A Changing Service

U nending change has characterized American health care in recent decades. The general practitioner in private practice, once the institutionalized symbol of medical care in the United States, has largely given way to specialists of many kinds. Where the general practitioner once sent a handwritten bill for services to the family home, he or she may now send a computerized invoice to an insurance company or a government agency. The “house call” has virtually disappeared.

Technology has taken over. Hospitals and other health care institutions may pay sums in seven figures for equipment that can save lives but that also demands to be used. A “technological imperative” requires that the new approach or instrument or drug at least be tried—experimented with, proven useful or useless, and made available to those who need it. In diagnosis and therapy in particular, physicians and other professionals are continually seeking the new and better.

Some seven million people work in the American health care system. Half a million of those are physicians. The facilities in which the system's personnel work range from rural clinics to high-technology urban medical centers. On balance, the consumer dealing with this system has many choices. Understanding those choices may make the difference between a beneficial experience and a frustrating search for help.

Health care reaches the American public at three broadly defined levels. The three are primary, secondary, and tertiary care.

Secondary Care

At the secondary care level the patient usually comes under the care of a specialist, often in a community hospital or other, similar setting. Secondary level specialties include such well-known areas of medicine as obstetrics and gynecology, dermatology, otolaryngology, and cardiology. While physicians often refer their patients for secondary level care, many persons “refer themselves.”

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