Choose Right Doctor for you
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Given the choice of many kinds of physicians, medical practices, and payment schedules, which doctor is right for you? Medically, seeing different physicians every time seems to work out about as well as seeing the same physician consistently, if the medical record is of good quality or if the problems are acute. However, many patients and physicians feel that the dignity and depth of the relationship is impaired if frequent doctor change are made.
Here are some things to remember when choosing a physician:
Usually, the type of physician is not as important as the individual physician. You can go to a general practitioner, a family doctor, a pediatriciar an internist, or a subspecialty internist for your primary care. Sometimes, women may use a gynecologist as their primary physician and have a Pap smear, breast examination, and blood pressure check during routine visits.
If you have a defined special problem, then a subspecialist in that area may be the best physician for you. The majority of your care can be provided and referral elsewhere arranged when it is needed. You may want everyone in your family to see the same physician. This avoids the inconvenience of having several different doctors. More important, the physician who sees the entire family is better able to understand individual problems. Rely upon your friends’ experiences with their doctors. Question them closely about office practices. When the name of a physician is needed and you have not been able to obtain reliable information elsewhere, call your county medical society. They will have a list of physicians in the area who will accept new patients. Note that the medical society is providing information-not making recommendations; any member of the local society who is available may be given to you as a name. If you live near a medical school, you can find a doctor by getting the names of their clinical faculty.
When choosing a doctor, do not pay attention to the social status of the office address, the depth of the carpet, the clothing of the staff, or the hair style of the physician. Also, don’t worry particularly about the length of the wait. The practice of medicine requires that the physician’s working day be busy, that some problems require more time than others, and that emergencies may arise in the middle of the day. Hence, delays occur in the best organized practices, particularly with the most conscientious physicians. Take something useful to do to the doctor’s office; don’t count on the office magazines. The central question is this: Is this physician acting in the best interests of each patient he or she is seeing? You may need this special attention later.
Paying Medical Bills
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The quality of medical care is not determined by the method of payment; nevertheless, there are psychological factors in payment arrangements which every patient should understand.
Fee-for-service is an awkward term which describes the usual method of paying the doctor in the United States, A service is performed, and payment is given for that service, The more services provided, the greater the patient’s bill. The more services provided, the greater the physician’s income. In a country where nearly everyone is paid by salary, the existence of piece-work payment in medicine has raised criticism,
When payment is determined by the number of services, there is a financial incentive to increase the number of services provided and/or to up-grade their level. In the business sense, “customer satisfaction” becomes important to the physician, A good “bedside manner” may be developed and extra services may be provided in response to special problems. Since considerable effort is expended in maintaining the relationship with the patient, respect of physicians by patients tends to be greatest in areas where physicians are paid for each service.
On the other hand, some problems have been attributed to this payment system. It has been charged that patients have been seen too frequently, given too many medications, given too many shots, had too many diagnostic procedures performed, and undergone too much surgery as a result of this financial incentive. Studies have suggested that the physician in the fee-forservice setting provides many more services than physicians paid by salary. Controversy remains as to whether these additional services represent better care, or simply greater expense.
In prepaid practice, a group of physicians offers to the patient a plan which looks like an insurance policy; to the physician it represents a rearrangement of the traditional incentives. The patient knows in advance the medical expenses for the year. A set monthly amount is paid regardless of whether the medical facility is used a great deal or isn’t required at all. When the patient needs a doctor, little or no additional expense is involved. The physician is now given an incentive to minimize the number of services provided, since the amount of money to be earned is already determined.
Advocates of prepayment have argued that the physician has an incentive toward “preventive medicine” and is more likely to treat conditions early rather than to let them get out of hand. Close observers doubt that this is true. Little attention has been placed on preventive medicine by most prepaid group practices; indeed, sometimes the very opposite has been observed. However, prepaid group practices do decrease the overall cost of medical care. Usually, the saving is about 20 percent. Studies which compare the quality of medical care under the different payment conditions have not shown a difference; thus, the average patient in the prepaid medical plan saves money and avoids the nuisance of excessive medical procedures with no apparent decrease in the quality of the health care. On the negative side, many patients are not happy with prepaid group practices. The most common complaints are that lines are too long, the physician too impersonal, and that they “feel like a number.” These systems have been burdened by the few patients that over-use the system. In many plans, 20% of the patients use 80% of the services. The excessive services received by these few people increase the payments for the rest. The prepaid group practice has a less direct stake in patient satisfaction than does the fee-for-service physician. As noted, the physician is now given the incentive to minimize the number of services provided since the amount of money is already determined. The dedication of most physicians counteracts these financial forces; with many doctors, these factors are unimportant. Still, as the patient should be aware of the biases inherent in the care you receive.
Solo Practice and Group Practice
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SOLO PRACTICE
The solo practitioner is just that-a physician without partners or organizational affiliation. The solo practitioner may be a general practitioner, a specialist, or a sub specialist in any of the medical disciplines. The solo practitioner generally ‘works from an office which mayor may not be near a hospital. With a solo practitioner, each time you are sick you will probably be seen by the same person. In small communities and rural areas, a solo practitioner may be the only source of medical care.
In recent years, busy solo practitioners have sometimes employed “physician’s assistants” to enable them to care for a larger number of patients. Use of the “physician’s assistant” is still undergoing evaluation, but early experience indicates that these health professionals, who are not themselves doctors, may provide excellent care in many areas of medicine. It is rumored that, in the old days, a doctor was always available. One doubts that this was ever true: at any rate, it is not true now. The typical solo practitioner spends several weeks of the year on vacation or attending medical meetings. The doctor goes to concerts and parties like everybody else. A weekend may be spent at a cabin in the mountains. Obviously, suer. diversions are important for the mental health of the physician. On the other hand, these factors mean that you will not always see the same physician even if your doctor is a solo practitioner. Upon reaching your doctor’s answering service, you may be referred to another physician who is “on call.’
GROUP PRACTICE
The medical group or “group practice” came into being some years ago a’ an answer to some of the problems of single practice. The sharing of nigl: and weekend coverage, the lowering of office cost by shared expense, the availability of consultation, and a more medically stimulating environment for the physician all contributed to the increase in group practices. Group practices come in all sizes and varieties. The smallest group practice is the partnership; there may be two partners, or more. The partners may be incorporated into a “medical corporation.”
The larger groups include hundreds of physicians. The group practice may include only general practitioners or only specialists in a particular area such as internal medicine, Other groups include a variety of medical specialties. Group practice has a number of advantages. You may be able to obtain a variety of medical services at a single location; the physicians will frequently have an organized education program which will assist in keeping them up-to-date; and there is likely to be a reliable on-call system.
On the other hand, a medical group is frequently more expensive than the solo practitioner, because members tend to refer you to other doctors. You mayor may not see the same physician in the medical group at each visit, depending upon the design of the practice. Also, some patients have felt that relationships are more impersonal in these larger medical practices.
Specialists and Subspecialists
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The five major clinical specialties are internal medicine, surgery, pediatrics, obstetrics and gynecology, and psychiatry. There are other specialties such as radiology, clinical pathology, and anesthesiology; these are not included in our chart because the patient seldom goes directly to such physicians. The largest specialty is internal medicine. Physicians may refer to this specialty as “medicine,” and to its practitioner as an “internist.” The internist is sometimes confused with the “intern.” An intern is a recent medical school graduate undergoing hospital apprenticeship in any area of medicine; an internist is a specialist in internal medicine usually having completed three or more years of training after graduation from medical school. Each of the other specialties has a similar length of training.
Subspecialties have developed within the major specialty areas; some are listed in Fig. 1. In internal medicine, there is a specialist for nearly every organ system. Thus, the heart has its cardiologists, the skin its dermatologists, the nervous system its neurologists, the kidney its renal disease specialists, and so forth. Within surgery, different types of operations have defined the specialties of particular surgeons. The ophthalmologist performs surgery on the eyes; the ear, nose, throat specialist rENT] on those areas, the thoracic surgeon in the chest, and the cardiac surgeon on the heart. The general surgeon operates in the abdominal cavity as well as other areas.
Within pediatrics, specialties have developed similar to those within adult internal medicine. In addition, since certain types of problems, particularly genetic and developmental, are more common in children, they have resulted in subspecialties unique to pediatrics. Increasingly, “obstetrics and gynecology” has been divided into the obstetrician who delivers babies and the gynecologist who deals with diseases of the female organs. Psychiatry does not have formal subspecialties, but a variety of schools
of psychotherapy exist-like Freudian and Jungian-which are somewhat similar to subspecialties in the other disciplines. Recently, obesity, alcoholism, and other specific problems have started to become subjects for separate disciplines within psychiatry.
The different kinds of doctors listed in this chapter provide their services under various arrangements. Sometimes, they practice alone, sometimes in groups, often under different financial conditions. You should know the strengths and weaknesses of each. By combining the right doctor with your medical and financial needs, you have a better chance of good medical care.
Physician and Famil Doctor
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Who is the right doctor for you? There are all kinds of physicians, and the distinctions among them can be extremely confusing. This chapter is designed to help you understand the different types of doctors and how they run their medical practices. We provide you with some guidelines to help you choose the right doctor for you and your family.
To identify the different types of physicians, look at the three levels of specialization in Fig. 1. First, there are generalists or primary care physicians. Second, there are specialists in internal medicine, surgery, pediatrics, obstetrics and gynecology, or psychiatry. And finally, there are a large number of subspecialties which are directly related to one of the specialties.
THE FAMILY DOCTOR
The primary care physician, or generalist, is commonly called a general practitioner, GP, or family doctor. Often, a specialist in internal medicine or pediatrics will serve as a primary care physician. Family doctors may refer patients to other physicians but they seldom receive referrals. These physicians represent the initial contact between the patient and the medical establishment. They accept responsibility for the continued care of a patient or a family and perform a wide variety of services. Usually, they have had some training in internal medicine, pediatrics, and gynecology. In the past, they performed both major and minor surgery; but in recent years, this practice has become much less common, and the family doctor will usually refer major surgical problems to surgeons. Obstetrics and gynecology, the female specialties, are not always handled by general practitioners.
Family doctors serve as the quarterbacks of the medical system and may direct and coordinate a variety of activities they do not perform personally. Next to the patient, the generalist makes the most important decisions in medicine by determining the nature and severity of the problem and what approach to its solution should be used