"EBOOK HSA546CHAPTER 1 International Physician and Health SystemPractice: Can U.S. Reform Efforts Learn from OtherNations? ? Grant T. Savage, PhD, MBA, BA Mohamed Bouras, MS Leo van der Reis, MD 1 The National Library of Medicine defines medical group practice as: ?Any group of three ormore full-time physicians organized in a legally recognized entity for the provision of healthcareservices, sharing space, equipment, personnel and records for both patient care and businessmanagement, and who have a predetermined arrangement for the distribution of income.?Medical group practice—which also may refer to collaborative medical work by physicians—isgrounded in the social and economic, as well as the preventive and curative practices ofphysicians. The physician‘s role as a healer has had many different facets since prehistory. Fromshaman to herbalist to surgeon to specialist, the role of the physician has been intertwined withsocial, economic, scientific, and technological change.Throughout most of Western history—albeit, with some notable exceptions—physicians havehad solo practices. However, beginning in the eighteenth century and accelerating rapidly in thenineteenth and twentieth centuries, several forces radically changed not only what physicianswere capable of accomplishing, but also how and where their services could be accomplished inthe United States and in Europe.This chapter examines changes in the physician‘s role and traces the emergence of medical grouppractice in the United States and other industrialized nations. It is divided into three sections:? ¦ Section one reviews the history of Western medicine, starting with Egypt; traces the originof medical group practice up to the twentieth century; and concludes by noting theinstitutional forces influencing physician practices. ? ¦ Section two focuses on the modern development of medical group practice in the UnitedStates, notes the influence of healthcare financing on group practices, explores the impact ofthe Patient Protection and Affordable Care Act of 2010, and documents the benefits thatmedical group practices provide to physicians. ? ¦ Section three contrasts the financial access, cost, and quality of healthcare in the U.S. healthsystem with those of 11 other countries, examines the growth of medical groups within theseother countries, analyzes the systems of medical malpractice liability used by seven of thesecountries and the United States, and concludes with a set of recommendations for improvinghealth reforms in the United States.Origins of Medical Group Practice The Western notion of medical group practice has its origins in the ancient medical practices ofthe Egyptians (circa 2600–450 BC) and the Greeks and Romans (circa 600 BC–476 AD).Although the Egyptian and Greco-Roman frameworks for medical practice overlapped,separately these frameworks endured for 2,000 years each; together, they spanned nearly 3,5002 years. The modern practice of medicine is the result of a paradigmatic shift in scientific thinkingthat started with the Muslims (circa 750–1100 AD) and continued through the IndustrialRevolution (circa 1760–1900 AD). Because ancient medicine is far removed from modernpractice, the following sections delve into the Egyptian and Greco-Roman medical practices, andthen briefly highlight the shifts in paradigmatic thinking about medicine that have implicationsfor medical group practice from the fifth through the nineteenth centuries. Table 1-1 provides anoverview.Egyptian Medical Practices Within the Western tradition, the earliest known physicians engaging in group practice served in3 the court and temples of the Egyptian pharaohs. For the Egyptians, religious and medicalpractices were separate but intertwined, with three types of physicians: priests, magicians (sau),and professionals (swnw). As with the prehistoric practice of shamanism, religion and medicine4 were the purview of physician-priests. Most notable among these physician-priests were thosewho worshiped the lion-goddess Sekhmet, the punisher of sinners; of slightly less note were5 those who worshiped Serqet, the goddess of breath who is identified with the scorpion.For illnesses without observable causes—such as infectious diseases—only magic, invokedthrough incantations or prayers by the priest- or magician-physicians (sau), could placate angry5-8 gods or confront and drive away demons and cure disease. For these and other mystifyingdiseases, Egyptians believed that medicine used alone would only relieve suffering, but—when9 paired with magic—medicine allowed the patient to recover strength and vitality.Medical Practices, Physicians, and Specialization Nonetheless, the medicine practiced during the 2,000 years of Egyptian reign included animpressive pharmacology, a rudimentary knowledge of human anatomy and the circulatorysystem, and a sophisticated approach to treating trauma-related injuries. Contributing to generalhealth were beliefs and practices of personal hygiene and public cleanliness. The knowledgeabout medical practices was regarded as sacred and was codified in scrolls, which were availablein scriptoriums called Peri-Anhk or Houses of Life. Religious beliefs that the body was the vesselfor the afterlife prohibited physicians from dissecting and gaining a sophisticated understanding5-8 of human anatomy and physiology.Interestingly, the Egyptians employed physicians, at public expense, to care for the workersbuilding the pyramids, as well as those working the mines and quarries. There also is someevidence to suggest that workers were allowed sick leave and were awarded pensions forphysically incapacitating on-the-job injuries. Although evidence of medical practices in the military are scant, it is known that physicians accompanied and treated wounded soldiers andthat standards of physical hygiene, including shaving facial hair and trimming hair, were7 enforced.Most medical doctors were the professional physicians (swnw), who could be either male orfemale. According to records from the Old Kingdom and First Intermediate Period (circa 2686– 2040 BC), the professional physicians were organized hierarchically, with the swnw supervised5-8 by overseers of physicians (imy-r swnw). Moreover, several authorities argue that the overseers6-8 reported to chief physicians, who were led by master physicians. At the apex of the hierarchywere the inspectors of physicians who were subject to the Overseer of the Physicians of Upper5-8 and Lower Egypt. Importantly, although some swnws were scribes—able to write and, thus,read medical texts—most were not. Given the extensive medical knowledge of the Egyptians,and the limited literacy of the physicians, this was probably a factor driving medical5,6 specialization.Implications for Medical Group Practice The written and archeological evidence from the Old Kingdom (circa 2600 BC) through the LatePeriod (circa 600 BC) reveals that physicians became highly specialized. Physicians specializedin treating ailments of the eye, teeth, mouth, or stomach. They also specialized in women‘s5-8 health, including pregnancy testing, childbirth, and contraception. With each physicianspecializing in the treatment of different body parts and illnesses, the physicians for the court of3 the pharaoh formed a de facto multispecialty group. The major force that influenced physicianpractices during this period was the demand for organized labor for public projects like thepyramids.Table 1-1 Historical Influences on the Formation of MedicalGroup Practice in Western Culture PhysicianHistorical PeriodCircaDescriptionKey Influences Practice The Egyptians were the firstto organize medical groups,both to serve the courts of thepharaohs and to serve thegeneral population. MedicineOrganized laborwas specialized aroundMultispecialty for public projects;2600-450 illnesses and symptomsEgyptianand solo magical and sacredBC affecting each part of thepractices beliefs aboutbody. Significantly, medical,diseasereligious, and magicalpractices were all drawn uponto treat illnesses.Multispecialist groups wereformed because of medical PhysicianHistorical PeriodCircaDescriptionKey Influences Practice specialization and the need totreat injured and sick workersfor public projects, such as thepyramids, as well as to treatmilitary-related traumas.Medical texts on scrolls werepreserved in Peri-Anhk(Houses of Life) at Memphisand other cities.The Houses ofLife served as scriptoriums,precursors to the librariesdeveloped by the Greeks.The Greeks rationalizedmedicine, separating it frommagical and religiouspractices. Their framework ofthe four humors alloweddoctors and patients to have ashared understanding of whyillnesses occurred andencouraged a systematicapproach to treating illnesses.600BC-476This framework encouraged Military hospitals600BC-476physicians to begeneralistsand and governmentADto workassolo practitioners. policies(WesternThe Romans adopted and Mostly solo establishing publicGreco-RomanRomanextended Greek medical practices health as aEmpire)practices. Roman innovations priority; humoral300-1000during its Imperial period framework ofAD (Easternincluded creating a medical diseaseEmpire)staff and establishinghospitals for the military;providing public physiciansfor citizens in cities; andbuilding public baths,aqueducts, and sewers. Forboth the Greeks and Romans,religious temples also weremedical practice arenas andprecursors of medical schools.The followers of Mohammed Religious beliefs;600-1100 not only created a new empire Mostly solo scientificIslamic Empire AD stretching from Spain to practices advancement andNorthern Africa to Persia, but public hospitals; PhysicianHistorical PeriodCircaDescriptionKey Influences Practice also helped develop the humoralmodern notion of the hospital framework ofas a place to operate on and diseasetreat the sick, regardless ofclass or wealth. Translatingand drawing upon Greek andRoman books on medicine,Arab scientists and scholarsadvanced the knowledge ofchemistry, as well as humananatomy and the circulationsystem. They also introducedthe practice of inoculation tocombat smallpoxand othercontagious diseases.With the support of theRoman Catholic Church,medical schools thrivedduring the late Middle Ages;the licensing of physicianswas introduced, along withprofessional training andpractice restrictions. Duringthe Renaissance, Greco- Roman and Muslim medicalReligious beliefs;practices were rediscoveredschools ofMedieval and and extended. The humoral500-1600 Mostly solo medicine andRenaissance theory of disease wasAD practices hospitals; humoral(Western Europe)challenged, as an accurateframework ofunderstanding of humandiseaseanatomy and newunderstandings of circulationand chemistry weredeveloped. Groups ofphysicians deliveredhealthcare for the military,taught and practiced inmedical schools, and providedcare in almshouses,dispensaries, and hospitals.Enlightenment The germ theory of disease Emergence of Scientific andand 1600-1900 gradually became dominant, single-and technologicalIndustrialization AD supplanting the humoral multispecialty advancements;(Europe and frame-work. as modern practices germ theory of PhysicianHistorical PeriodCircaDescriptionKey Influences Practice North America)understandings of circulation diseaseand respiration weredeveloped and infectiousmicro-organisms werediscovered. New technologies(e.g., microscopes, vaccines,stethoscopes, antiseptics,radiology) added complexityto the practice of medicine.The new technologiesstimulated specialization andthe growth of multi- andsingle-specialty medical grouppractices, as well as hospitals.Greco-Roman Medical Practices In contrast to the Egyptians, the Greeks emphasized the microcosm–macrocosm connection, therelationship between the healthy human body and the harmonies of nature. This philosophy canbe traced to Empedocles (circa 450 BC), who? . . . regarded the four elements, fire, air, earth and water, as ?the roots of all things,? and thisbecame the corner stone in the humoral pathology of Hippocrates. As in the Macrocosm—theworld at large[—]there were four elements, fire, air, earth, and water, so in the Microcosm— the world of man‘s body—there were four humours (elements), viz., blood, phlegm, yellowbile (or choler) and black bile (or melancholy), and they corresponded to the four qualities ofmatter, heat, cold, dryness and moisture. For more than two thousand years these views9 prevailed. Hippocratic Medicine Egyptian medicine, as well as the philosophy of Ionia (western Asia Minor) and mainlandGreece, influenced Hippocrates, who was born on the Greek island of Kos (circa 460 BC) into anaristocratic family, which was renowned for its medical knowledge. Hippocrates learned,practiced, and taught medicine in Kos, but he also traveled widely throughout northern Greece10 (Macedonia, Thrace) and died in Thessaly. Hippocratic medicine is distinct from Egyptian andother ancient approaches to medicine because of its appeal to reason and observation, rather thanto rituals and supernatural forces. For example, despite the basic stability of the four humors— the bodily fluids of blood, phlegm, yellow bile, and black bile—Hippocrates argued that peoplewere affected by climatic and, especially, seasonal changes: ?phlegm, cold and moist, prevails inwinter; blood, warm and moist in spring; yellow bile, warm and dry in summer; and black bile,10 cold and dry, in autumn.? Hence, a person was healthy when the four humors were inequilibrium; illness caused the humors to become unbalanced, but climatic and seasonal changes also affected this balance. The role of the doctor was to apprehend both the type (diagnosis) andthe probable outcome (prognosis) of the disease. Physicians should counter the imbalance in thehumors of the ill person, allowing the power of nature to cure the disease.Hippocratic medicine was also known for being patient-centered; the compendium of writingsascribed to Hippocrates and his disciples underscore the importance of careful observation, thewriting of comprehensive medical histories, the provision of comfort to dying as well as10,11 recovering patients, and the injunction to do no harm to patients. The significance ofHippocratic medicine is four-fold, in that it:? ¦ Created a lofty role for the selfless physician—which has survived as a contemporary12 model for professional identity and behavior ? ¦ Taught that the understanding of sickness was inseparable from the understanding of13 nature ? ¦ Began the Greek tradition of teaching medical knowledge to nonfamily members, laying14 the foundation for modern medical schools ? ¦ Enabled physicians to be trained in all aspects of medicine, reinforcing the notion of thesolo, general practitioner Alexandrian Medicine Hippocratic medicine had its shortcomings because it lacked a clear understanding of the internalworkings of the human body. The framework of the four humors was a speculative way to linkexternal signs of health with the internal workings of the body. It would take numerous scientificcontributions from Aristotle (circa 384–322 BC) to Galen (circa 129–216 AD), as well as majorchanges in ancient society, to arrive at a more developed understanding of human anatomy,13,14 pathology, and physiology.Importantly, many of the ancient advances in human anatomy and physiology are traced to theGreek studies of medicine in Alexandria, Egypt. The city was established by Alexander the Greatin 332 BC, and was ruled by his foremost general, Ptolemy, and his descendants until the deathof Cleopatra IV in 30 BC. Under both Ptolemaic and Roman rule, the library in Alexandria wasthe leading center for knowledge in the ancient world. About 300 BC, Ptolemy I established a15 university and school of medicine. Studies of human anatomy and physiology briefly flourished13 in Alexandria as both dissection and vivisection of criminals was allowed.During this period (circa 300–250 BC), Herophilus and Erasistratus made notable discoveriesand contributions to medical knowledge. An adherent to the humoral framework of Hippocrates,Herophilus studied the brain (which he regarded as the site of intelligence) and the spinal cord;both he and Erasistratus distinguished between motor and sensory nerves. Herophilus alsoinvestigated the eye, the alimentary canal (he is credited with naming the duodenum), thereproductive organs, and the arteries and veins. Erasistratus also contributed to the study ofanatomy, accurately describing the four chambers of the heart and other aspects of the vascularand nervous system. Moreover, combining pneumatic theory with corpuscular theory,Erasistratus attempted to explain processes such as respiration, nutrition, digestion, and13,14 growth. Galenic Medicine Galen, a central figure in medicine during the second century AD in the Roman Empire, wouldmake the four humors the dominant framework for medicine until the Renaissance. Born inPergamon (129 AD), a major Greek city in Asia Minor, Galen emerged as the leading medicalauthority in Rome during the reign of Marcus Aurelius (161–180 AD). Following his father‘sdeath and with his newly inherited wealth, Galen continued his medical education in Smyrna,Corinth, and Alexandria. He then spent several years (157–161 AD) in a prominent position asthe chief physician for the gladiators in Pergamon before practicing his art in Rome (162–166AD). His surgical, diagnostic, and therapeutic abilities were so extraordinary that when he brieflyreturned to his native Pergamon in 166 AD to avoid the plague, he was invited by the EmperorMarcus Aurelius to join him on his campaign against the Germanic tribes. Galen continued to16 practice in Rome until he died around 216 AD.Building on the work of Hippocrates, Plato, and Aristotle, as well as Herophilus and Erasistratus,Galen expanded the framework of the four humors, linking human temperament to theframework illustrated in Table 1-2.Unlike Hippocrates, Galen argued that humoral imbalances can be located in specific organs16,17 (i.e., heart, gallbladder, liver, and head), as well as in the body as a whole. Galen looselylinked these points of the body to Plato‘s notion of the tripartite soul: head (reason), heart(emotion or spiritedness), and liver and gallbladder (desire). As Boylan points out,? [T]he sort of just balance of the soul that Plato argues for in the Republic is also the ground ofnatural health. When one part of the soul/body is out of balance, then the individual becomesill. The physician‘s job is to assist the patient in maintaining balance. If a person is too full ofuncontrollable emotion or spiritedness, for example, then he is suffering from too much16 blood. The obvious answer is to engage in bloodletting (guaranteed to calm a person down). Moreover, drawing from Aristotle, Galen helped to systemize humoral theory further by linkingthe treatment of illnesses to the theory of contraries, categorizing various mixtures to account forthe properties of drugs: ?Drugs were supposed to counteract the disposition of the body. Thus, ifa patient were suffering from cold and wet (upper respiratory infection), then the appropriatedrug would be one that is hot and dry (such as certain molds and fungi—perhaps hinting at the16 potential of penicillin).?Galen not only excelled as a practitioner, but also as a critical empiricist and as a synthesizer ofall existing medical knowledge. He experimented with live animals to study their nervous,circulatory, and muscular systems, and provided public demonstrations of his dissections of apes,goats, pigs, sheep, and other animals. Galen‘s body of writing included at least 300 titles, of17 which 150 survive on topics ranging from anatomy to physiology to surgery to philosophy.Moreover, as a court physician (archiatri sancti palatii) for the Emperor Marcus Aurelius, Galensurmounted the stratification of society during Roman times, elevating the role of physician to18 what some consider its highest point. Physicians, Court and Public Practices, Military Medicine,and Public Health Table 1-2 Galen’s Expanded Framework of the Four13,16 Humors Elements SeasonsLife CycleHumorsQualityTemperament Childhood Warm and Sanguine (serene,AirSpring Blood (heart)(morning) moist unruffled)Yellow bile Warm and Choleric (bold,FireSummerYouth (noon)(gallbladder) dry exuberant)Adulthood Melancholic (stubborn,EarthAutumn Black bile (liver) Cold and dry(afternoon) insolent)Cold andWaterWinter Old age (evening) Phlegm (head) Phlegmatic (idle, foolish)moistUnlike the Greeks, the early Romans did not practice rational medicine, but relied on folkremedies passed down from father to son and, following Etruscan practices, on appeals tovarious deities. Like the Egyptians, the Romans believed that illnesses were caused by divineintervention. As the Greek city-states crumbled between 200 BC and 146 BC, the ruling Romanclass began to adopt many Greek practices, including the use of professional physicians. SomeGreek physicians traveled to Rome to seek employment as free men; however, many physicianswere purchased as slaves by wealthy Romans, who saved medical fees by having these slave15,19 doctors attend to the health of their families.Between the second and first century BC, the Roman Empire became a world power,encompassing numerous cultures and religions. Understandably, with the influx of foreigners inRome—and because anyone could declare him- or herself a healer—the practice of medicinewas in low repute and dominated by charlatans who claimed specialties in one or anotherdisease. Roman decrees and laws would gradually change the status of physicians, starting withJulius Caesar‘s granting of citizenship to all professional physicians practicing in Rome, circa 5020 BC, and culminating in Hadrian‘s decree in 133 AD granting immunity from taxes and military19 service to public physicians.Beginning around 100 BC, the Romans established hospitals (valetudinaria) to treat their sickand injured soldiers, along with corps of field medics and hospital-based physicians. The care ofsoldiers was important because the power of Rome was based on the integrity of the legions.Both military and gladiator-based medical practices led to advanced surgical techniques,including the treatment of head fractures, limb amputations, suturing, ligatures, andcauterization. Diet and exercise also were emphasized, with soldiers undergoing intense training15,21 and receiving ample rations, including hardtack for sustained marches.Moreover, in matters of public health, the Romans surpassed both the Egyptians and the Greeks.For example, the city of Rome had an unrivaled fresh water supply, gymnasiums, public baths, domestic sanitation, and adequate disposal of sewage. The Romans placed cities and militaryfortifications carefully, avoiding or draining swampy areas while also assuring easy access to15 water.Implications for Medical Group Practice On one hand, the widespread specialization found in Egyptian medicine diminished in Greco- Roman times as literacy, libraries, and a liberal education of physicians was supported. On theother hand, Greco-Roman medicine surpassed Egyptian medicine in its practices in surgery,22,23 pharmacology, ophthalmology, and internal medicine. Following Hippocrates, Greco-Romanmedicine focused on the patient‘s diet, exercise, and environment.The most reputable physicians, such as Galen, were broadly educated and trained in all aspectsof medicine. As opposed to Egyptian practice, the sophisticated forms of Greco-Roman medicineencouraged physicians to enter solo practice to serve the wealthy ruling class and to aspire toserve the Emperor and his subordinates as archiatri sancti palatii. The imperial funding of publicor municipal physicians (archiatri populaires) recognized the need for greater access to medicalcare among the poor and working citizens of Rome and its provinces. Because these publicpractices were also a training ground for those studying medicine, a loose form of group practicewas encouraged. Significantly, the empire also promoted a more structured group medicalpractice in military hospitals, along with the training of field medics and other mid-levelproviders.From Islamic to Renaissance Medical Practices The fall of the Western Roman Empire in 476 AD not only devastated Rome, but also shatteredthe institutions supporting public health and medicine throughout most of Western Europe. Theimmediate effect was the deterioration of medical knowledge and the corruption of practice,particularly in public health and the training of physicians; however, the long-term impact wasmitigated by the libraries and institutions sustained by the Byzantine Empire and the IslamicEmpire. Foremost among these was the library and university at Alexandria, which remained astorehouse and institution for medical knowledge and training. The growth of the RomanCatholic Church also contributed to the preservation of medical knowledge and its practicalextension. The most remarkable attribute of this historical period was the seeds for a revolutionin scientific and medical thinking that started with the Islamic Empire, grew during the lateMiddle Ages, and blossomed during the Renaissance.Islamic Medical Practice Fortunately for western medicine, the followers of Mohammed not only created a new empirestretching from Spain to North Africa to Persia, but also respected and embraced the study ofmedicine. Significantly, the Greco-Roman knowledge that was retained in the impressivelibraries of the former Roman Empire, especially in Alexandria, came under the control of thecaliphs of the newly founded Islamic Empire. "