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Specialty (medicine)


Source: http://en.wikipedia.org/wiki/Specialty_(medicine)
Updated: 2017-05-30T21:29Z

A specialty (or speciality) in medicine is a branch of medical practice. After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple year residency to become a medical specialist.[1]

History of medical specialization

To a certain extent, medical practitioners have always been specialized. According to Galen, specialization was common among Roman physicians. The particular system of modern medical specialities evolved gradually during the 19th century. Informal social recognition of medical specialization evolved before the formal legal system. The particular subdivision of the practice of medicine into various specialities varies from country to country, and is somewhat arbitrary.[2]

Classification of medical specialization

Medical specialties can be classified along several axes. These are:

  • Surgical or internal medicine
  • Age range of patients
  • Diagnostic or therapeutic
  • Organ-based or technique-based

Throughout history, the most important has been the division into surgical and internal medicine specialties. The surgical specialties are the specialties in which an important part of diagnosis and treatment is achieved through major surgical techniques. The internal medicine specialties are the specialties in which the main diagnosis and treatment is never major surgery. In some countries Anesthesiology is classified as a surgical discipline, since it is vital in the surgical process, though anesthesiologists never perform major surgery themselves.

Many specialties are organ-based. Many symptoms and diseases come from a particular organ. Others are based mainly around a set of techniques, such as radiology, which was originally based around X-rays.

The age range of patients seen by any given specialist can be quite variable. Paediatricians handle most complaints and diseases in children that do not require surgery, and there are several subspecialties (formally or informally) in paediatrics that mimic the organ-based specialties in adults. Paediatric surgery may or may not be a separate specialty that handles some kinds of surgical complaints in children.

A further subdivision is the diagnostic versus therapeutic specialties. While the diagnostic process is of great importance in all specialties, some specialists perform mainly or only diagnostic examinations, such as pathology, clinical neurophysiology, and radiology. This line is becoming somewhat blurred with interventional radiology, an evolving field that uses image expertise to perform minimally invasive procedures.

Specialties that are common worldwide

SpecialtyCan be subspecialty ofDiagnostic (D) or therapeutic (T) specialtySurgical (S) or internal medicine specialty (I)Age range of patientsOrgan-based (O) or technique-based (T)
Allergy and immunologyPaediatrics or Internal medicineBothIAllO
Adolescent medicinePaediatricsBothIPaediatricT
AnaesthesiologyNoneTUnknownAllBoth
Aerospace medicineNoneBothNeitherAllBoth
PathologyNoneDNeitherAllT
CardiologyInternal medicineTIAdultsO
Cardiothoracic surgeryGeneral surgeryTSAdultsO
Child and adolescent psychiatry and psychotherapyPsychiatryTIPaediatricT
Clinical neurophysiologyNeurologyDIAllBoth
Colon and Rectal SurgeryGeneral SurgeryBothSAllO
Dermatology-VenereologyNoneTIAllO
Emergency medicineAnaestheticsBothIAllBoth
EndocrinologyInternal medicineTIAdultsO
GastroenterologyInternal medicineTIAdultsO
General practiceNoneBothNeitherAllMultidisciplinary
GeriatricsInternal medicine or family medicineTIGeriatricMultidisciplinary
Obstetrics and gynaecologyNoneTSAllO
Health informaticsNoneBothNeitherAllMultidisciplinary
Hospice and palliative medicineVariousBothNeitherAllNeither
Infectious diseasePediatrics or Internal medicineBothIAllNeither
Internal medicineNoneTIAdultsNeither
Interventional radiologyRadiologyBothUnknownAllMultidisciplinary
Vascular medicineInternal medicineTIAdultsO
MicrobiologyNoneDIAllT
NephrologyInternal medicineTIAllO
NeurologyInternal medicineTIAllO
NeurosurgerySurgeryTSAllO
Nuclear medicineNoneBothIAllT
Occupational medicineNoneTIAdultsMultidisciplinary
OphthalmologyNoneTSAllO
OrthodonticsNoneTSAllO
OrthopaedicsGeneral surgeryTSAllO
Oral and maxillofacial surgerySurgeryTSAllO
OtorhinolaryngologyNoneTSAllO
PaediatricsNoneTIPaediatricNeither
Paediatric allergologyPaediatricsTIPaediatricO
Paediatric cardiologyPaediatricsTIPaediatricO
Paediatric endocrinology and diabetesPaediatricsTIPaediatricO
Paediatric gastroenterology, hepatology and nutritionPaediatricsTIPaediatricO
Paediatric haematology and oncologyPaediatricsTIPaediatricO
Paediatric infectious diseasesPaediatricsTIPaediatricO
NeonatologyPaediatricsTINeonatalNeither
Paediatric nephrologyPaediatricsTIPaediatricO
Paediatric respiratory medicinePaediatricsTIPaediatricO
Paediatric rheumatologyPaediatricsTIPaediatricO
Paediatric surgeryGeneral SurgeryTSPaediatricO
Physical medicine and rehabilitationNoneTIAllMultidisciplinary
Plastic, reconstructive and aesthetic surgeryGeneral surgeryTSAllO
PulmonologyInternal medicineTIAdultsO
PsychiatryInternal medicineTIAllT
Public HealthNoneNeitherNeitherAllT
Radiation OncologyNoneTNeitherAllT
RadiologyNoneBothIAllT
Sports medicineFamily medicineBothNeitherAllMultidisciplinary
NeuroradiologyRadiologyBothIAllBoth
General surgeryNoneTSAdultsT
UrologyGeneral surgeryTSAllO
Vascular surgeryGeneral surgeryTSAllO

List of specialties recognized in the European Union and European Economic Area

The European Union publishes a list of specialties recognized in the European Union, and by extension, the European Economic Area.[3] Note that there is substantial overlap between some of the specialties and it is likely that for example "Clinical radiology" and "Radiology" refer to a large degree to the same pattern of practice across Europe.

  • Accident and emergency medicine
  • Allergology
  • Anaesthetics
  • Biological hematology
  • Cardiology
  • Child psychiatry
  • Clinical biology
  • Clinical chemistry
  • Clinical neurophysiology
  • Craniofacial surgery
  • Dental, oral and maxillo-facial surgery
  • Dermato-venerology
  • Dermatology
  • Endocrinology
  • Gastro-enterologic surgery
  • Gastroenterology
  • General hematology
  • General Practice
  • General surgery
  • Geriatrics
  • Immunology
  • Infectious diseases
  • Internal medicine
  • Laboratory medicine
  • Maxillo-facial surgery
  • Microbiology
  • Nephrology
  • Neuro-psychiatry
  • Neurology
  • Neurosurgery
  • Nuclear medicine
  • Obstetrics and gynecology
  • Occupational medicine
  • Ophthalmology
  • Orthopaedics
  • Otorhinolaryngology
  • Paediatric surgery
  • Paediatrics
  • Pathology
  • Pharmacology
  • Physical medicine and rehabilitation
  • Plastic surgery
  • Podiatric Surgery
  • Psychiatry
  • Public health and Preventive Medicine
  • Radiation Oncology
  • Radiology
  • Respiratory medicine
  • Rheumatology
  • Stomatology
  • Thoracic surgery
  • Tropical medicine
  • Urology
  • Vascular surgery
  • Venereology

List of North American medical specialties and others

In this table, as in many healthcare arenas, medical specialties are organized into the following groups:

  • Surgical specialties focus on manually operative and instrumental techniques to treat disease.
  • Medical specialties that focus on the diagnosis and non-surgical treatment of disease.
  • Diagnostic specialties focus more purely on diagnosis of disorders.
SpecialtyCodeGroupSub-specialtiesFocus
Allergy and immunologyAllergic reactions, asthma, and the immune system
AnesthesiologyAN, PANSurgery[4][citation needed]Anesthesia
CardiologyMedicineDisease of the cardiovascular system
Cardiovascular surgerySurgeryThe operation of heart and major blood vessels of the chest.
Clinical laboratory sciencesDiagnosticApplication of diagnostic techniques in medical laboratories such as assays, microscope analysis.
DermatologyD, DSMedicineDermatology, Mohs surgerySkin and its appendages (hair, nails, sweat glands etc.).
DieteticsRD[5]Food and nutrition
Emergency medicineEMMedicine
  • Disaster medicine
  • Emergency medical services
  • Hospice and palliative medicine
  • International Emergency Medicine and Global Health
  • Medical toxicology
  • Pediatric emergency medicine
  • Research
  • Simulation
  • Sports medicine
  • Toxicology
  • Ultrasound
  • Undersea and hyperbaric medicine
  • Wilderness medicine
The initial management of emergent medical conditions, often in hospital emergency departments or the field.
EndocrinologyMedicineThe endocrine system (i.e., endocrine glands and hormones) and its diseases, including diabetes and thyroid diseases.
Family medicineFMMedicine
  • Adolescent medicine
  • Geriatric medicine
  • Hospice and palliative medicine
  • Sleep medicine
  • Sports medicine
Continuing, comprehensive healthcare for the individual and family, integrating the biological, clinical and behavioral sciences to treat patients of all ages, sexes, organ systems, and diseases.
Forensic medicineMedicine
GastroenterologyGIMedicineThe alimentary tract
General surgeryGSSurgery
  • Colorectal surgery
  • Gastrointestinal surgery
  • Transplant surgery
  • Trauma surgery
GeriatricsIMGMedicine[4][citation needed]Elderly patients
GynecologyFemale reproductive health
HepatologyMedicineThe liver and biliary tract, usually a part of gastroenterology.
Hospital medicineMedicine
Infectious diseaseIDMedicineDiseases caused by biological agents
Intensive care medicineMedicineLife support and management of critically ill patients, often in an ICU.
Medical researchAnatomy, Biochemistry, Embryology, Genetics, Pharmacology, ToxicologyCare of hospitalized patients
NephrologyMedicineKidney diseases
NeurologyNMedicineDiseases involving the central, peripheral, and autonomic nervous systems
NeurosurgeryNSSurgeryDisease of the central nervous system, peripheral nervous system, and spinal column.
Obstetrics and gynecologyOB/GYNSurgery[4][citation needed]
OncologyONMedicineCancer and other malignant diseases, often grouped with hematology.
OphthalmologyOPHSurgeryRetina, CorneaDiseases of the visual pathways, including the eyes, brain, etc.
Oral and maxillofacial surgeryMaxfacs, OMSSurgery
  • Oral and Craniofacial surgery (Head and neck)
  • Facial cosmetic surgery
  • Craniomaxillofacial trauma
Disease of the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region.
Orthopedic surgeryORSSurgeryHand surgery, surgical sports medicine, adult reconstruction, spine surgery, foot and ankle, musculoskeletal oncology, orthopedic trauma surgery, pediatric orthopedic surgeryInjury and disease of the musculoskeletal system.
Otorhinolaryngology, or ENTORL, ENTSurgeryHead and neck, facial cosmetic surgery, Neurotology, LaryngologyTreatment of ear, nose, and throat disorders. The term head and neck surgery defines a closely related specialty that is concerned mainly with the surgical management of cancer of the same anatomical structures.
Palliative carePLMMedicineA relatively modern branch of clinical medicine that deals with pain and symptom relief and emotional support in patients with terminal illnesses including cancer and heart failure.
PathologyPTHDiagnosticUnderstanding disease through examination of molecules, cells, tissues and organs. The term encompasses both the medical specialty that uses tissues and body fluids to obtain clinically useful information and the related scientific study of disease processes.
PediatricsPDMedicineChildren. Like internal medicine, pediatrics has many sub-specialties for specific age ranges, organ systems, disease classes, and sites of care delivery. Most sub-specialties of adult medicine have a pediatric equivalent such as pediatric cardiology, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology, pediatric oncology, pediatric ophthalmology, and neonatology.deals with the medical care of infants, children, and adolescents (from newborn to age 16-21, depending on the country).
Pediatric surgerySurgeryTreats a wide variety of thoracic and abdominal (and sometimes urologic) diseases of childhood.
Physical medicine and rehabilitation Or PhysiatryPM&RMedicineConcerned with functional improvement after injury, illness, or congenital disorders.
Plastic surgeryPSSurgery
  • Cosmetic surgery
  • Burn
  • Microsurgery
  • Hand surgery
  • Craniofacial surgery
Elective cosmetic surgery as well as reconstructive surgery after traumatic or operative mutilation.
PodiatryPODSurgery
  • Forefoot surgery
  • Midfoot surgery
  • Rearfoot surgery
  • Ankle surgery
  • Soft tissue leg surgery
Elective podiatric surgery of the foot and ankle, lower limb diabetic wound and salvation, peripheral vascular disease limb preservation, lower limb mononeuropathy conditions. Reconstructive foot & ankle surgery.
ProctologyPROMedicine(or Colorectal Surgery) Treats disease in the rectum, anus, and colon.
PsychiatryPMedicineThe bio-psycho-social study of the etiology, diagnosis, treatment and prevention of cognitive, perceptual, emotional and behavioral disorders. Related non-medical fields include psychotherapy and clinical psychology.
PulmonologyMedicineThe lungs and respiratory system. Pulmonology is generally considered a branch of internal medicine, although it is closely related to intensive care medicine when dealing with patients requiring mechanical ventilation.
RadiologyR, DRDiagnostic and Therapeutic
  • Interventional radiology is concerned with using expert imaging of the human body, usually via CT, ultrasound, fluoroscopy, or MRI to perform a breadth of intravascular procedures (angioplasty, arterial stenting, thrombolysis, uterine fibroid embolization), biopsies and minimally invasive oncologic procedures (radiofrequency and cryoablation of tumors & transarterial chemoembolization)
  • Nuclear medicine uses radioactive substances for in vivo and in vitro diagnosis either using imaging of the location of radioactive substances placed into a patient or using in vitro diagnostic tests utilizing radioactive substances.
The use of expertise in radiation in the context of medical imaging for diagnosis or image guided minimally invasive therapy. X-rays, etc.
RheumatologyRHUMedicineAutoimmune and inflammatory diseases of the joints and other organ systems, such as arthritis and other rheumatic diseases.
StomatologyDentistryDiseases of the mouth
Surgical oncologySOSurgeryCurative and palliative surgical approaches to cancer treatment.
Thoracic surgeryTSSurgerySurgery of the organs of the thoracic cavity: the heart, lungs, and great vessels.
Transplant surgeryTTSSurgeryTransplantation of organs from one body to another
Urgent Care MedicineUCMMedicineImmediate medical care offering outpatient care for the treatment of acute and chronic illness and injury
UrologyUSurgeryUrinary tracts of males and females, and the male reproductive system. It is often practiced together with andrology ("men's health").
Vascular surgeryVSSurgeryThe peripheral blood vessels – those outside of the chest (usually operated on by cardiovascular surgeons) and outside of the central nervous system (treated by neurosurgery)

Physician compensation

The mean annual salary of a medical specialist is $175,011[6][citation needed] in the US, and $272,000[6][citation needed] for surgeons. However, because of commodity inflation, increasing negligent costs, steep price rise of rental, the annual salary range of a medical specialist varies and is not rising as fast as other professional pay. Often, especially in the United States, physicians practice in groups of specialists within a particular medical specialty. These practice groups are often formed to help reach economies of scales in rental, insurance and staff costs as well as other benefits of practicing with other professionals and are typically governed by various legal documents.[7]

The table below details the average range of salaries for physicians of selected specialties as of July 2010. Also given in the average number of hours worked per week for full-time physicians (numbers are from 2003).

SpecialtyMedian salary (USD)[8][citation needed]Average hours

work/week[9]

Average salary/hour (USD)[10]
Anaesthesia331,000 to $423,50761
Dermatology313,100 to $480,08845.5103
Emergency medicine239,000 to $316,2964687
Cardiac Surgery218,684 to $500,00055
Family medicine175,000 to $220,19652.558
Internal medicine184,200 to $231,6915758
Neurology213,000 to $301,32755.593
Obstetrics and Gynecology251,500 to $326,9246183
Ophthalmology150,000 to $351,00047
Orthopedic surgery397,879 to $600,00058
Otolaryngology191,000 to $393,00053.5
Oral and Maxillofacial Surgery260,000 to $440,21053
Pediatrics160,111 to $228,7505469
Podiatry170,800 to $315,1504580
Psychiatry173,800 to $248,1984872
Radiology (diagnostic)377,300 to $478,00058
Surgery (general)284,642 to $383,33360
Urology331,192 to $443,51860.5
Neurological surgery350,000 to $705,000132
Plastic surgery265,000 to $500,000114
Gastroenterology251,026 to $396,45093
Pulmonology165,000 to $365,87572

According to a 2010 study, physician and surgeon median annual income was $166,400.[11]

Specialties by country

Australia and New Zealand

Specialty training in Australia and New Zealand is overseen by the specialty colleges:

Canada

Specialty training in Canada is overseen by the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and by Collège des médecins du Québec.

India

Specialty training in India is overseen by the Medical Council of India, which is responsible for recognition of post graduate training and by the National Board of Examinations. And education of Ayurveda in overseen by Central Council of Indian Medicine (CCIM), the council conducts u.g and p.g courses all over India, while Central Council of Homoeopathy does the same in the field of Homeopathy.

United States

There are three agencies or organizations in the United States that collectively oversee physician board certification of MD and DO physicians in the United States in the 26 approved medical specialties recognized in the country. These organizations are the American Board of Medical Specialties (ABMS) and the American Medical Association (AMA); the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) and the American Osteopathic Association; the American Board of Physician Specialties (ABPS) and the American Association of Physician Specialists (AAPS). Each of these agencies and their associated national medical organization functions as its various specialty academies, colleges and societies.

Certifying boardNational organizationPhysician type
ABMSAMAMD and DO
AOABOSAOADO only
ABPSAAPSMD and DO

All boards of certification now require that medical practitioners demonstrate, by examination, continuing mastery of the core knowledge and skills for a chosen specialty. Recertification varies by particular specialty between every seven and every ten years.

Specialty and Physician Location

There are hierarchies of medical specialties in the cities of a region. Small towns and cities have primary care, middle sized cities offer secondary care, and metropolitan cities have tertiary care. Income, size of population, population demographics, distance to the doctor, all influence the numbers and kinds of specialists and physicians located in a city. (Smith, 1977, 1979)

Economic demand influences the location of particular specialties. For example, more orthopedic surgeons are found in ski areas, obstetricians in the suburbs, and boutique specialties such as hypnosis, plastic surgery, psychiatry are more likely to practice in high income areas. Small populations can usually only support primary care. A large population is needed to support specialists who treat rare diseases. Some specialties need to cooperate and thus locate near each other, such as hematology, oncology, and pathology, or cardiology, thoracic surgery and pulmonology.

A population's income level determines whether sufficient physicians can practice in an area and whether public subsidy is needed to maintain the health of the population. Developing countries and poor areas usually have shortages of physicians and specialties, and those in practice usually locate in larger cities. For some underlying theory regarding physician location, see Central Place Theory. (Smith, 1977, 1979)

Other uses

In the U.S. Army, the term "medical specialist" refers to occupational therapists, physical therapists, dietitians and physician assistants, also known as allied health professionals. Also included in the term "medical specialist", but not in the term "allied health professional" are EMT/combat medics.[citation needed]

Training

In Sweden, a medical license is required before commencing specialty training. Those graduating from Swedish medical schools are first required to do a rotational internship of about 1.5 to 2 years in various specialties before attaining a medical license. The specialist training lasts 5 years.[12]

In the United States, graduates from medical schools can start specialty training directly in the form of residency. The medical license is attained during the course of the residency.

Satisfaction

A survey of physicians in the United States came to the result that dermatologists are most satisfied with their choice of specialty followed by radiologists, oncologists, plastic surgeons, and gastroenterologists.[13] In contrast, primary care physicians were the least satisfied, followed by nephrologists, obstetricians/gynecologists, and pulmonologists.[13] Surveys have also revealed high levels of depression among medical students (25 - 30%) as well as among physicians in training (22 - 43%), which for many specialties, continue into regular practice.[14][15]

SpecialtyOverall satisfaction[13]Feeling of enough compensation[13]Would have chosen same specialty again[13]
Dermatologist80%71%93%
Radiologist72%69%82%
Oncologist70%55%79%
Gastroenterologist69%52%80%
Ophthalmologist67%55%79%
Infectious disease/HIV physician66%54%73%
Plastic surgeon66%53%82%
Anesthesiologist65%63%70%
Orthopedic surgeon65%47%83%
Psychiatrist65%58%67%
Rheumatologist65%53%66%
Podiatrist64%51%75%
Emergency medicine physician63%65%56%
Urologist63%47%78%
Cardiologist62%46%75%
Pediatrician62%51%61%
Diabetes specialist/Endocrinologist61%45%68%
Neurologist60%49%63%
General surgeon58%44%60%
Nephrologist57%45%55%
Obstetrician/Gynecologist57%50%53%
Pulmonologist57%45%52%
Primary care physician54%48%43%

See also

Notes

  1. ^ http://www.webmd.com/a-to-z-guides/medical-specialists-medical-specialists
  2. ^ Weisz G (Fall 2003). "The Emergence of Medical Specialization in the Nineteenth Century". Bull Hist Med. 77 (3): 536–574. PMID 14523260. doi:10.1353/bhm.2003.0150. 
  3. ^ "Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications". European Parliament and Council. Retrieved 19 April 2011. 
  4. ^ a b c Regeringen.se – new grouping of the medical specialties Archived April 10, 2008, at the Wayback Machine.
  5. ^ "Becoming a Registered Dietitian". Department of Food Science and Human Nutrition. University of Illinois at Urbana-Champaign. Retrieved 21 April 2016. 
  6. ^ a b ibmdllc.com -Physician income not rising as fast as other professional pay Archived April 10, 2008, at the Wayback Machine.
  7. ^ "Physician Separation Issues". The National Law Review. Baker & Hostetler LLP. 2011-11-21. Retrieved 2012-01-13. 
  8. ^ Physician Compensation Survey [special feature]. Modern Healthcare. July 19, 2010: 20-26. [1] Archived November 30, 2010, at the Wayback Machine.
  9. ^ Physician work hours (2003) Medfriends.org. Accessed 15 December 2010.
  10. ^ Leigh JP; Tancredi D; Jerant A; Kravitz RL (October 2010). "Physician wages across specialties: informing the physician reimbursement debate". Arch. Intern. Med. 170 (19): 1728–34. PMID 20975019. doi:10.1001/archinternmed.2010.350.  [2]
  11. ^ Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Physicians and Surgeons, on the Internet at http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited November 01, 2013).
  12. ^ "Specialty training / residency". Lund University, Faculty of Medicine. 2015-05-20. Retrieved 2016-11-26. 
  13. ^ a b c d e Medscape Physician Compensation Report: 2011
  14. ^ Rotenstein, Lisa S.; Ramos, Marco A.; Torre, Matthew; Segal, J. Bradley; Peluso, Michael J.; Guille, Constance; Sen, Srijan; Mata, Douglas A. (2016-12-06). "Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis". JAMA. 316 (21): 2214–2236. ISSN 1538-3598. PMID 27923088. doi:10.1001/jama.2016.17324. 
  15. ^ Douglas A. Mata, Marco A. Ramos, Narinder Bansal, Rida Khan, Constance Guille, Emanuele Di Angelantonio & Srijan Sen (2015). "Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis". JAMA. 314 (22): 2373–2383. PMC 4866499Freely accessible. PMID 26647259. doi:10.1001/jama.2015.15845. 

References

  • Smith, Margot W. "Physician's Specialties and Medical Trade Areas: An Application of Central Place Theory." Papers and Proceedings of Applied Geography Conferences, Vol. 9, West Point NY 1986.
  • Smith Margot W (1979). "A Guide to the Delineation of Medical Care Regions, Medical Trade Areas and Hospital Service Areas". Public Health Reports. 94 (3): 247. 
  • Smith, Margot W. "The Economics of Physician Location," Western Regional Conference, American Association of Geographers, Chicago, Illinois, 1979
  • Smith, Margot W. "The Distribution of Medical Care in Central California: a Social and Economic Analysis," Thesis, School of Public Health, University of California, Berkeley, 1977 - 1004 pages
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