social class differences in purchasing power for primary medical care are reduced or eliminated. There are differences in the availability of primary physicians, but these are considerably reduced by this relative or absolute equalization of medical purchasing power. In the United States, on the other hand, the system of voluntary health insurance generally excludes ambulatory care, so that the difference in the purchasing power of rich and poor is reflected fully in the medical marketplace. The results are well known: a glut of physicians in the wealthy neighborhoods and suburbs and the virtual disappearance of physicians from the poorest areas of the cities. The difficulties are intensified by the fact that most specialists in the United States are in private practice outside the hospitals, with no restrictions on their proliferation. This situation, further, forces hospitals to develop residency-training programs in order to have full-time physicians to care for patients; such programs inevitably emphasize training in inpatient care and specialty areas rather than in primary care. As a result, the number of approved hospital residencies has been inflated beyond all reasonable criteria of need for specialists or quality of training. In 1941 there were about 5,000 residencies, all of which were filled by North American graduates. In 1973 there were almost 54,000 residencies, 9% of which were unfilled. In 1974 more than 65,000 residencies were available.22
Bull. N.Y. Acad. Med.
FALSE STARTS AND LESSER ALTERNATIVES
139
EFFECTIVE SOLUTIONS What should be done? The most effective solution would be to establish a national health service with a rationally planned and regionally integrated system of health centers and hospitals providing equitable services to communities and neighborhoods. If this is politically unfeasible, then a national health-insurance system should be established which approaches the characteristics of a national health service, including 100% coverage of both services and population. The services should be provided primarily by group and team practice in health centers organized in accordance with federal standards. This can be achieved by substituting capitation for fee-for-service payment, establishing financial and other inducements to practitioners to work in health centers, and making higher capitation payments to centers in rural areas and poor neighborhoods. Federal standards should include requirements for 1) the regionalization of health centers and hospitals, 2) correcting the imbalance in residency-training programs, realigning them to meet the needs of the public, 3) emphasis on primary care and preventive services, 4) reasonable staffing patterns and salary structures, and 5) mandatory periods of postgraduate education for physicians and other health personnel, with the costs included in the capitation payment. Finally, to make certain that the national health-insurance system is oriented toward health service rather than payment, administration should be the responsibility of a federal department of health, its regional offices, and state and area health departments. These should have sufficient professional resources to provide competent administration and supervision of the healthcare program and its integration with preventive services in the community. Not until such measures are taken will the crisis in primary care be resolved. REFERENCES 1. Overpeck, M. D.: Physicians in family Economics, University of Michigan practice 1931-67. Public Health Rep. School of Public Health, 1972. 85:485-494, 1970. 4. Jacobs, A. R., Gavett, J. W., and Wer2. Roback, G. A.: Distribution of Physisinger, R.: Emergency department utilicians in the U.S., 1972, Regional, State, zation in an urban community. County. Chicago, Amer. Med. Assoc., J.A.M.A. 216:307-12, 1971. 1973, vol. 1. 5. Sidel, V. W.: Feldshers and "feld3. Donabedian, A., Axelrod, S. J., sherism." The role and training of the Swearingen, C., and Jameson, J.: Medfeldsher in the U.S.S.R. N. Engl. J. ical Care Chart Book, fifth ed. Ann ArMed. 278:934-40, 981-92, 1968. bor, Mich., Bureau of Public Health
Vol. 53, No. 1, January-February 1977
140
M. TERRIS
6. Ashurkov, E. D., Zhuk, A., and Lisitsin, Y.: The Work and Training of Feldshers and Nurses in the U.S.S.R. In: Aspects of Public Health Nursing. Public Health Papers No. 4. Geneva, World Health Organization, 1961. 7. Storey, P. B.: The Soviet Feldsher as a Physician's Assistant. DHEW Publication No. (NIH) 72-58. Washington, D.C., Govt. Print. Off., 1972. 8. Ministry of Health of the U. S. S. R.: The Training and Utilization of Feldshers in the U.S.S.R. Public Health Papers No. 56. Geneva, World Health Organization, 1974. 9. Cooper, J. A. D.: Education for the health professions in the Soviet Union. J. Med. Educ. 46:412-18, 1971. 10. Lisitsin, Y.: Health Protection in the U.S.S.R. Moscow, Progress Publishers, 1972. 11. Pustovoy, I. V.: Health Care Planning in the U.S.S.R. Chicago, The Center for Studies, Administration Health Graduate School of Business, the University of Chicago, 1975. 12. Hsu, R. C.: The barefoot doctors of the People's Republic of China-Some problems. N. Engl. J. Med. 291:12427, 1974. 13. Sidel, V. W.: The barefoot doctors of the People's Republic of China. N. Engl. J. Med. 286:1292-1300, 1972.
14. Sidel, V. W.: Medical education in the People's Republic of China. New Phys. 21:284-91, 1972. 15. Wen, C.-P. and Hays, C. W.: Medical education in China in the postcultural revolution era. N. Engl. J. Med. 292:998-1005, 1975. 16. Lampton, D. M.: Public health and politics in China's past two decades. Health Serv. Rep. 87:895-904, 1972. 17. Ch'en, J.: Mao Papers: Anthology and Bibliography. London, Oxford University Press, 1970, pp. 100-01. 18. Dimond, E. G.: Medical education and care in People's Republic of China. J.A.M.A. 218:1552-57. 1971. 19. Walls, P. D., Walls, L. H., and Langsley, D. G.: Medical education in the People's Republic of China. J. Med. Educ. 50:371-83. 1975. 20. Ferrer Gracia, H. (National Director of Epidemiology, Ministry of Public Health, Republic of Cuba). Personal communication. 21. Garfield, S. R., Collen, M. F., Feldman, R., et al.: Evaluation of an ambulatory medical-care delivery system. N. Engl. J. Med. 294:426-31.
1976. 22. Directory of Approved Residencies, 1974-75. Chicago, Amer. Med. Assoc., 1975.
Bull. N.Y. Acad. Med.
