INTRODUCTION TO HEALTH AND THE HEALTH CARE SYSTEM
The World Health Organization (WHO) defines health as the absence of illness or disease and a state of being in which the individual feels well and is able to carry out the daily functions of life with no difficulties and no pain. In reality, no one reaches this optimum level of health. Everyone has aches and pains, psychological if not physical.
In our health care system, the physician’s responsibility is to examine hundreds of people in the course of a week and try to focus on medical problems that meet the following criteria: The problem is causing or can cause severe difficulties in carrying out the daily functions of life, and the problem can be treated either by reducing the effects of the symptoms or by eradicating the problem altogether.
Each individual the physician sees has a different group of presenting physical symptoms as well as a different set of social circumstances and emotional issues. The physician listens to the patient’s description of his or her life, performs objective laboratory and diagnostic tests, identifies medical problems, and assesses the nature of each problem.
Physicians know that the vast majority of medical problems do not pose a long-term threat to health. Most medical conditions get better over time. Effective treatments are available to cure many conditions (curative treatment). In other cases the physician can reduce the symptoms even if the underlying medical condition is not significantly affected. This type of treatment is called symptomatic treatment (responding to symptoms) or palliative treatment (seeking to reduce the effects of a disease or condition without curing the underlying disease). For example, a patient with a urinary tract infection who is given a prescription for antibiotics receives curative treatment, whereas a patient who has diabetes mellitus receives palliative treatment. The patient is prescribed insulin, which alleviates the symptoms of the diabetes; however, the treatment does not cure the diabetes.
Most treatments are based on scientific study. In Western scientific medicine, as in no other medical tradition, approaches to diagnosis and treatment have been studied and tested over hundreds of years. As long ago as the fourth century BC, a physician named Hippocrates in Greece believed that disease was not a punishment for transgressions against the gods, but rather the result of physiologic and environmental factors that could be studied. Since the time of Hippocrates, the practice of medicine has changed considerably in response to scientific discoveries (Table 1-1).
SHIFT FROM HOSPITAL-BASED TO COMMUNITY-BASED HEALTH CARE
Three trends running in parallel through modern medicine have led to an increasingly important role for office-based health care.
The first trend is the desire by those who pay the bills— employers, the federal and state governments, and insurance companies—to reduce the costs of health care whenever and wherever possible.
A second trend is the pressure for medical offices and clinics to provide a broad range of diagnostic and treatment services to avoid having to admit patients to the hospital. The increased cost of hospitalization has provided this pressure. Developments in diagnostic equipment, increased availability of home health care, and less invasive surgical procedures have facilitated the process.
The third trend is an increased understanding, through empirical evidence (information learned from experimental research), that people feel better the less they must be confined to a hospital or go to a hospital for treatment. Being able to be diagnosed and treated in an outpatient setting with follow-up at home allows people to feel more in control of their lives as medical patients. This is especially important for people who have frequent contact with the medical system, such as the parents of infants and children, the elderly, and those with chronic illnesses. Many people who would have been hospitalized for long periods or possibly even institutionalized 50, 25, or even 10 years ago are currently living independently in the community.
Today the hospital’s role is primarily to provide acute care and diagnostic services. In order for a patient to be hospitalized, his or her condition must be unstable or necessitate constant regulation of therapy. If the patient does not meet these strict criteria, he or she goes home to be followed as an outpatient; is transferred to a rehabilitation facility for intense, regular rehabilitative treatment; or is sent to a nursing home for long-term maintenance care.
MANAGED CARE VERSUS PATIENT CARE: COMPETING FORCES FACING THE MEDICAL OFFICE IN THE TWENTY-FIRST CENTURY
Fee-for-Service Insurance Plans
Traditionally, medical care in the United States was paid for on a fee-for-service basis. Each service was billed and paid for as a separate charge: so much for the office visit, so much for the electrocardiogram, so much for the urinalysis, and so on. Fee-for-service payments can be thought of as ordering food at a restaurant a la carte: so much for the main course, so much for a salad, so much for coffee.
During the first part of the twentieth century, health insurance (if the patient had any) paid only for hospitalization, and usually the patient completed most of the paperwork. Health insurance is a system by which a person or the person’s employer pays an insurance company a yearly amount of money, and the insurance company pays some or most of the person’s medical expenses for that year. The theory behind insurance is that, although a few people will have large medical bills over the course of the year, most people will have small bills. By setting the fee for everyone
|Table 1-1||1 Milestones in the History of Medicine|
|3000 bc||Writings about the circulation of blood in China.|
|c. 460 BC||Birth of Hippocrates (called the “Father of Medicine”) in Greece—based medical care on observation and believed that illness was a natural biologic event.|
|1514-1564||Andreas Vesalius—wrote the first relatively correct anatomy textbook.|
|1578-1657||William Harvey—discovered circulation of blood (England).|
|1632-1723||Antony van Leeuwenhoek—discovered the microscope (Holland).|
|1728-1793||John Hunter—developed surgical techniques used in surgery.|
|1749-1823||Edward Jenner—first vaccine for smallpox (England).|
|1818-1865||Ignaz Semmelweis—theorized that handwashing prevents childbirth fever (Austria); his theories were rejected during his lifetime and not accepted until the work of Pasteur and Lister.|
|1820-1910||Florence Nightingale—began training for nurses; established first nursing school; before this time nurses received no training and the profession had little status (England).|
|1821-1910||Elizabeth Blackwell—first woman to complete medical school in the United States; established a medical school in Europe for women only.|
|1821-1912||Clara Barton—acted as a nurse on the battlefields of the Civil War; was a civil rights activist and suffragette; organized the American Red Cross.|
|1822-1895||Louis Pasteur—developed pasteurization of wine, beer, and milk to prevent growth of microorganisms; microbiology (France).|
|1827-1912||Joseph Lister—demonstrated that microorganisms cause illness; his experiments with phenol, carbolic acid, and other antiseptics laid the groundwork for modern surgery (England).|
|Mid-1800s||First large hospitals, such as Bellevue, Johns Hopkins, and Massachusetts General, established in U.S. cities. Discovery of anesthesia in the United States is credited to a Southern physician named Crawford Williamson Long.|
|1843-1910||Robert Koch—isolated the bacteria that cause anthrax and cholera; established principles to determine that a specific type of bacteria causes a specific disease (Germany).|
|1845-1923||Wilhelm Roentgen—discovered x-rays (Germany) based on the discovery of radium and radioactivity by Marie Curie (18671934) and Pierre Curie (1859-1906).|
|1851-1902||Walter Reed—proved that yellow fever is transmitted by mosquitoes, not direct contact, while working as a U. S. army physician in Cuba. An aggressive spraying program made it possible to complete the Panama Canal.|
|1854-1915||Paul Ehrlich—coined the term chemotherapy; predicted autoimmunity; developed Salvarsan (arsphenamine), an effective treatment for syphilis, in 1909. This led to the development of sulfa drugs and other antibiotics (Germany).|
|1881-1955||Alexander Fleming—discovered penicillin (England); identified it in 1929, but an efficient method of producing large amounts was not developed until needed in World War II. Other antibiotic medications such as sulfa were soon discovered.|
|1891-1941||Frederick Banting—co-discoverer of insulin with Charles Best and John Macleod in 1922 (Canada).|
|1906-1993||Albert Sabin—developed oral polio vaccine.|
|1914-1995||Jonas Salk—developed parenteral polio vaccine.|
|1922-2001||Christiaan Neethling Barnard—South African surgeon who is remembered for succeeding at the first human-to-human heart transplant in 1967.|
|1978||Birth of Louise Joy Brown, the first child born by in vitro fertilization, in Great Britain.|
at a level above the actual cost of care for most people, the insurance company can pay for the care of the well, the occasionally ill, and the often ill and still make a profit.
This system encouraged health care providers to provide a high level of care for everyone with health insurance because the insurance paid for every test and every procedure. Physicians’ incomes soared between the end of World War II and the early 1980s. With the increasing costs of laboratory and diagnostic testing, hospital services, and office visits, the cost of medical care increased far more rapidly than the cost of other goods and services in the U.S. economy. (In economic terms, health care inflation increased much more rapidly than the general rate of inflation.)
During this time, ever-better health insurance became a standard employee benefit at many companies. The first kind of health insurance offered, in the 1950s and 1960s, was coverage for hospital care. Coverage for office visits became standard in the 1970s.
Government Insurance Plans
Recognizing that there were large segments of the population without insurance because they are not employed, the federal government began to provide health insurance to large segments of the population starting in the 1960s. Medicaid began to provide health insurance for low-income children without parental support and later expanded to cover all low-income people. Medicare initiated health insurance for the elderly, the disabled, and those with endstage kidney disease. The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS; now called TRICARE) provided health insurance for dependents of active-duty military personnel. With these programs, the
Historians generally place the beginning of Western medicine with Hippocrates, an ancient Greek physician who saw medicine as an independent discipline based on clinical practice rather than prayer and ritual. For several centuries there were few treatment methods other than rest, exercise, diet, and a few medications derived from plants. The intensive study of the human body in the 1500s fostered a better understanding of physiologic processes. For example, the English scientist William Harvey, who rejected the traditional belief that blood was made up of “spirits” and that body fluids were “humors,” developed a theory, later proved true, that blood flows from the heart to the lungs, throughout the body via arteries, and back to the heart via veins.
Physician in the Middle Ages taking a patient’s pulse and holding a flask of urine.
The first microscopic lens was invented in 1677 by Antony van Leeuwenhoek. Through his microscope van Leeuwenhoek saw yeasts, molds, and algae, adding evidence to the theory that diseases could be caused by particles too small to be seen with the eyes. He also identified red blood cells passing through capillaries.
Throughout the nineteenth century, other scientists and physicians advanced the understanding of the cause of disease. Some found ways to combat disease without understanding the mechanism by which the disease acted; others determined the actual cause of a particular disease.
In the 1840s the Viennese obstetric assistant Ignaz Semmelweis discovered that puerperal fever, or so-called “childbed fever,” a fatal illness of women who had just given birth, could be reduced if physicians washed their hands. He came to believe that physicians were infecting women by transferring disease-causing substances from one woman to another.
Semmelweis conducted what today would be called an epidemiologic study. He studied the records of women who had died and determined which physicians and medical students had attended which birth. His study of the records led him to conclude that most of the women who died had been attended to by
Early microscope, about 1765.
Extracting blood for a transfusion, eighteenth century.
physicians and medical students who had come into the birthing room directly from the anatomy laboratory, where they had worked with cadavers, without first washing their hands. Most of Sem- melweis’s colleagues dismissed his notion that simple handwashing could reduce childbirth deaths as nonsense, and during his lifetime, Semmelweis was ridiculed. It was not until decades later that physicians regularly began washing their hands.
The Scottish surgeon Joseph Lister worked on similar ideas to develop the first practice of antisepsis (cleaning areas where germs may be) and later asepsis (creating a germ-free environment). Lister started by pouring carbolic acid on the wounds of those who had just had surgery. Over time, he found milder substances. Lister found that far fewer patients who were treated with these substances died from gangrene that developed in the open wounds.
Semmelweis, Lister, and others worked empirically, which means they sought results through experiments that could be repeated with the same results. Although they were able to decrease infection rates, they never completely understood what caused infectious diseases. Other scientists sought to determine that bacteria caused specific diseases.
The German physician Robert Koch is called the “Father of Microbiology” because of his work with specific bacteria such as Mycobacterium tuberculosis, the bacterial agent that causes tuberculosis. Koch also isolated the bacterial agent that causes anthrax. Koch grew the anthrax bacillus in a number of different liquid media in his laboratory, used the microscope to identify it, injected the organism into a healthy animal, waited for the animal to become sick, and then recovered the same organism from the sick animal. This proved that one specific type of bacteria causes one specific disease. Today we know that it is possible to break the chain of illness by keeping those who are contagious away from those who are vulnerable to disease.
The work of Louis Pasteur and Koch, among others, helped set the stage for the understanding of infectious disease and for worldwide vaccination programs to eradicate smallpox and to try to eradicate the “childhood illnesses” of mumps, measles, and rubella (German measles).
The first vaccination actually had been performed a century earlier. Edward Jenner , an English physician in the farming country of Gloucestershire, used the pus from one person’s cowpox lesion to vaccinate another individual against smallpox in 1796.
Edward Jenner vaccinating an infant.
Cowpox is a variant of smallpox. It is lethal to animals but relatively harmless to humans. For centuries, people had realized that people who had been infected with cowpox did not develop smallpox. Today, we understand what had happened—their immune systems had developed antibodies to cowpox that also prevented smallpox infection by attacking the smallpox virus.
Jenner used “humanized cowpox” to establish immunity by taking pus from a lesion on a human infected with cowpox and rubbing it into an open wound on another human. A couple of weeks later, he inoculated the second person with smallpox. Not only did the individual not become ill, but he also was not contagious. A century later Pasteur would discover fully the mechanism by which vaccination works. Vaccines were discovered for many diseases. By the beginning of the twentieth century, vaccines had been developed for diphtheria and tetanus, and most children received these vaccines as infants by the middle of the twentieth century. New immunizations continue to be developed not only for infants but also for adolescents, adults, and the elderly.
Medications to kill bacteria were another important tool in the fight against infectious disease. Paul Ehrlich is credited with the development of the first medication to kill bacteria. In 1909 he developed a drug called Salvarsan (arsphenamine), which could be used to effectively treat syphilis. Unfortunately the medication itself was extremely toxic. The first of the sulfanilamide drugs, Prontosil, was developed in 1932 in Germany. It was effective against infections caused by streptococci and some other types of bacteria. The sulfanilamides became popular before and during World War II because they were the only antiinfective agents widely available. Penicillin, a mold that kills bacteria, had been discovered in 1922 by Alexander Fleming in London after it attacked bacteria that he was growing on agar plates. Initially the scientific community did not believe that it would be effective inside the body, and little follow-up research was done. During World War II, two medical researchers, Howard Florey and Ernst Chain, took up the research on penicillin and managed to prove that the medication was effective. The first human was treated in 1941, and within a few years mass production had been established and penicillin was in widespread use.
Discovery of the first virus is credited to Dimitri Ivanowski, a Russian botanist, in 1892. He discovered that a substance could pass through a ceramic filter that trapped all known bacteria and still cause a disease of tobacco called mosaic tobacco disease. We now know that the culprit is the tobacco mosaic virus. Yellow fever was the first viral disease of humans to be identified. During construction of the Panama Canal, workers were devastated by this disease. Research done by Walter Reed established that the disease was caused by a virus transmitted by mosquitoes and not direct contact. Controlling mosquitoes facilitated the work on the canal. The development of the electron microscope in 1930 allowed viruses to be seen, but progress to control viral diseases was slow. For most viruses the body has adequate defenses to overcome the infection, but there are some significant exceptions. The retroviruses, such as human immunodeficiency virus (HIV), are notable because they are able to overcome the body’s immune system. In the 1970s the first deaths from acquired immunodeficiency syndrome (AIDS) were reported in the United States. Within the next 20 years, a worldwide epidemic occurred. By 1997 more than 6 million deaths worldwide had been caused by the AIDS virus. Treatments have been developed to slow the progression of the disease, but to date there is no effective immunization or cure for this disease. The ability of viruses to mutate rapidly has resulted in recent viral pandemics from diseases such as severe acute respiratory syndrome (SARS) in 2004 and H1N1 influenza in 2009. ■
federal government has become the primary insurer for more than 50 million Americans. These plans, which included payments for office visits for illness, greatly increased the number of Americans who had medical insurance. There was little incentive for the consumer (the patient) to control costs because insurance was covering those costs, and care in most cases was “free” to the consumer.
Although most Americans who were insured did not feel that they were “paying” for their medical care, they were, indirectly. The huge increases in health care costs were one of the major sources of the generally high rates of inflation in the 1970s. Employers, who paid for the insurance, had to pay ever-rising premiums and offset these large premium increases with small increases in cash wages, which did not keep up with inflation. So American workers did, in fact, pay for health insurance and health care costs in lower purchasing power for the cash they received as salary.
Health maintenance organizations (HMOs) were originally formed with a belief that consistent, routine care would help prevent later expensive care. The expansion of health insurance to cover office visits originally covered only visits for illness or injury and did not cover so-called “routine care” (well-child visits, immunizations, regular checkups, or physical examinations). Managed care was based on the belief that increasing prevention and promoting early detection and diagnosis of chronic and life-threatening medical conditions would reduce costs. The HMO movement, which gained acceptance in the 1970s, pushed traditional health insurance companies to begin providing coverage for routine care.
In the late 1970s, insurance companies began to respond to escalating health care costs by reviewing care to find out if it was medically necessary. This process, called utilization review, identifies patients who, according to the insurance companies, no longer need to be hospitalized. Originally, utilization review was used by Medicare and Medicaid. Other insurance companies soon realized that shortening hospital stays was an important way of reducing overall health care costs. The combination of HMO insurance plans and strict utilization review for hospitalized patients is the basis of what we call managed care.
The original HMO model had two components: insurance and services including diagnostic tests and pharmacy. HMO plans set up full-service medical clinics. Physicians were employees. The HMO established a contractual relationship with a hospital for inpatient services, and patients had to go to the specific hospital with which the HMO had a contract.
In the late 1980s HMO services began to separate from HMO insurance. A second type of HMO model based on networks of physicians who agreed to provide care for HMO patients came into being. Some of these networks operated under the old fee-for-service plans but agreed to discounted fees from the HMOs in exchange for access to the rapidly growing patient populations enrolled in HMOs. In an effort to reduce payments, HMOs tried to have physicians accept a flat monthly fee for each subscriber in their practice and agree to provide all necessary primary care for that fee. This type of payment is called capitation. This reduces the incentive to provide extra services because their cost will not be reimbursed separately.
The managed care movement in general, as well as the trend to decrease reimbursement for primary care in particular, put the burden on physicians to compete with one another to provide the most care for the least money. As a result, physicians often feel pressure to limit diagnostic tests, reduce hospitalizations and the number of days patients stay in the hospital, and use generic instead of brand-name drugs. (Generics are identical in chemical formulation to brand-name drugs and can be manufactured only after the brand-name drug’s patent protection has expired.)
Managed care also puts pressure on physicians to see more patients, spend less time with each patient, and justify all services including diagnostic tests and referrals. The expense of handling sicker patients is expected to be balanced by those patients who use less than the average amount of medical services.
In addition, insurance plans have tried to reduce their costs for prescription medications by restricting drug coverage to lists of approved drugs. Such a list, called a formulary, usually includes one or two of the less expensive drugs for each possible medical condition. Exceptions are made if the physician can show that the less expensive drugs have been ineffective for his or her patient and that a more expensive drug is necessary. In some plans the patient can receive a more expensive medication by paying more of the cost.
Despite these measures, however, beginning in the late 1990s, both insurance premiums and health care costs began to increase at more than double and even triple the underlying rate of inflation. There has also been an increase in the number of individuals and families who do not qualify for government insurance plans, and also do not have health insurance through their employers. This may be because they work part-time or are self-employed. The Patient Protection and Affordable Care Act, which became law in March 2010, expands insurance coverage to an estimated 32 million Americans who were previously uninsured. Among the provisions that went into effect in September 2010, insurance companies are no longer allowed to exclude children with preexisting health conditions or to drop customers after discovering technical mistakes on applications. By 2014 this law will require all individuals to purchase health insurance or pay an annual fine. Even though this law has been challenged in the courts, a strong belief persists that society has an obligation to make appropriate health care accessible to all citizens.
There is no such thing as a “typical” medical office. The style of any particular medical office depends on the personality of the physician or physicians who practice there, as well as the general population of patients who come there. Regardless of the physician’s personality and the patients’ personal background, the same kinds of activities occur in any physician’s office setting.
Today, the trend in medical care is toward an increasing amount of ambulatory care—defined as the patient coming to the care rather than the patient receiving care in a home or hospital setting (Figure 1-1). To take advantage of ambulatory care, the patient must be able to walk into the physician’s office or at least be brought to the office in a wheelchair.
Figure 1-1 The patient check-in area in a clinic.
In addition to private physicians’ offices, offices of physicians who make up a staff model HMO, community health centers, multispecialty clinics, and hospitals are increasingly making more space available for outpatient care.
The flow of activities for each patient in an outpatient setting is similar. The patient will do the following:
Figure 1-2 is a flowchart of how a patient moves through the medical office.
Once a patient has been seen in the medical office, the office begins the process of obtaining payment for its services. The medical payment may come from a private
insurance plan, a government-funded insurance program, and/or from the patient. The patient may be responsible for a percentage of the charges or the entire bill if he or she does not have insurance.
After the examination the patient receives instructions to prepare for a test or procedure to be performed or information about medication that has been prescribed. Patients who are seen regularly because of a chronic illness may spend time with a physician or medical assistant reviewing the patient’s individual treatment plan. A follow-up appointment is made if necessary.
Most medical offices provide health education materials in the waiting room. These materials may consist of pamphlets, article reprints, health education videos, or health news reports specially prepared for viewing in the medical office.
The Health Care Team
A medical assistant works as a member of a dedicated health care team. The physician or group of physicians expects each medical assistant to fill a slightly different role within the office team. This role will depend on the style of the practice, the region of the country where the practice is located, and what types of medical professionals make up the team.
As the operations of a medical practice become more complex, physicians may employ individuals with more specialized medical business and medical management experience to run the business side of the office. In these offices, medical assistants play more of a clinical role. In smaller offices, medical assistants usually perform both clinical and administrative activities.
Members of the Health Care Team
The members of the medical team who typically work in ambulatory care, be it a private practice, a community or public health clinic, or a hospital clinic, include physicians, NPs, PAs, medical assistants, registered nurses (RNs) or licensed practical nurses, a business manager, a receptionist, a medical secretary, file clerks, and one or more insurance specialists. Medical transcription is occasionally done in the medical office, but increasingly it is outsourced or replaced by the electronic medical record or voice recognition software. If the office performs moderate- or high-complexity laboratory tests, a certified medical technologist may also be on the staff or serve as a consultant.
Hospital or community-based clinics will possibly also have a staff of social workers, outreach workers, and case managers to provide social services to patients. Practices specializing in women’s health (obstetrics and gynecology) may also have certified nurse-midwives.
Physicians and Other Health Care Providers
Physicians have either an MD (medical doctor) or DO (doctor of osteopathy) degree, either of which is awarded after 4 years of college, then 4 years of medical or osteopathic school. In addition, they complete a hospital-based, intensive postgraduate training period, traditionally called a residency, which lasts from 2 to 7 years, depending on the specialty. To receive a medical license from the state where he or she will practice, the physician must pass Parts I, II, and III of the U.S. Medical Licensing Examination (USMLE). The first two parts of the examination are taken during medical school, but Part III cannot be taken until the physician has completed at least 1 year of residency (sometimes called an internship).
If a physician wants to be “board certified” in a specialty, he or she must pass another examination, administered by the certification board of the particular specialty. The physician does not need to be board certified to obtain a state license to practice medicine.
A PA must have at least 2 years of college plus 2 years of PA school, although most PA programs award a master’s degree. A PA usually specializes (e.g., in pediatrics, in adult medicine) and manages a group of patients receiving routine care. He or she must practice with a physician. All states have laws regulating PAs, and students must pass the national certification examination.
An NP is an RN who has completed a program in advanced practice nursing, a program that usually grants a Master of Science in Nursing (MSN) or higher degree. NPs can specialize in pediatrics, family practice, gerontology, or other specialty areas.
The educational requirements and scope of an NP’s ability to practice independently are determined by each state. In all states, NPs are allowed to carry a caseload and manage routine patient care. Most states allow NPs to write
Table 1-2 Nurses and Allied Health Professionals
|Certified Professional Coder||CPC||Assigns codes to patient charges and diagnoses for insurance billing. There are|
|Certified Coding Associate||CCA||many coding certifications depending on knowledge and specialty.|
|Diagnostic Medical||DMS||Performs ultrasound scans in hospitals and ambulatory care facilities. Ultrasound|
|Sonographer||uses high-frequency sound waves to produce images. A sonographer may specialize in ultrasound of the heart (echocardiography).|
|Emergency Medical Technician||EMT; paramedic||Provides emergency services and life support in the community. Several levels of|
|Paramedic||emergency service personnel exist, depending on training and experience.|
|Health Information Specialist||RHIA; RHIT||Works with patient medical records; may provide assistance in planning, managing information, gathering data for medical research, and policy making.|
|Medical Assistant||CMA (AAMA); RMA||Performs administrative and clinical tasks in ambulatory care.|
|Medical (Clinical) Technologist||MT; MLT||Performs laboratory tests in the clinical laboratory and may supervise laboratory operations or provide consulting services.|
|Medical Secretary||CMS||Secretary who specializes in administrative procedures in a health care setting.|
|Nuclear Medicine Technologist||CNMT||Operates devices that detect and map absorption of radioactive substances given by injection to create diagnostic images.|
|Nurse, Practical||LPN; LVN||Performs direct patient care and clinical procedures. May work in hospitals, nursing homes, and ambulatory care settings.|
|Nurse Practitioner||NP||Specializes in a specific area such as internal medicine, pediatrics, and women’s health and often manages routine patient care in ambulatory care settings.|
|Nurse, Registered||RN||Plans and provides nursing care in inpatient settings. Provides supervision for caregivers in both inpatient and outpatient settings.|
|Occupational Therapist||OT; OTA||Plans therapeutic activities for rehabilitation, especially for activities of daily living|
|Occupational Therapy Assistant||(ADLs). Implements treatment plans.|
|Physical Therapist||PT; PTA||Plans exercises for large muscle groups for rehabilitation and implements|
|Physical Therapy Assistant||treatment plans.|
|Physician Assistant||PA||Manages routine patient care under the supervision of a physician. Usually works in ambulatory care.|
|Radiologic Technologist||RT||Takes radiographs and assists with special radiographic examinations. After completing education, may specialize in computed tomography, mammography, or therapeutic radiation.|
|Registered Dietician||RD||Assists with nutrition of patients in hospitals and ambulatory care. Performs nutrition screening and counseling. Coordinates all aspects of food service in many settings.|
|Respiratory Therapist||RRT||Provides respiratory treatments and manages patients on ventilators.|
|Surgical Technologist||CST||Assists during surgery in hospital and day surgery centers by setting up operating rooms, preparing instruments and equipment, and passing|
instruments during surgery.
Case Study 1
In the examination room, Alicia Darwin, a new patient, tells Aida that she has switched physicians because she had often been seen by a nurse practitioner in the medical office where she used to go. “I don’t think a nurse practitioner has as much experience as a doctor,” she said, “and besides, the nurse practitioner can’t give me medication if I need it.” She asked Aida to confirm that she would always be seen by the physician in this office. She added, “I don’t have anything against nurses like you; I just want to have a real doctor take care of me.” ■
prescriptions; in other states a physician must cosign the order. In some states, NPs are allowed to practice independently, but in most they must practice in an office with supervision by a physician. In a few states, NPs are allowed to admit patients to hospitals.
Working as an effective health care team does not just happen. To be effective, team members work together to provide appropriate care for each patient. The more people involved, the more crucial this teamwork is. Each member of the team must be committed to problem solving, communicating, and coordinating effective care.
Teamwork is reinforced at regular staff meetings, which can be directed by either the medical or the business director of the office, depending on the particular topics of the meeting. But the true test of teamwork occurs on a daily basis as health care is provided.
Each health care team member has a certain responsibility and restrictions on activities and areas about which he or she is allowed to make decisions. Sometimes this scope is defined by federal or state law. For example, medical assistants are allowed to administer injections in some states, but in others they cannot. The medical assistant must learn what areas fall within the proper scope of decision-making responsibility in his or her state.
The specific education and role of the medical assistant is discussed in Chapter 2. The medical assistant plays an important role by keeping the work of the office flowing smoothly. He or she must communicate well with other health team members. Because a patient will not always repeat all information to the physician, the medical assistant must communicate anything related to the patient’s health verbally or through the medical record. At the same time, the medical assistant must be careful to avoid using diagnostic terminology in the medical record or giving medical advice to the patient (unless following specific guidelines established by the physician).
Teamwork is enhanced when each team member helps and supports other members and avoids blaming or criticizing others. Because the number of employees in a medical office is often small, it is important for everyone to do his or her best to get along and deal with conflict. When a problem arises, it is important to try to find solutions to the problem rather than focusing on who caused the problem or whose fault it is. It is also helpful to maintain perspective and accept that things do go wrong, and most problems can be dealt with. In any conflict situation, it is important to listen to the point of view of others and validate their feelings. Effective communication techniques are discussed in more detail in Chapter 4.
PARTS OF THE MEDICAL OFFICE
A physician’s office has a number of different physical spaces in it. Each space has a particular purpose. Every physician’s office has three basic areas: a reception area and waiting room, examination and treatment rooms, and an area for other activities. This may include medical records storage, if the office uses paper medical records; storage for supplies; and staff offices or cubicles.
In most offices, physicians also have their own offices, separate from examination rooms, but some physicians have examination tables in their offices, combining the two spaces in one room.
Larger offices may have several additional areas such as an office laboratory; separate treatment rooms or special procedure rooms; a business office, which is separate from the front office (reception, telephones, appointments); and a lunch or break room for the staff.
All physicians’ offices must meet a number of specifications laid out by regulatory agencies. These include the federal Occupational Safety and Health Administration (OSHA), which regulates workplace health and safety. They also must meet the specifications of the Americans with Disabilities Act, which requires that doorways be at least 3 feet wide and hallways at least 5 feet wide. Restroom facilities must be available for both patients and staff. Office laboratories are regulated by the Clinical Laboratory Improvement Amendments of 1988 (CLIA’88). Local boards of health also inspect and regulate hospitals and clinics.
Reception Area and Waiting Room
The reception area and waiting room are the first place any new or prospective patient will see. First impressions are important. The waiting room should be clean and well lit. Furniture should be arranged and not haphazardly placed. Up-to-date, general-interest reading material should be available; many physicians also have patient education materials available in the waiting room. Waiting rooms in pediatric and family practice offices also have toys available for children. Large pediatric practices may have a separate waiting room for sick children or for adolescents.
The waiting room should have enough chairs for two people per patient visit, multiplied by the number of patients seen in 2 hours. It needs to present a calm atmosphere and look professional. Usually the waiting area is carpeted. It should have comfortable chairs, grouped in blocks if possible rather than just lined up around the walls. Colors should be muted, and music should be soft. Red, yellow, and orange are typically avoided; today, physician’s office decor often uses shades of green, dusty pink, or salmon. Music is usually a tape or radio station of the “easy listening” variety.
The reception area adjoins the waiting room. The medical assistant at the reception desk should greet each patient as he or she enters the waiting room. Most reception areas have a counter so that the patient can fill out or sign forms, and many have a sliding window so that patients cannot hear the conversations occurring behind the receptionist.
Patients check in here when they enter the office. New patient forms are received here, and health insurance cards are copied. Copayments are taken from patients whose insurance is provided through HMOs. Appointments may be made by the receptionist or in a separate area of the office.
Examination Rooms and Laboratory
Examination rooms are designed for the convenience of the physician and assisting personnel who will work there. However, they also need to be as comfortable and calming to the patient as possible. Reading material should be available in each examination room. Although good scheduling will ensure that patients will not wait too long in these rooms for a physician, most physicians do see patients in at least two examination rooms. Additional delays may occur if the physician has to respond to urgent telephone calls or office emergencies (Figure 1-4).
Many physicians perform treatments or diagnostic procedures in examination rooms, but complex procedures (such as suturing a laceration) are often performed in larger rooms with extra equipment and/or supplies. These are called treatment rooms.
If laboratory tests are performed in the medical office, there is a special room or area set aside for this. CLIA ’88 regulates laboratory testing. Medical assistants are trained to perform low-complexity tests (CLIA-waived tests) and
may also perform more complex texts with special training.
CLIA ’88 specifies who can supervise laboratories and lays out the process for inspection and accreditation. It sets strict guidelines for quality control, quality assurance, handling of hazardous materials, documentation, and proficiency training. Offices that perform only CLIA-waived laboratory tests may perform laboratory testing in the patient preparation area. Ideally the bathroom is adjacent to this area, with an opening in the wall so that urine samples can be passed directly into the laboratory area.
Medical Records Storage and Business Office
If the office uses paper records, the medical records may be stored near the reception area, in the business areas, adjacent to the patient preparation area, or in a separate room. Charts of active patients—those who have been seen within the past 2 to 3 years—are kept in the records storage area in the office. Inactive charts are removed regularly and stored in a less accessible location such as the basement of the building or off-site in a facility that maintains records in storage. Charts needed for patients who will be coming in during a specified period—morning, afternoon, or an entire day—are removed from the storage area and prepared for use.
Some practices are moving away from paper records to computerized medical records. In this case, patient records are stored on a computer’s hard disk and are simply pulled up from the database as needed. The process of placing old records into the computerized record is lengthy, and many offices that use an electronic medical record store the former paper record of established patients in an accessible area and make it available to the provider during patient visits.
Posting of patient charges, billing, and computer operations may be performed in an area behind the reception
Case Study 2
The physician complains to Aida that there are always dishes in the sink in the break room and crumbs and used paper coffee cups on the table. Even though the area is not seen by patients, the physician is concerned that an insect or rodent problem could develop. Aida knows that the part-time file clerk and the parttime receptionist have a tendency to leave dirty dishes and trash after their afternoon break. She herself is so busy that she rarely has time to either clean or sit down in the break room. ■
desk or in a separate business office. If the practice has one or more satellite locations, the billing and insurance tasks are usually done in the practice’s main office for all locations. Some offices contract billing and insurance claim processing to an outside company, which may even be located in another state.
Additional Areas Found in Many Offices
Physicians’ private offices are often a reflection of their personal tastes. This room is where a physician meets privately with patients, patients’ families, and other visitors. He or she usually displays degrees and certificates of membership in professional organizations on the walls of the office. Even if the practice has a small library for the use of all staff, physicians will usually have at least a few important references in this office. Art and memorabilia that show the physician’s personal taste also help to make the private office a pleasant place for the physician to do quiet work and hold meetings.
Recognizing the needs of staff for a quiet place to take their breaks and eat their lunch, newer offices often include a staff break or lunch room. This room may have a refrigerator and microwave for staff to prepare lunches they bring from home. There should be at least one table and chairs. The lunch or break room should not double as a storage area, and staff should avoid using the room for meetings that deprive others of use of the room. Depending on the type of medical practice, particular rooms may be set aside for specific treatments or diagnostic procedures. Types of special rooms include the following:
Since the middle of the twentieth century, the practice of medicine has been broken down into fields of specialty and
Aida Reyes: The clinic where I did my externship was so large that at first I kept getting lost. Another thing that confused me was the doors that the staff used to get from one part of the clinic to another. It was arranged by department, but the layout of rooms in each department was different. I spent the majority of my time in internal medicine working with one medical assistant and one physician, but my preceptor arranged for me to spend time in other departments like medical records, billing, and pediatrics and with the referral coordinator. In addition to the full-time physicians, there were some specialists who came in once or twice a week, including a neurologist, an orthopedic surgeon, and an ophthalmologist. The clinic also employed a social worker and a dietician. In each department there was a nurse and there were at least two medical assistants in addition to the receptionist. The amazing thing was how quickly I adapted and became comfortable finding my way around. After only a few weeks, it felt like I belonged there. I was so proud when my preceptor said, “Aida, you have become one of the team. I don’t know how we ever got along without you.” ■
subspecialty. In 1950 most Americans received their medical care from a general practitioner, who took care of adults and children, often delivered babies, and performed many general surgical procedures.
Today, Americans may see two, three, or more physicians routinely. Box 1-1 describes the medical specialties recognized by the American Board of Medical Specialties. In many areas, there are several subspecialties. If the physician wants to work in a subspecialty, after the residency training he or she participates in additional training called a fellowship for 2 to 3 years. It is not possible to be board certified in any specialty or subspecialty without completing a residency.
Primary care physicians specialize in internal medicine (treatment of the internal organs of adults by other than surgical means), pediatrics (general medical care of children and adolescents), or family medicine (general medical care of children, adolescents, and adults—today’s equivalent of general practice).
Over the course of time, the activities of different types of physicians have shifted. For instance, fewer family practitioners deliver babies today than did general practitioners in the 1950s and 1960s, preferring to leave that task to obstetricians owing to the cost of malpractice insurance. Although some women continue to see a gynecologist for an annual pelvic examination and Pap test, the primary care provider performs these activities more often today than in the past.
Because of the requirements for a primary care provider in managed care plans, some specialists, especially
BOX 1-1 Medical Specialties
Allergy and Immunology (Allergist, Immunologist): Treats adults and/or children with allergies and problems of the immune system. Many individuals experience allergies and/or asthma in the presence of allergens. The immune system can also malfunction either through inherited or acquired diseases. Allergists and immunologists diagnose, manage, and treat allergic diseases, immunodeficiency conditions, and autoimmune diseases.
Anesthesiology (Anesthesiologist): Provides anesthesia during surgery and other procedures, as well as medical care to patients before, during, and after surgery. The anesthesiologist also supervises other anesthesia personnel in the operating room such as nurse anesthetists and anesthesiology residents.
Colon and Rectal Surgery: Performs surgical treatment on the large intestine and rectum. These surgeons specialize in the diagnosis and treatment of diseases of the colon and rectum in addition to full training in general surgery. They perform diagnostic and screening procedures and perform surgery when necessary.
Dermatology (Dermatologist): Specializes in conditions of the skin. Dermatologists diagnose skin diseases and also perform surgery on the skin. Laser treatments are commonly used for skin conditions in addition to medication, cryotherapy, and surgery.
Emergency Medicine: Treats patients for emergency conditions, usually in the emergency department of a hospital. Emergency medicine focuses treatment of acute illnesses and injuries that require immediate care. The physician is often an employee of a hospital emergency department or other urgent care center.
Family Medicine (Family Practitioner): Treats adults and children for routine care and complaints; often the primary care physician for all family members. The family practitioner is concerned with the total health of the individual and the family. Specialized training is available for the subspecialties of geriatric medicine and sports medicine.
Internal Medicine (Internist): Provides medical treatment for conditions of various body systems. The internist may be the primary care provider for adults. Within the discipline of internal medicine are several subspecialties such as adolescent medicine, cardiovascular disease, critical care medicine, endocrinology, gastroenterology, geriatric medicine, hematology, medical oncology, nephrology, pulmonary disease, rheumatology, and sports medicine.
Medical Genetics: Provides diagnostic procedures and treatment for individuals with genetically linked diseases. Also provides genetic counseling and prenatal diagnosis. May specialize in laboratory testing or in research related to genetic diseases.
Neurological Surgery (Neurosurgeon): Performs prevention, diagnosis, surgical and nonsurgical treatment, and rehabilitation for conditions of the brain, spine, and nervous system. Also provides surgical and nonsurgical treatment of pain. Subspecialties include vascular neurosurgery and pediatric neurosurgery.
Nuclear Medicine: Specializes in diagnosis using radionuclides, atoms that give off electromagnetic radiation. Nuclear physicians are usually employed by a hospital or university (or both) and have little direct patient care. They are responsible for diagnosis and recommending treatment of abnormalities detected by the various imaging modalities used in the nuclear medicine department.
Obstetrics (Obstetrician) and Gynecology (Gynecologist): Specializes in care during pregnancy and delivery (obstetrician); specializes in other care and surgery of the female reproductive system (gynecologist). The gynecologist is responsible for screening procedures, diagnostic procedures, and both medical and surgical treatments. He or she also frequently uses hormone-modulating treatments.
Ophthalmology (Ophthalmologist): Specializes in the care of the eye. The ophthalmologist manages diseases and conditions of the eye with both medical and surgical treatment including laser treatments. May also manage errors of refraction and prescribe corrective lenses, although this is often delegated to an optometrist. Several subspecialties deal with specific eye diseases or parts of the eye.
Orthopedic Surgery (Orthopedic Surgeon): Specializes in diagnosis and treatment of acute and traumatic injuries of the musculoskeletal system, as well as diseases of the muscular or skeletal system. Both surgical and nonsurgical treatments are used. Some orthopedic surgeons specialize in specific joints, specific age groups, orthopedic sports medicine, or orthopedic oncology.
Otolaryngology (Otolaryngologist or ENT): Specializes in the care of the ear, nose, throat, head, and neck. The ENT is responsible for the diagnosis and surgical or nonsurgical treatment of a variety of disorders. Many physicians specialize in the care of only one organ or area and may focus on either reconstruction or diseases of that organ.
Pathology (Pathologist): Examines cells, tissues, and other specimens to determine whether their structure is normal or abnormal; attempts to determine the nature or cause of disease. Pathologists examine tissue biopsies and other specimens to identify abnormal cells. They also perform autopsies. They may be trained within two primary specialty areas: clinical pathology and/or anatomic pathology.
Pediatrics (Pediatrician): Specializes in the care of children from birth through adolescence. In the United States, pediatricians are considered to be primary care practitioners. However, many pediatricians specialize, and almost every specialty for adult medicine is represented as a pediatric subspecialty.
Physical Medicine and Rehabilitation (Physiatrist): Specializes in the treatment and rehabilitation of patients with disabling conditions such as spinal cord injury and stroke. A physiatrist sees patients across several age groups and specialty areas and focuses on restoring maximal function to patients. He or she may specialize in specific age groups or types of injury such as spinal cord injury.
Plastic Surgery: Specializes in surgical and nonsurgical treatment of physical defects of various areas of the body. The plastic surgeon performs procedures for cosmetic enhancement or reconstruction of various parts of the body. Cosmetic surgery has become popular in the past 2 decades. Reconstructive surgery includes craniofacial surgery, hand surgery, and maxillofacial surgery to repair congenital defects and problems that result from injury or disease.
Preventative Medicine: Includes aerospace medicine, occupational medicine, and public health. In this medical specialty, physicians practice in one of the specialty areas or one of the subspecialties (medical toxicology or undersea and hyperbaric medicine).
Psychiatry (Psychiatrist) and Neurology (Neurologist): Specializes in preventing, diagnosing, and treating mental illness and conditions of the nervous system. Psychiatrists have completed the same general training as any other physician, and they are able to prescribe medication for mental illness and monitor the effects of medication therapy. Like other mental health professionals, they usually also have training in psychotherapy, psychoanalysis, and/or cognitive behavioral therapy.
Radiology (Radiologist): Specializes in the use of x-ray and other ionizing radiation for diagnosis (diagnostic radiology) and treatment (radiation oncology). A radiologist has the training to manage several types of diagnostic imaging including x-ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI).
Surgery (General Surgeon or Vascular Surgeon): Performs general surgical procedures or vascular surgical procedures. A general surgeon performs primarily abdominal surgery using traditional methods or laparoscopic methods. A vascular surgeon manages diseases or conditions of the arteries and veins, except for the blood vessels of the heart and brain. Cardiothoracic surgeons manage conditions of the heart including the blood vessels, and neurosurgeons manage all conditions of the brain.
Thoracic Surgery (Thoracic Surgeon): Performs surgery of the chest including cardiac surgery, although thoracic surgeons usually specialize in surgery of the chest or cardiac surgery. Because cardiac surgery requires a high degree of skill, preparation for this specialty requires long and intensive training. Thoracic surgeons may limit their practice by age group served or by type of condition (such as congenital heart disease or heart transplantation).
Urology (Urologist): Specializes in the care of the urinary system in males and females and the reproductive tract in males; also specializes in surgery of the urinary tract and male reproductive tract. The urologist may provide medical conditions as for infections or surgical repair for abnormal growths or correction of congenital malformations.
obstetrician/gynecologists, also provide general care for some patients in their practice.
Osteopathy is a mix of traditional scientific medicine and holistic medicine which focuses more on healing the entire person than a specific disease or condition. This branch of medical practice seeks to balance the structure and function of the body through manipulation of muscles and joints. Osteopathy was started in the late 1800s by Andrew Taylor Still (1828-1917). Osteopaths see disease as the result of dysfunction in the skeletal and muscular systems. Pain,
“asymmetry” (the difference in anatomy or joint movement between one side of the body and the other), and tissue tenderness are used to gauge symptoms. Osteopaths, who hold DO degrees, today are given all the privileges of those with MD degrees. The majority of osteopaths practice as primary care doctors, where they believe their holistic and structural approach can be most effective.
Podiatrists use traditional medical and surgical techniques but are limited in their practice to treatment of disorders of the feet and ankles. Since the 1970s, podiatry has worked to enlarge its area of practice by focusing on surgery of the foot to alleviate such problems as bone spurs and bunions. Podiatrists work closely with primary care doctors in the management of diabetic patients and the elderly, who often require specialized foot care.
Chiropractic is the technique of spinal manipulation. Chiropractors believe that vertebral subluxations (partially dislocated spinal joints) cause nerve blockages, which in turn lead to pain in the back, neck, shoulders, and legs. Begun in 1895 by Daniel David Palmer (1845-1913), chiropractic holds that the body has its own ability to heal and maintain balance. According to chiropractic theory, the nervous system is the center of all disease and healing. Some chiropractors believe that subluxation is the reason for all disease. Today’s chiropractors, who are licensed by the state in which they practice, limit their treatment to discomfort clearly associated with the spine and integrate their practices into standard Western medical practice.
Figure 1-5 demonstrates a chiropractic adjustment.
Fifty years ago most physicians who were not full-time members of hospital staffs worked by themselves in an office, either in their home or in an office building. They paid their office expenses, taxes, and liability insurance out of their income, and the difference was considered their “net income” from their practice. As their practice got busier, their income increased. Today many physicians work with other physicians. Some of them have an ownership position in the practice or facility in which they work, but others are employees and receive a salary from their employer. The following categories refer to the way the office is structured, not the business arrangement or ownership.
It is still possible for a physician to work in a solo practice. But to do so, he or she must make a number of trade-offs. Solo practices are limited in their size by the number of patients one physician can manage. When a physician practices alone, the medical assistant is usually responsible for aspects of both administrative and clinical support.
Even if a solo practitioner employs an NP or PA to see additional patients, the physician still must factor into his or her workday some time to oversee the work of these nonphysician professionals. In addition, the physician, as the employer, is usually responsible for paying the malpractice insurance premiums for all of the licensed professionals in his or her office. Physicians in solo practice are also completely responsible for their patients. Usually they make arrangements with other physicians to share after-hours and weekend call responsibilities and to cover for vacations.
Many physicians today participate in a group practice. The most common type of group practice includes three or four physicians of the same medical specialty who band together to share resources such as office space and personnel. In these groups, medical assistants usually specialize in either clinical or administrative work, although they expect to help out in other areas.
Depending on the business form used, patients are the responsibility of either one physician or “the group.” In either case, if a patient’s regular physician is not available, another physician in the office can see the patient. In addition, physicians who work in group practices usually share after-hours and weekend call responsibilities. They usually split the cost of malpractice insurance, and the policy is written for the group rather than for each individual.
Large medical groups with physicians who provide primary care, as well as physicians with other medical specialties, are becoming increasingly common throughout the country. Their names often include the words “associates” or “medical associates.” This organizational form allows a sharing of resources that, in turn, allows each physician in the group to provide a broader range of services. In the past, these groups have been more common in particular regions and in rural areas, where a single group of physicians has the responsibility of being both the physicians in town and the staff of a small, rural hospital. HMOs that provide all services in one building, so-called “closed-panel HMOs,” also operate as multispecialty groups.
These practices often have separate administrative departments for billing, appointment scheduling, and referrals and separate clinical departments for phlebotomy, electrocardiography, laboratory work, and radiography. In such practices, medical assisting jobs can be limited in scope, and specific responsibilities depend on the department where the medical assistant works.
Traditionally a clinic was connected to a hospital and provided ambulatory care, often to patients with limited financial resources. Patients were either seen at no charge or billed by the clinic, and physicians were paid a salary for their services and/or saw patients as part of their residency program. Today a clinic usually refers to a public or nonprofit facility that provides outpatient public health services, although multispecialty group practices may use the word “clinic” in their name. Community health centers, established by the federal government in the late 1960s, operate as clinics and have physicians as well as NPs, PAs, and nurse-midwives all on salary. In many states separate laws apply to clinics related to licensing and supervision by public health agencies.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Numerous other practices are used for the treatment of illness, some of which have a long tradition and some of which have developed more recently. Studies from the early 1990s found that Americans annually spend literally millions of dollars on therapies that are not part of their physician’s standard approach. Patients often do not even tell their physicians about these other treatments. When practices have been used for extended periods in specific cultures, they may be called traditional medicine. The term complementary medicine is usually used for medical treatments that patients use in addition to standard medical treatments. The term alternative medicine refers to practices that are used instead of standard medical treatment. For many patients, these may overlap. Acupuncture, for example, has been a definitive method of treatment in traditional Chinese medicine for centuries (Figure 1-6). In the United States it has become a popular treatment method used in addition to standard treatment. It has become so popular that there are many schools to train practitioners, and the practice of acupuncture requires a license in about 40 states.
Since the early 1990s, scholars of medicine have begun to take an interest in studying complementary and alternative practices scientifically. The federal government has since established the National Center for Complementary and Alternative Medicine within the National Institutes of Health. This agency coordinates and funds scientific research to study the effectiveness of these health practices. The most well respected medical journals such as the New England Journal of Medicine and JAMA have published a number of studies about the effectiveness of various nonstandard therapies, and numerous specialized journals have also been established to publish research about such therapies. When research demonstrates that practice is effective, physicians trained in the classical Western medical tradition are more accepting and may even incorporate some of these practices or refer patients to practitioners.