Coordinator or consultant? Managed care intensifies debate over internists' roles.
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Biomedical subjects
Publications and source records attributed to F A Riddick.
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The major multispecialty clinics have established their niche as centers of excellence in coordinated patient care and patient-centered teaching and research. They will be increasingly dependent on local practice and participation in health care plans in future years. Their status as referral centers will hinge on their documentation of cost-effective care of high quality for the ultratertiary patient and on their ability to be recognized for this care by employers, insurers, and national health plans.
Many physician-managers enter the field of management in mid-career. There are ample opportunities for learning the principles of management through societies such as the American Academy of Medical Directors, through graduate degree and shorter programs targeted to mature physicians, and through institutionally developed programs of continuing education. Mastery of these principles requires application in practice. The challenges are great, and both personal satisfaction and financial rewards are good; but there is more risk in retaining such a position than there is in the practice of medicine.
Public perception that the challenges of meeting medical manpower and facility needs and of providing access to complex medical care have been met, coupled with concerns over mounting costs of medical care, will significantly reduce commitment to funding of graduate medical education. There will be reduced funding for longer educational programs and subspecialties and for foreign medical graduates, but not for primary care specialties and US medical graduates. The medical care system must ensure that each US medical graduate has access to the postgraduate education necessary as preparation for practice. The system will be challenged to develop necessary techniques for funding that education. An all-payor's system based on health insurance premiums, funds from the faculty practice plans, and sponsored programs carrying obligations of future service are reasonable possibilities for meeting funding needs.
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Graves' disease and Hashimoto's thyroiditis are autoimmune processes considered distinct diseases in light of current knowledge. In Graves' disease, antibodies directed against the thyrotropin receptor of the thyroid cell stimulate the gland to hyperfunction. The ophthalmopathy of Graves' disease may result from a different autoimmune reaction, directed against orbital tissue. In Hashimoto's thyroiditis, humoral and cellular immune processes are directed against elements of the thyroid cell and result in destruction and glandular hypofunction.
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Patients with a wise variety of medical problems have been labeled as having "hypoglycemia" during the past several years. Hypoglycemia, however, indicates only a diminished content of blood or plasma glucose. In individual cases the existence of hypoglycemia needs to be ascertained by objective laboratory measurements. Once confirmed, it is necessary to determine which of the many conditions capable of inducing hypoglycemia is present. Therapy must be directed against a specific diagnosis. It is not sufficient to decide by history without laboratory confirmation that a patient has hypoglycemia and then prescribe dietary modification.
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