J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from

FAMILY PRACTICE - WORLD PERSPECTIVE Comparisons of UK and US Practice

Daniel K. Onion, MD, MPH, Robert M. Berrington, MBE, FRCGP

Both the United Statesl -3 and the United King­ the substantial differences between the dom4,5 are in the midst of major restructurings of systems and family-general practice education in their health care systems to expand and create Britain and the United States. Educators in both more central roles for . These new countries can learn much from each other about approaches create valuable financial efficiencies training methods for common generalist profes­ and improve quality of care.6-13 sional skills. At the same time, however, they still In the United States extensive definition and must tailor their educational systems to produce planning for these has been ongoing for graduates who have the skills to succeed in their more than 2 decades, especially by family practice own national systems. A glossary of terms that educators. To a lesser degree, such planning has have different meanings in the United States and occurred in and internal , spe­ the is displayed in Table 1. cialties that share primary care responsibilities with . Only recently, in the past 5 Commonalties years, as a result of the dramatic shift to managed The essence of primary care has the same compo­ care health insurance systems, have the prestige, nents in both countriesll: first-contact medical income, and job opportunities led to a reversal of care provided continuously by the same to the decline in primary care training. The number individual patients; comprehensive, without body of graduating US medical students choosing train­ system or agent restriction; coordinated ing in primary care was estimated to be as high as with social, , and other paramedical ser­ 27 percent in 1995 14- 16 and 37 percent in 1997.J7 vices as well as with specialized, secondary and

In the United Kingdom the role of the general tertiary medical care; holistic, considering both http://www.jabfm.org/ practitioner has been defined and redefined dur­ scientific and psychosocial aspects of patients and ing the past 25 years. 18,19 Although the UK gov­ their health status. In both countries primary care ernment has emphasized the key role of the gen­ doctors are clinical generalists who apply the sci­ eral practitioner in the primary care-led National entific disease model to illness, when appropriate, Health Service (NHS), in 1995 only 26 percent of then deliver or advocate for the patient to obtain doctors finishing their required preregistration medical diagnostic and therapeutic care, and fi­ on 27 September 2021 by guest. Protected copyright. () year planned to enter general prac­ nally interpret the whole process to the patient. tice, a rate that represented a 20 percent decline When the disease model is inappropriate, the doc­ within the past 10 years20,21 despite strenuous re­ tor guards the patient against ineffective specialist cruitment campaigns by general practice educa­ , testing, treatment, and medicalization of tors. Thus, primary care in both countries ap­ nonmedical symptoms.22 peared to be at roughly the same recruitment level This latter portion of the role is often described in 1995, but on the rise in the United States while as "gatekeeper," a description that can falsely imply on the decline in the United Kingdom. the primary care doctor's primary duty is to ration In this article we examine the similarities and a medical "commons" rather than to advocate for the individual patient.9,23,24 The tensions between guardian and gatekeeping roles have increased re­ Submitted, revised, 10 April 1998. From the Maine-Dartmouth Family Practice Program cently in both countries. Health care payers have (DKO), Augusta, Maine, and The Anglia Deanery (RMB), created financial incentives for primary care doc­ Cambridge, United Kingdom. Address correspondence to Daniel K. Onion, MD, MPH, Maine-Dartmouth Family tors to ration medical services by capitating not Practice , 15 E Chestnut St, Augusta, ME 04330. only primary care but also secondary care services

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Table 1. Glossary of Tenns With Different Meanings and medical service needs that are met through in the United States and the United Kingdom. separate and minimally congruent delivery sys­ tems. Having generalist, one-stop social service USTenn UKTenn systems integrated with primary care medical Continuing medical Continuing professional practices could decrease the frustration of deliver­ education development ing primary care, especially to poor and mentally Faculty Trainer ill patients.30,3! In both countries fragmented, Family practice General practice rapidly changing, categorically organized social Internist Physician service and mental health systems remote from Junior resident, intern CRl) Preregistration officer Junior resident (R2) medical practices prevent maximal coordination Office of social and primary medical care services. Even Office visit Consultation so, British home health nursing services are more Partner Principal closely linked with general practices than in the Physician Doctor United States by virtue of shared and defined geo­ Preceptor Trainer graphic territories, regular meetings, and often Residency program Training scheme shared office space. In its most recent White Pa­ Residency director Course organizer per on the ,28 the UK Resident Trainee government requires general practitioners to lead Senior resident (R3) Registrar multiprofessional primary care groups to manage Specialist community-oriented primary care locally. These Visiting or home health District nurse (community nurse nursing sister) groups will include nurses, managers, social work­ (No similar tenn or Higher professional education ers, and as well as local training) (additional training while in general practitioners. practice immediately or soon after residency training) In both countries women represent an increas­ ing percentage (nearly 50 percent) of medical stu­ dents, postgraduate trainees, and practitioners in all fields, especially primary care.20.32.33 As a result, through managed care contracts in the United educational and practice systems are searching for States and by fund holding2s-n and, more recently, ways to accommodate part-time training and 28 commissioning in the United Kingdom. This work both for women who have traditional family http://www.jabfm.org/ conflict between the needs of the individual patient responsibilities and men who wish to assume and distributive justice for the collective good is greater responsibilities for child care. In both now a major ethical dilemma in both countries. countries the social values and work expectations In both the United States and United King­ of more recent generations of doctors are chang­ dom, primary care doctors are recognized as hav­ ing considerably.34 They seek increased medical ing an important role in promoting healthy life career structure flexibility3s and are more reluc­ styles at individual patient encounters,29 Overkill is tant to commit to the traditional 60-hour or more on 27 September 2021 by guest. Protected copyright. possible, however, and many British general practi­ work weeks and substantial personal financial in­ tioners reasonably point out that when health pro­ vestment in long-term practice commitments. motion is required by payers at the potential ex­ Furthermore, because a crucial and most profes­ pense of other, more appropriate types of care, sionally gratifying element of primary care is con­ elements of blaming the victims of inadequate tinuity of patient care, finding ways to balance re­ public health protection can result. For example, in quests for increased personal time without Britain until 1996 physician payments were effec­ sacrificing the essence of the professional experi­ tively contingent upon documenting that smoking ence is difficult but necessary in both educational cessation be brought up at every encounter with a systems. smoking patient. This policy has now been re­ In professional self-regulation, the United versed to allow practices to determine individually Kingdom adopted a uniform summative assess­ their strategies. ment method of certifying graduates of general UK primary care doctors and US primary care practice training programs in 1996, similar to physicians experience enmeshed social, mental, in the United States. Rather

US and UK Primary Care Training 163 J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from than periodic recertification testing as in the has uniform, comprehensive health coverage free United States, however, general practitioners and at the point of delivery and paid by national taxa­ directors of postgraduate education are piloting tion, with a small proportion of the population (12 practice-based recertification. Thus, the British percent) having additional, sometimes partial sup­ approach is to follow Berwick's admonition36 that plemental private insurance, often a perquisite for "the profession should polish all the apples rather top business executives. A large but decreasing than select out rotten ones." Regular rigorous proportion of the US population has some form of training program oversight and accreditation oc­ health insurance coverage, 85 percent in 1992,39 cur in both countries by the regional directors of which in many cases is less than comprehensive.40 general practice and the Joint Committee on Post­ These differences are the result of the two, very graduate Training for General Practice in the different roles played by the respective national United Kingdom and by the Accreditation Coun­ governments in the provision of health care. cil on Graduate in the United In contrast to the United States, the British States. Such systems of accountability enhance government runs a nationalized secondary and primary care doctors' arguments for retaining pro­ tertiary medical care system. Primary care services fessional autonomy, a goal commonly held in both are contractually purchased by the government countries. from individual general practitioners. Within this Finally, primary care doctors on both sides of system the government pays age-specific fixed the Atlantic are experiencing patients who are be­ capitation fees for and most chronic medical coming more demanding consumers.37,38 Such care, as well as fee-for-service payments for much feedback is, appropriately, also being incorporated preventive care and some specific chronic disease into parts of quality assurance processes on both monitoring. Thus the responsibility and account­ sides of the Atlantic. ability for health care and its costs are centralized and public in the United Kingdom, despite some Political Differences extremely modest, recent, and soon-to-be-aban­ Arguably the greatest difference between the two doned attempts at decentralization and quasi-pri­ countries is the percentage of the gross national vatization. These attempts included the creation product devoted to health care: 7 percent in the of so-called "NHS internal markets" (modest hos­ United Kingdom and 15 percent in the United pital competition by US standards) and of fund

States. These rates represent the extremes of the holding (modest, by US standards, financial risk http://www.jabfm.org/ Western world.4 The options for British medical sharing with general practices for secondary med­ educators planning change in general practice ed­ ical care costs, such as orthopedic referrals and ucation or practice are greatly restricted unless the physical ). The new Labor government total British allocation for medical care or the rel­ has announced its intention to abandon these ative proportion spent on primary care can be fur­ schemes in favor of community-wide variant com­ ther increased. In the United Kingdom approxi­ missioning.4,37,41 By April 1999 general practices, on 27 September 2021 by guest. Protected copyright. mately 20 percent of these limited total health along with other primary care and social services, care funds are spent on general medical (primary will be formed into primary care groups, each care) services,H whereas even within US primary serving populations of around 100,000, to com­ care-oriented health maintenance organizations, mission and plan local health care and community the comparable figure is usually 12 to 15 percent. services and to govern clinical standards.28 Thus, reallocation to primary care practice and This huge difference in the governmental ap­ education is much more possible within the more proach to health care in the two countries reflects generous total US health care budget. an underlying substantial difference in public tol­ Another dramatic difference is that costs of erance of inequities in access to health care. In medical care for the UK population are univer­ contrast to the United States, in the recent UK na­ sally covered by a National Health Service, tional election, prominent public debate occurred whereas the American population is only partially between the Conservative and Labor parties about covered by a patchwork of employer-based, per­ whether to extend or retract the modest risk con­ sonal, and federal categorical health insurance tracting with general practitioners (fund holding) schemes. Thus 100 percent of the British public and internal market health care experi-

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ments of the past 5 years. Certainly the concern decline. First, despite the national vision of a "pri­ about the potential development of a two-tiered mary care-led NHS," the morale of general prac­ system, with some subsets of the population having titioners in the United Kingdom has declined better access to care than others, has been hotly rapidly.46-48 Since 1990 general practice contract debated within the UK medical community as well revisions have been viewed as imposed and oner­ as the general public and is the basis for the current ous by most general practitioners, and early retire­ government's actions to abolish fund holding for ments have increased dramatically.46 As in the selected practices in favor of area-based commis­ United States, discouragement of medical stu­ sioning for all general practitioners.28 dents as well as interns from general practice by A further major difference between the two specialty teachers is thought to play some role. countries is in the approach to workforce plan­ Ironically, attempts to humanize specialty training ning. The United States relies principally on mar­ in the United Kingdom have had the unintended ket forces, which, given the 10-year pipeline for consequence of further contributing to this de­ practicing physicians, has a boom-or-bust effect cline in interest in entering general practice, as de­ on primary care as well as specialty recruitment. scribed below. UK general practice planning has been impaired by a lack of national statistics on numbers enter­ Training Program Differences ing, in, and finishing general practice training, un­ Formal training in general and family practice is 3 like the United States, where primary care num­ years' duration in both countries, but there are bers are available annually despite the more substantial differences nevertheless. Unlike Amer­ complex job of counting subsets of internal medi­ ican medical students, upon completion of sec­ cine and pediatric trainees destined for primary ondary school, British students enter 5 years of care compared with other specialty training. The medical study. After completing , United Kingdom is now investing in national they must do a 12-month preregistration or in­ workforce planning not only for physicians but ternship year of training in medicine and surgery also for all health care professionals because of and occasionally general practice before being al­ commitments by the UK Department of Health lowed to enter training in a specialty or general to collect better statistics and require regional practice. Even at that point, commitment to a par­ NHS executive offices to devise coherent work­ ticular field is often tentative; in general practice force plans for all health professionals.42 in recent years more than 50 percent construct http://www.jabfm.org/ Finally, there are major differences between the their own training program, usually in 6-month popularity of primary care careers in the United blocks of various hospital specialty training posts, States and the United Kingdom. The percentage until committing later to a final year of general of physicians both already in and planning to enter practice training. primary care (100 percent of family physicians and Combining high standards of teaching by ac­

a smaller percentage of pediatricians and in­ credited, paid trainers in general practice, large on 27 September 2021 by guest. Protected copyright. ternists) declined constantly in the United States numbers of applicants, formal educational assess­ from 50 percent in the late 1950s to 35 percent in ment strategies, and direction by general practice practice and only 14 percent of graduating medical educational specialists, general practice training in students entering primary care training in 1992 .14- the United Kingdom was for many years a model 16 In the last 5 years, the number intending to en­ of good educational practice and regarded as a ref­ ter primary care has doubled as a result of both erence standard by many other countries. Now, limited job opportunities for specialists and however, the directors of general practice educa­ markedly enhanced job opportunities, salaries, and tion and the NHS chief medical officer perceive prestige for primary care physicians. In contrast, serious flaws in the training structure.49 general practice in the United Kingdom has his­ In contrast to US family practice residency torically been dominant with nearly one half the training, a typical UK medical school graduate practicing doctors engaged in general practice, but destined to train as a will first fewer than 26 percent of young doctors are now spend a preregistration (internship) year and then entering general practice.20,43-45 2 more years on in-hospital rotations run exclu­ There might well be multiple causes for this sively by various specialists before experiencing

US and UK Primary Care Training 165 J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from primary care in an office setting. During their first from the trainee, usually verbal, is solicited during year, they must do two 6-month rotations, one in both the hospital and office phases of training, this medicine and one in surgery. During their second effort is undertaken only two or three times a year. postgraduate year, they must do two 6-month ro­ Our observation is that program evaluation is usu­ tations from among those in general medicine, ally less open and frank than in the United States, , pediatrics, , -gyne­ where monthly written evaluations encourage cology, accident and emergency, and general more constructive criticisms. But 1 year's time to surgery. And in their third year, they must do two undo specialist attitudes and teach all trainees need 6-month rotations from a longer list of specialty to know about office practice is too little. Recent, service rotations approved by the respective spe­ but so far unfunded, legislation might in the future cialty and general practice royal colleges and the allow one half of the last 3 years of general practice regional general practice postgraduate committee. training to occur in primary care practices. Despite these arrangements and despite guide­ More extensive integration of postgraduate lines published by the government's Standing training with undergraduate medical student train­ Committee on Postgraduate Medical and Dental ing in primary care occurs in the United States. Education, service pressures and the specialists' Unlike Britain, US medical school departments of overall lack of primary care teaching skills have re­ family practice usually oversee undergraduate sulted in considerably lower standards of primary training as well as some residency training in fam­ care teaching in UK than in the general ily practice; this system allows substantially more practice training practices. vertical integration of family practice education During their second and third postgraduate from medical student through residency training. years, those already committed to general practice In the United Kingdom undergraduate and post­ and in a formal program supervised by general graduate education are distinctly separate and practice course organizers (currently about 50 rarely integrated, with the medical schools respon­ percent of those who will eventually commit to sible for the former and the postgraduate deans general practice) attend a half-day per week "gen­ with the regional directors of general practice re­ eral practice release day" seminar series along with sponsible for the latter. those in their fourth, office-based year of training. There are also major differences between the On specialty rotations UK general practice resi­ two countries in medical school debt load carried dents (trainees) are exposed to strong hospital spe­ by trainees upon entry into postgraduate training. http://www.jabfm.org/ cialist role modeling and sometimes, as are Ameri­ British general practice residents rarely owe more can family practice residents, to anti-primary-care than £3000 to £5000 ($4500 to $7500) unlike the prejudice. Trainee work hours, 65 to 85 hours a frequent debts in excess of $60,000 incurred by week, are similar in both countries. many US medical students. As a result, newly In the fourth year of their training, British trained British general practitioners are generally

trainees apply to work with an approved, practic­ freer than American family practice graduates to on 27 September 2021 by guest. Protected copyright. ing general practice preceptor (trainer) in his or take time off before entering practice and lose less her practice. There the resident, now called a gen­ personally if they change fields completely. eral practice registrar, constructs an educational The number of training slots in family practice plan with the preceptor and is supervised and in the United States has been climbing steadily summatively assessed in both clinical and adminis­ from 2600 in 1989 to more than 3600 per year17 as trative aspects of general practice. The registrar family practice training programs have prolifer­ sees patients at a slightly slower rate than the se­ ated, expanded their enrollment, and responded to nior physician but in all other ways is integrated increasing demand for training by medical students into the small, 3- to 6-physician group practice and family physician recruiters (Figure 1). Finan­ structure. Much one-on-one precepting in office cially and legally there is no central control of pro­ and on home visits occurs. Communication skills gram numbers or size, so medical education is also teaching, especially using videotaping, is well de­ a marketplace wherein programs compete with veloped, perhaps more so than in the United each other for the medical school graduates. Until States. the recently passed 1997 budget reconciliation act, Although feedback about these experiences federal funding of residency training in any spe-

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3,700 --<>-- Total Trainees - July 3,200 --0-- Matched Total

~ Matched US Grads

'"c: -CI) "'CI 2,700 'iii CI) .....a:: a:: iii 2,200 -~

1,700

1,200 -f------.....------,..------r------,r------, 1986 1988 1990 1992 1994 1996 Year

Figure 1. First-year residents in family practice residencies, 1986-1996. Total and US graduates matched in annual March National Residency Match Program (NRMP) and total first-year family practice residents in July, 1986-1996; July numbers reflect recruitment of both US and international graduates to slots unfilled in the March NRMP match each year.

Data from Kahn et al. 17 cialty has been open-ended and unrestricted de­ country-2000 in 1990,7000 in 1995.16 spite urgings by the Council on Graduate Medical In Britain the distribution of practicing general Education for the past 5 years.so Increasing US practitioners is controlled by the British Medical medical student interest in entering primary care Association Medical Practices Committee. Al­ http://www.jabfm.org/ since the low of 15 percent in 1993 has led to fill though more coordinated workforce planning is rates of family practice training programs, with US anticipated, as in the United States, there cur­ graduates rising from 56 to 72 percent in the last 5 rendy is no national manpower planning for gen­ years. I ? This increase is all the more impressive eral practice. Paradoxically, with the implementa­ given the extensive expansion of family practice tion of dle 1993 CaIman report on revising training programs during the same period. specialist training,S I national manpower planning on 27 September 2021 by guest. Protected copyright. A huge pool of foreign-trained immigrant for all other specialties became required. The CaI­ physicians of widely variable backgrounds and man revisions also for the first time guaranteed English language skills is available to US pro­ trainees in hospital-based specialties full training grams unable to fill with highly qualified Ameri­ and employment after a predictable (usually 5 can medical school graduates. More than 400 ap­ years) training period and thus gready enhanced plications from this immigrant pool are received the attractiveness of specialty training. each year by most family medicine residency pro­ This increased attractiveness of specialty train­ grams. In the early 1990s many US family prac­ ing has worked to the detriment of general prac­ tice programs accepted many such physicians, but tice training recruitment. These changes, the with the growing popularity of prinlary care train­ post-1990 contract morale decline,46-48 and an ex­ ing with US graduates, is more selec­ pansion of the total number of hospital resident tive and less frequent now. About 17,000 physi­ (senior house officer) positions (Figure 2) to di­ cians graduate from US medical schools annually, minish house staff workloads, all contributed to and up until 1998, an increasing number of inuni­ further decreases in general practice residents grant physicians were permitted to enter the (trainees) (Figure 3). Many general practice train-

US and UK Primary Care Training 167 J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from

28,000 1,800 27,000 1,100 26,000 li> 1,600 ..c 25,000 E '"c -CI) ~ 1,500 ·en-= 24,000 co CI) a:: .2- 1,400 co 23,000 .2- 22,000 1,300 21,000 1,200 20,000 1986 1988 1990 1992 1994 1996 1986 1988 1990 1992 1994 Year Year Figure 3. Total, third-year general practice trainees (one­ Figure 2. Total, all hospital trainees on October 1 in year class) on October 1 in England and Wales, 1986- England and Wales, 1986-1994 (General Hospital 1996 (General Medical Services Statistics 1986-1996) Services 1986-1994); these numbers are much larger than in Figure 1 both because they include aU year­ mitment by general practitioners to a single com­ classes of trainees including preregistration house munity and a geographically defined population officers (interns) as well as registrars and senior gready enhances continuity of care, whereas in the registrars (residents and fellows) and because many United States greater physician and patient tran­ specialties required or allowed 5-15 years of training. sience limit it. Similarly, the UK geographical practice defInition allows for potentially much ing programs now have substantial numbers of easier, clearer identification of a doctor's COlnmu­ trainees from other European Union countries nity in which to practice community-oriented pri­ filling positions no longer attractive to UK gradu­ mary care. ates, much like the immigrant family physician phenomenon in the United States a decade ago. Practice Arrangements and Clinical Components In Britain changing aspirations, perhaps associ­ A striking difference exists between the plethora

ated with the increasing proportion of women en­ of practice options in the United States and the http://www.jabfm.org/ tering the field (more than 50 percent in 19942°), single predominant UK model. In the United have led to an increasingly common disinclination States multiple and complex practice organization by recendy trained general practitioners to com­ possibilities range from solo independent practice mit to the predominant single practice mode for to a salaried position in a multispecialty group. general practice, that of permanendy buying into Clinical components of family practice range from a smail-group practice and thereby providing the practices with broad responsibilities, including retirement fund for retiring partners. obstetrics, surgery, and intensive care and coro­ on 27 September 2021 by guest. Protected copyright. nary care units, as well as extensive office proce­ Practice Differences dures, to variations of a skill set such as that of the Continuity ofCare for Patients and Communities typical British general practitioner of stricdy am­ Patient care continuity, a central element of pri­ bulatory, home, and nursing home consultations, mary care, is on average probably better in the few procedures, and almost no hospital practice. United Kingdom. Self-referral and referral by Nevertheless, US primary care physicians are in­ other health care providers are not possible, al­ creasingly preferring to be employees of corporate though this situation is becoming more common health care systems, both because of the lesser in the United States as managed care systems are personal fInancial investment required and the implemented. In the United Kingdom the use of buffering from the external regulatory climate accident and emergency departments does not re­ such arrangements afford.52,53 In Britain, very few quire general practitioner referral, but triaging of general practitioners hold salaried contracts, but nonurgent problems to longer waits discourages older schemes for salaried employment are being overuse for minor illness. Also, dle lifetime com- restructured and new ones piloted.

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OffICe (Surgery) Clinical Support Systems monitor chronic in patients by protocol UK general practice and US family practice of­ but do relatively little acute visit care in substitu­ fices differ in several important ways. With pow­ tion for the general practitioner, as is done in the erful NHS reimbursement incentives and subsi­ United States. Although some are called nurse dies, British general practice offices () practitioners, few office nurses are trained as ex­ have been nearly universally computerized in the tensively in diagnosis and treatment as US family last 5 years with systems that have a clinical orien­ nurse practitioners. tation rather than the billing-financial orientation Visiting (district) and public health (health visi­ of most American office practice computer sys­ tor) nurses work closely with British general prac­ tems. Office note dictation and transcription, so titioners, often having office space in the physi­ common in the United States, is unheard of in cians' surgeries; the overlapping geographically the United Kingdom. The British general practi­ defined population responsibilities of both means tioner enters patient information directly into an they have more patients in common and hence examination room desktop personal computer work together more. There is also an extensive and in many practices prints out prescriptions as network of community-based nurse well after the system has checked for drug inter­ who share antenatal and postnatal care responsi­ actions. Health-screening information, episodic bilities with the general practitioner and who are visit diagnosis and treatment, and patient educa­ integrated with district hospital obstetrical units. tion materials are all readily available. Other surgery support personnel are probably This type of system also allows for easy, prac­ comparable, since US offices employ on average 3 tice-wide audits and patient recalls. On-line refer­ employees for every physician54 and the British, ence searches and evidence-based practice proto­ with less complicated multiple payer insurance cols are now being implemented into these extant systems, have 2 per doctor.33 systems. Several competing software programs vie for the general practice business and support. Al­ Relationships With Other Medical Practitioners though several American systems can duplicate Relationships with other medical practitioners are parts of these services, none achieve the wide use more competitive in the United States because and easy accessibility found in British surgeries, chiropractors, nurse practitioners, specialists, and although some worry about the effect of a com­ can all practice without the referral of puter screen between physician and patient. patients from family physicians, at least until the http://www.jabfm.org/ Laboratory testing in the United Kingdom is recent proliferation of managed care systems. rarely available in offices, unlike their US coun­ Even with managed care the tradition of more terparts, and it is used much more sparingly. US open access remains while the transition from fee stipulations that model practice units for resident for service, with completely open referral systems, training in family practice must have laboratory occurs. testing capability on site would not make sense in on 27 September 2021 by guest. Protected copyright. Britain. Responsibilities Examination room use is also dramatically dif­ Clinically, the US family physician usually has ferent. US family physicians insist on and use two both inpatient as well as office (surgery) responsi­ to three examination rooms per physician when bilities each day. Obstetrics, including deliveries, seeing patients, whereas British general practition­ is an important practice component for about one ers rarely use more than one room. Even so, both third of family physicians, who typically deliver 25 groups of physicians see roughly the same number to 50 babies annually. The US family physician of office (surgery) patients each day, 25 to 30. usually will do several procedures both in the of­ Physician assistants are relatively unheard of in fice and the hospital, see 25 to 30 office patients the United Kingdom, but they, along with nurse each workday, manage most common chronic and practitioners, provide a considerable amount of acute diseases, and take call every 4 to 5 nights in a acute and chronic care to ambulatory patients in call pool with other family physicians. On nights more than one half the family practice offices in and weekends patients who need to be seen are the United States. Office nurses in the United seen either in the office or more commonly by Kingdom provide advice and the family physician in the emergency depart-

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ment, not or only rarely at home. Medication or geography make the number ascertainable. dispensing is rarely part of US family practice. British general practitioners are uniformly ex­ In contrast the British general practitioner pected to co-manage a small 3- to 4-physician rarely has hospital responsibilities, sees a more practice or to delegate those responsibilities to uniform mix of outpatient illness in the surgery, one of the other partners. Recent subsidy support and is interrupted at midday typically by three to for practice managers by the NHS has increased five house calls. Patients with chronic diseases, the presence of some additional trained manager­ such as asthma, , and hypertension, are ial help, but the ultimate responsibility of the now more frequently being cared for by general practices still rests with the partners (principals). practitioners rather than in hospital-based , The NHS contracts with each general practi­ as they commonly were 5 to 10 years ago. The tioner individually, so with the exception of cer­ percentage of general practitioners doing obstet­ tain programs,55 practices cannot corporately rics has declined from 28 percent 20 years ago to assume patient care. This system differs from that 2.5 percent now. 33 in the United States, where family physicians can Night call is typically similar to that of the US run their own practice, with variations all the way family physician but without hospital responsibili­ from an autonomous practice to being simply an ties, and patients who need to be seen are usually employee of a corporation of other physicians, a seen in the patient's home. General practitioners hospital, an insurance company, or some other believe this house call tradition is being increas­ corporate entity running a primary care practice. ingly abused, especially after health care reforms in the early 1990s enhanced the expectations for Fears for the Future emergency house calls by the unilateral govern­ General practitioners in the United Kingdom fear mental promulgation of a patient charter that in­ increased clinical responsibilities for what was cluded all patient-requested house calls as one of previously specialty care without any commensu­ the general practitioner's duties. Britain does not rate increase in resources. 56 They hope for longer yet have a contingency fee-type malpractice litiga­ patient visit times and fear further loss of control tion system, which further contributes to in­ in their work because of increased consumerism creased anxiety regarding patient expectations in and management bureaucracy. They also fear the the United States. greater administrative burdens of more system With national government financial support, changes, including universal general practice http://www.jabfm.org/ traditional 4- to 5-physician coverage arrange­ "commissioning" and primary care group plan­ ments for night and weekend call are being rapidly ning in the NHS. They share US physicians' fears replaced with so-called "general practice coopera­ about competition from other medical practition­ tives," which are responsible for whole regions ers but have more enthusiasm for collaborative and require the individual general practitioner to primary care delivery. They share none of the US

take 6- to 12-hour call once every 3 to 4 weeks; family physician's worries about exclusion from on 27 September 2021 by guest. Protected copyright. these cooperatives operate from acute care clinics, clinical areas, exclusion from caring for their cur­ some hospital-based. They have reduced the out­ rent patients by managed care company contracts of-hours house calls, because usually one member for primary care with other physicians, or unfairly of a team of doctors sees patients in the applied managed care organization cost-based while another is out doing house calls. The coop­ standards.57 eratives lack any primary care doctor records on patients but fax a report back to the primary gen­ Conclusions eral practitioner the next working day. National US family practice and UK general practice educa­ patient education campaigns to encourage more tors thus share a substantial number of common appropriate use of primary care on-call services training goals and curricula objectives that are have had equivocal success. more extensively advanced on one side of the At­ Total patient panel (list) sizes are apparently lantic than the other. By increasing dialogue be­ fairly similar, 1500 to 2000 per practitioner in the tween us, we believe each might be able to adopt or United Kingdom and roughly the same in systems incorporate successful methodologies developed in in the United States, where managed care systems the other country into our own training programs.

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