(Received October 2, 1972; revision accepted for publication January 11, 1973.)
The data used in this paper were collected as part of the World Health Organization/International Collaborative Study of Medical Care Utilization, supported in the Baltimore Study Area by grant 5 RO1 HS 00110 from the National Center for Health Services Research and Development of the U.S. Department of Health, Education, and Welfare. Dr. Starfield is a recipient of a Career Scientist Development Award
(K02 HS46225) from the National Center for Health Services Research and Development USDHEW. ADDRESS FOR REPRINTS: (B.S.) The Johns Hopkins Hospital, 601 North Broadway, Baltimore, Mary-land 21205.
PEDIATRICS, Vol. 51, No. 5, May 1973
822
ARTICLES
HOW
“REGULAR”
IS THE “REGULAR
SOURCE
OF MEDICAL
CARE”?
Barbara Starfield, M.D., M.P.H., Thomas Bice, Ph.D., Elisabeth Schach, MA.,
David Rabin, M.D., M.P.H., and Kerr L. White, M.D.
From the Department of Pediatrics, The Johns Hopkins University School of Medicine,
Baltimore, Maryland
ABSTRACT. This paper presents the characteris-tics of the regular source of care identified for chil-dren in a household survey and relates these to perceived accessibility of services. Except in the preschool age group, a minority of children have a pediatrician as their regular source of care. Avail-ability of services at various times during the week is not consistently related to specialty or to board certification but geographic access to pediatricians, especially board-certified pediatricians, is more dif-ficult than is access to other types of physicians.
This is evidenced by a greater need to make ap-pointments (except in emergencies), and more re-mote, less convenient l&ation of physicians’ offices. Family income is related to the type of physician identified even among families who pay out-of-pocket the entire office visit fee. Accessibility of services should be considered with quality and cost in evaluating the adequacy of health care.
Pediat-rics, 51:822, 1973, ACCESSIBILITY, AvAILABILITY, SPECIALTY, BOARD CERTIFICATION, ADEQUACY OF
HEALTH CARE.
A
“MEDICAL HOME” and continuity ofcare are essential features of first-rate medical care.1 Many American children have no constant source of care.2’3 Even
those who do may question the extent to which their “medical home” provides a
“continuum”l of care. Availability and ac-cessibility are clearly the primary problems confronting patients.4 No individual physi-cian can provide absolute availability and continuity, particularly when optimal ac-cess, cost, and quality are competing priori-ties. Therefore, it is important to examine
the relationships between the types of phy-sicians serving as the regular source of care and the extent to which these sources are believed to be accessible in situations other than medical emergencies. Characteristics
which are of interest include the specialties of physicians, their certification by specialty boards, and the types of services they
pro-vide to patients.
METHOD
The data are derived from a household
survey conducted in 1968 to 1969 in 12
areas of seven countries as part of the World Health Organization/International
Collaborative Study of Medical Care Utili-zation.5 Only children in the Baltimore Standard Metropolitan Statistical Area
(Baltimore and its five surrounding coun-ties, hereafter designated as Baltimore
SMSA) are included in this report. With a questionnaire used in all 12 areas and a
supplement used only in Baltimore, trained
interviewers obtained information on 1,103 children in an area cluster probability sam-ple of 1,132 households of which 509 had children. All information on each child’s
TABLE I
TYPE OF PHYSICIAN SERVING AS THE REGULAR SoulIcE OF CARE FOR CHILDREN, BALTIMORE SMSA 1968 TO 1969
.
Type of PhysicIan
Age of Child, Yr
0-4 5-9 10-14 Total
No. of
Children 0/
0
No. of
Children 0
No. of
Children 0
No. of
Children 0
General Practitioner 31 22.8 32 31 .4 59 40.4 122 31 .8
Pediatrician
Board Certified 44 32.3 16 15.7 22 15.0 82 21.4 Not Board Certified 29 21.3 21 20.6 20 13.7 70 18.2
Internist0 18 13.2 14 13.7 288 19.2 60 15.6
Other Specialist
Board Certified 3 2.2 4 3.9 3 2.1 10 2.6
Not Board Certified 11 8.0 15 14.7 14 9.6 40 10.4
Total 136 100.0 102 100.0 146 100.0 384 100.0
* Only one was board certified.
physician was the regular source of care#{176} for a child, she was asked to identify the physician by name so that specialty and
board certification could be independently
determined from the AMA directory and records kept by the City Health
Depart-ment.
Of the 509 families with children, 200 had only one child. In 80% of the families with more than one child, all children were
reported to have the same regular source of
care.
Because families with several children might introduce bias in the findings if each
child were considered an independent ob-servation, two forms of analysis were
con-ducted: the first included all children and the second included only one randomly chosen child in each family. Only results
from the analyses employing the 509 ran-dom children are reported in this paper.
0 In response to the question, “Is there a
partic-ular doctor or doctors (talks with) (consults) (vis-its) when help is needed or advice is wanted about (his) (her) health?”
This procedure magnifies the importance of the child in single-child families in contrast
to their actual proportion in the population. However, the results of the two analyses were compared and found to be almost
identical.6
RESULTS
Extent to Which Physicians are the
Regular Source of Care
For the 509 random children, 31 (6%)
had no regular source of care, 64 (13%) identified a place which served as the regu-lar source of care rather than a physician,
30 (6%) had a physician who could not be
identified, and 384 (75%) a physician who could be identified. Of these 384, a general practitioner was mentioned for 32%, a
board-certified pediatrician for 21%, a
non-board-certified pediatrician for 18%, and another specialist for 29% (11 physicians were board-certified and 99 were not).
Table I shows the extent to which chil-dren of different ages were cared for by
0 10 20 30 40 50 60 70 80 90 100
121
80
68
11
95
375
: Appointment RequIred
824 SOURCE OF MEDICAL CARE
FIG. 1. Requirement for appointment to see their physicians, Baltimore SMSA children, 1968 to 1969.
Accessibilityt of Services
AvAILrnLrrY. Sixty-one percent of chil-dren with a regular physician and 60% of children with a regular place needed an
ap-pointment to see the physician (except in emergencies). Figure 1 shows that children who consult pediatricians are more likely to
need an appointment than children with
other types of physicians (p < .01
)4
Board certification of physicians is significantly re-lated to the need for appointments: 89% forcertified specialists, 58% for noncertified spe-cialists, and 45% for general practitioners
(p < .01).
Beliefs about the availability of services
during weekdays, weekday nights, and
weekends were also elicited (Table II).
+ Accessibility includes availability (“present in such form as to be usable”), geographic access, and “socio-organizational access” (the extent to which factors other than spatial or temporal ones facilitate or hinder efforts of clients to reach care ).
Chi Square test has been used to calculate the significance of differences reported. Winch and Campbell’ discuss the choice of such a test even in situations where it is, strictly speaking, unorthodox.
Physicians for 80% of the children were
said to be available every weekday; the cor-responding figure for children with a regu-lar place was 89%. Pediatricians are more
likely than others to be available every weekday: 88% compared with 75% for
other types of physicians (p < .01). Pedia-tricians are also more likely than other physicians to be considered available every
weekday night (71% compared with 54%; p < .01) but an even greater proportion of children for whom a place was mentioned said that care was available every weekday
night (85%). Similar differences were ob-served for availability on weekends: 85% for children for whom a place was
men-tioned, 64% for children for whom a pedia-trician was mentioned, and 46% for
chil-dren with other types of physicians. Board certification was not related to availability. However, differences were noted for
chil-dren whose physicians were not always available at these times. Another physician taking the calls of the regular source of care was said to be always available 96% to
100% of the time (depending on whether it
Type of Physician N-0
General Practitioner Pedialcian
Board Certified
Not Board Certified
Other Specialist Board Certified Not Board Certified
All Physicians
I
1
ii:.___
1
1
1
TABLE II
AVAILABILITY OF PHYSICIANS AT VARIOUS TIMES DuRING THE WEEK, BALTIMORE SMSA CHILDREN 1968 TO 1969
.
Type of Physician
Time of Week
Weekdays Weekday Nights Weekends
No. of % Always Children Available
No. of % Always Children Available
No. of % Always Children Available
General Practitioner 118 72 118 48 115 40
Pediatrician
Board Certified Not Board Certified
79 91
66 83
72 68
62 74
76 58
62 69
Other Specialist Board Certified Not Board Certified
10 80
92 79
10 70
92 60
10 30
89 55
Total 365* 80 354* 60 352* 53
* The difference between these totals and the 384 children with physicians who could be identified is due to the children for whom the answer was said to be “unknown”.
was weekday, weekday night, or weekend) when the regular source was a
board-certi-fied pediatrician, 78% to 91% of the time
for non-board-certified pediatricians, and only 58% to 64% of the time for other physicians.
GEOGRAPHIC ACCESSIBILITY. In this study,
respondents for 78% of children with an identified particular physician said the
physician would make a home visit; the difference was striking between this figure and the 3.5% of children for whom a par-ticular place was identified. There was no significant difference in availability of home
visits for children for whom a pediatrician was identified and for those with other types
of physicians. However, board-certified pediatricians were reported to be less likely than non-board-certified pediatricians to make house calls, 72% and 84%, respectively
(p < .1). This was also true for other
spe-cialists.
For nine out of ten children with a place
serving as the regular source of care the
lo-cation was considered “convenient.” For 50% the place was located less than 15 minutes
away and for 17%, an hour or more away.
Table III, which gives the corresponding
data for children with physicians, shows that pediatricians’ offices are somewhat less
accessible than other physicians’ offices,
whether measured by stated convenience of
the location (p < .2) or by the time required to travel to the office (p ( .01 for time with-in 15 minutes or not). Moreover, offices of
board-certified physicians are less accessible than offices of physicians who are not
certified (p < .01).
Patterns of Use of Physicians’ Services
Respondents indicated that virtually all
children (more than 95%) would be taken to their particular physician for a general medical examination, a certificate, or an ill-ness. Differences did emerge, however, in
the extent to which the children actually went to this source the last time they made such a visit. For children with a particular place, 87% went there for the last general
examination, 91% for illness or injury, and
88% for a certificate for school or camp.
* Only children who actually made a visit for a particular type of service were included.
826 SOURCE OF MEDICAL CARE
TABLE Ill
EASE OF ACCESS TO PHYSICIANS, BALTIMORE SMSA CHILDREN 1968 TO 1969
Time to Physician’s Office Convenience
Type of Physician C II n % Within % 16 to 59 % An Hour
15 Minutes Minutes or More
Convenient
Away Away Away
General Practitioner (122) 90.2 77.9 18.8 3.3
Pediatrician
Board Certified (82) 76.8 57.3 30.5 12.2
Not Board Certified (70) 97.1 62.9 31 .4 5.7
Other Specialist
Board Certified (11) 72.7 27.3 72.7 0.0
Not Board Certified (99) 94.9 73.7 25.3 1 .0
Total (384) 89.3 68.2 26.8 5.0
more likely to have gone to their regular terest to determine the duration of time source of care than children with other since the last visit. Due to the known
rela-types of physicians. The differences, how- tionship of age and use of physician
ser-ever, were more pronounced (p < .01) for vices,9 these data are given by separate age
general examinations than for other rea- groups (0 to 4, 5 to 9, 10 to 14). For
chil-sons. dren with a particular place, 25%, 8%, and
Because of these differences, it was of in- 4%, respectively, of those 0 to 4, 5 to 9, and
TABLE IV
CHILDREN WHO WENT TO THEIR REGULAR PHYSICIAN THE LAST TIME THEY REQUIRED CERTAIN SERVICES, BALTIMORE SMSA 1968 TO 1969
Type of Service
Certificole for School,
General Examination illness or injury
Camp, etc.
Type of Physician -__________________
No of % Going No of Going No of % Going
Children0 to Regular Children0 to Regular Children0 to Regular
Physician Physician Physician
General Practitioner 119 73.1 118 79.8 71 73.2
Pediatrician
Board CertifIed 79 93.7 74 88.3 39 87.2
Not Board Certified 69 89.9 64 83.6 32 81.3
Other Specialist
Board Certified 11 72.7 7 88.9 5 80.0
Not Board Certified 94 79.8 92 84.0 50 80.0
TABLE V
CHILDREN VISITING THEIR PHYSICIAN IN SPECIFIED TIME PERIODS, BALTIMORE SMSA 1968 TO 1969*
Type of Physician
No. of Children
% With
Last
a Visit in The
Two Weeks
% With a Visit More Than
One Year Ago or Never
0-4 (135 )
5-9
(102)
10-14
(146)
0-4 5-9 10-14
(135 ) (102) (146)
GeneraiPractitioner (122) 6.5 6.3 1.7 19.4 31.2 45.8
Pediatrician Board Certified
Not Board Certified
(82)
(70)
22.7
13.8
25.0
4.8
22.7
5.0
4.6 0.0 27.3
3.4 9.5 30.0
Other Specialist Board Certified Not Board Certified
(11) (98t)
25.0
50.0
25.0
13.8
0.0
2.4
0.0 0.0 33.3
7.2 3.4 4.8
Total (383t) 31.1 21.6 14.4 5.2 11.8 31.5
* The difference between 100% and the horizontal sum in the age group is the % of children who had a visit between two weeks and one year ago.
t Respondent for one child did not know the answer to this question.
10 to 14 years old had been there within two weeks; 7%, 42%, and 39% had not
been there in more than a year. Table V displays the corresponding information for
children with a particular physician. Al-though the findings should be interpreted with caution because of relatively small cell
frequencies, it appears that, in all age groups, children cared for by a general
practitioner tend to have longer intervals of
time since the last visit than do children cared for by other physicians. Since it is
possible that children with special health needs (and therefore increased rates of use
of health services) are selectively choosing specialists as their regular source of care, data were examined on the duration of time since the last visits which were not illness-related. Children who identified a
pediatri-cian were likely to have had a more recent
general examination only if the child went to that pediatrician for the examination. If the child went elsewhere, the specialty of the particular physician was unrelated to
the duration of time since the most recent nonillness visit. Therefore, it appears likely that the greater frequency of visits to
pedi-atricians cannot be merely a result of
selec-tion of children with more illness.
Financial Resources and Type of
Regular Source of Care
A composite variable consisting of
Medi-caid registration (Title 19 in Maryland), annual family income, and the family’s abil-ity to meet an unusual expense was formed.
One in 15 (6.8%) children was enrolled on Medicaid. The other children were distrib-uted approximately equally in each of three categories: low income (no more than
$11,000) and unable to meet unusual
ex-penses (32.1%), low income and able to meet unusual expenses (33.5%), and high
income (more than $11,000) (27.6%). An-other question determined the extent to which the family had to pay a fee when the
child sought a physician’s care: none of the fee, some, or all of the fee.
Figure 2 indicates the differences in these
variables among children for whom the reg-ular source of care was a place; children with no regular source of care; and children whose regular source was a physician.
SOURCE OF MEDICAL CARE
Regular Source
of Care
S 0 10 20 30 40 50 60 70 80 90 100
Place
1
No Regular
1UJ10l110lMl11MMMJllhii
1
Physician
I01000h1H1100h10hI0101L4i1
N-63
29
365
S
62
30
380
Fic. 2. Regular source of care and income, Baltimore SMSA children, 1968 to 1969.
828
source of care was a place were from
fami-lies with poor financial resources, compared with only one-half of children with no
regu-lar source of care and one-third of children whose regular source of care was a
physi-cian. Half of children whose regular source was a place did not have to pay for
physi-cian services, compared with less than a fifth of children with no regular source and one in twenty children with a physician as
the source.
Figure 3 shows the distribution by type of physician for children naming a physi-cian in each of the composite income groups. Despite the previous finding (Fig. 2) that almost all families with a physician
as the regular source of care pay all of the
physician’s fee, level of income is clearly
re-lated to the type of physician. As income rises, the proportion of children with a
gen-eral practitioner or nonpediatric specialty
falls, while the proportion mentioning a pe-diatrician rises.
Validity of Respondents’ Perceptions
about Availability
Because the questions about physicians’ availability depended upon the
respon-dents’ reports, it was important to estimate their validity. This was done in two ways,
both of which supported the accuracy of the survey data.
(1) There were 246 different physicians identified as the regular source of care. Seven physicians were mentioned by five separate families; ten other physicians were
mentioned by four families; 25 by three
families, 52 others by
two
families, and 152 physicians were named by only one family.Counting responses about a particular
-
Medicaidwrnrnuii
-
Low Income - unable to meet usual expensesLow Income - eble to meet usual expenses
F 1 HIgh Income
Regular Souroes of Cars and Extent of Payment
for Physician Srvices
0 10 20 30 40 50 60 70 80 90 100
Place
0101111
1011011
OlOhlIlli
1111111111
010111
-No Regular Source
Physician
IIOllllhI1Ohl11h1
.i
11
Proportion of Physicians Fee Paid: I _J All
-iT:1 Some
Compound Income Variable General PractitIoner (118)
Non-Board Certified Other Specialist (94)
Board Certified Other Specialist (10) Non- Roard Certified Pediatrician (65) Board Certified Pediatrician (78)
S of
Children
with a
Physician as the regular
source of
care
No. of families
-Fic. 3.Type of physician and family income, Baltimore SMSA children, 1968
to 1969.
physician only orce for each family, a
com-parison was made among the responses of different families who identified the same physician. Table VI shows that agreement
among families about a physician’s accessi-bility is quite high and considerably above what might be expected by chance alone.
(2) A separate survey of a probability sample of Baltimore SMSA physicians1 elicited information about home visits, need for appointments, and hours of availability
to patients. Among the office-based physi-cians, more general practitioners and non-certified specialists than board-certified spe-cialists said they make home visits. More
certified specialists than noncertified spe-cialists see their patients by appointment but even fewer general practitioners do so. However, generalists reported more hours of care to ambulatory patients than did
spe-cialists, both during regular practice hours and outside regular hours. Information to
determine whether this was the case for both adults and children seen by these physicians was not elicited.
DISCUSSION
Evidence of considerable concentration with respect to the source of care was
found for families in this large urban area, although for 14% of the children a place rather than a physician served this purpose.
The fact that so many of the children in this study reported having a regular source of care is undoubtedly because Baltimore, like
many American cities of comparable size,
has two medical schools and a relatively
good supply of physicians.’1 Mothers have been found to be quite accurate in report-ing the type of physician used as the regu-lar source of care for their children.12
Balti-more mothers were no different in this re-gard; general practitioners were identified correctly 98% of the time. Physicians who
were not pediatricians were identified as pediatricians in only eight instances. Among pediatricians, those with board
830 SOURCE OF MEDICAL CARE
TABLE VI
AGREEMENT AMONG FAMILIES ON ACCESSIBILITY OF SERvIcEs OF AN INDIVIDtTAL PHYSICIAN,
BALTIMORE SMSA CHILDREN 1968 TO 1969
No. of
7
Different Phyncian,s*
9 26 48
No. of Families Naming the
Same Physician Accessibility Variable 5 4 3 2
Appointment Required 100
% Agreement
94 91 77
Available
Every weekday 86 94 82 65
Every weekday night 70 83 77 73
Every weekend 68 78 74 56
House calls made 87 86 71 64
* j a few cases, a family responded “don’t know” to the question. These families were eliminated from the calculations. This had the effect of lowering the number of different doctors named by several families by four in the two-family category; because one of the family pairs indicated “don’t know,” the pair had to be eliminated from observation of agreement-disagreement. It also lowered (from ten to nine) the number of families in the four-family category and raised it by one (from 25 to 26)
in the three-family category.
If mothers are able to identify the type of physician, and if the geographic area is well supplied with medical resources, what ac-counts for the fact that only one-fifth of
children have a board-certified pediatrician as their regular source of care? One reason is that all specialties are not equally repre-sented in the universe of physicians who provide care. In the United States as a whole, there are only 1.67 self-identified,
office-based pediatricians for every 10,000 children under the age of 15;” in
Balti-more there are not many more (two per
10,0001315) and just under half of these are
board certified.36 In contrast, each of six large prepaid group practices with re-sources presumably related to some
mea-sure of consumer need has one pediatrician for every 2,000 to 4,000 enrollees under 19
years of age.’7 Cost may also be a factor. Data from the American Medical Associa-tion indicate that fees for office visits to
general practitioners are 15% to 20% less than those for pediatricians;’8 no data
con-cerning the influence of board certification on fees are available. The idea of cost as a
possible selective factor was supported in this study. As the ability to pay for services increases, so does the proportion of children
who regularly receive care from a pediatri-cian, especially from a board-certified pedi-atrician. Distance to pediatricians’ offices may also be a deterrent.
§
Does the identification of different types of physicians have any implications for the
care received by the children? Of all physi-cians, the board-certified pediatrician is the only type of physician who is eligible, by virtue of having passed an examination, for
membership in the professional
organiza-tion which regularly distributes special ed-ucational material on pediatric problems to its members. Accessibility of physician
ser-vices also differs depending upon the type of physician. For needs which do not
re-quire immediate attention, pediatricians are less accessible than other physicians. The requirement that office visits be scheduled in advance may act as a considerable deter-rent to certain types of families, as may the
more remote office locations and
improba-bility of home visits. Low-income families are at a particular disadvantage when ser-vices are organized so as to make access more difficult.’#{176}
The finding that children who identify a pediatrician as their regular source of care have more frequent routine care may be
due either to a greater propensity of pedia-tricians to instigate such care or to an
in-creased initiation of such visits on the part of parents who seek the services of pediatri-cians. The data to choose between these al-ternatives are not at hand. In either case, the evidence that children with a
pediatri-§ Half of the Baltimore pediatricians are located
in census tracts with average family incomes over
$14,000. Only one-eighth have their offices in census
tracts with average incomes under $9,000, and none
831
cian receive a unique type of care is
su.ffi-cient to warrant attempts to make such ser-vices more readily available.
The data indicating that home visits were possible for more than three-fourths of the
children with an identified physician was
surprising in light of the fact that in the
United States, for all children, less than 2% of physician visits take place in the home.20 For children with private physicians as
their source of care, the proportion may be as much as twice that great, as several
sur-veys of physicians report that approxi-mately 5% of physician-patient contacts
take place in the home.1#{176}In actuality, the beliefs of the respondents about the poten-tial availability of home visits was sup-ported by data from a physician survey in Baltimore1#{176} which showed that 93% of gen-eral practitioners, 83% of pediatricians,
65% of internists, 10% of surgical special-ists, and 11% of obstetrician-gynecologists
report making house calls, although they
make very few. Because the site of care has been shown to be a variable which
signifi-cantly influences the physician-patient in-teraction,21 the wisdom of the increasing
tendency of American physicians to shun home visits has been questioned.22
The data on utilization of physician ser-vices indicate that there may be an
imbal-ance between accessibility and continuity of care; physicians who are most accessible may not be consulted for all types of care.
That access to, and costs of care are the pri-mary concerns of people is clear. Until
ser-vices are accessible and affordable, patients are unlikely to complain about their qual-ity. For the present, then, it would appear appropriate for medical societies, medical practice foundations, specialty groups, and
other health care organizations to consider accessibility of medical services first in their
efforts to assure a high standard of “quality” medical care.
REFERENCES
1. Council on Pediatric Practice: Standards of Child Health Care. Evanston, Illinois: Amer-ican Academy of Pediatrics, 1967, p. 78.
2. Mindlin, R., and Densen, P. : Medical care of urban infants: Continuity of care. Amer. J. Public Health, 39: 1294, 1969.
3. Andersen, R., and Anderson, 0. : A Decade of Health Services. Chicago and London : Uni-versity of Chicago Press, 1967, p. 14. 4. Lengthening Shadows. A Report of the
Coun-cil on Pediatric Practice of the American Academy of Pediatrics on The Delivery of Health Care to Children, 1970. Evanston, Il-linois : American Academy of Pediatrics,
1971, pp. 250-251.
5. International Comparisons of Medical Care. In Rabin, D. L., ed : The Milbank Memorial Fund Quarterly, 1 (part 2) : July 1972. 6. Part of the data on all children was presented
at The National Conference on Health Man-power, National Center for Health Services
Research and Development, Chicago,
Illi-flOis: American Medical Association, 1971. 7. Doiiabedian, A. : Some Aspects of Medical
Care Administration. Cambridge,
Massa-chusetts : Harvard University Press, in press, chap. 4.
8. Winch, R., and Campbell, D. : Proof? No. Evi-dence? Yes. The significance of tests of sig-nificance. Amer. Sociol., 4:140, 1969.
9. U.S. Department of HEW National Center for
Health Statistics: Volume of Physician Vis-its, U.S. 1966-1967. Series 10, No. 49, No-vember 1968.
10. Starfield, B., Rabin, D., Clickstein, M., Mc-Cormick, M., Jackson, A., and Broske, S.: Medical resources and medical education: A student survey of physicians. J. Med. Educ.,
46:419, 1971.
11. Rabin, D., Starfield, B., Burns, C., Krasno, J., and McCormick, M.: Estimated physicians’ services in a United States metropolitan area.
mt.
j. Health Services Res., in press.12. U.S. Department of HEW National Center for
Health Statistics: Characteristics of Patients of Selected Types of Medical Specialists and
Practitioners. Series 10, Number 28, May
1966.
13. American Medical Association Center for
Health Services Research: 1969 Distribution of Physicians, Hospitals and Hospital Beds in the U.S. Chicago, Illinois: American Medi-cal Association, 1969.
14. Population Estimates and Projections. U.S. Bu-reau of the Census, Current Population
Re-ports. Series P-25, No. 400, August 13,
1968.
15. General Population Characteristics of Mary-land. U. S. Bureau of the Census, 1970
Cen-sus of Population. PC (1) Series B22, 1970.
832 SOURCE OF MEDICAL CARE
Gorten, M.: Assessing the balance of physi-cian manpower in a metropolitan area. Pub-lic Health Rep., 85:1001, 1970.
17. Calculated from data given in Mason, H.:
Manpower needs by specialty. JAMA, 219:
1621, 1972.
18. Balfe, B., Lorant, J., and Todd, C.: Reference
Data on the Profile of Medical Practice. Cen-ter for Health Services Research and Devel-opment, Chicago, Illinois: American Medical Association, 1971.
19. Bergner, L., and Yerby, A.: Low income and
barriers to use of health services. New Eng.
J.
Med., 278:541, 1968.
20. US Department of HEW National Center for Health Statistics: Age Patterns in Medical Care, Illness, and Disability. U.S. 1968-69, Series 10, Number 70, April 1972.
21. Gibson, C. D.: Site for care in medical prac-tice. Med. Care, 3:14, 1965.
22. Elford, R. W., Brown, J. W., Robertson, L. S.,
Alpert, J. J., and Kosa, J.: A study of house calls in the practices of general practitioners.
Med. Care, 10:173, 1972.
ANSWERS
FOR SOME PEDIATRIC PATIENTS
(p. 821)1. James Phipps: first patient to be vaccinated by Dr. Edward Jenner (1796).
2. Joseph Meister: first patient to be given Pasteur’s rabies vaccine (1885).
3. Daniel Oliver Waterhouse: first patient to receive cowpox vaccine in America (1803). 4. Laura Dewey Bridgman: Dr. Samuel
Grid-ley Howe’s most famous patient. She was totally blind and deaf and spent her life at the Perkins Institution in Boston which was founded by Dr. Howe.
5. Little Hans: Sigmund Freud’s first pediatric patient (1908).
6. James Sarkett: patient with paralytic polio-myelitis from whom Salk isolated his type III strain of poliomyelitis (1949).
7. Eileen Saxon: the first patient with tetralogy of Fallot operated on by Dr. Alfred Blalock
(November 24, 1944).
8. Victor of Aveyron: a wild child found in the woods in southern France and studied in-tensely by Dr.
J.
E. M. Itard (1801 and 1807). Victor, a so-called homo sapien$ferus, was the subject of Fran#{231}oisTruffaut’s recent film “The Wild Child.”
