medical services essay

10 Successful Medical School Essays

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-- Accepted to: Harvard Medical School GPA: 4.0 MCAT: 522

Sponsored by A ccepted.com : Great stats don’t assure acceptance to elite medical schools. The personal statement, most meaningful activities, activity descriptions, secondaries and interviews can determine acceptance or rejection. Since 1994, Accepted.com has guided medical applicants just like you to present compelling medical school applications. Get Accepted !

I started writing in 8th grade when a friend showed me her poetry about self-discovery and finding a voice. I was captivated by the way she used language to bring her experiences to life. We began writing together in our free time, trying to better understand ourselves by putting a pen to paper and attempting to paint a picture with words. I felt my style shift over time as I grappled with challenges that seemed to defy language. My poems became unstructured narratives, where I would use stories of events happening around me to convey my thoughts and emotions. In one of my earliest pieces, I wrote about a local boy’s suicide to try to better understand my visceral response. I discussed my frustration with the teenage social hierarchy, reflecting upon my social interactions while exploring the harms of peer pressure.

In college, as I continued to experiment with this narrative form, I discovered medical narratives. I have read everything from Manheimer’s Bellevue to Gawande’s Checklist and from Nuland’s observations about the way we die, to Kalanithi’s struggle with his own decline. I even experimented with this approach recently, writing a piece about my grandfather’s emphysema. Writing allowed me to move beyond the content of our relationship and attempt to investigate the ways time and youth distort our memories of the ones we love. I have augmented these narrative excursions with a clinical bioethics internship. In working with an interdisciplinary team of ethics consultants, I have learned by doing by participating in care team meetings, synthesizing discussions and paths forward in patient charts, and contributing to an ongoing legislative debate addressing the challenges of end of life care. I have also seen the ways ineffective intra-team communication and inter-personal conflicts of beliefs can compromise patient care.

Writing allowed me to move beyond the content of our relationship and attempt to investigate the ways time and youth distort our memories of the ones we love.

By assessing these difficult situations from all relevant perspectives and working to integrate the knowledge I’ve gained from exploring narratives, I have begun to reflect upon the impact the humanities can have on medical care. In a world that has become increasingly data driven, where patients can so easily devolve into lists of numbers and be forced into algorithmic boxes in search of an exact diagnosis, my synergistic narrative and bioethical backgrounds have taught me the importance of considering the many dimensions of the human condition. I am driven to become a physician who deeply considers a patient’s goal of care and goals of life. I want to learn to build and lead patient care teams that are oriented toward fulfilling these goals, creating an environment where family and clinician conflict can be addressed efficiently and respectfully. Above all, I look forward to using these approaches to keep the person beneath my patients in focus at each stage of my medical training, as I begin the task of translating complex basic science into excellent clinical care.

In her essay for medical school, Morgan pitches herself as a future physician with an interdisciplinary approach, given her appreciation of how the humanities can enable her to better understand her patients. Her narrative takes the form of an origin story, showing how a childhood interest in poetry grew into a larger mindset to keep a patient’s humanity at the center of her approach to clinical care.

This narrative distinguishes Morgan as a candidate for medical school effectively, as she provides specific examples of how her passions intersect with medicine. She first discusses how she used poetry to process her emotional response to a local boy’s suicide and ties in concern about teenage mental health. Then, she discusses more philosophical questions she encountered through reading medical narratives, which demonstrates her direct interest in applying writing and the humanities to medicine. By making the connection from this larger theme to her own reflections on her grandfather, Morgan provides a personal insight that will give an admissions officer a window into her character. This demonstrates her empathy for her future patients and commitment to their care.

Her narrative takes the form of an origin story, showing how a childhood interest in poetry grew into a larger mindset to keep a patient's humanity at the center of her approach to clinical care.

Furthermore, it is important to note that Morgan’s essay does not repeat anything in-depth that would otherwise be on her resume. She makes a reference to her work in care team meetings through a clinical bioethics internship, but does not focus on this because there are other places on her application where this internship can be discussed. Instead, she offers a more reflection-based perspective on the internship that goes more in-depth than a resume or CV could. This enables her to explain the reasons for interdisciplinary approach to medicine with tangible examples that range from personal to professional experiences — an approach that presents her as a well-rounded candidate for medical school.

Disclaimer: With exception of the removal of identifying details, essays are reproduced as originally submitted in applications; any errors in submissions are maintained to preserve the integrity of the piece. The Crimson's news and opinion teams—including writers, editors, photographers, and designers—were not involved in the production of this article.

-- Accepted To: A medical school in New Jersey with a 3% acceptance rate. GPA: 3.80 MCAT: 502 and 504

Sponsored by E fiie Consulting Group : “ EFIIE ” boasts 100% match rate for all premedical and predental registered students. Not all students are accepted unto their pre-health student roster. Considered the most elite in the industry and assists from start to end – premed to residency. EFIIE is a one-stop-full-service education firm.

"To know even one life has breathed easier because you have lived. This is to have succeeded." – Ralph Waldo Emerson.

The tribulations I've overcome in my life have manifested in the compassion, curiosity, and courage that is embedded in my personality. Even a horrific mishap in my life has not changed my core beliefs and has only added fuel to my intense desire to become a doctor. My extensive service at an animal hospital, a harrowing personal experience, and volunteering as an EMT have increased my appreciation and admiration for the medical field.

At thirteen, I accompanied my father to the Park Home Animal Hospital with our eleven-year-old dog, Brendan. He was experiencing severe pain due to an osteosarcoma, which ultimately led to the difficult decision to put him to sleep. That experience brought to light many questions regarding the idea of what constitutes a "quality of life" for an animal and what importance "dignity" plays to an animal and how that differs from owner to owner and pet to pet. Noting my curiosity and my relative maturity in the matter, the owner of the animal hospital invited me to shadow the professional staff. Ten years later, I am still part of the team, having made the transition from volunteer to veterinarian technician. Saving a life, relieving pain, sharing in the euphoria of animal and owner reuniting after a procedure, to understanding the emotions of losing a loved one – my life was forever altered from the moment I stepped into that animal hospital.

As my appreciation for medical professionals continued to grow, a horrible accident created an indelible moment in my life. It was a warm summer day as I jumped onto a small boat captained by my grandfather. He was on his way to refill the boat's gas tank at the local marina, and as he pulled into the dock, I proceeded to make a dire mistake. As the line was thrown from the dock, I attempted to cleat the bowline prematurely, and some of the most intense pain I've ever felt in my life ensued.

Saving a life, relieving pain, sharing in the euphoria of animal and owner reuniting after a procedure, to understanding the emotions of losing a loved one – my life was forever altered from the moment I stepped into that animal hospital.

"Call 911!" I screamed, half-dazed as I witnessed blood gushing out of my open wounds, splashing onto the white fiberglass deck of the boat, forming a small puddle beneath my feet. I was instructed to raise my hand to reduce the bleeding, while someone wrapped an icy towel around the wound. The EMTs arrived shortly after and quickly drove me to an open field a short distance away, where a helicopter seemed to instantaneously appear.

The medevac landed on the roof of Stony Brook Hospital before I was expeditiously wheeled into the operating room for a seven-hour surgery to reattach my severed fingers. The distal phalanges of my 3rd and 4th fingers on my left hand had been torn off by the rope tightening on the cleat. I distinctly remember the chill from the cold metal table, the bright lights of the OR, and multiple doctors and nurses scurrying around. The skill and knowledge required to execute multiple skin graft surgeries were impressive and eye-opening. My shortened fingers often raise questions by others; however, they do not impair my self-confidence or physical abilities. The positive outcome of this trial was the realization of my intense desire to become a medical professional.

Despite being the patient, I was extremely impressed with the dedication, competence, and cohesiveness of the medical team. I felt proud to be a critical member of such a skilled group. To this day, I still cannot explain the dichotomy of experiencing being the patient, and concurrently one on the professional team, committed to saving the patient. Certainly, this experience was a defining part of my life and one of the key contributors to why I became an EMT and a volunteer member of the Sample Volunteer Ambulance Corps. The startling ring of the pager, whether it is to respond to an inebriated alcoholic who is emotionally distraught or to help bring breath to a pulseless person who has been pulled from the family swimming pool, I am committed to EMS. All of these events engender the same call to action and must be reacted to with the same seriousness, intensity, and magnanimity. It may be some routine matter or a dire emergency; this is a role filled with uncertainty and ambiguity, but that is how I choose to spend my days. My motives to become a physician are deeply seeded. They permeate my personality and emanate from my desire to respond to the needs of others. Through a traumatic personal event and my experiences as both a professional and volunteer, I have witnessed firsthand the power to heal the wounded and offer hope. Each person defines success in different ways. To know even one life has been improved by my actions affords me immense gratification and meaning. That is success to me and why I want to be a doctor.

This review is provided by EFIIE Consulting Group’s Pre-Health Senior Consultant Jude Chan

This student was a joy to work with — she was also the lowest MCAT profile I ever accepted onto my roster. At 504 on the second attempt (502 on her first) it would seem impossible and unlikely to most that she would be accepted into an allopathic medical school. Even for an osteopathic medical school this score could be too low. Additionally, the student’s GPA was considered competitive at 3.80, but it was from a lower ranked, less known college, so naturally most advisors would tell this student to go on and complete a master’s or postbaccalaureate program to show that she could manage upper level science classes. Further, she needed to retake the MCAT a third time.

However, I saw many other facets to this student’s history and life that spoke volumes about the type of student she was, and this was the positioning strategy I used for her file. Students who read her personal statement should know that acceptance is contingent on so much more than just an essay and MCAT score or GPA. Although many students have greater MCAT scores than 504 and higher GPAs than 3.80, I have helped students with lower scores and still maintained our 100% match rate. You are competing with thousands of candidates. Not every student out there requires our services and we are actually grateful that we can focus on a limited amount out of the tens of thousands that do. We are also here for the students who wish to focus on learning well the organic chemistry courses and physics courses and who want to focus on their research and shadowing opportunities rather than waste time deciphering the next step in this complex process. We tailor a pathway for each student dependent on their health care career goals, and our partnerships with non-profit organizations, hospitals, physicians and research labs allow our students to focus on what matters most — the building up of their basic science knowledge and their exposure to patients and patient care.

Students who read her personal statement should know that acceptance is contingent on so much more than just an essay and MCAT score or GPA.

Even students who believe that their struggle somehow disqualifies them from their dream career in health care can be redeemed if they are willing to work for it, just like this student with 502 and 504 MCAT scores. After our first consult, I saw a way to position her to still be accepted into an MD school in the US — I would not have recommended she register to our roster if I did not believe we could make a difference. Our rosters have a waitlist each semester, and it is in our best interest to be transparent with our students and protect our 100% record — something I consider a win-win. It is unethical to ever guarantee acceptance in admissions as we simply do not control these decisions. However, we respect it, play by the rules, and help our students stay one step ahead by creating an applicant profile that would be hard for the schools to ignore.

This may be the doctor I go to one day. Or the nurse or dentist my children or my grandchildren goes to one day. That is why it is much more than gaining acceptance — it is about properly matching the student to the best options for their education. Gaining an acceptance and being incapable of getting through the next 4 or 8 years (for my MD/PhD-MSTP students) is nonsensical.

-- Accepted To: Imperial College London UCAT Score: 2740 BMAT Score: 3.9, 5.4, 3.5A

My motivation to study Medicine stems from wishing to be a cog in the remarkable machine that is universal healthcare: a system which I saw first-hand when observing surgery in both the UK and Sri Lanka. Despite the differences in sanitation and technology, the universality of compassion became evident. When volunteering at OSCE training days, I spoke to many medical students, who emphasised the importance of a genuine interest in the sciences when studying Medicine. As such, I have kept myself informed of promising developments, such as the use of monoclonal antibodies in cancer therapy. After learning about the role of HeLa cells in the development of the polio vaccine in Biology, I read 'The Immortal Life of Henrietta Lacks' to find out more. Furthermore, I read that surface protein CD4 can be added to HeLa cells, allowing them to be infected with HIV, opening the possibility of these cells being used in HIV research to produce more life-changing drugs, such as pre-exposure prophylaxis (PreP). Following my BioGrad laboratory experience in HIV testing, and time collating data for research into inflammatory markers in lung cancer, I am also interested in pursuing a career in medical research. However, during a consultation between an ENT surgeon and a thyroid cancer patient, I learnt that practising medicine needs more than a scientific aptitude. As the surgeon explained that the cancer had metastasised to her liver, I watched him empathetically tailor his language for the patient - he avoided medical jargon and instead gave her time to come to terms with this. I have been developing my communication skills by volunteering weekly at care homes for 3 years, which has improved my ability to read body language and structure conversations to engage with the residents, most of whom have dementia.

However, during a consultation between an ENT surgeon and a thyroid cancer patient, I learnt that practising medicine needs more than a scientific aptitude.

Jude’s essay provides a very matter-of-fact account of their experience as a pre-medical student. However, they deepen this narrative by merging two distinct cultures through some common ground: a universality of compassion. Using clear, concise language and a logical succession of events — much like a doctor must follow when speaking to patients — Jude shows their motivation to go into the medical field.

From their OSCE training days to their school’s Science society, Jude connects their analytical perspective — learning about HeLa cells — to something that is relatable and human, such as a poor farmer’s notable contribution to science. This approach provides a gateway into their moral compass without having to explicitly state it, highlighting their fervent desire to learn how to interact and communicate with others when in a position of authority.

Using clear, concise language and a logical succession of events — much like a doctor must follow when speaking to patients — Jude shows their motivation to go into the medical field.

Jude’s closing paragraph reminds the reader of the similarities between two countries like the UK and Sri Lanka, and the importance of having a universal healthcare system that centers around the just and “world-class” treatment of patients. Overall, this essay showcases Jude’s personal initiative to continue to learn more and do better for the people they serve.

While the essay could have benefited from better transitions to weave Jude’s experiences into a personal story, its strong grounding in Jude’s motivation makes for a compelling application essay.

-- Accepted to: Weill Cornell Medical College GPA: 3.98 MCAT: 521

Sponsored by E fie Consulting Group : “ EFIIE ” boasts 100% match rate for all premedical and predental registered students. Not all students are accepted unto their pre-health student roster. Considered the most elite in the industry and assists from start to end – premed to residency. EFIIE is a one-stop-full-service education firm.

Following the physician’s unexpected request, we waited outside, anxiously waiting to hear the latest update on my father’s condition. It was early on in my father’s cancer progression – a change that had shaken our entire way of life overnight. During those 18 months, while my mother spent countless nights at the hospital, I took on the responsibility of caring for my brother. My social life became of minimal concern, and the majority of my studying for upcoming 12th- grade exams was done at the hospital. We were allowed back into the room as the physician walked out, and my parents updated us on the situation. Though we were a tight-knit family and my father wanted us to be present throughout his treatment, what this physician did was give my father a choice. Without making assumptions about who my father wanted in the room, he empowered him to make that choice independently in private. It was this respect directed towards my father, the subsequent efforts at caring for him, and the personal relationship of understanding they formed, that made the largest impact on him. Though my decision to pursue medicine came more than a year later, I deeply valued what these physicians were doing for my father, and I aspired to make a similar impact on people in the future.

It was during this period that I became curious about the human body, as we began to learn physiology in more depth at school. In previous years, the problem-based approach I could take while learning math and chemistry were primarily what sparked my interest. However, I became intrigued by how molecular interactions translated into large-scale organ function, and how these organ systems integrated together to generate the extraordinary physiological functions we tend to under-appreciate. I began my undergraduate studies with the goal of pursuing these interests, whilst leaning towards a career in medicine. While I was surprised to find that there were upwards of 40 programs within the life sciences that I could pursue, it broadened my perspective and challenged me to explore my options within science and healthcare. I chose to study pathobiology and explore my interests through hospital volunteering and research at the end of my first year.

Though my decision to pursue medicine came more than a year later, I deeply valued what these physicians were doing for my father, and I aspired to make a similar impact on people in the future.

While conducting research at St. Michael’s Hospital, I began to understand methods of data collection and analysis, and the thought process of scientific inquiry. I became acquainted with the scientific literature, and the experience transformed how I thought about the concepts I was learning in lecture. However, what stood out to me that summer was the time spent shadowing my supervisor in the neurosurgery clinic. It was where I began to fully understand what life would be like as a physician, and where the career began to truly appeal to me. What appealed to me most was the patient-oriented collaboration and discussions between my supervisor and his fellow; the physician-patient relationship that went far beyond diagnoses and treatments; and the problem solving that I experienced first-hand while being questioned on disease cases.

The day spent shadowing in the clinic was also the first time I developed a relationship with a patient. We were instructed to administer the Montreal cognitive assessment (MoCA) test to patients as they awaited the neurosurgeon. My task was to convey the instructions as clearly as possible and score each section. I did this as best I could, adapting my explanation to each patient, and paying close attention to their responses to ensure I was understood. The last patient was a challenging case, given a language barrier combined with his severe hydrocephalus. It was an emotional time for his family, seeing their father/husband struggle to complete simple tasks and subsequently give up. I encouraged him to continue trying. But I also knew my words would not remedy the condition underlying his struggles. All I could do was make attempts at lightening the atmosphere as I got to know him and his family better. Hours later, as I saw his remarkable improvement following a lumbar puncture, and the joy on his and his family’s faces at his renewed ability to walk independently, I got a glimpse of how rewarding it would be to have the ability and privilege to care for such patients. By this point, I knew I wanted to commit to a life in medicine. Two years of weekly hospital volunteering have allowed me to make a small difference in patients’ lives by keeping them company through difficult times, and listening to their concerns while striving to help in the limited way that I could. I want to have the ability to provide care and treatment on a daily basis as a physician. Moreover, my hope is that the breadth of medicine will provide me with the opportunity to make an impact on a larger scale. Whilst attending conferences on neuroscience and surgical technology, I became aware of the potential to make a difference through healthcare, and I look forward to developing the skills necessary to do so through a Master’s in Global Health. Whether through research, health innovation, or public health, I hope not only to care for patients with the same compassion with which physicians cared for my father, but to add to the daily impact I can have by tackling large-scale issues in health.

Taylor’s essay offers both a straightforward, in-depth narrative and a deep analysis of his experiences, which effectively reveals his passion and willingness to learn in the medical field. The anecdote of Taylor’s father gives the reader insight into an original instance of learning through experience and clearly articulates Taylor’s motivations for becoming a compassionate and respectful physician.

Taylor strikes an impeccable balance between discussing his accomplishments and his character. All of his life experiences — and the difficult challenges he overcame — introduce the reader to an important aspect of Taylor’s personality: his compassion, care for his family, and power of observation in reflecting on the decisions his father’s doctor makes. His description of his time volunteering at St. Michael’s Hospital is indicative of Taylor’s curiosity about medical research, but also of his recognition of the importance of the patient-physician relationship. Moreover, he shows how his volunteer work enabled him to see how medicine goes “beyond diagnoses and treatments” — an observation that also speaks to his compassion.

His description of his time volunteering at St. Michael's Hospital is indicative of Taylor's curiosity about medical research, but also of his recognition of the importance of the patient-physician relationship.

Finally, Taylor also tells the reader about his ambition and purpose, which is important when thinking about applying to medical school. He discusses his hope of tackling larger scale problems through any means possible in medicine. This notion of using self interest to better the world is imperative to a successful college essay, and it is nicely done here.

-- Accepted to: Washington University

Sponsored by A dmitRx : We are a group of Chicago-based medical students who realize how challenging medical school admissions can be, so we want to provide our future classmates with resources we wish we had. Our mission at AdmitRx is to provide pre-medical students with affordable, personalized, high-quality guidance towards becoming an admitted medical student.

Running has always been one of my greatest passions whether it be with friends or alone with my thoughts. My dad has always been my biggest role model and was the first to introduce me to the world of running. We entered races around the country, and one day he invited me on a run that changed my life forever. The St. Jude Run is an annual event that raises millions of dollars for St. Jude Children’s Research Hospital. My dad has led or our local team for as long as I can remember, and I had the privilege to join when I was 16. From the first step I knew this was the environment for me – people from all walks of life united with one goal of ending childhood cancer. I had an interest in medicine before the run, and with these experiences I began to consider oncology as a career. When this came up in conversations, I would invariably be faced with the question “Do you really think you could get used to working with dying kids?” My 16-year-old self responded with something noble but naïve like “It’s important work, so I’ll have to handle it”. I was 16 years young with my plan to become an oncologist at St. Jude.

As I transitioned into college my plans for oncology were alive and well. I began working in a biochemistry lab researching new anti-cancer drugs. It was a small start, but I was overjoyed to be a part of the process. I applied to work at a number of places for the summer, but the Pediatric Oncology Education program (POE) at St. Jude was my goal. One afternoon, I had just returned from class and there it was: an email listed as ‘POE Offer’. I was ecstatic and accepted the offer immediately. Finally, I could get a glimpse at what my future holds. My future PI, Dr. Q, specialized in solid tumor translational research and I couldn’t wait to get started.

I was 16 years young with my plan to become an oncologist at St. Jude.

Summer finally came, I moved to Memphis, and I was welcomed by the X lab. I loved translational research because the results are just around the corner from helping patients. We began a pre-clinical trial of a new chemotherapy regimen and the results were looking terrific. I was also able to accompany Dr. Q whenever she saw patients in the solid tumor division. Things started simple with rounds each morning before focusing on the higher risk cases. I was fortunate enough to get to know some of the patients quite well, and I could sometimes help them pass the time with a game or two on a slow afternoon between treatments. These experiences shined a very human light on a field I had previously seen only through a microscope in a lab.

I arrived one morning as usual, but Dr. Q pulled me aside before rounds. She said one of the patients we had been seeing passed away in the night. I held my composure in the moment, but I felt as though an anvil was crushing down on me. It was tragic but I knew loss was part of the job, so I told myself to push forward. A few days later, I had mostly come to terms with what happened, but then the anvil came crashing back down with the passing of another patient. I could scarcely hold back the tears this time. That moment, it didn’t matter how many miraculous successes were happening a few doors down. Nothing overshadowed the loss, and there was no way I could ‘get used to it’ as my younger self had hoped.

I was still carrying the weight of what had happened and it was showing, so I asked Dr. Q for help. How do you keep smiling each day? How do you get used to it? The questions in my head went on. What I heard next changed my perspective forever. She said you keep smiling because no matter what happened, you’re still hope for the next patient. It’s not about getting used to it. You never get used to it and you shouldn’t. Beating cancer takes lifetimes, and you can’t look passed a life’s worth of hardships. I realized that moving passed the loss of patients would never suffice, but I need to move forward with them. Through the successes and shortcomings, we constantly make progress. I like to imagine that in all our future endeavors, it is the hands of those who have gone before us that guide the way. That is why I want to attend medical school and become a physician. We may never end the sting of loss, but physicians are the bridge between the past and the future. No where else is there the chance to learn from tragedy and use that to shape a better future. If I can learn something from one loss, keep moving forward, and use that knowledge to help even a single person – save one life, bring a moment of joy, avoid a moment of pain—then that is how I want to spend my life.

The change wasn’t overnight. The next loss still brought pain, but I took solace in moving forward so that we might learn something to give hope to a future patient. I returned to campus in a new lab doing cancer research, and my passion for medicine continues to flourish. I still think about all the people I encountered at St. Jude, especially those we lost. It might be a stretch, but during the long hours at the lab bench I still picture their hands moving through mine each step of the way. I could never have foreseen where the first steps of the St. Jude Run would bring me. I’m not sure where the road to becoming a physician may lead, but with helping hands guiding the way, I won’t be running it alone.

This essay, a description of the applicant’s intellectual challenges, displays the hardships of tending to cancer patients as a milestone of experience and realization of what it takes to be a physician. The writer explores deeper ideas beyond medicine, such as dealing with patient deaths in a way to progress and improve as a professional. In this way, the applicant gives the reader some insight into the applicant’s mindset, and their ability to think beyond the surface for ways to become better at what they do.

However, the essay fails to zero in on the applicant’s character, instead elaborating on life events that weakly illustrate the applicant’s growth as a physician. The writer’s mantra (“keep moving forward”) is feebly projected, and seems unoriginal due to the lack of a personalized connection between the experience at St. Jude and how that led to the applicant’s growth and mindset changes.

The writer explores deeper ideas beyond medicine, such as dealing with patient deaths in a way to progress and improve as a professional.

The writer, by only focusing on grief brought from patient deaths at St. Jude, misses out on the opportunity to further describe his or her experience at the hospital and portray an original, well-rounded image of his or her strengths, weaknesses, and work ethic.

The applicant ends the essay by attempting to highlight the things they learned at St. Jude, but fails to organize the ideas into a cohesive, comprehensible section. These ideas are also too abstract, and are vague indicators of the applicant’s character that are difficult to grasp.

-- Accepted to: New York University School of Medicine

Sponsored by MedEdits : MedEdits Medical Admissions has been helping applicants get into medical schools like Harvard for more than ten years. Structured like an academic medical department, MedEdits has experts in admissions, writing, editing, medicine, and interview prep working with you collaboratively so you can earn the best admissions results possible.

“Is this the movie you were talking about Alice?” I said as I showed her the movie poster on my iPhone. “Oh my God, I haven’t seen that poster in over 70 years,” she said with her arms trembling in front of her. Immediately, I sat up straight and started to question further. We were talking for about 40 minutes, and the most exciting thing she brought up in that time was the new flavor of pudding she had for lunch. All of sudden, she’s back in 1940 talking about what it was like to see this movie after school for only 5¢ a ticket! After an engaging discussion about life in the 40’s, I knew I had to indulge her. Armed with a plethora of movie streaming sights, I went to work scouring the web. No luck. The movie, “My Son My Son,” was apparently not in high demand amongst torrenting teens. I had to entreat my older brother for his Amazon Prime account to get a working stream. However, breaking up the monotony and isolation felt at the nursing home with a simple movie was worth the pandering.

While I was glad to help a resident have some fun, I was partly motivated by how much Alice reminded me of my own grandfather. In accordance with custom, my grandfather was to stay in our house once my grandmother passed away. More specifically, he stayed in my room and my bed. Just like grandma’s passing, my sudden roommate was a rough transition. In 8th grade at the time, I considered myself to be a generally good guy. Maybe even good enough to be a doctor one day. I volunteered at the hospital, shadowed regularly, and had a genuine interest for science. However, my interest in medicine was mostly restricted to academia. To be honest, I never had a sustained exposure to the palliative side of medicine until the arrival of my new roommate.

The two years I slept on that creaky wooden bed with him was the first time my metal was tested. Sharing that room, I was the one to take care of him. I was the one to rub ointment on his back, to feed him when I came back from school, and to empty out his spittoon when it got full. It was far from glamorous, and frustrating most of the time. With 75 years separating us, and senile dementia setting in, he would often forget who I was or where he was. Having to remind him that I was his grandson threatened to erode at my resolve. Assured by my Syrian Orthodox faith, I even prayed about it; asking God for comfort and firmness on my end. Over time, I grew slow to speak and eager to listen as he started to ramble more and more about bits and pieces of the past. If I was lucky, I would be able to stich together a narrative that may or may have not been true. In any case, my patience started to bud beyond my age group.

Having to remind him that I was his grandson threatened to erode at my resolve.

Although I grew more patient with his disease, my curiosity never really quelled. Conversely, it developed further alongside my rapidly growing interest in the clinical side of medicine. Naturally, I became drawn to a neurology lab in college where I got to study pathologies ranging from atrophy associated with schizophrenia, and necrotic lesions post stroke. However, unlike my intro biology courses, my work at the neurology lab was rooted beyond the academics. Instead, I found myself driven by real people who could potentially benefit from our research. In particular, my shadowing experience with Dr. Dominger in the Veteran’s home made the patient more relevant in our research as I got to encounter geriatric patients with age related diseases, such as Alzhimer’s and Parkinson’s. Furthermore, I had the privilege of of talking to the families of a few of these patients to get an idea of the impact that these diseases had on the family structure. For me, the scut work in the lab meant a lot more with these families in mind than the tritium tracer we were using in the lab.

Despite my achievements in the lab and the classroom, my time with my grandfather still holds a special place in my life story. The more I think about him, the more confident I am in my decision to pursue a career where caring for people is just as important, if not more important, than excelling at academics. Although it was a lot of work, the years spent with him was critical in expanding my horizons both in my personal life and in the context of medicine. While I grew to be more patient around others, I also grew to appreciate medicine beyond the science. This more holistic understanding of medicine had a synergistic effect in my work as I gained a purpose behind the extra hours in the lab, sleepless nights in the library, and longer hours volunteering. I had a reason for what I was doing that may one day help me have long conversations with my own grandchildren about the price of popcorn in the 2000’s.

The most important thing to highlight in Avery’s essay is how he is able to create a duality between his interest in not only the clinical, more academic-based side of medicine, but also the field’s personal side.

He draws personal connections between working with Alice — a patient in a hospital or nursing home — and caring intensely for his grandfather. These two experiences build up the “synergistic” relationship between caring for people and studying the science behind medicine. In this way, he is able to clearly state his passions for medicine and explain his exact motives for entering the field. Furthermore, in his discussion of her grandfather, he effectively employs imagery (“rub ointment on his back,” “feed him when I came back from school,” etc.) to describe the actual work that he does, calling it initially as “far from glamorous, and frustrating most of the time.” By first mentioning his initial impression, then transitioning into how he grew to appreciate the experience, Avery is able to demonstrate a strength of character, sense of enormous responsibility and capability, and open-minded attitude.

He draws personal connections between working with Alice — a patient in a hospital or nursing home — and caring intensely for his grandfather.

Later in the essay, Avery is also able to relate his time caring for his grandfather to his work with Alzheimer’s and Parkinson’s patients, showcasing the social impact of his work, as the reader is likely already familiar with the biological impact of the work. This takes Avery’s essay full circle, bringing it back to how a discussion with an elderly patient about the movies reminds him of why he chose to pursue medicine.

That said, the essay does feel rushed near the end, as the writer was likely trying to remain within the word count. There could be a more developed transition before Avery introduces the last sentence about “conversations with my own grandchildren,” especially as a strong essay ending is always recommended.

-- Accepted To: Saint Louis University Medical School Direct Admission Medical Program

Sponsored by Atlas Admissions : Atlas Admissions provides expert medical school admissions consulting and test preparation services. Their experienced, physician-driven team consistently delivers top results by designing comprehensive, personalized strategies to optimize applications. Atlas Admissions is based in Boston, MA and is trusted by clients worldwide.

The tension in the office was tangible. The entire team sat silently sifting through papers as Dr. L introduced Adam, a 60-year-old morbidly obese man recently admitted for a large open wound along his chest. As Dr. L reviewed the details of the case, his prognosis became even bleaker: hypertension, diabetes, chronic kidney disease, cardiomyopathy, hyperlipidemia; the list went on and on. As the humdrum of the side-conversations came to a halt, and the shuffle of papers softened, the reality of Adam’s situation became apparent. Adam had a few months to live at best, a few days at worst. To make matters worse, Adam’s insurance would not cover his treatment costs. With no job, family, or friends, he was dying poor and alone.

I followed Dr. L out of the conference room, unsure what would happen next. “Well,” she muttered hesitantly, “We need to make sure that Adam is on the same page as us.” It’s one thing to hear bad news, and another to hear it utterly alone. Dr. L frantically reviewed all of Adam’s paperwork desperately looking for someone to console him, someone to be at his side. As she began to make calls, I saw that being a physician calls for more than good grades and an aptitude for science: it requires maturity, sacrifice, and most of all, empathy. That empathy is exactly what I saw in Dr. L as she went out of her way to comfort a patient she met hardly 20 minutes prior.

Since high school, I’ve been fascinated by technology’s potential to improve healthcare. As a volunteer in [the] Student Ambassador program, I was fortunate enough to watch an open-heart surgery. Intrigued by the confluence of technology and medicine, I chose to study biomedical engineering. At [school], I wanted to help expand this interface, so I became involved with research through Dr. P’s lab by studying the applications of electrospun scaffolds for dermal wound healing. While still in the preliminary stages of research, I learned about the Disability Service Club (DSC) and decided to try something new by volunteering at a bowling outing.

As she began to make calls, I saw that being a physician calls for more than good grades and an aptitude for science: it requires maturity, sacrifice, and most of all, empathy.

The DSC promotes awareness of cognitive disabilities in the community and seeks to alleviate difficulties for the disabled. During one outing, I collaborated with Arc, a local organization with a similar mission. Walking in, I was told that my role was to support the participants by providing encouragement. I decided to help a relatively quiet group of individuals assisted by only one volunteer, Mary. Mary informed me that many individuals with whom I was working were diagnosed with ASD. Suddenly, she started cheering, as one of the members of the group bowled a strike. The group went wild. Everyone was dancing, singing, and rejoicing. Then I noticed one gentleman sitting at our table, solemn-faced. I tried to start a conversation with him, but he remained unresponsive. I sat with him for the rest of the game, trying my hardest to think of questions that would elicit more than a monosyllabic response, but to no avail. As the game ended, I stood up to say bye when he mumbled, “Thanks for talking.” Then he quickly turned his head away. I walked away beaming. Although I was unable to draw out a smile or even sustain a conversation, at the end of the day, the fact that this gentleman appreciated my mere effort completely overshadowed the awkwardness of our time together. Later that day, I realized that as much as I enjoyed the thrill of research and its applications, helping other people was what I was most passionate about.

When it finally came time to tell Adam about his deteriorating condition, I was not sure how he would react. Dr. L gently greeted him and slowly let reality take its toll. He stoically turned towards Dr. L and groaned, “I don’t really care. Just leave me alone.” Dr. L gave him a concerned nod and gradually left the room. We walked to the next room where we met with a pastor from Adam’s church.

“Adam’s always been like that,” remarked the pastor, “he’s never been one to express emotion.” We sat with his pastor for over an hour discussing how we could console Adam. It turned out that Adam was part of a motorcycle club, but recently quit because of his health. So, Dr. L arranged for motorcycle pictures and other small bike trinkets to be brought to his room as a reminder of better times.

Dr. L’s simple gesture reminded me of why I want to pursue medicine. There is something sacred, empowering, about providing support when people need it the most; whether it be simple as starting a conversation, or providing support during the most trying of times. My time spent conducting research kindled my interest in the science of medicine, and my service as a volunteer allowed me to realize how much I valued human interaction. Science and technology form the foundation of medicine, but to me, empathy is the essence. It is my combined interest in science and service that inspires me to pursue medicine. It is that combined interest that makes me aspire to be a physician.

Parker’s essay focuses on one central narrative with a governing theme of compassionate and attentive care for patients, which is the key motivator for her application to medical school. Parker’s story focuses on her volunteer experience shadowing of Dr. L who went the extra mile for Adam, which sets Dr. L up as a role model for Parker as she enters the medical field. This effectively demonstrates to the reader what kind of doctor Parker wants to be in the future.

Parker’s narrative has a clear beginning, middle, and end, making it easy for the reader to follow. She intersperses the main narrative about Adam with experiences she has with other patients and reflects upon her values as she contemplates pursuing medicine as a career. Her anecdote about bowling with the patients diagnosed with ASD is another instance where she uses a story to tell the reader why she values helping people through medicine and attentive patient care, especially as she focuses on the impact her work made on one man at the event.

Parker's story focuses on her volunteer experience shadowing of Dr. L who went the extra mile for Adam, which sets Dr. L up as a role model for Parker as she enters the medical field.

All throughout the essay, the writing is engaging and Parker incorporates excellent imagery, which goes well with her varied sentence structure. The essay is also strong because it comes back full circle at its conclusion, tying the overall narrative back to the story of Dr. L and Adam, which speaks to Parker’s motives for going to medical school.

-- Accepted To: Emory School of Medicine

Growing up, I enjoyed visiting my grandparents. My grandfather was an established doctor, helping the sick and elderly in rural Taiwan until two weeks before he died at 91 years old. His clinic was located on the first floor of the residency with an exam room, treatment room, X-ray room, and small pharmacy. Curious about his work, I would follow him to see his patients. Grandpa often asked me if I want to be a doctor just like him. I always smiled, but was more interested in how to beat the latest Pokémon game. I was in 8th grade when my grandfather passed away. I flew back to Taiwan to attend his funeral. It was a gloomy day and the only street in the small village became a mourning place for the villagers. Flowers filled the streets and people came to pay their respects. An old man told me a story: 60 years ago, a village woman was in a difficult labor. My grandfather rushed into the house and delivered a baby boy. That boy was the old man and he was forever grateful. Stories of grandpa saving lives and bringing happiness to families were told during the ceremony. At that moment, I realized why my grandfather worked so tirelessly up until his death as a physician. He did it for the reward of knowing that he kept a family together and saved a life. The ability for a doctor to heal and bring happiness is the reason why I want to study medicine. Medical school is the first step on a lifelong journey of learning, but I feel that my journey leading up to now has taught me some things of what it means to be an effective physician.

With a newfound purpose, I began volunteering and shadowing at my local hospital. One situation stood out when I was a volunteer in the cardiac stress lab. As I attached EKG leads onto a patient, suddenly the patient collapsed and started gasping for air. His face turned pale, then slightly blue. The charge nurse triggered “Code Blue” and started CPR. A team of doctors and nurses came, rushing in with a defibrillator to treat and stabilize the patient. What I noticed was that medicine was not only about one individual acting as a superhero to save a life, but that it takes a team of individuals with an effective leader, working together to deliver the best care. I want to be a leader as well as part of a team that can make a difference in a person’s life. I have refined these lessons about teamwork and leadership to my activities. In high school I was an 8 time varsity letter winner for swimming and tennis and captain of both of those teams. In college I have participated in many activities, but notably serving as assistant principle cellist in my school symphony as well as being a co-founding member of a quartet. From both my athletic experiences and my music experiences I learned what it was like to not only assert my position as a leader and to effectively communicate my views, but equally as important I learned how to compromise and listen to the opinions of others. Many physicians that I have observed show a unique blend of confidence and humility.

What I noticed was that medicine was not only about one individual acting as a superhero to save a life, but that it takes a team of individuals with an effective leader, working together to deliver the best care.

College opened me up to new perspectives on what makes a complete physician. A concept that was preached in the Guaranteed Professional Program Admissions in Medicine (GPPA) was that medicine is both an art and a science. The art of medicine deals with a variety of aspects including patient relationships as well as ethics. Besides my strong affinity for the sciences and mathematics, I always have had interest in history. I took courses in both German literature and history, which influenced me to take a class focusing on Nazi neuroscientists. It was the ideology of seeing the disabled and different races as test subjects rather than people that led to devastating lapses in medical ethics. The most surprising fact for me was that doctors who were respected and leaders in their field disregarded the humanity of patient and rather focused on getting results from their research. Speaking with Dr. Zeidman, the professor for this course, influenced me to start my research which deals with the ethical qualms of using data derived from unethical Nazi experimentation such as the brains derived from the adult and child euthanasia programs. Today, science is so result driven, it is important to keep in mind the ethics behind research and clinical practice. Also the development of personalized genomic medicine brings into question about potential privacy violations and on the extreme end discrimination. The study of ethics no matter the time period is paramount in the medical field. The end goal should always be to put the patient first.

Teaching experiences in college inspired me to become a physician educator if I become a doctor. Post-MCAT, I was offered a job by Next Step Test Prep as a tutor to help students one on one for the MCAT. I had a student who stated he was doing well during practice, but couldn’t get the correct answer during practice tests. Working with the student, I pointed out his lack of understanding concepts and this realization helped him and improves his MCAT score. Having the ability to educate the next generation of doctors is not only necessary, but also a rewarding experience.

My experiences volunteering and shadowing doctors in the hospital as well as my understanding of what it means to be a complete physician will make me a good candidate as a medical school student. It is my goal to provide the best care to patients and to put a smile on a family’s face just as my grandfather once had. Achieving this goal does not take a special miracle, but rather hard work, dedication, and an understanding of what it means to be an effective physician.

Through reflecting on various stages of life, Quinn expresses how they found purpose in pursuing medicine. Starting as a child more interested in Pokemon than their grandfather’s patients, Quinn exhibits personal growth through recognizing the importance of their grandfather’s work saving lives and eventually gaining the maturity to work towards this goal as part of a team.

This essay opens with abundant imagery — of the grandfather’s clinic, flowers filling the streets, and the village woman’s difficult labor — which grounds Quinn’s story in their family roots. Yet, the transition from shadowing in hospitals to pursuing leadership positions in high schools is jarring, and the list of athletic and musical accomplishments reads like a laundry list of accomplishments until Quinn neatly wraps them up as evidence of leadership and teamwork skills. Similarly, the section about tutoring, while intended to demonstrate Quinn’s desire to educate future physicians, lacks the emotional resonance necessary to elevate it from another line lifted from their resume.

This essay opens with abundant imagery — of the grandfather's clinic, flowers filling the streets, and the village woman's difficult labor — which grounds Quinn's story in their family roots.

The strongest point of Quinn’s essay is the focus on their unique arts and humanities background. This equips them with a unique perspective necessary to consider issues in medicine in a new light. Through detailing how history and literature coursework informed their unique research, Quinn sets their application apart from the multitude of STEM-focused narratives. Closing the essay with the desire to help others just as their grandfather had, Quinn ties the narrative back to their personal roots.

-- Accepted To: Edinburgh University UCAT Score: 2810 BMAT Score: 4.6, 4.2, 3.5A

Exposure to the medical career from an early age by my father, who would explain diseases of the human body, sparked my interest for Medicine and drove me to seek out work experience. I witnessed the contrast between use of bone saws and drills to gain access to the brain, with subsequent use of delicate instruments and microscopes in neurosurgery. The surgeon's care to remove the tumour, ensuring minimal damage to surrounding healthy brain and his commitment to achieve the best outcome for the patient was inspiring. The chance to have such a positive impact on a patient has motivated me to seek out a career in Medicine.

Whilst shadowing a surgical team in Texas, carrying out laparoscopic bariatric procedures, I appreciated the surgeon's dedication to continual professional development and research. I was inspired to carry out an Extended Project Qualification on whether bariatric surgery should be funded by the NHS. By researching current literature beyond my school curriculum, I learnt to assess papers for bias and use reliable sources to make a conclusion on a difficult ethical situation. I know that doctors are required to carry out research and make ethical decisions and so, I want to continue developing these skills during my time at medical school.

The chance to have such a positive impact on a patient has motivated me to seek out a career in Medicine.

Attending an Oncology multi-disciplinary team meeting showed me the importance of teamwork in medicine. I saw each team member, with specific areas of expertise, contributing to the discussion and actively listening, and together they formed a holistic plan of action for patients. During my Young Enterprise Award, I facilitated a brainstorm where everyone pitched a product idea. Each member offered a different perspective on the idea and then voted on a product to carry forward in the competition. As a result, we came runners up in the Regional Finals. Furthermore, I started developing my leadership skills, which I improved by doing Duke of Edinburgh Silver and attending a St. John Ambulance Leadership course. In one workshop, similar to the bariatric surgeon I shadowed, I communicated instructions and delegated roles to my team to successfully solve a puzzle. These experiences highlighted the crucial need for teamwork and leadership as a doctor.

Observing a GP, I identified the importance of compassion and empathy. During a consultation with a severely depressed patient, the GP came to the patient's eye level and used a calm, non-judgmental tone of voice, easing her anxieties and allowing her to disclose more information. While volunteering at a care home weekly for two years, I adapted my communication for a resident suffering with dementia who was disconnected from others. I would take her to a quiet environment, speak slowly and in a non-threatening manner, as such, she became talkative, engaged and happier. I recognised that communication and compassion allows doctors to build rapport, gain patients' trust and improve compliance. For two weeks, I shadowed a surgeon performing multiple craniotomies a day. I appreciated the challenges facing doctors including time and stress management needed to deliver high quality care. Organisation, by prioritising patients based on urgency and creating a timetable on the ward round, was key to running the theatre effectively. Similarly, I create to-do-lists and prioritise my academics and extra-curricular activities to maintain a good work-life balance: I am currently preparing for my Grade 8 in Singing, alongside my A-level exams. I also play tennis for the 1st team to relax and enable me to refocus. I wish to continue my hobbies at university, as ways to manage stress.

Through my work experiences and voluntary work, I have gained a realistic understanding of Medicine and its challenges. I have begun to display the necessary skills that I witnessed, such as empathy, leadership and teamwork. The combination of these skills with my fascination for the human body drives me to pursue a place at medical school and a career as a doctor.

This essay traces Alex's personal exploration of medicine through different stages of life, taking a fairly traditional path to the medical school application essay. From witnessing medical procedures to eventually pursuing leadership positions, this tale of personal progress argues that Alex's life has prepared him to become a doctor.

Alex details how experiences conducting research and working with medical teams have confirmed his interest in medicine. Although the breadth of experiences speaks to the applicant’s interest in medicine, the essay verges on being a regurgitation of the Alex's resume, which does not provide the admissions officer with any new insights or information and ultimately takes away from the essay as a whole. As such, the writing’s lack of voice or unique perspective puts the applicant at risk of sounding middle-of-the-road.

From witnessing medical procedures to eventually pursuing leadership positions, this tale of personal progress argues that Alex's life has prepared him to become a doctor.

The essay’s organization, however, is one of its strengths — each paragraph provides an example of personal growth through a new experience in medicine. Further, Alex demonstrates his compassion and diligence through detailed stories, which give a reader a glimpse into his values. Through recognizing important skills necessary to be a doctor, Alex demonstrates that he has the mature perspective necessary to embark upon this journey.

What this essay lacks in a unique voice, it makes up for in professionalism and organization. Alex's earnest desire to attend medical school is what makes this essay shine.

-- Accepted To: University of Toronto MCAT Scores: Chemical and Physical Foundations of Biological Systems - 128, Critical Analysis and Reading Skills - 127, Biological and Biochemical Foundations of Living Systems - 127, Psychological, Social, and Biological Foundations of Behavior - 130, Total - 512

Moment of brilliance.

Revelation.

These are all words one would use to describe their motivation by a higher calling to achieve something great. Such an experience is often cited as the reason for students to become physicians; I was not one of these students. Instead of waiting for an event like this, I chose to get involved in the activities that I found most invigorating. Slowly but surely, my interests, hobbies, and experiences inspired me to pursue medicine.

As a medical student, one must possess a solid academic foundation to facilitate an understanding of physical health and illness. Since high school, I found science courses the most appealing and tended to devote most of my time to their exploration. I also enjoyed learning about the music, food, literature, and language of other cultures through Latin and French class. I chose the Medical Sciences program because it allowed for flexibility in course selection. I have studied several scientific disciplines in depth like physiology and pathology while taking classes in sociology, psychology, and classical studies. Such a diverse academic portfolio has strengthened my ability to consider multiple viewpoints and attack problems from several angles. I hope to relate to patients from all walks of life as a physician and offer them personalized treatment.

I was motivated to travel as much as possible by learning about other cultures in school. Exposing myself to different environments offered me perspective on universal traits that render us human. I want to pursue medicine because I believe that this principle of commonality relates to medical practice in providing objective and compassionate care for all. Combined with my love for travel, this realization took me to Nepal with Volunteer Abroad (VA) to build a school for a local orphanage (4). The project’s demands required a group of us to work closely as a team to accomplish the task. Rooted in different backgrounds, we often had conflicting perspectives; even a simple task such as bricklaying could stir up an argument because each person had their own approach. However, we discussed why we came to Nepal and reached the conclusion that all we wanted was to build a place of education for the children. Our unifying goal allowed us to reach compromises and truly appreciate the value of teamwork. These skills are vital in a clinical setting, where physicians and other health care professionals need to collaborate as a multidisciplinary team to tackle patients’ physical, emotional, social, and psychological problems.

I hope to relate to patients from all walks of life as a physician and offer them personalized treatment.

The insight I gained from my Nepal excursion encouraged me to undertake and develop the role of VA campus representative (4). Unfortunately, many students are not equipped with the resources to volunteer abroad; I raised awareness about local initiatives so everyone had a chance to do their part. I tried to avoid pushing solely for international volunteerism for this reason and also because it can undermine the work of local skilled workers and foster dependency. Nevertheless, I took on this position with VA because I felt that the potential benefits were more significant than the disadvantages. Likewise, doctors must constantly weigh out the pros and cons of a situation to help a patient make the best choice. I tried to dispel fears of traveling abroad by sharing first-hand experiences so that students could make an informed decision. When people approached me regarding unfamiliar placements, I researched their questions and provided them with both answers and a sense of security. I found great fulfillment in addressing the concerns of individuals, and I believe that similar processes could prove invaluable in the practice of medicine.

As part of the Sickkids Summer Research Program, I began to appreciate the value of experimental investigation and evidence-based medicine (23). Responsible for initiating an infant nutrition study at a downtown clinic, I was required to explain the project’s implications and daily protocol to physicians, nurses and phlebotomists. I took anthropometric measurements and blood pressure of children aged 1-10 and asked parents about their and their child’s diet, television habits, physical exercise regimen, and sunlight exposure. On a few occasions, I analyzed and presented a small set of data to my superiors through oral presentations and written documents.

With continuous medical developments, physicians must participate in lifelong learning. More importantly, they can engage in research to further improve the lives of their patients. I encountered a young mother one day at the clinic struggling to complete the study’s questionnaires. After I asked her some questions, she began to open up to me as her anxiety subsided; she then told me that her child suffered from low iron. By talking with the physician and reading a few articles, I recommended a few supplements and iron-rich foods to help her child. This experience in particular helped me realize that I enjoy clinical research and strive to address the concerns of people with whom I interact.

Research is often impeded by a lack of government and private funding. My clinical placement motivated me to become more adept in budgeting, culminating in my role as founding Co-President of the UWO Commerce Club (ICCC) (9). Together, fellow club executives and I worked diligently to get the club ratified, a process that made me aware of the bureaucratic challenges facing new organizations. Although we had a small budget, we found ways of minimizing expenditure on advertising so that we were able to host more speakers who lectured about entrepreneurship and overcoming challenges. Considering the limited space available in hospitals and the rising cost of health care, physicians, too, are often forced to prioritize and manage the needs of their patients.

No one needs a grand revelation to pursue medicine. Although passion is vital, it is irrelevant whether this comes suddenly from a life-altering event or builds up progressively through experience. I enjoyed working in Nepal, managing resources, and being a part of clinical and research teams; medicine will allow me to combine all of these aspects into one wholesome career.

I know with certainty that this is the profession for me.

Jimmy opens this essay hinting that his essay will follow a well-worn path, describing the “big moment” that made him realize why he needed to become a physician. But Jimmy quickly turns the reader’s expectation on its head by stating that he did not have one of those moments. By doing this, Jimmy commands attention and has the reader waiting for an explanation. He soon provides the explanation that doubles as the “thesis” of his essay: Jimmy thinks passion can be built progressively, and Jimmy’s life progression has led him to the medical field.

Jimmy did not make the decision to pursue a career in medicine lightly. Instead he displays through anecdotes that his separate passions — helping others, exploring different walks of life, personal responsibility, and learning constantly, among others — helped Jimmy realize that being a physician was the career for him. By talking readers through his thought process, it is made clear that Jimmy is a critical thinker who can balance multiple different perspectives simultaneously. The ability to evaluate multiple options and make an informed, well-reasoned decision is one that bodes well for Jimmy’s medical career.

While in some cases this essay does a lot of “telling,” the comprehensive and decisive walkthrough indicates what Jimmy’s idea of a doctor is. To him, a doctor is someone who is genuinely interested in his work, someone who can empathize and related to his patients, someone who can make important decisions with a clear head, and someone who is always trying to learn more. Just like his decision to work at the VA, Jimmy has broken down the “problem” (what his career should be) and reached a sound conclusion.

By talking readers through his thought process, it is made clear that Jimmy is a critical thinker who can balance multiple different perspectives simultaneously.

Additionally, this essay communicates Jimmy’s care for others. While it is not always advisable to list one’s volunteer efforts, each activity Jimmy lists has a direct application to his essay. Further, the sheer amount of philanthropic work that Jimmy does speaks for itself: Jimmy would not have worked at VA, spent a summer with Sickkids, or founded the UWO finance club if he were not passionate about helping others through medicine. Like the VA story, the details of Jimmy’s participation in Sickkids and the UWO continue to show how he has thought about and embodied the principles that a physician needs to be successful.

Jimmy’s essay both breaks common tropes and lives up to them. By framing his “list” of activities with his passion-happens-slowly mindset, Jimmy injects purpose and interest into what could have been a boring and braggadocious essay if it were written differently. Overall, this essay lets the reader know that Jimmy is seriously dedicated to becoming a physician, and both his thoughts and his actions inspire confidence that he will give medical school his all.

The Crimson's news and opinion teams—including writers, editors, photographers, and designers—were not involved in the production of this content.

Emergency Medical Services: At the Crossroads (2007)

Chapter: 2 history and current state of ems, 2 history and current state of ems.

Across the country, emergency medical services (EMS) agencies face numerous challenges with regard to their funding, management, workforce, infrastructure, and research base. Though the modern EMS system was instituted and funded in large part by the federal government through the Highway Safety Act of 1966 and the EMS Act of 1973, federal support for EMS agencies declined precipitously in the early 1980s. Since that time, states and localities have taken more prominent roles in financing and designing EMS programs. The result has been considerable fragmentation of EMS care and wide variability in the type of care that is offered from state to state and region to region. This chapter traces the development of the modern EMS system and describes the current state of EMS at the federal, state, and local levels.

A BRIEF HISTORY OF EMS

EMS dates back centuries and has seen rapid advances during times of war. At least as far back as the Greek and Roman eras, chariots were used to remove injured soldiers from the battlefield. In the late 15th century, Ferdinand and Isabella of Spain commissioned surgical and medical supplies to be provided to troops in special tents called ambulancias . During the French Revolution in 1794, Baron Dominique-Jean Larrey recognized that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army. He instituted a system in which trained medical per-

sonnel initiated treatment and transported the wounded to field hospitals (Pozner et al., 2004).

This model was emulated by Americans during the Civil War. General Jonathan Letterman, a Union military surgeon, created the first organized system in the United States to treat and transport injured patients. Based on this experience, the first civilian-run, hospital-based ambulance service began in Cincinnati in 1865. The first municipally based EMS began in New York City in 1869 (NHTSA, 1996).

In 1910, the American Red Cross began providing first-aid training programs across the country, initiating an organized effort to improve civilian bystander care. During World Wars I and II, further advances were made in EMS, although typically these were not replicated in the civilian setting until much later (Pozner et al., 2004). Following World War II, city EMS activities were for the most part run by municipal hospitals and fire departments. In smaller communities, funeral home hearses often served as ambulances because they were the only vehicle capable of transporting patients quickly in stretchers. With the advent of federal involvement in EMS in the early 1970s and the articulation of standards at the state and regional levels, these EMS providers were gradually replaced by others, including third-service providers, fire departments, rescue squads, and private ambulances (NHTSA, 1996).

By the late 1950s, prehospital emergency care in the United States was still little more than first aid (IOM, 1993). Around that time, however, advances in medical care began to spur the rapid development of modern EMS. While the first recorded use of mouth-to-mouth ventilation had been in 1732, it was not until 1958 that Dr. Peter Safar demonstrated it to be superior to other modes of manual ventilation. In 1960, cardiopulmonary resuscitation (CPR) was shown to be efficacious. These two clinical advances led to the realization that rapid response of trained community members to cardiac emergencies could improve outcomes. The introduction of CPR and the development of portable external defibrillators in the 1960s provided the foundation for advanced cardiac life support (ACLS) that fueled much of the development of EMS systems in subsequent years.

In 1965, the President’s Committee for Traffic Safety published the report Health, Medical Care and Transportation of the Injured . The report recommended a national program to reduce highway deaths and injuries. The following year, the National Academy of Sciences (NAS) and National Research Council (NRC) released Accidental Death and Disability: The Neglected Disease of Modern Society (NAS/NRC, 1966). That report emphasized that the health care system needed to address injuries, which at the time were the leading cause of death for those aged 1–37. It noted that in most cases, ambulances were inappropriately designed, ill-equipped, and often staffed with inadequately trained personnel. For example, the report

called attention to the fact that at least 50 percent of ambulance services nationwide were being provided by morticians. The report contained a total of 29 recommendations, 11 of which applied directly to prehospital EMS (Delbridge et al., 1998). These included recommendations to (1) develop federal standards for ambulances (design, construction, equipment, supplies, personnel training and supervision); (2) adopt state ambulance regulations; (3) ensure provision of ambulance services applicable to the conditions of the local government; (4) initiate pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas; (5) assign radio channels and equipment suitable for voice communications between ambulances and emergency departments (EDs) and other health-related agencies; and (6) develop a single nationwide telephone number for summoning an ambulance. The report also laid out a vision for the establishment of trauma systems as we know them today.

In addition to the momentum that had been provided by the President’s Commission, support for the NAS/NRC report was fueled by surgeons with military experience in Korea and World War II who recognized that the trauma care available to soldiers overseas was better than the care available in local communities. In 1966, Congress passed the Highway Safety Act, which led to the formation of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation (DOT). NHTSA was given authority to fund improvements in EMS. Among those improvements, NHTSA developed a national EMS education curriculum and model state EMS legislation. NHTSA’s 70-hour basic EMT curriculum became the first standard EMT training in the United States. The department developed more extensive advanced life support (ALS) training several years later. Also as part of the 1966 act, DOT offered grant funding to states with the goal of improving the provision of EMS.

1970s: Rapid Expansion of Regional EMS Systems

In the early 1970s, additional research and policy planning focused on the unmet needs of EMS. In 1972, the NAS/NRC released another report on EMS entitled Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services (NAS and NRC, 1972). The report expressed concern that the federal effort to upgrade EMS had not kept pace with what was needed. It urged integration of all federal EMS efforts into the Department of Health, Education and Welfare (DHEW, which later became the Department of Health and Human Services [DHHS]). The report also stated that the focal point for local EMS should be at the state rather than the federal level, and that all efforts should be coordinated through regional programs.

In 1973, Congress enacted the EMS Systems Act, which created a new grant program to further the development of regional EMS systems. The intent of the law was to improve and coordinate care throughout the country through the creation of a categorical grant program run by the new Division of Emergency Medical Services within DHEW. This program became a decisive factor in the nationwide development of regional EMS systems. Millions of dollars were earmarked for EMS training, equipment, and research. In total, more than $300 million was appropriated for EMS feasibility studies, planning, operations, expansion and improvement, and research. (In 2004 dollars, this investment equates to $1.3 billion.) Also, in 1974 The Robert Wood Johnson Foundation appropriated $15 million to fund 44 regional EMS projects ($64 million in 2004 dollars). To this day, this remains the largest private grant for EMS system development ever awarded.

An important feature of the grant program was its emphasis on the need for effective planning at the state, regional, and local levels to ensure coordination of prehospital and hospital emergency care. Across the country, state EMS offices began to emerge. With the federal support, states established a total of about 300 EMS regions—most covering several counties—each eligible to receive up to 5 years of funding (NHTSA, 1996). The law also identified 15 essential elements that should be included in an EMS system: manpower, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, coordinated patient record keeping, public information and education, review and evaluation, disaster plan, and mutual aid. The EMS Systems Act helped guide the development of models of service delivery; informed system functions such as medical direction, triage protocols, communication, and quality assurance; and set the tone of the EMS system’s interaction with the larger health care and public health systems. While the act identified ideal components of an EMS system from the federal government’s perspective, however, the organization of systems on the ground, including their scope of practice and overall structure, was fundamentally driven by local needs, characteristics, and concerns. A patchwork quilt of systems began to emerge.

A 1978 report by the NAS/NRC, Emergency Medical Services at Mid-passage , expressed criticism of DHEW and focused on the coordination problem between DOT and DHEW at the federal level (NAS and NRC, 1978). The report criticized the conflicting education standards developed by the two departments and recommended more research and evaluation of EMS system development. By 1981, an agreement between DOT and DHEW to coordinate efforts had been canceled, and the EMS program and DHEW grants had been eliminated.

1980s: Withdrawal of Federal Support and Leadership in EMS

In 1981, the Omnibus Budget Reconciliation Act (OBRA) eliminated the categorical federal funding to states established by the 1973 EMS Systems Act in favor of block grants to states for preventive health and health services. This change shifted responsibility for EMS from the federal to the state level. Once states had greater discretion regarding the use of funds, most chose to spend the money in areas of need other than EMS. Thus the immediate impact of the shift to block grants was a sharp decrease in total funding for EMS (U.S. Congress, Office of Technology Assessment, 1989). Moreover, states were left to develop their systems in greater isolation. Some increased their involvement in EMS, but others chose to cede more authority to cities and counties. Political, geographic, and fiscal disparities contributed to fragmented and diverse development of EMS systems at the local level. In addition, a lack of objective scientific evidence regarding the best models for EMS organization and delivery left many systems in the dark regarding appropriate steps to take.

The structure provided to local EMS systems by state governments varied. Lead state EMS agencies remained in all states, but with varying degrees of authority and funding. Maryland, for example, chose to maintain an active role and retained significant authority at the state level. The Maryland Institute for Emergency Medical Services Systems was established in 1972 and continued to take a strong leadership role in subsequent years. The state elected to provide emergency air and ground transportation as a public service and created a sophisticated trauma system that designates trauma centers on the basis of compliance with standards and demonstrated need (IOM, 1993).

By contrast, California and many other states elected to take a less active role. By default as much as by design, regional and county EMS systems took the lead in designing and managing their EMS programs. California state government maintained responsibility for such issues as investigating EMS system complaints and setting EMS training standards, but otherwise had a diminished role in the overall direction of EMS systems. During the 1980s, some states maintained vestiges of the regional systems that were developed in the 1970s, but other systems were fractured along smaller and smaller local lines. The result was even greater diversity among systems.

In the early to mid-1980s, the role of voluntary national EMS organizations increased. These included the National Association of State EMS Officials (NASEMSO, formerly the National Association of State EMS Directors [NASEMSD]), the National Association of Emergency Medical Technicians (NAEMT), the National Association of EMS Physicians (NAEMSP), the American College of Surgeons Committee on Trauma (ACS COT), and the American College of Emergency Physicians (ACEP) EMS Committee. In 1984, the Emergency Medical Services for Children (EMS-C) program was

established at the Health Resources and Services Administration (HRSA) within DHHS.

In 1985, the NRC report Injury in America: A Continuing Health Problem described the limited progress that had been made in addressing the problem of accidental death and disability (IOM, 1985). The report described the need for a federal agency to focus on injuries as a public health problem. In response, an injury program was established at the Centers for Disease Control and Prevention (CDC) that approached injury prevention and control from a public health perspective. This program was later elevated to the status of a center at CDC—the National Center for Injury Prevention and Control (NCIPC).

During this period, rural EMS development lagged behind. The loss of federal funding and the limited financial resources available in states with large rural populations exacerbated this problem. In 1989, the Office of Technology Assessment released a report detailing the challenges faced by rural EMS (U.S. Congress, Office of Technology Assessment, 1989) (see the discussion of rural EMS below).

NHTSA implemented a statewide EMS technical assessment program in 1988. During these assessments, statewide EMS systems are evaluated on the basis of 10 essential components: regulation and policy, resource management, human resources and training, transportation, facilities, communications, public information and education, medical direction, trauma systems, and evaluation.

1990s to the Present: EMS—Looking Toward the Future

In 1995, through the urging of then NHTSA Administrator Ricardo Martinez, NHTSA and HRSA commissioned a strategic plan for the future EMS system. The resulting report, Emergency Medical Services Agenda for the Future (NHTSA, 1996), outlined a vision of an EMS system that is integrated with the health care system, proactive in providing community health, and adequately funded and accessible (see Table 2-1 ).

TABLE 2-1 New Vision for the Role of Emergency Medical Services

In 1997, NHTSA gathered members of the EMS community to develop an implementation guide for making the recommendations in Agenda for the Future a reality. The implementation guide focused on three strategies: improving linkages between EMS and other components of the health care system, creating a strong infrastructure, and developing new tools and resources to improve the effectiveness of EMS.

Agenda for the Future , now a decade old, has been effective in drawing attention to EMS and placing a spotlight on the vital role played by EMS within the emergency and trauma care system. Several of the goals it set forth, however, have not yet been realized. Its vision, such as placing a focus on the care provided to entire communities rather than individuals and thinking proactively rather than reactively, still represents a significant conceptual leap for most EMS systems. The types of changes envisioned by the Agenda are discussed in the relevant context in the chapters that follow.

More recently, in 2001, the U.S. General Accounting Office (GAO) released a comprehensive study of local EMS system needs and of the state regulatory agencies responsible for improving EMS outcomes. The report characterized the needs as substantial and wide-ranging, and grouped the problems identified under four categories: personnel, training, equipment, and medical direction. The report noted that the extent of local needs was difficult to determine since little standard and quantifiable information exists for use in comparing performance across systems. The report also noted that most of the available information is localized and anecdotal (GAO, 2001b).

The terrorist attacks of September 11, 2001, focused attention on the heroism of public safety personnel (fire, police, and EMS), but also exposed many of the technical and logistical challenges that confront the nation’s public safety systems. Communications capabilities were shown to be grossly deficient among the units that responded to the World Trade Center attacks, and a lack of interoperability and inadequate communications with rescuers within the towers probably contributed to the deaths of many rescue personnel (National Commission on Terrorist Attacks upon the United States, 2004). In the aftermath of the disaster, the federal government took a number of steps to improve response capabilities, including development of the National Response Plan and the National Incident Management System (NIMS) (discussed in Chapter 6 ).

Boxes 2-1 and 2-2 detail the development and recent experience of EMS systems in two U.S. cities.

THE TROUBLED STATE OF EMS

EMS operates at the intersection of health care, public health, and public safety and therefore has overlapping roles and responsibilities (see

Figure 2-1 ). Often, local EMS systems are not well integrated with any of these groups and therefore receive inadequate support from each of them. As a result, EMS has a foot in many doors, but no clear home.

Prehospital EMS faces a number of special challenges. First and foremost, EMS systems throughout the country are often highly fragmented. Although they are frequently required to work side by side, turf wars between EMS and fire personnel are not uncommon (Davis, 2003a, 2004). In addition, as noted above, the events of September 11, 2001, demonstrated that public safety agencies (including fire, police, emergency management, and EMS) often use incompatible equipment and are unable to communicate with each other during emergencies. Many of these problems are

magnified when incidents cross jurisdictional lines. Significant problems are often encountered near municipal, county, and state borders. Where a street delineates the boundary between two city or county jurisdictions, responsibility for care—as well as the protocols and procedures employed—depends on the side of the street on which the incident occurred. One county in Michigan has 18 different EMS systems with a range of service models and protocols. In addition, EMS providers have found that coordinating services across state lines is particularly challenging.

In addition, coordination between EMS and hospitals is often inadequate. While hospital ED staff often provide direct, on-line medical direction to EMS personnel during transport, time pressures, competing demands, and a lack of trust can at times hinder these interactions. In addition, cultural differences between EMS and hospital staff can impede the exchange of information. Upon arrival at the hospital, busy ED staff who are strug-

FIGURE 2-1 The overlapping roles and responsibilities of EMS.

SOURCE: NHTSA, 1996.

gling to manage a very crowded ED often greet arriving EMS units with, at best, a lack of enthusiasm. As a result, clinically important information is sometimes lost in patient handoffs between EMS and hospital staff.

Second, there is little doubt that ED crowding has had a very adverse impact on prehospital care. When an ED is crowded, ED staff may be unable to find the physical space needed to off-load patients. Under these circumstances, EMS units may be stuck in the ED for prolonged periods of time, leaving them out of service for other emergency calls. In addition, ED diversion has become commonplace in many major cities, further hindering the performance of EMS. In major metropolitan areas, it is not uncommon for all of the city’s trauma centers to request ambulance diversion at the same time. When hospital EDs go on diversion status, ambulances may have to drive longer distances and take patients to less appropriate facilities (GAO, 2003). Fully 45 percent of EDs reported going on diversion at some point in 2003, and the problem was especially pronounced in urban areas. Overall, it is estimated that 501,000 ambulances were diverted during that year (Burt et al., 2006).

Although it is likely that ambulance diversions endanger patients, there are no data directly linking ambulance diversions with higher mortality rates. No agency has sponsored a systematic study to examine this question, and fears of legal liability inhibit candid disclosure of adverse events (IOM, 2000). However, a study by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) revealed that more than

half of all “sentinel” ED events—defined as “an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof”—were caused by delayed treatment. While this study was not centered on ambulance diversion, its findings are consistent with the argument that delays in treatment resulting from diversion can have deleterious effects on patients.

Third, the cost of maintaining an EMS system in a state of readiness is extremely high, and it is rarely compensated. The EMS reimbursement model used by the Centers for Medicare and Medicaid Services (CMS) and emulated by many payers reimburses on the basis of transport to a medical facility. This model ignores the increasingly sophisticated care provided by EMS personnel, as well as the growing proportion of elderly patients with multiple chronic conditions who frequently utilize EMS. Medicaid typically pays a fixed rate—as low as $25 in some states—for an EMS transport, regardless of the complexity of the case or the resources utilized. The fact that payers generally withhold reimbursement in cases where transport is not provided is a major impediment to the implementation of processes that allow EMS to “treat and release,” to transport patients directly to a dialysis unit or another appropriate site, or to terminate unsuccessful cardiac resuscitation in the field. In addition, many systems of all types provide both 9-1-1 call services and medical transportation. To make up for funding shortfalls, these systems often offset the cost of the former services with revenues from the latter.

EMS is widely viewed as an essential public service, but it has not been supported through effective federal and state leadership and sustainable funding strategies. Unlike other such services—electricity, highways, airports, and telephone service, for example—all of which were created and are actively maintained through major national infrastructure investments, access to timely and high-quality emergency and trauma care has largely been relegated to local and state initiatives. As a result, EMS care remains extremely uneven across the United States. Even when EMS is located within a publicly funded agency such as the fire service, it may receive a disproportionately small amount of fire service funding (including grants and line item disbursements), despite the fact that a large majority of calls to fire departments are medical in nature.

Fourth, EMS agencies face a number of personnel challenges. The training of EMTs and paramedics is uneven across the United States, and as a result, EMS professionals exhibit a wide range of skill levels. There are currently no national requirements for training, certification, or licensure, nor is there required national accreditation of schools that provide EMS training. In addition, recruitment and retention are significant challenges for EMS systems. The work of prehospital providers can be challenging and dangerous. EMS personnel face potential violence from patients; risks

due to bloodborne and airborne pathogens; and dangers from ambulance crashes, which increasingly result in provider fatalities (Franks et al., 2004). In addition, many EMS professionals are frustrated by low pay—the average salary for EMTs is about $18,000 and for paramedics is $34,000 (Brown et al., 2003)—and limited career growth opportunities, especially relative to firefighters and other public servants with whom they work side by side. Worse, they are often treated as second-class citizens by those same colleagues, by the systems in which they work, and by the state and federal institutions that fund and support the services they provide. As a result of these and other challenges, recently surveyed EMS agencies and administrators ranked recruitment and retention as the number one issue they face (EMS Insider, 2005).

Perhaps most disturbing is how little is known about what does and does not work in prehospital emergency care. There is little or no scientific evidence to support many widely employed EMS clinical procedures and system design features. The value and proper application of common clinical practices, such as rapid sequence intubation (Murray et al., 2000; Gausche et al., 2000; Davis et al., 2003; Wang et al., 2004) and cardiac resuscitation (Keim et al., 2004), remain unresolved. Field triage models that are widely considered to be out of date are still in use today. Evidence on the value of delivery models, such as tiered levels of response, intensity of on-line medical direction, type of EMS system (e.g., fire-based, volunteer), and deployment of paramedics, is either nonexistent or inconclusive.

The lack of available data on prehospital care not only discourages research on the effectiveness of prehospital interventions, but also hinders the development of process and outcome measures for evaluating the performance of the system. In fact, policy makers and the public have very little information on how well local EMS systems function and how care varies across jurisdictions.

Rural areas face a different set of problems, principally involving a scarcity of resources. EMS and trauma services are dispersed across wide distances, and recruitment and retention of EMTs and paramedics is a pervasive problem. In rural areas, volunteers make up the majority of the EMS workforce (National Registry of Emergency Medical Technicians, 2003). EMS is the only component of the U.S. medical system that has a significant volunteer component, but in many rural communities, younger residents are leaving as the remaining population becomes more elderly. As a result, the pool of potential volunteers is dwindling as their average age and the demands on their time increase. The closure or restructuring of many rural hospital facilities has further increased the demand on rural EMS agencies by creating an environment that requires long-distance, time-consuming, and high-risk interfacility transfers. The final section of this chapter provides a detailed discussion of rural EMS.

EMS is the first line of defense in responding to the medical needs of the public in the event of a disaster, yet EMS personnel are often the least prepared and most poorly equipped of all public safety personnel. According to New York University’s Center for Catastrophe Preparedness and Response, more than half of EMTs and paramedics have received less than 1 hour of training in dealing with biological and chemical agents and explosives since the September 11 terrorist attacks, and 20 percent have received no such training. Fewer than 33 percent of EMTs and paramedics have participated in a drill during the past year simulating a radiological, biological, or chemical attack. And in 25 states, half or fewer EMTs and paramedics have adequate personal protective equipment to respond to a biological or chemical attack (Center for Catastrophe Preparedness and Response NYU, 2005). These findings call into question the readiness of the current EMS system to deal with potential disasters.

FEDERAL OVERSIGHT AND FUNDING

The federal government is extremely fragmented in its approach to regulating EMS. A host of departments, divisions, and agencies at the federal level play a role in various aspects of EMS, but none is officially designated as the lead agency. With the passage of the Highway Safety Act in 1966, EMS found its unofficial home within NHTSA in DOT. At the time, a principal focus of the government’s effort in EMS was on reducing the number of deaths and disabilities caused by crashes on the nation’s motorways, so this placement within DOT seemed appropriate.

As described above, NHTSA’s Office of EMS has been able to provide significant leadership in the field over the past several decades. Indeed, since the early 1970s, NHTSA is the only federal agency that has consistently focused on improving the overall EMS system (AEMS, 2005a). However, NHTSA’s Office of EMS is a small program within a very large federal department that is devoted to transportation. Obscured as it often is within the vast federal bureaucracy, EMS is sometimes overlooked and at times virtually forgotten. This is evidenced by the fact that to date, EMS has received only a small percentage of homeland security funds allocated by the federal government. Although EMS providers represent a third of the nation’s first responders and have a key mission in treating the casualties of a terrorist strike, they received only 4 percent of the $3.38 billion allocated by the Department of Homeland Security for enhancing emergency preparedness in 2002 and 2003 (Center for Catastrophe Preparedness and Response NYU, 2005).

While NHTSA has served as the informal lead agency for EMS within the federal government, a number of other federal agencies also have a stake in EMS. DHHS houses several programs within HRSA, including

the EMS-C program and the Trauma and EMS Program (although both of these programs have been targeted for elimination in recent federal budgets). HRSA also administers the Office of Rural Health Policy. CMS is responsible for Medicare and Medicaid reimbursement for emergency services, which makes up a significant portion of EMS revenues. CDC’s NCIPC plays an important role in trauma and prevention research that is closely allied with emergency services. The National Institutes of Health (NIH) funds emergency- and trauma-related research. The Department of Homeland Security’s Preparedness Directorate supports emergency preparedness programs through the Chief Medical Officer, the U.S. Fire Administration, the Office of Grants and Training, and other agencies.

In an effort to coordinate the efforts of these various components of the federal bureaucracy, Congress established a Federal Interagency Committee on Emergency Medical Services (FICEMS) in 2005. This group was formed to ensure coordination among the federal agencies involved with state, local, or regional EMS and 9-1-1 systems and to identify ways of streamlining the process through which federal agencies provide support to these systems (see Chapter 3 ).

Federal Funding of EMS

Today, financial support for EMS is provided by the various departments and agencies that have jurisdiction over EMS. An array of federal grant programs provide limited amounts of funding to states, localities, and EMS providers (see Table 2-2 for examples). Typically, EMS receives a very small percentage of the funds devoted to larger programs.

Within DHHS, both HRSA and CDC fund EMS. HRSA operates a number of EMS-related programs, including trauma and EMS (funded at $3.5 million in fiscal year 2005), rural outreach grants ($39 million), hospital flex grants ($39 million), a poison control program ($23 million), and the EMS-C program ($23 million). As noted, however, recent budget proposals would eliminate several of these programs, including trauma and EMS, EMS-C, and the poison control program. By far the largest of the HRSA programs is the Hospital Bioterrorism Preparedness program ($495 million). This program aims to improve the capacity of hospitals, EDs, health centers, EMS systems, and poison control centers to respond to acts of terrorism and other public health emergencies. As detailed in Chapter 6 , however, a very small percentage of these funds is directed to EMS.

CDC operates two large EMS-related programs. The Preventive Health and Health Services block grant ($131 million) provides states with resources to address priority health concerns in their communities. States are also charged with designing prevention and health promotion programs that address the national health objectives contained in Healthy People

TABLE 2-2 EMS-Related Fiscal Year 2005 Federal Funding

2010. These include increasing the proportion of adults who are aware of the early warning signs of a heart attack and the importance of accessing emergency care by calling 9-1-1 (GAO, 2001b). CDC also runs NCIPC, which works to reduce morbidity, disability, mortality, and costs associated with injuries (funded at $138 million in fiscal year 2005). Overall, however, a small percentage of the funds allotted to these CDC programs is devoted specifically to EMS.

The Department of Homeland Security’s Office of Domestic Preparedness awarded nearly $4 billion in federal funding in fiscal year 2005 under its first-responder grant programs—the Firefighter Assistance Grants program ($895 million) and the State and Local Programs fund ($3.1 billion). The latter included $885 million for high-threat, high-density urban areas; $150 million each for port security and rail and transit security; and $135 million for the national domestic preparedness consortium. As detailed in Chapter 6 , however, non-EMS first responders were the primary recipients of these funds.

Federal Reimbursement for EMS Services

In addition to small portions of the federal funding detailed above, EMS systems across the country receive federal funds through reimbursements from the Medicare program. Because the elderly are heavy users of EMS, Medicare represents a very large percentage of billings and collections in a typical EMS agency. Those aged 65 and older are 4.4 times more likely to use EMS than younger individuals, and they represent a growing segment of the population. Since Medicare payments have traditionally been used to cross-subsidize Medicaid and uninsured EMS users, Medicare represents an even larger percentage of total patient revenues for EMS agencies (Overton,

2002). An example from the Richmond Ambulance Authority is shown in Figure 2-2 . In that system, Medicare represents 40 percent of billings, but 55 percent of revenues.

The Medicare program recently completed a 5-year transition to a new fee schedule. Under the old reimbursement system, EMS agencies received two payments per transport. The primary payment was a cost-based, fee-for-service rate that reimbursed EMS for the service provided. The secondary payment was reimbursement for the number of miles the ambulance traveled. Under that system, ambulance services were concerned primarily with reporting their charges and mileage. The new system keeps the mileage reimbursement but abandons the cost-based payment and replaces it with a prospective payment system, similar to the system in place for outpatient health services (Overton, 2002). EMS was the last Medicare Part B provider to transition from a fee-for-service to a prospective payment system. Under the new system, ALS transports are reimbursed at a higher rate than basic life support (BLS) transports, and higher payments are provided for transport in rural areas to reflect the typically long travel times to and from hospitals (MedPAC, 2003).

Overall, the new fee schedule significantly reduces Medicare payments to EMS providers. Two years into the transition to the new system, data indicated that Medicare reimbursements were approximately 45 percent below the national cost average for transport, leading to a $600 million shortfall for services provided to Medicare beneficiaries. As a result, local EMS systems may now need greater subsidization from local governments or may be forced to reduce costs through personnel cuts, reductions in

FIGURE 2-2 EMS patient revenues, Richmond, Virginia.

SOURCE: Overton, 2002.

capital expenditures, or other means. These dynamics illustrate the tension among federal, state, and local governments regarding the locus of responsibility for funding EMS systems across the country.

Medicare payments have significantly shaped the provision of EMS nationwide, as evidenced in several areas, including the availability of responders, the therapeutic interventions provided, treat and release practices, and transport and transfer policies (NASEMSD, 2005). For example, EMS systems relying on Medicare and other third-party payers for significant revenue must generally provide patient transportation to be reimbursed for their services. While the primary determinants of EMS costs relate to maintaining readiness capacity, the primary determinant of payment for services is patient transport. Thus in an urban area that receives a large number of 9-1-1 calls, the cost of readiness is spread over a large number of users, keeping the cost per transport relatively low, whereas in rural areas, the lower volume of emergency calls in relation to the high overhead of maintaining a prepared staff results in very high costs per transport. Although many rural EMS squads rely on volunteers rather than paid EMS personnel to reduce these costs, doing so results in a less stable system.

Federal Regulation of EMS

The current organization and delivery of emergency and trauma care is shaped largely by federal and state legislation. The legal and regulatory framework provides many protections and benefits, but also presents obstacles to achieving efficient and high-quality care delivery.

Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA represents one example of how the federal government’s fragmented regulatory structure has resulted in confusion for EMS providers and potential harm to emergency patients. This law, passed in 1986, requires hospitals that participate in the Medicare program to provide a medical screening exam and stabilize all patients that come to the hospital for care before they are discharged or transferred to another hospital. EMTALA was intended to protect access to emergency care by preventing private hospitals from turning away needy emergency patients who are uninsured or underinsured or precipitously transferring these patients to the closest public hospital, a practice known as “dumping” (GAO, 2001a).

Over time, the law has progressively expanded, and it now covers patients seen anywhere on hospital property, which includes ambulances owned and operated by the hospital (Wanerman, 2002; Elting and Toddy, 2003). As a result, hospitals may be required to provide medical screening exams to patients arriving in a hospital-owned ambulance even if the pa-

tient requires immediate care at a regional trauma center because the local hospital does not have the personnel or equipment required to respond effectively to the patient’s critical medical needs. This situation also arises in cases where a ground and an air ambulance are attempting to rendezvous at a hospital’s helipad so that the patient can be transported quickly to a trauma center. Providers in the field have experienced confusion as to whether a screening exam is mandated in this case.

The expansion of EMTALA to include transports by hospital-owned ambulances created a barrier to regional coordination. The goal of regional coordination is to ensure that patients receive the optimal care, and a key component of that task is ensuring that avoidable and costly delays are eliminated. However, EMTALA may require that patients receive initial care at a less-than-optimal facility, creating avoidable delays in the provision of needed care.

This problem is compounded by the fact that no one agency is responsible for making regulatory decisions regarding EMTALA, and as a consequence, federal rules on this issue are not clear. The Office of the Inspector General (OIG) has produced advisories on EMTALA, including a letter of opinion stating that ambulances may take patients directly to hospitals that are appropriate for the patient’s condition (including trauma centers) in cases where there are “regional protocols” in place (DHHS, 2003). However, the OIG is not a rule-making entity and is not responsible for enforcement. CMS’s enforcement of EMTALA has been shown to be highly variable among regions (GAO, 2001a). Consequently, providers across the country are uncertain as to whether EMTALA requires that a medical screening exam be conducted even when a patient requires immediate care at a trauma facility, and there is no simple or straightforward way to have this issue clarified. Various people involved in making the decision at the local level, including the hospital administrator, the hospital’s attorney, the state EMS office, and others, may all have a different point of view. As a result, providers are making decisions that may compromise care based on their own reading of this complex regulatory environment.

Health Insurance Portability and Accountability Act (HIPAA)

The federal regulatory environment has also created confusion with HIPAA. Enacted to regulate the transmission of electronic health data among providers and payers and to protect the privacy of patient health information, HIPAA often presents challenges for providers seeking to share health information with other providers, potentially compromising both patient care and provider protections; it also creates difficulties for investigators seeking to obtain research data. There are exceptions to HIPAA that recognize the unique characteristics of emergency and trauma care, such

as the urgency of care and the potential inability of patients in distress to provide consent (Lewis et al., 2001); however, HIPAA continues to pose a number of impediments to EMS.

The regulatory environment at the federal level does not provide clear assurances regarding HIPAA rules for dispatch centers and radio communications, resulting in guesswork at the local level. EMS represents a small segment of the health care continuum and received little attention during the development of the HIPAA regulations, but the cost of HIPAA compliance for EMS providers is substantial.

Based on their interpretation of current federal rules and their fear of liability, some hospitals believe HIPAA excludes outside agencies from participating in multidisciplinary quality assurance projects. As a result, trauma morbidity and mortality conferences convened by hospitals may exclude EMS personnel. This happens despite the fact that EMS personnel are responsible for transporting patients to the hospital, often have salient information about events on the scene, and may benefit from learning what happened after patients reached the hospital.

HIPAA has created additional barriers to information sharing between hospitals and EMS agencies. For example, EMS agencies may want to assess patient outcomes following hospital transport; however, patient-specific outcome data often are not shared. EMS personnel may also seek to determine whether a particular patient transported to the hospital is suffering from an air- or bloodborne pathogen or some other malady that may compromise the safety of the transporting EMS personnel. But hospitals are often unwilling to share this information with EMS agencies for fear of violating HIPAA regulations, even in cases where such information sharing may be allowable.

For researchers investigating patient outcomes resulting from out-of-hospital interventions such as cardiac resuscitation, it is necessary to obtain outcome information from each of the facilities in which patients were treated. Out-of-hospital and ED records must be linked with hospital records, vital statistics, and coroner’s records when appropriate. The patient identifiers required to perform such linkages are subject to the confidentiality provisions of the HIPAA legislation, making gathering these data difficult in an environment where EMS-related research is already lacking.

EMS OVERSIGHT AT THE STATE LEVEL

In most states, state law governs the scope, authority, and operation of local EMS systems. Each state has a lead EMS agency that is typically a part of the state health department, but in some states may be part of the public safety department or an independent agency. The mission, funding, and size of EMS agencies vary considerably from state to state. For example,

a survey conducted by NASEMSO found that the number of full-time positions within state EMS agencies varied from a low of 4 to a high of 90. Most states have an EMS medical director, though many do not. Table 2-3 shows the range of functions that EMS agencies provide.

State EMS agencies regulate and oversee local and regional EMS systems and personnel. They typically license and certify EMS personnel and ambulance providers and establish testing and training requirements. Some may also be responsible for approving statewide EMS plans, allocating federal EMS resources, and monitoring performance (GAO, 2001b). States have begun to take a more proactive role in trauma planning, with 35 states having formal trauma systems. One key function of many EMS agencies is data collection. However, only about half of state EMS offices have the capabilities to provide information on how many EMS responses occur in their state (Mears, 2004).

In regulating local and regional EMS systems, many state EMS offices are placed in the difficult position of being both an advocate/technical advisor and a regulator. This dual role can create internal conflicts. For example, state EMS offices are often responsible for both ensuring an adequate supply of EMS personnel and regulating those personnel. If an EMS office seeks to increase the educational requirements for EMS personnel, it may also create the type of workforce shortage it is working to avoid. For this reason, other professions separate the regulatory and advocacy roles (Shimberg and Roederer, 1994; Schmitt and Shimberg, 1996).

TABLE 2-3 State EMS Agency Functions

Some states provide direct funding for EMS, which may be derived from vehicle or driver licensing fees, motor vehicle violations, or other taxes. However, EMS funding is subject to cutbacks in tight fiscal environments. Approximately 87 percent of funds for state EMS office budgets comes from in-state revenues. The remaining 13 percent that comes from the federal government includes grants from multiple agencies with diverse priorities. There is currently no single, comprehensive federal vision for the development of the EMS system nationwide. NASEMSO maintains that this situation may have contributed to the lack of sustained and meaningful development in many areas identified in Emergency Medcical Services Agenda for the Future (NASEMSD, 2005).

State Medicaid agencies are responsible for developing Medicaid reimbursement policies for EMS. It is estimated that for most EMS agencies, Medicaid patients represent 20–40 percent of all EMS patients. The proportion of users covered by Medicaid tends to be higher in rural areas. The way EMS services are reimbursed can vary greatly from state to state; however, Medicaid reimbursement rates are almost universally low. As noted earlier, the majority of states use a fee-for-service payment system and a mileage rate for Medicaid reimbursement; five states pay EMS a “reasonable charge,” an amount that the state has decided is reasonable for the public to pay (Kaiser Commission on Medicaid and the Uninsured, 2003). Medicaid reimbursement is typically based on transportation rather than service provided. Thus, for example, EMS agencies in Virginia receive $75 for transporting a patient 0–5 miles to a hospital, regardless of whether the patient was transported by BLS or ALS providers and regardless of the severity of the patient’s condition or the services rendered. In most states, payment is not provided unless the EMS agency actually transports the patient.

NHTSA provides some technical assistance to state EMS agencies through statewide assessments. For the assessments and reassessments, NHTSA serves as a facilitator by assembling a team of experts in EMS development and implementation to work with and advise the state. The state EMS office provides NHTSA and the assessment team with background information on the EMS system, and the technical assistance team develops a findings report. A mid-1990s review of EMS assessments revealed “widespread fundamental problems in most areas,” but the lack of quality management programs was a common theme across systems. The review found that the majority of states did not have quality improvement programs for evaluating patient care, methods for assessing current levels of system resources, or mechanisms for identifying necessary system improvements (NHTSA Technical Assistance Program, 2000). The technical assistance provided to state EMS agencies is critical. All of these agencies face complex structural and operational issues that include system design, reimbursement strategies, quality management, performance improvement, and business

remodeling. EMS administrators are typically career EMS personnel; many have little formal training in organizational management, and there are no standardized courses for providing them with this training (Mears, 2004).

MODELS OF ORGANIZATION AND SERVICE DELIVERY AT THE LOCAL LEVEL

Across the United States today, EMS systems are fundamentally local in nature (GAO, 2001b). Counties and municipalities play central roles in deciding how their systems will be structured and how they will adapt to changes in the environment (e.g., changes in Medicare payment rates or added liability concerns). They determine the organization of the delivery system, the structure of EMS response times, the development of finance mechanisms, and the management of other system components. As a result of this local control, EMS systems across the country are extremely variable and fragmented. This diversity of systems can be viewed as a strength in that it promotes local self-determination and tailors systems to the needs and expectations of local residents. However, it is also a profound weakness, especially in cases where local standards of care fall below generally accepted standards and patients suffer as a result. Across cities, for example, the percentage of people suffering ventricular fibrillation who survive and are later discharged from the hospital with good brain function ranges from 3 to 45 percent (Davis, 2003a). EMS response times overall vary substantially, and many cities do not collect the data necessary to track their performance.

Emergency Dispatch Centers

Today, virtually all Americans (99 percent) have access to 9-1-1 service (National Emergency Number Association, 2004). However, the apparent uniformity of the 9-1-1 system is misleading: the system is actually locally based and operated, and its structure varies widely across the country. There currently exist more than 6,000 public safety answering points (PSAPs), or 9-1-1 call centers, nationwide. These include both primary PSAPs, which field all types of 9-1-1 calls (police, fire, and EMS), and secondary PSAPs, which handle service-specific calls, such as medical emergencies. These emergency call centers are operated primarily by public safety agencies, as well as city and county communications centers, hospitals, and others (see Figure 2-3 ). Over time, it may become necessary to reduce the large number of call centers, especially in the context of disaster preparedness efforts, which dictate a more streamlined emergency call structure in response to catastrophic events.

In 2004, 9-1-1 call centers fielded approximately 200 million emergency calls, including medical, police, fire, and other calls. In some cases, medical

FIGURE 2-3 Agency responsible for dispatch in the 200 most populous cities.

SOURCE: Monosky, 2004.

calls are received by primary call centers and then routed to secondary calls centers with dedicated medical dispatch. In other cases, all calls are handled at the primary call center. When different types of calls are handled by different call centers, the potential for “call switching” and miscommunication is dramatically increased.

Not only do 9-1-1 dispatchers determine the appropriate level of response, but they also often provide prearrival instructions to the caller. The prototype for this process was dispatcher-assisted CPR, pioneered by Eisenberg and colleagues in King County, Washington, and subsequently validated by an independent research team in Memphis. The list of conditions amenable to prearrival instructions was quickly expanded to include, for example, childbirth, seizures, and trauma/bleeding.

Prearrival instructions are designed to enable the caller to provide assistance when certain emergency conditions are present, to protect the

patient and caller from potential hazards, and to protect the patient from well-meaning bystanders who could provide assistance that might do more harm than good (Hauert, 1990). The level of prearrival assistance from the dispatcher can vary from simple advice, such as “call a doctor,” to instructions for performing CPR. Instructions are typically available to the dispatcher on flip cards.

EMS Systems

A survey of EMS systems conducted in 2003 by NASEMSD and HRSA’s Office of Rural Health Policy indicated that there were 15,691 credentialed EMS systems in the United States (Mears, 2004). However, the survey also indicated that the definition of an EMS system varies from state to state, making accurate tabulations nearly impossible. Among the systems identified by the survey, 45 percent were fire department–based, 6.5 percent were hospital-based, and 48.5 percent were labeled as neither (see Figure 2-4 ). The total number of ALS and BLS transport vehicles reported was 24,570. More recent data from the American Ambulance Association (AAA) indicate that there are 12,254 ambulance services operating in the United States (a figure that includes private for-profit and not-for-profit, hospital-based, volunteer, and fire department–based services), and a total of 23,575 ground ambulance vehicles (AAA, 2006).

While no statistics are available to provide greater detail about EMS system types nationwide, the Journal of Emergency Medical Services conducts an annual survey of the 200 largest metropolitan areas in the United

FIGURE 2-4 Types of EMS systems.

SOURCE: Mears, 2004.

TABLE 2-4 Reported Provider Types

States and is able to provide statistics for these areas (Williams, 2005) (see Table 2-4 ). The figures shown do not reflect smaller cities or rural areas. Results of the 2006 survey indicate that 36 percent of ambulance systems in these large metropolitan areas are private (either for-profit or not-for-profit), 32 percent are fire department–based, and just under 10 percent are third-service and hospital-based. However, an overwhelming number of first responders are fire department–based (89 percent).

Fire Department–Based EMS Systems

As is evident from the Mears (2004) survey, a strong plurality of EMS systems nationwide is fire department–based. The number of services has steadily increased over the past several decades as fire chiefs have recognized the central role of EMS in firefighting operations. EMS is an element of the response and service delivery of approximately 80 percent of fire departments in America (U.S. Fire Administration, 2005).

At an operational level, a fire department–based EMS system is one in which EMS is part of the fire department and ambulances are housed in or operate out of fire stations, with integrated dispatch. The integration of fire and EMS varies with each department. Some departments utilize person-

nel whose sole function is to provide EMS, while others utilize dual-role personnel who function as both firefighters and EMS providers. Some fire departments offer a full range of EMS, including BLS and ALS response and transport, while others limit their role to providing first-responder BLS or ALS care without transport.

Fire departments have chief officers who oversee operations and provide leadership at multiple levels. The chief of the department is usually a firefighter and, increasingly, may also have an EMS background, although frequently this is not the case. The organization and leadership of EMS within fire departments vary considerably. Some departments divide EMS and firefighting into separate divisions, while others integrate the two services under general operations. All fire departments that provide ALS must have a physician medical director, whether paid or volunteer; those that provide only BLS services may not.

Fire departments are financed primarily through public funds. Some departments bill for EMS, but collection rates vary. Collections are especially low in urban areas. Many small-town and rural fire departments in the United States, especially the latter, are volunteer, but the number of volunteer firefighters appears to be declining (see the discussion in Chapter 4 ).

In most jurisdictions, EMS calls now exceed fire-related calls by a wide margin. According to the National Fire Protection Association (2005), 80 percent of national fire service calls are EMS-related. This trend is likely to persist as fire prevention techniques continue to improve and as the aging of the U.S. population adds to the projected number of EMS calls.

One advantage of having an integrated fire and EMS system is structural efficiency. Firehouses are traditionally well positioned to serve the local population in most areas of the country. These physical structures can provide a strategic location for the EMS units they house, as well as a place for EMS personnel to rest between calls. Fire departments also provide the administrative infrastructure necessary to manage personnel, provide training, and purchase and maintain equipment and supplies.

But there are also disadvantages to fire-based EMS systems. A series of articles in USA Today documented the cultural divide, discussed earlier, that can exist between EMS and fire personnel (Davis, 2003b). Generally, the orientation of EMS personnel centers on providing medical care, whereas that of firefighters centers on conducting rescue operations and battling fires. As a result, there is some difference between the types of individual who become EMTs and firefighters (Davis, 2003a). These personnel often do not work together in a coordinated fashion.

In many cities, such as Washington, D.C., and Los Angeles, EMS is under the leadership of the fire department, which tends to consider fire suppression its principal mission, with medical services assuming a secondary role (Davis, 2003a). As a result, priority is given to fire suppression when

it comes to training and budget allocations. In many cases, firefighters are paid more than EMS personnel and have separate unions and command structures, even when based within the same fire department. Medical directors who are hired to supervise fire department–based emergency medical response may be viewed as outsiders, and may defer to the fire chiefs on the way resources should be deployed. Over the past decade, many EMS systems have become integrated with the fire service, although there is significant variation with respect to the level of integration.

Hospital-Based EMS Systems

Hospital-based EMS systems may provide stand-alone EMS coverage to a community or may operate in conjunction with a fire department. Typically, a hospital-based service is located at a community hospital and dispatched through a public safety communications system (9-1-1) or routed through a secondary call center that receives dispatches from a 9-1-1 center. Hospital-based systems function as private entities and typically bill for their services.

An advantage of a hospital-based system is that EMS personnel may benefit from the closer relationship between the ED and the hospital and may be better able to maintain professional skills through greater opportunities to observe ED procedures. Hospital-based systems also benefit from the reputation of the hospital with which they are affiliated and may be recognized by members of the community.

A challenge for hospital-based systems is potential competition among services and the need for better coordination of system resources. Since hospital-based ambulances bill for services and provide transport to their base hospital, there is an inherent competition for patients. For example, ambulance companies may seek to advertise their services, providing their own phone number and encouraging people to call them instead of 9-1-1. This may also occur with private ambulance services.

Another challenge in larger communities that use a number of hospital-based systems is optimizing system resources. Hospitals are not always located proportionally to populations or areas of greatest need. Further, depending on state regulations, hospitals may not be required to increase the number of available ambulances if EMS call volumes increase.

Private Systems

In some areas, local governments run their ambulance service by contracting with a private entity—either a local EMS operation or a national company. In these instances, private ambulance companies contract their services to local governments to provide 9-1-1 transports, including person-

nel, equipment, and vehicles. The contracts may or may not require medical oversight. The private firms compete for contracts, typically every several years. Some of these private firms are publicly owned stock-issuing corporations. For-profit providers now operate throughout most of the country.

Private EMS systems face some of the same challenges as fire department–based EMS systems. Some cities have found them to be a more economical alternative than expanding fire departments to provide EMS. However, their profit orientation also makes it more likely that EMS will suffer when contract disputes occur with the municipal agency.

There are several different models for private systems. First, under a level-of-effort model, a local government develops a contract with a private firm for a certain number of ambulances and other resources. The contractor is not held to specific performance standards, but must simply provide the contracted services. Under a performance-based model, the contractor is expected to meet specific performance standards to fulfill the contract. Finally, under a high-performance model, the contract creates a business relationship that tightly aligns the interests of the contractor with public needs. The contractor may be responsible for patient billing and may own some long-term infrastructure items, such as ambulances and medical communications systems. Additionally, an independent body is responsible for performance, medical oversight, and financial oversight; rate regulation; licensing; and market allocation (AAA, 2004).

One difficulty in evaluating the pros and cons of any service model (whether locally or nationally) is the dearth of objective process and outcome data for comparing one model of service delivery or even one ambulance company with another. As a result, local governments frequently rely on crude measures, such as numbers of personnel, numbers of ambulances operating per unit of time, EMS fractile response times by urgency of call, and patient complaints. These are poor proxies for quality of care and outcome-based measures of system performance.

Municipal Services

At the local level, municipal and county governments often deliberate between contracting out to a private EMS company and developing and operating an EMS unit themselves. In many cases, the locality chooses the latter option. This involves purchasing or leasing ambulance units, hiring EMS personnel to provide direct services and administrative personnel to run the program, and stocking ambulances with necessary medical and communications equipment. Some of these operations bill private insurers for services, while others rely solely on direct funding from the city or county.

In Kansas City, Missouri, fire department personnel serve as first responders, but transport is handled through a public utility model. This

model entails a quasigovernmental authority with overall responsibility for EMS transport that owns all the equipment, including ambulances, and carries out billing and other logistical functions, but contracts with a private company for human resources. Kansas City was one of the first major cities to offer EMS transport using this model.

EMS System Staffing: Career- and Volunteer-Based

In career-based EMS systems, providers are paid to staff the ambulance units and have preassigned shifts. Benefits of such a system are thought to include greater standardization in the quality of patient care through employer oversight, mandated training, and quality assurance and improvement. Many states and communities, however, still rely heavily on volunteers to provide ambulance coverage; in particular, volunteer personnel have traditionally been the lifeblood of rural EMS agencies. Volunteers may also have preassigned shifts but generally are not paid for their time, although recent research suggests that a fairly large percentage of volunteers receive financial compensation for their EMS activity (Margolis and Studnek, 2006). Equipment and vehicles are frequently maintained using donations or public funds. Oversight of volunteer systems is sometimes provided by the municipal or county agency responsible for EMS, if one exists. The benefits of a volunteer system include the significant cost savings from not having to pay personnel. However, the challenge is maintaining a response system that consistently meets the public demand for quality services.

Most experts agree that there appears to be a national trend toward decreasing volunteerism and an increase in EMS personnel seeking paid careers. During the early stages of EMS, it was not uncommon for volunteers to be on call nearly 24 hours a day. Today, however, increased time demands, the rise in families’ needs for dual incomes, and vying interests create an environment in which volunteers may donate one specific weeknight or a few hours on a weekend. As a result, rural EMS agencies in particular are currently faced with volunteer staffing shortages, particularly during weekday work hours.

Many systems are a combination of volunteer- and career-based because of the challenges of maintaining an entirely volunteer system. Such combined systems represent an attempt to achieve cost savings while ensuring adequate services to the public. However, the sustainability of each type of system—career, volunteer, and combination—is unclear as a result of the resource demands on career systems and the lack of personnel for volunteer systems.

Air Ambulance Systems

Air medical operations have grown substantially since their inception in the 1970s. Today there are an estimated 650–700 medical helicopters operating in the United States (Gearhart et al., 1997; Helicopter Association International, 2005; Meier, 2005; Baker et al., 2006), up from approximately 230 in 1990 (Blumen and UCAN Safety Committee, 2002; Helicopter Association International, 2005). These helicopter operations are owned and managed by a variety of entities, including for-profit providers, nonprofit organizations such as local hospitals, government agencies such as the state police, and military air medical service providers. Many air medical providers were originally employed as hospital contractors but now work on an independent basis. Typically, the base helipads for these providers are located in airports, independent hangars and helipads, and designated areas of a hospital (Branas et al., 2005).

Air ambulance operations have served thousands of critically ill or injured persons over the past several decades (Blumen and UCAN Safety Committee, 2002). However, there has been growing concern about the safety of these operations. Approximately 200 people have lost their lives as a result of air medical crashes since 1972, and these deaths have been increasing as the industry continues to expand (Blumen and UCAN Safety Committee, 2002; Bledsoe, 2003; Baker et al., 2006). Crashes are often attributable to pilots flying in poor weather or at night. Li and colleagues (2001) found a four-fold risk of a fatal crash in flights that encountered reduced visibility. Baker and colleagues (2006) found that crashes in darkness represented 48 percent of all crashes and 68 percent of all fatal crashes. In addition, some companies are flying older, single-engine helicopters that lack the instruments needed to help pilots navigate safely (Meier, 2005). In 2004 and 2005 a total of 12 fatal air ambulance crashes occurred—the highest number of fatal crashes in two consecutive years experienced in the industry’s history (Isakov, 2006). Recent increases in Medicare payments have led to greater competition in the industry, which has added to concerns regarding safety (Meier, 2005).

Air medical services are believed to improve patient outcomes because of two primary factors: reduced transport time to definitive care and a higher skill mix applied during transport. However, presumed gains in transport time do not necessarily occur, given the time it takes the helicopter crew to launch, find a suitable landing position, and provide care at the scene. This is especially true when the distance to the scene is short. Questions have also been raised regarding the appropriateness of air ambulance deployments in specific patient care situations (Schiller et al., 1988; Moront et al., 1996; Cunningham et al., 1997; Arfken et al., 1998; Dula et al., 2000). A 2002 study found that helicopters were used excessively for patients who were not

severely injured and that they often did not deliver patients to the hospital more rapidly than ground ambulances (Levin and Davis, 2005).

On the other hand, a number of other studies suggest benefits of air ambulance service relative to ground transport. Davis and colleagues (2005) found that patients with moderate to severe traumatic brain injury who received care through air ambulance had improved outcomes. In addition, the study found that out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from air medical transport. And Gearhart and colleagues (1997) reviewed the literature and reported 1–12 additional survivors per 100 patients flown.

EMS in Rural Areas

According to the 2000 U.S. Census, 21 percent of the nation’s population lives in rural and frontier areas. Residents of these areas experience significant health disparities relative to their urban counterparts (Pollock, 2001). A large portion of these disparities results from the distinctive cultural, social, economic, and geographic characteristics that define rural America, but the situation also reflects the difficulty of applying medical systems designed for urban environments to rural and frontier communities.

Rural EMS Challenges

Rural EMS systems face a multitude of challenges. A particularly daunting challenge is providing adequate access to care given the distances involved and the limited assets available. Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. In 1989, the Office of Technology Assessment estimated that three-quarters of rural prehospital EMS personnel were volunteers (U.S. Congress, Office of Technology Assessment, 1989). A more recent national assessment found that 77 percent of EMS personnel in rural areas were volunteers, compared with 33 percent in urban areas (Minnesota Department of Health, Office of Rural Health Primary Care, 2003).

State health directors list access to quality EMS care as a major rural health concern (O’Grady et al., 2002). In a 2003 survey of national and state rural health experts, 73 percent identified access to health care as a priority issue, and EMS access was cited as a primary concern (Gamm et al., 2003; Rawlinson and Crewes, 2003). In its 2004 report Quality Through

Collaboration: The Future of Rural Health , the Institute of Medicine cited EMS as one of four essential health care services for rural residents, along with primary, dental, and mental health care (IOM, 2004).

As noted in Chapter 1 , EMS response times from the instigating event to arrival at the hospital are significantly longer in rural than in urban areas. These prolonged response times occur at each step in EMS activation and response, including time to EMS notification, time from EMS notification to arrival at the scene, and time from arrival at the scene to arrival at the hospital. A 2002 survey found that 30 percent of rural patients fatally injured in a crash (compared with 8.3 percent in urban areas) arrived at the hospital more than 60 minutes after the crash, after the “golden hour” had expired (NHTSA, 2005). These prolonged response times are attributable to the increased distances involved, but also to other factors, such as the limits of 9-1-1 availability in sparsely populated areas. While the availability of 9-1-1 extends to the vast majority of the U.S. population, 4 percent of the nation’s counties still do not have access to basic 9-1-1 (see Chapter 5 ). Moreover, enhanced 9-1-1, which provides geographic data to the dispatch center so the location of an incident can be pinpointed, is difficult to implement when a large portion of the rural population uses rural routes and post office boxes to designate addresses (Gausche and Seidel, 1999). In addition, the small number of ambulances available in some rural regions and the inability to priority dispatch these ambulances if there is only one unit available remain a challenge (Key, 2002).

One of the first obstacles to timely EMS activation in rural areas is the delay that commonly occurs in the discovery of crash scenes. On infrequently traveled rural roads, a long time may elapse before victims are discovered. This delay may be the single largest contributor to prolonged times until transport to a hospital (Esposito et al., 1995). In a study of rural Missouri, only 39 percent of calls alerting EMS came within 5 minutes of the collision, compared with 90 percent in urban study areas (Brodsky, 1992). Automated collision notification systems offer the potential for significant improvement in this area (see Chapter 5 ). In a rural demonstration project conducted by NHTSA during 1995–2000, this technology was demonstrated not only to work, but also to reduce response times (NHTSA, 2001).

When prehospital EMS is activated, there is significant local variation in the type and quality of services provided. Rural EMTs working in an isolated environment while treating a critically ill or injured patient will spend more time with the patient and use fewer resources than urban EMTs or paramedics. Certain clinical scenarios may actually require a greater skill level and more multitasking on the part of rural EMTs as compared with their urban counterparts. As noted, however, EMS systems in rural areas are staffed largely by volunteers with highly variable levels of expertise, training, and experience. A rural EMT may encounter highly critical cases

very infrequently as a result of the small size of the local population and the number of volunteers required to cover a schedule. For the limited number of EMS personnel in a largely volunteer system, formal training and critical care experience are often lacking, and even when such training is attained, the low volume of calls contributes to the degradation of critical care skills. Moreover, access to continuing education may be scarce in rural areas (Key, 2002). Additionally, volunteer organizations experience a higher level of provider turnover, which may reduce the number of experienced volunteers. Taken together, these factors mean that rural EMS providers may be less proficient than urban providers.

A high percentage of rural EMS personnel may be trained only in BLS, and indeed, many rural programs offer only BLS services (Minnesota Department of Health, Office of Rural Health Primary Care, 2003). Even when rural EMTs are trained to perform critical tasks, such as endotracheal intubation, their success rate is poor (Sayre et al., 1998), in part because of the infrequent need to exercise such skills noted above. In one study, despite training, rural EMS personnel were able to intubate only 49 percent of their patients successfully. Cited as possible explanations for this low success rate were training deficiencies, infrequent intubation opportunities, and inconsistent supervision (Bradley et al., 1998). Likewise, Spaite (1998) pointed out that rural EMS personnel with defibrillator training may defibrillate a patient only two or three times in a decade, emphasizing a pivotal role for the use of automated external defibrillators. In addition, even when ALS is available in rural areas, the services have repeatedly been demonstrated to be provided at much lower levels of quality than in urban settings (Gausche et al., 1989; Svenson et al., 1996; Seidel et al., 1999).

The availability and qualifications of EMS medical directors are also an issue. Many of these individuals have little or no experience in EMS medical direction. A survey of state EMS directors indicated that recruitment of medical directors is frequently very difficult and that providers serving in that role are often primary care physicians with little or no emergency medicine training. While on-line continuing medical education is becoming more available, it has been slow to take hold; moreover, such training can impart cognitive information, but typically does not teach technical and procedural skills. Nevertheless, the use of telemedicine and distance learning allows previously inaccessible training to penetrate remote areas, while new, more realistic and dynamic patient simulators enable case-based honing of critical skills and decision-making abilities. These tools may be able to offset some of the problems with skill deterioration due to the limited experience attained in rural areas (McGinnis, 2004).

Addressing Rural EMS Challenges

A number of strategies for optimizing EMS resources have been proposed to deal with the paucity of funding, response units, and other resources in rural areas. One such proposal is the dynamic load-responsive deployment of ambulance units. With this approach, ambulances are positioned strategically throughout an area and are dispatched centrally in an effort to reduce response times. Determination of where to position individual units is based on the demand in each area combined with the distance to be traveled, using an established average response time. In one study, load-responsive deployment in a rural area resulted in a 32 percent increase in the number of calls responded to within the established time allowance of 8 minutes (Peleg and Pliskin, 2004). While promising, however, this approach is not possible in very isolated rural communities where EMS units are staffed by volunteers who respond from home.

Another method found to increase the efficiency of EMS systems in rural areas is the establishment of regionally based systems. Such systems may be organized in countywide or larger areas, with ambulances being prepositioned in strategic locations and dispatched centrally (Key, 2002). Basic EMS providers and fire departments scattered throughout the area can act as first responders, with fully equipped units responding after dispatch. Such a system has been used successfully on San Juan Island, a rural island off the coast of Washington State. Killien and colleagues (1996) demonstrated a survival to discharge rate for out-of-hospital cardiac arrest of 22 percent employing this type of system, whereas most studies in rural areas have found survival rates of less than 10 percent (Killien et al., 1996). One of the largest rural regional EMS systems in the United States is that of the East Texas Medical Center. This system serves nearly 17,000 square miles over 17 counties, with 85 ambulance units and two helicopters. Units are dispatched through a central 9-1-1 dispatcher using a modern global positioning system for geographic information (East Texas Medical Center Regional Healthcare System, 2004). In this way, a large rural area encompassing many counties can be served by an EMS system with up-to-date equipment and resources that could not be sustained financially by any one county alone.

Another issue pertinent to rural settings is the involvement of citizens or lay first responders who can provide first aid, start CPR, and take other measures while awaiting the arrival of EMS. The 2005 World Health Organization report Prehospital Trauma Care Systems strongly recommends such citizen engagement, particularly in resource-poor communities that cannot afford costly or sophisticated EMS systems (Sasser et al., 2005). Training dispatchers to give prearrival instructions can help reinforce citizen involvement, with or without prior CPR and first-aid training. Although the current standard for CPR training is a 4-hour class taught by a paid instruc-

tor, research has shown that citizens can teach themselves CPR with a video and inexpensive manikin in 30 minutes (see Chapter 4 ). Numerous benefits can result, including more consistent provision of first aid, rapid access to bystander CPR, enhanced community response to disasters and mass-casualty events, and possibly more rational use of EDs and EMS assets.

Role of EMS in Rural Public Health

Individuals in rural communities have less access to the full range of essential public health services than their urban counterparts (U.S. Congress, Office of Technology Assessment, 1989). Many such areas have no local county or city public health agency, and those public health departments that do serve rural areas have few if any staff with formal public health training (Pollock, 2001). As a result, the rural EMS system often assumes a broader role in the community than the typical urban system with regard to both the medical needs of individuals and the public health and safety of the community overall. Because of the lack of physicians and nurses and other medical facilities, it is not unusual in rural communities for EMS to provide informal evaluation, advice, and care that are never reflected in an EMS patient’s record and do not involve transportation (McGinnis, 2004). The lack of public health departments may require rural EMS personnel to assume leadership roles in tasks performed traditionally by public health departments, such as immunizations (Pollock, 2001). Finally, the lack of capacity of rural public health departments and a limited rural public safety infrastructure result in greater reliance on rural EMS personnel to participate in disaster preparedness relative to their urban counterparts (Spaite et al., 2001).

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Emergency Medical Services (EMS) is a critical component of our nation's emergency and trauma care system, providing response and medical transport to millions of sick and injured Americans each year. At its best, EMS is a crucial link to survival in the chain of care, but within the last several years, complex problems facing the emergency care system have emerged. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air medical crashes. This heightened public awareness of problems that have been building over time has underscored the need for a review of the U.S. emergency care system. Emergency Medical Services provides the first comprehensive study on this topic. This new book examines the operational structure of EMS by presenting an in-depth analysis of the current organization, delivery, and financing of these types of services and systems. By addressing its strengths, limitations, and future challenges this book draws upon a range of concerns:

• The evolving role of EMS as an integral component of the overall health care system.

• EMS system planning, preparedness, and coordination at the federal, state, and local levels.

• EMS funding and infrastructure investments.

• EMS workforce trends and professional education.

• EMS research priorities and funding.

Emergency Medical Services is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems.

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Medical School Examples

Craft a Winning Medical School Essay with Examples and Proven Tips

Published on: May 8, 2023

Last updated on: Jul 19, 2024

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Are you dreaming of becoming a doctor or a health care professional? 

The first step towards achieving that goal is to get accepted into a top-tier medical school. 

But with so many other qualified medical students competing for the same spot, how do you stand out from the crowd? 

It all starts with your medical school essay. 

Your essay is your opportunity to your unique qualities, experiences, and aspirations. 

In this blog, we'll provide you with examples that will help you catch the attention of admissions committees. 

From purpose to common mistakes to avoid, we'll cover everything you need to get accepted into the medical school of your dreams. 

So, let's dive in!

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Types of Medical School Examples 

Medical school essays come in many different forms, each with its own unique requirements and purpose.

In this section, we'll discuss some of the most common types of medical school essays and what you need to know to write them successfully.

Personal Statements 

Personal statements are the most common type of medical school essay. They are usually a one-page essay that introduces you to the admissions officers. 

It explains why you want to pursue medicine as a career. Personal statements should be engaging, and memorable, and show off your unique qualities.

An outline offers a framework to help you craft a compelling narrative that showcases your strengths and experiences.

Check out this personal statement example that can help future physicians getting into the schools of their dreams.

Medical School Personal Statement Examples pdf

Secondary Essays 

Secondary essays are additional essays that some medical schools require in addition to the personal statement. 

They often ask specific questions about your background, experiences, or interests. They give you an opportunity to show off your future patient care and problem-solving skills.

Here is a brief example of a secondary application medical school essay:

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Diversity Essays 

Diversity essays ask you to write about your experiences with diversity and how they have influenced you to pursue a career and your interest in medicine. 

These essays are becoming increasingly common in medical school applications as schools strive to build a more diverse and inclusive student body.

Good Medical School Essay Examples 

Are you struggling to write a standout medical school essay? They say that the best way to learn is by example. That's especially true when it comes to public health school essays. 

We'll provide you with some of the best examples to help you craft an essay that will help your career in medicine.

Medical College Essay Examples

Personal Statement Medical School Examples Pdf

Medical School Covid Essay Examples

Challenging Medical School Essay Examples 

Writing a medical school essay is more than just telling a story about yourself. It's an opportunity to demonstrate your critical thinking and analytical skills. 

In this section, we'll highlight some of the challenging medical school essay examples. This will give you a sense of what admissions committees are looking for. You can learn how to exceed those expectations by writing a successful medical school essay.

Greatest Challenge Medical School Essay Examples

Successful Medicine Personal Statement Examples

Medical School Scholarship Essay Examples

Medical School Essay Examples for Different Schools 

Each medical school has its own unique mission, values, and admissions criteria, and your essay should reflect that. 

In this section, we'll explore how to tailor your medical school essay for different schools and showcase some examples of successful essays.

Let’s explore these Stanford and Harvard medical school essay examples:

Medical School Personal Statement Examples Harvard

Medical School Personal Statement Examples Stanford

Tips on Crafting an Excellent Medical School Personal Statement 

The medical school personal statement is your opportunity to showcase your unique qualities and experiences. 

Here are some tips to help you craft an excellent personal statement:

Start Early 

Don't wait until the last minute to start writing your personal statement. Give yourself plenty of time to brainstorm, write, and revise your essay. Starting early also allows you to get feedback from mentors, professors, or peers.

Focus on Your Story 

Your personal statement should tell a story that showcases your journey to medicine. Highlight the experiences and qualities that have led you to pursue a career in medicine. Tell them how you plan to use your skills to make a difference.

Be Specific 

Use specific examples to illustrate your experiences and achievements. Don't just list your accomplishments, but show how they have prepared you for a career in medicine. Use concrete details to make your essay more engaging and memorable.

Show, Don't Tell 

Instead of simply stating your qualities, show them through your experiences and actions. For example, don’t say you're a team player. Describe a time when you worked effectively in a team to achieve a goal.

Tailor Your Essay to the School 

As mentioned earlier, each medical school has its own unique mission and values. Tailor your personal statement to each school to demonstrate your fit with their program and values.

Mistakes to Avoid in a Medical School Personal Statement 

When it comes to your medical school personal statement, there are some common mistakes you should avoid:

Avoid using cliched phrases and ideas that are overused in personal statements. Admissions committees want to see your unique perspective and experiences. They do not want generic statements that could apply to anyone.

Negativity 

Don't focus on negative experiences or aspects of your life in your personal statement. Instead, focus on your strengths and how you have grown from challenges.

Lack of Focus 

Make sure your personal statement has a clear focus and theme. Don't try to cover too many topics or experiences in one essay. Instead, focus on one or two experiences that are meaningful to you and illustrate your journey to medicine.

Too Formal or Informal Tone 

Make sure your personal statement strikes the right tone. Avoid being too formal or using overly complex language. Also, avoid being too informal or using slang.

Plagiarism 

Never copy someone else's personal statement or use a template to write your own. Admissions committees can easily spot plagiarism, and it will result in an immediate rejection.

Grammatical and Spelling Errors

Proofread your personal statement thoroughly for grammatical and spelling errors. Even a few small errors can detract from the overall quality of your essay.

Lack of Authenticity 

Be true to yourself in your personal statement. Don't try to present an image of yourself that is not authentic or that you think the admissions committee wants to see. Be honest and genuine in your writing.

In conclusion, crafting a winning medical school essay is a crucial step toward securing admission to the medical school of your dreams. 

This blog has provided examples of essays along with tips to craft an excellent medical school personal statement. By avoiding mistakes, you can increase your chances of standing out from the crowd and impressing the admissions committee. 

Struggling with your medical school essays or college papers? Look no further!

Our college paper writing service specializes in crafting exceptional papers tailored to your academic needs, including medical school essays. And for an extra boost in your writing tasks, don't forget to explore our AI essay generator .

Elevate your academic performance with our medical school essay writing service and unlock the potential of our AI essay tools.

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Frequently Asked Question (FAQs)

What is the ideal med school personal statement word limit.

There is no set length for a medical school personal statement, but most schools typically require a personal statement of 500-800 words.

How do I choose a topic for my medical school essay?

Choose a topic that showcases your unique perspective and experiences, and illustrates your journey to medicine. Consider what makes you stand out and what you are passionate about.

Should I mention my grades and test scores in my medical school essay?

It is not necessary to mention your grades and test scores in your medical school essay as they are already included in your application. Instead, focus on showcasing your unique qualities, experiences, and perspective.

Can I get help with writing my medical school essay?

Yes, there are various resources available to help you with writing your medical school essay. Consider seeking help from a writing tutor, career services office, or professional writing service like ours.

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IELTS Essay: Private or Public Healthcare

by Dave | Real Past Tests | 11 Comments

This is an IELTS writing task 2 sample answer essay on the topic of private or public healthcare and medical services from the real IELTS exam.

Please consider supporting me on Patreon.com/howtodoielts to receive my exclusive IELTS Ebooks – you can even sign up for private live lessons with me!

Some feel governments, rather than private companies, should be in charge of medical services.

To what extent do you agree or disagree?

There has been widespread debate in recent years concerning whether healthcare should be private or public. In my opinion, despite the importance of government regulation in the healthcare industry, a freer system will naturally encourage greater innovation.

The best support for government controlled healthcare comes from the exorbitant costs of private care. The United States is the best known example of this phenomenon. There are countless stories of vulnerable individuals requiring medical attention who face the prospect of years of nearly insurmountable medical bills. If the government runs the hospitals, as is the case in more progressive nations including Canada and England, the average person does not have to worry about prohibitively expensive medical emergencies. Citizens living in these countries now consider free medical treatment for the injured or ill as a foundational human right that governments have a responsibility to safeguard.

However, governments are notorious for stiffling innovation. This applies to a range of sectors and can best be evidenced by the failure of communism as an economic model. The less extreme forms of socialism that guide many European nations guarantee basic care but hospitals are not motivated to compete and excel. Despite the many drawbacks of the U.S. healthcare system, hospitals there routinely fund and are driven to uncover new treatments and procedures in order to attract more patients. While surging costs may leave behind vulnerable segments of the population, hospitals have a powerful motivation to produce the best possible results for those who can afford treatment.

In conclusion, medicine should be available for all citizens but this cannot be at the expense of the quality of healthcare. Governments should regulate the medical industry and provide welfare schemes yet still allow for a competitive environment.

1. There has been widespread debate in recent years concerning whether healthcare should be private or public. 2. In my opinion, despite the importance of government regulation in the healthcare industry, a freer system will naturally encourage greater innovation.

• Paraphrase the overall essay topic.
• Write a clear opinion. Read more about introductions here .

1. The best support for government controlled healthcare comes from the exorbitant costs of private care. 2. The United States is the best known example of this phenomenon. 3. There are countless stories of vulnerable individuals requiring medical attention who face the prospect of years of nearly insurmountable medical bills. 4. If the government runs the hospitals, as is the case in more progressive nations including Canada and England, the average person does not have to worry about prohibitively expensive medical emergencies. 5. Citizens living in these countries now consider free medical treatment for the injured or ill as a foundational human right that governments have a responsibility to safeguard.

• Write a topic sentence with a clear main idea at the end.
• Explain your main idea.
• Develop it with specific examples.
• Keep developing it fully.
• Relate it back to the overall topic.

1. However, governments are notorious for stiffling innovation. 2. This applies to a range of sectors and can best be evidenced by the failure of communism as an economic model. 3. The less extreme forms of socialism that guide many European nations guarantee basic care but hospitals are not motivated to compete and excel. 4. Despite the many drawbacks of the U.S. healthcare system, hospitals there routinely fund and are driven to uncover new treatments and procedures in order to attract more patients. 5. While surging costs may leave behind vulnerable segments of the population, hospitals have a powerful motivation to produce the best possible results for those who can afford treatment.

• Write a new topic sentence with a new main idea at the end.
• Explain your new main idea.
• Include specific details and examples.
• Continue developing it fully!
• Vary short and long sentences.

1. In conclusion, medicine should be available for all citizens but this cannot be at the expense of the quality of healthcare. 2. Governments should regulate the medical industry and provide welfare schemes yet still allow for a competitive environment.

• Summarise your main ideas.
• Include a final thought. Read more about conclusions here .

What do the words in bold below mean? Make some notes on paper to aid memory and then check below.

There has been widespread debate in recent years concerning whether healthcare should be private or public . In my opinion , despite the importance of government regulation in the healthcare industry , a freer system will naturally encourage greater innovation .

The best support for government controlled healthcare comes from the exorbitant costs of private care . The United States is the best known example of this phenomenon . There are countless stories of vulnerable individuals requiring medical attention who face the prospect of years of nearly insurmountable medical bills . If the government runs the hospitals, as is the case in more progressive nations including Canada and England, the average person does not have to worry about prohibitively expensive medical emergencies . Citizens living in these countries now consider free medical treatment for the injured or ill as a foundational human right that governments have a responsibility to safeguard .

However, governments are notorious for stiffling innovation . This applies to a range of sectors and can best be evidenced by the failure of communism as an economic model . The less extreme forms of socialism that guide many European nations guarantee basic care but hospitals are not motivated to compete and excel . Despite the many drawbacks of the U.S. healthcare system , hospitals there routinely fund and are driven to uncover new treatments and procedures in order to attract more patients. While surging costs may leave behind vulnerable segments of the population , hospitals have a powerful motivation to produce the best possible results for those who can afford treatment.

In conclusion, medicine should be available for all citizens but this cannot be at the expense of the quality of healthcare. Governments should regulate the medical industry and provide welfare schemes yet still allow for a competitive environment .

For extra practice, write an antonym (opposite word) on a piece of paper to help you remember the new vocabulary:

widespread debate lots of controversy

in recent years in the last several years

concerning having to do with

healthcare hospital and medicine

private not public, open to companies and profit making

public owned by the government

In my opinion I think

despite regardless of

regulation rules

healthcare industry hospitals

freer system more open industry

naturally of course

encourage foster

greater innovation more new ideas

best support superior help

government controlled healthcare nations running hospitals

exorbitant costs very expensive

private care not public hospitals

best known example most famous instance

phenomenon development

countless stories many instances

vulnerable weak

requiring medical attention need help from doctors

face the prospect potentially must deal with

nearly insurmountable almost unbeatable

medical bills money to be paid to hospitals

runs in charge of

as is the case in more progressive nations which is true in more modern countries

including such as

average person normal person

prohibitively expensive costs too much

emergencies have to deal with right away

consider free medical treatment think of free hospitals

injured hurt

foundational human right basic human privilege

responsibility duty

safeguard keep safe

notorious infamous

stiffling innovation slowing new ideas

range of sectors many industries

best be evidenced clearest support

failure didn’t work

communism system of government with state-owned enterprises

economic model way of running a country

less extreme forms of socialism not as a severe as communism

guide way forward

guarantee basic care safeguard a degree of help

compete fight agains each other

excel do well

drawbacks tradeoffs

U.S. healthcare system United States hospitals

routinely fund typically give money to

driven pushed by

uncover discover

treatments new techniques

procedures ways of treating a sickness

attract bring people in

surging increasing

leave behind can’t catch up

vulnerable segments of the population poorer people

powerful motivation big incentives

produce make

best possible results ideal outcomes

afford can pay for

available on offer

at the expense of to the detriment of

quality how good something is

regulate keep in check, supervise

medical industry hospitals

provide welfare schemes support poor people

allow for gives the opportunity

competitive environment capitalist economy

Pronunciation

Practice saying the vocabulary below and use this tip about Google voice search :

ˈwaɪdsprɛd dɪˈbeɪt   ɪn ˈriːsnt jɪəz   kənˈsɜːnɪŋ   ˈwɛðə   ˈhɛlθkeə   ˈpraɪvɪt   ˈpʌblɪk ɪn maɪ əˈpɪnjən dɪsˈpaɪt   ˌrɛgjʊˈleɪʃən   ˈhɛlθkeər ˈɪndəstri ˈfriːə ˈsɪstɪm   ˈnæʧrəli   ɪnˈkʌrɪʤ   ˈgreɪtər ˌɪnəʊˈveɪʃən bɛst səˈpɔːt   ˈgʌvnmənt kənˈtrəʊld ˈhɛlθkeə   ɪgˈzɔːbɪtənt kɒsts   ˈpraɪvɪt keə bɛst nəʊn ɪgˈzɑːmpl   fɪˈnɒmɪnən ˈkaʊntlɪs ˈstɔːriz   ˈvʌlnərəbl   rɪˈkwaɪərɪŋ ˈmɛdɪkəl əˈtɛnʃ(ə)n   feɪs ðə ˈprɒspɛkt   ˈnɪəli ˌɪnsə(ː)ˈmaʊntəbl   ˈmɛdɪkəl bɪlz rʌnz   æz ɪz ðə keɪs ɪn mɔː prəʊˈgrɛsɪv ˈneɪʃənz   ɪnˈkluːdɪŋ   ˈævərɪʤ ˈpɜːsn   prəˈhɪbɪtɪvli ɪksˈpɛnsɪv   ɪˈmɜːʤənsiz kənˈsɪdə friː ˈmɛdɪkəl ˈtriːtmənt   ˈɪnʤəd   ɪl   faʊnˈdeɪʃən(ə)l ˈhjuːmən raɪt   rɪsˌpɒnsəˈbɪlɪti   ˈseɪfgɑːd nəʊˈtɔːrɪəs   ˈstaflɪɪŋ ˌɪnəʊˈveɪʃən reɪnʤ ɒv ˈsɛktəz   bɛst biː ˈɛvɪdənst   ˈfeɪljə   ˈkɒmjʊnɪzm   ˌiːkəˈnɒmɪk ˈmɒdl lɛs ɪksˈtriːm fɔːmz ɒv ˈsəʊʃəlɪzm   gaɪd   ˌgærənˈtiː ˈbeɪsɪk keə   kəmˈpiːt   ɪkˈsɛl ˈdrɔːbæks   juː . ɛs .  ˈhɛlθkeə ˈsɪstɪm ruːˈtiːnli fʌnd   ˈdrɪvn   ʌnˈkʌvə   ˈtriːtmənts   prəˈsiːʤəz   əˈtrækt   ˈsɜːʤɪŋ   liːv bɪˈhaɪnd   ˈvʌlnərəbl ˈsɛgmənts ɒv ðə ˌpɒpjʊˈleɪʃən ˈpaʊəfʊl ˌməʊtɪˈveɪʃən   ˈprɒdjuːs   bɛst ˈpɒsəbl rɪˈzʌlts   əˈfɔːd   əˈveɪləbl   æt ði ɪksˈpɛns ɒv   ˈkwɒlɪti   ˈrɛgjʊleɪt   ˈmɛdɪkəl ˈɪndəstri   prəˈvaɪd ˈwɛlfeə skiːmz   əˈlaʊ fɔː   kəmˈpɛtɪtɪv ɪnˈvaɪərənmənt

Vocabulary Practice

I recommend getting a pencil and piece of paper because that aids memory. Then write down the missing vocabulary from my sample answer in your notebook:

There has been w____________________e i________________s c_____________g w____________r h______________e should be p__________e or p_______c . I_____________n , d_________e the importance of government r___________n in the h___________________y , a f_______________m will n___________y e_____________e g___________________n .

The b_______________t for g______________________________e comes from the e_________________s of p_____________e . The United States is the b________________e of this p________________n . There are c__________________s of v______________e individuals r____________________________n who f_____________________t of years of n_________________________e m______________s . If the government r______s the hospitals, a________________n m_____________________s i______________g Canada and England, the a_________________n does not have to worry about p_________________________e medical e________________s . Citizens living in these countries now c____________________________t for the i_________d or i__l as a f____________________________t that governments have a r_______________y to s__________d .

However, governments are n___________s for s________________n . This applies to a r_________________s and can b________________d by the f__________e of c_______________m as an e_________________l . The l__________________________m that g_________e many European nations g___________________e but hospitals are not motivated to c_________e and e_______l . Despite the many d______________s of the U___________________m , hospitals there r________________d and are d________n to u_________r new t_____________s and p_____________s in order to a__________t more patients. While s_________g costs may l_______________d v_________________________n , hospitals have a p_____________________n to p____________e the b_________________________s for those who can a_________d treatment.

In conclusion, medicine should be a______________e for all citizens but this cannot be a___________________f the q__________y of healthcare. Governments should r_____________e the m________________y and p______________________s yet still a_____________r a c_____________________________t .

Listening Practice

Learn more about this topic in the video below and practice with these activities :

Reading Practice

Read more about this topic and use these ideas to practice :

How does health spending in the U.S. compare to other countries?

Speaking Practice

Practice with the following speaking questions from the real IELTS speaking exam :

• How can people improve their physical health?
• What about their mental health?
• In what ways can teachers encourage students to do sports?
• What is the role of doctors in raising health awareness?
• Can social media also play a role?

Writing Practice

Practice with the related IELTS essay topic below:

Some think that governments should tax unhealthy foods to encourage people to eat healthier.

IELTS Writing Task 2 Sample Answer Essay: Unhealthy Foods (Real Past IELTS Tests/Exams)

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11 Comments

It is really helpful for me ,thnx a lot sir for this great effort keep it up

You’re welcome, Arshdeep!

A highly controversial issue today in the air is apropos with the healthcare system. Certain people asserts that public should be the charge of health services while has a different sights onto it as well. In my opinion, despite the benefits of freer system in the medical field, government management has an overall positive impact on society.

The compelling reason to support my side is financial crisis and corruption. In the recent world 65% people are fighting with trade depression to maintain a household activity. Numerous medical operations consist a lot amount of dollars which slightly cheaper in the government hospitals as a result it is an ease for middle class people. If such rights are under the citizen’s hand then situation will become terrible as everyone comes with a possible outcome which can save their banking accounts. This approach will indirectly creating a caution for doctors as they do not have a specific digits income. Under the rules of government equality will manage and it reflects the progress of nation and economy both because such trade skill workers are high paid tax workers.

Nonetheless, detractors have their evolution with credentials and job opportunities. Several master degree physician never getting a high paid workplace whereas operating a private clinic with surplussing charge is only productive method for them to gain an experience and income. To illustrate, in many countries like India above a quarter people prefer a veteran private hospitals than surgery in local centers. While hospitals are providing a powerful result but conveniently and fast focus individual outcome can possible in private sectors who can afford the treatment.

To encapsulate, both the side have their comparatively merits and demerits. It is an onus of an individual to potentially counter the benefits for everyone to pay and get equal healthcare. I believe that, in the future the thought of public involvement will entirely eliminate with initiative of government to raise the position of doctors and medical workers in the hospitals.

Nice work, Y!

There are too many informal idioms though and some collocations are incorrect.

Try to be more accurate and keep working hard!

Would you please tell me which bands my essay is currently on?

Opinions are divided regarding whether the government or privately-owned companies should be responsible for providing medical services for the masses. Although the authorities can make healthcare widely accessible for everyone, regardless of their socioeconomic statuses, I am strongly convinced that private organizations should also be allowed to participate in this industry. Skeptics of private companies performing medical services may point out the exorbitant prices of healthcare these days. Perhaps the quintessential example of this would be the United States whereby healthcare services are prohibitively expensive. Consequently, the unwell in this country, most especially those suffering from severe illnesses, are likely to face the prospects of bankruptcy due to colossal medical bills. However, when the government uses restrictive legislation to strictly regulate the medical industry, which is the case in various progressive countries such as Canada or England, chances are individuals do not have to bear the financial burden stemming from medical treatment when being ill.   Despite the aforementioned argument, I claim that the availability of private healthcare providers can bring enormous benefits to society. Although the government may make healthcare more affordable for everyone, the public budget may not be able to accommodate the insatiable demands of the public for this service. Therefore, the participation of private companies in offering medical treatment for the masses, be it building more clinics and hospitals or buying more medical facilities, can alleviate the burden the governments, otherwise, have to carry alone. A good example of this would properly be the COVID-19 pandemic that state-owned hospitals fail to treat millions of patients suffering from this disease at once, therefore having to rely on the assistance of their privately-owned counterparts. This is a testament to why it is justifiable for private companies to partake in the healthcare industry. In conclusion, although the benefits of medical services being controlled by the governments are undeniable, I am of the opinion that the involvement of private companies in this industry is also necessary.  

Good work, Manual!

There are some words that are slightly off but otherwise you are around the level of a native speak and should expect at least an 8.5.

Impressive!

Thanks for your comment! 🙂

You’re welcome!

I am grateful that I fortunately hit with this link and collect immense vocabulary . Thanksalot Mr.Dave

You’re very welcome!

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Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Every citizen of every country in the world should be provided with free and high-quality medical services. Health care is a fundamental need for every human, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal health care is the provision of healthcare services by a government to all its citizens (insurancespecialists.com). This means each citizen can access medical services of standard quality. In the United States, about 25% of its citizens are provided with healthcare funded by the government. These citizens mainly comprise the elderly, the armed forces personnel, and the poor (insurancespecialists.com).

Introduction

Thesis statement.

• Universal Healthcare Pros
• Universal Healthcare Cons

Works Cited

In Russia, Canada, and some South American and European countries, the governments provide universal healthcare programs to all citizens. In the United States, the segments of society which do not receive health care services provided by the government usually pay for their health care coverage. This has emerged as a challenge, especially for middle-class citizens. Therefore, the universal health care provision in the United States is debatable: some support it, and some oppose it. This assignment is a discussion of the topic. It starts with a thesis statement, then discusses the advantages of universal health care provision, its disadvantages, and a conclusion, which restates the thesis and the argument behind it.

The government of the United States of America should provide universal health care services to its citizens because health care is a basic necessity to every citizen, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal Healthcare Provision Pros

The provision of universal health care services would ensure that doctors and all medical practitioners focus their attention only on treating the patients, unlike in the current system, where doctors and medical practitioners sped a lot of time pursuing issues of health care insurance for their patients, which is sometimes associated with malpractice and violation of medical ethics especially in cases where the patient is unable to adequately pay for his or her health care bills (balancedpolitics.org).

The provision of universal health care services would also make health care service provision in the United States more efficient and effective. In the current system in which each citizen pays for his or her health care, there is a lot of inefficiency, brought about by the bureaucratic nature of the public health care sector (balancedpolitics.org).

Universal health care would also promote preventive health care, which is crucial in reducing deaths as well as illness deterioration. The current health care system in the United States is prohibitive of preventive health care, which makes many citizens to wait until their illness reach critical conditions due to the high costs of going for general medical check-ups. The cost of treating patients with advanced illnesses is not only expensive to the patients and the government but also leads to deaths which are preventable (balancedpolitics.org).

The provision of universal health care services would be a worthy undertaking, especially due to the increased number of uninsured citizens, which currently stands at about 45 million (balancedpolitics.org).

The provision of universal health care services would therefore promote access to health care services to as many citizens as possible, which would reduce suffering and deaths of citizens who cannot cater for their health insurance. As I mentioned in the thesis, health care is a basic necessity to all citizens and therefore providing health care services to all would reduce inequality in the service access.

Universal health care would also come at a time when health care has become seemingly unaffordable for many middle income level citizens and business men in the United States. This has created a nation of inequality, which is unfair because every citizen pays tax, which should be used by the government to provide affordable basic services like health care. It should be mentioned here that the primary role of any government is to protect its citizens, among other things, from illness and disease (Shi and Singh 188).

Lastly not the least, the provision of universal health care in the United States would work for the benefit of the country and especially the doctors because it would create a centralized information centre, with database of all cases of illnesses, diseases and their occurrence and frequency. This would make it easier to diagnose patients, especially to identify any new strain of a disease, which would further help in coming up with adequate medication for such new illness or disease (balancedpolitics.org).

Universal Healthcare Provision Cons

One argument against the provision of universal health care in the United States is that such a policy would require enormous spending in terms of taxes to cater for the services in a universal manner. Since health care does not generate extra revenue, it would mean that the government would either be forced to cut budgetary allocations for other crucial sectors of general public concern like defense and education, or increase the taxes levied on the citizens, thus becoming an extra burden to the same citizens (balancedpolitics.org).

Another argument against the provision of universal health care services is that health care provision is a complex undertaking, involving varying interests, likes and preferences.

The argument that providing universal health care would do away with the bureaucratic inefficiency does not seem to be realistic because centralizing the health care sector would actually increase the bureaucracy, leading to further inefficiencies, especially due to the enormous number of clientele to be served. Furthermore, it would lead to lose of business for the insurance providers as well as the private health care practitioners, majority of whom serve the middle income citizens (balancedpolitics.org).

Arguably, the debate for the provision of universal health care can be seen as addressing a problem which is either not present, or negligible. This is because there are adequate options for each citizen to access health care services. Apart from the government hospitals, the private hospitals funded by non-governmental organizations provide health care to those citizens who are not under any medical cover (balancedpolitics.org).

Universal health care provision would lead to corruption and rent seeking behavior among policy makers. Since the services would be for all, and may sometimes be limited, corruption may set in making the medical practitioners even more corrupt than they are because of increased demand of the services. This may further lead to deterioration of the very health care sector the policy would be aiming at boosting through such a policy.

The provision of universal health care would limit the freedom of the US citizens to choose which health care program is best for them. It is important to underscore that the United States, being a capitalist economy is composed of people of varying financial abilities.

The provision of universal health care would therefore lower the patients’ flexibility in terms of how, when and where to access health care services and why. This is because such a policy would throw many private practitioners out of business, thus forcing virtually all citizens to fit in the governments’ health care program, which may not be good for everyone (Niles 293).

Lastly not the least, the provision of universal health care would be unfair to those citizens who live healthy lifestyles so as to avoid lifestyle diseases like obesity and lung cancer, which are very common in America. Many of the people suffering from obesity suffer due to their negligence or ignorance of health care advice provided by the government and other health care providers. Such a policy would therefore seem to unfairly punish those citizens who practice good health lifestyles, at the expense of the ignorant (Niles 293).

After discussing the pros and cons of universal health care provision in the United States, I restate my thesis that “The government of United States of America should provide universal health care to its citizens because health care is a basic necessity to every citizen, regardless of age, sex, race, religion, and socio economic status”, and argue that even though there are arguments against the provision of universal health care, such arguments, though valid, are not based on the guiding principle of that health care is a basic necessity to all citizens of the United States.

The arguments are also based on capitalistic way of thinking, which is not sensitive to the plight of many citizens who are not able to pay for their insurance health care cover.

The idea of providing universal health care to Americans would therefore save many deaths and unnecessary suffering by many citizens. Equally important to mention is the fact that such a policy may be described as a win win policy both for the rich and the poor or middle class citizens because it would not in any way negatively affect the rich, because as long as they have money, they would still be able to customize their health care through the employment family or personal doctors as the poor and the middle class go for the universal health care services.

Balanced politics. “Should the Government Provide Free Universal Health Care for All Americans?” Balanced politics: universal health . Web. Balanced politics.org. 8 august https://www.balancedpolitics.org/universal_health_care.htm

Insurance specialists. “Growing Support for Universal Health Care”. Insurance information portal. Web. Insurance specialists.com 8 august 2011. https://insurancespecialists.com/

Niles, Nancy. Basics of the U.S. Health Care System . Sudbury, MA: Jones & Bartlett Learning, 2010:293. Print.

Shi, Leiyu and Singh, Douglas. Delivering Health Care in America: A Systems Approach . Sudbury, MA: Jones & Bartlett Learning, 2004:188. Print.

• A Behavioural Health Clinic Mission
• The Role of Health Care Systems and Industrial System Engineering in Improvement of Health
• The Pros and Cons of Using Pie Charts in Healthcare
• Skin Grafting and Its Pros and Cons
• Affordable Care Act Medicaid Expansion Pros & Cons
• Substandard Patient Care or Health Care Delivery
• Health Care Communication Methods
• Evolution of Hospice Care
• Home Based and Community Based Services (HCBS)
• Long-Term Care Diversification
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2018, October 11). Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/

"Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." IvyPanda , 11 Oct. 2018, ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

IvyPanda . (2018) 'Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons'. 11 October.

IvyPanda . 2018. "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

1. IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Bibliography

IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

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Structural changes in the Russian health care system: do they match European trends?

• Sergey Shishkin   ORCID: orcid.org/0000-0002-0807-3277 1 ,
• Igor Sheiman   ORCID: orcid.org/0000-0002-5238-4187 2 ,
• Vasily Vlassov   ORCID: orcid.org/0000-0001-5203-549X 2 ,
• Elena Potapchik   ORCID: orcid.org/0000-0001-7004-3100 1 &
• Svetlana Sazhina   ORCID: orcid.org/0000-0002-2023-3384 1  

Health Economics Review volume  12 , Article number:  29 ( 2022 ) Cite this article

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In the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS.

We address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system.

The main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery.

The structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.

In the last two decades, health care systems in the European Union countries have faced global challenges, including aging populations, a substantial rise in chronic and multiple diseases, the emergence of new medical and information technologies, and a growing citizen awareness of the role of a healthy lifestyle in disease prevention [ 1 ]. The responses of health systems to these challenges included structural changes in their organization with a focus on the promotion of healthy lifestyles and disease prevention, the growing scale of screening for early disease detection, strengthening primary care, changing the role of the hospitals, the development of chronic disease management programs, etc. [ 2 , 3 ]

Studies of these trends address mostly Western countries. Much less attention has been paid to the post-Soviet countries. In this paper, we study structural changes in the health care in Russia. Russian health care has inherited the Semashko model of health care organization. Its main distinction is state-centered financing, regulation, and provision of health care. The model has specific forms of provider organization, for example, outpatient clinics (polyclinics) with a large number of various specialists, the separation of care for adults and children, and large highly-specialized hospitals [ 4 ].

The Soviet and post-Soviet health systems have been underfunded. Public health funding in the 1990s dropped almost by one third in real terms [ 5 ]. The organization of medical care in the 1990s has not changed significantly relative to Soviet times, and the system has adapted through the reduction in the volume of services and increased payments by patients, frequently informal [ 6 ]. The surge in oil prices after 2000 allowed health funding to increase and while encouraged noticeable changes in service delivery.

The changes in the Russian health system have been discussed in the literature mostly focusing on specific sectors and health finance reforms [ 5 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. But these changes in different sectors were not analyzed together, from a single methodological position, as changes in the structural characteristics of the Russian health care system, i.e. the changes in the ratio of different types of medical care, in the structure of medical service providers, in functionalities and modes of their interaction.

The objective of this paper is to explore the entire complex of structural changes over the past two decades in comparison with European trends. What were the structural changes in European health care systems, what were they like in Russia, and how can their differences be explained?

Study design

We followed a six-step methodological framework. The first stage involved designation of the types of medical care and the types of structural changes for identification and comparison. We considered four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. We focused on three different dimensions of structural changes: i) changes in the organizational structure of medical service providers; ii) changes in the structure of their activities (in its types and in their coverage of the population / patients); iii) changes in the organization of interaction between different service providers.

The second stage consisted of identifying for each type of medical care the changes in these three dimensions in the last twenty years before the COVID-19 pandemic. We described the changes that met two criteria: 1) these changes are assessed in the OECD, WHO, and World Bank reviews, and other review publications on this topic as the most noteworthy characteristics of the development of European health care systems, and 2) they have spread in a large number of European countries.

The changes identified according to the formulated criteria cover not all dimensions of structural changes for each type of medical care. For preventive activities, there are changes in the types of activities and in their coverage of the population. In primary and inpatient care, there are changes in the organizational structure of service providers, in the structure of their activities, and in the organization of interaction with other providers. In long-term care, there are changes in the structure of developed activities and their coverage of the population.

To describe the ongoing changes, we use both qualitative characteristics and, if possible, quantitative indicators that highlight them to the greatest extent.

The third stage involved detection of structural changes in four main areas of medical care delivery in Russia. We used the results of our previous studies and conducted an additional search for data characterizing structural changes in health care, using new statistical data, evidence derived from our survey of physicians and interviews with top managers in medical care system.

On the fourth stage we compared the identified structural changes in European health care systems (HCS) with the changes taking place in Russian health care. We identified the presence or absence of similar types of structural changes and the differences between them. The fifth stage was the consideration of the driving forces of structural changes in the Russian health care system. The sixth stage included discussion of the reasons for the distinctions with European developments.

Data sources

To identify the main structural changes in medical care delivery during last twenty years we searched the literature addressing both European HCS and Russia in the all aspects of changes of health care system indicators, better classified by MeSH term “health care reform”. We searched MEDLINE using the query: (russia OR europ* OR “european union” OR semashko) AND health care reform [mh] AND 2000:2021[dp]). All 788 findings were checked manually and 86 were relevant. We also used sources snowballed from these reports and the grey literature related to Russian health care, including those in limited circulation, unpublished documents, memorandums, and presentations from our personal collections covering more than twenty years.

We also used data from an online survey of 999 primary care physicians (further – survey) conducted by the authors in April–May 2019. The respondents representing 82 out of 85 regions of the Russian Federation were asked about implementation of the national prophylactic medical examination program. We also interviewed four leading specialists of the national Ministry of Health on the criteria for the inclusion of the components into the program.

To identify the driving forces of structural changes in the Russian health care system, we used materials from 10 interviews on the issues of implementing state health care programs that we conducted in 2019 with current and former top-managers in the federal government and in five regional governments. We also used the grey literature as well as published reports.

We used statistical data from the international databases of OECD [ 18 ], WHO [ 19 ], World Bank [ 20 ], as well as the Russian sources — the Federal State Statistics Service [ 21 ] and the Russian Research Instuitute of Health [ 22 ]. The data was analyzed for the period from 2000 to the latest date with available data for both EU member states and Russia. To ensure the comparability of the composition of countries in different years, the analysis of the dynamics of some indicators was limited to EU 19 members, i.e. excluding Cyprus, Greece, Croatia, Bulgaria, Luxemburg, Malta, Netherland, Poland, and Romania. The averages for EU 19 estimates are based on population size-weighted averages. If the studied publications and databases did not contain the necessary indicators, we made our own estimates.

Each section of the paper contains a brief description of the main trends in the European countries, and then provides a comparative analysis of the corresponding changes in Russian health care. The comparison is followed by a discussion of the driving forces and the limitations of structural changes in Russia compared to the main European trends. We limited our analysis to the pre – COVID-19 pandemic years.

The development of preventive activities

European hcs.

Most of them have implemented health check-ups, and population and opportunistic screenings for the early detection of diseases. These activities are viewed as a way to improve outcomes by ensuring that health services can focus on diagnosing and treating disease earlier [ 23 ]. The population covered by screenings is high and growing. In Germany 81% of population between 50 and 74 years in 2014 had been tested for colorectal cancer at least once, in Austria 78%, France 60%, Great Britain 48% [ 24 ].

The impact of these activities on health outcomes depends on the selection of preventive services, as well as on their implementation in specific national contexts. The selection of preventive services is increasingly based on research into their potential impact on mortality and other health indicators, as well as their cost effectiveness, with some services being declined because of their inadequate input into health gains [ 25 ]. It is particularly important that screenings are focused on socially disadvantaged groups with the highest probability of disease identification and the expected benefits of their management. Therefore, screening programs are based on the evaluation of local needs. Physicians have discretion in the choice of patients for screenings, depending on their importance for specific groups of the population, and individual risks and preferences.

It is increasingly common for a screening program to include follow-up management of any detected illnesses, with the implication that policy makers design such programs as a set of interrelated preventive and curative activities [ 26 ].

The original Semashko model and the current legislation prioritize preventive activities, while their implementation has been limited by the chronic underfunding of the health system. In the 2000s, the priority of prevention campaigns was revitalized in the form of a national prophylactic medical examination program (Prophylactic Program, called Dispanserization) that is a set of health check-ups and screenings. The major expectation from this Prophylactic Program is the same as in European HCS [ 27 ].

To supplement the analysis of the Prophylactic Program, we analyzed the evidence base for the components of the program and interviewed leading specialists of the federal Ministry of Health on the criteria for the inclusion of the components into the program. We found that some screenings were not evidence based and effect on the population health and/or health of participants is small [ 28 ]. The screening package of the dispanserization was expanded and reduced couple of times, but still number of ineffective screenings are included in the package (electrocardiography (ECG) screening of healthy subjects, prostate specific antigen (PSA) screening of middle age and adult men, urinalysis and routine blood tests, mammography from age 40 etc.).

Primary care physicians play a major role in conducting screenings and check-ups as well as subsequent interventions. There are also public health units responsible exclusively for these preventive activities in big polyclinics. Polled in 2019, primary care physicians responded that in 11% of polyclinics check-ups are carried out in these departments only, and in 24% of primary care organizations the check-ups are conducted by district physicians as well as by staff of these preventive units.

Under the current Prophylactic Program, people over 40 are supposed to have a set of check-ups annually; those 18–39 every three years. Most children go through physicals only. The official estimates of the coverage of the eligible population in the Prophylactic Program are around 100% [ 29 ], while service providers are less optimistic. According to the survey, more than half of the respondents reported that this share was less than 60%, while 17.4% reported less than 20% [ 27 ].

An important shortcoming of the Prophylactic Program design and implementation is the gap between its major objective and the capacity of primary care. The shortage of primary care physicians does not allow the target groups to be provided with all preventive services. Physicians have to distort the service to their registered population and to underprovide the follow-up care of detected cases. The lack of a systematic approach, less focus on local conditions, and the lack of a professional autonomy of providers are the major distinctions between Russian prevention campaigns and similar activities in Europe.

The Prophylactic Program is built on the presumption that preventive activities should include the follow-up management of any detected conditions. There is some evidence, however, that this is not taking place: according to our survey, a half of primary care physicians are unaware of the results of check-ups and screenings. The reported coverage and quality of the follow-up management of identified cases are low: a half of the respondents indicate that less than 60% of patients with identified diseases become objects of the follow-up disease management. Only 7.7% of respondents indicate that a set of disease management services corresponds to a pattern of dispensary surveillance issued by the federal Ministry of Health. The majority reports that these requirements are met only for some patients or are not met at all.

Disease management of newly identified chronic and multiple cases is focused on process rather than outcome indicators. The information on the latter is very fragmented. According to our survey, a decrease in the number of disability days of chronic patients is reported by only 14% of physicians. More than a half of respondents are unaware of the number of emergency care visits and hospital admissions of their chronic patients.

Strengthening primary care

There is a trend of multi-disciplinary primary care practices or networks development and promotion of teamwork and providers coordination in response to the growing complexity of patients. In Spain, France, and the UK it is increasingly common for large general practices to serve more than 20,000 people and provide a wider spectrum of services than in traditional solo and group practices. These emerging extended practices include pharmacists, mental care professionals, dieticians, and sometimes 2–3 specialists [ 30 , 31 ]. The role of nurses is also expanding. Most advanced nurses independently see patients, provide immunizations, health promotion, routine checks for chronically ill patients in all EU member states [ 32 ]. Related to these extended practices is the growing concentration of primary care providers via mergers and reconfigurations that increase the size of the units. The major benefits are economies of scale and scope through staff sharing and better integrated care.

There is also a general trend to strengthen the links with the local community, social care and hospitals [ 32 ]. Primary care providers are increasingly involved in chronic disease management programs together with other professionals in and out of general practices. Links with hospitals are developing beyond simple referral systems [ 33 ].

The trend of multidisciplinary practices development has greatly affected Russian health care. However, this trend in Russia differs significantly from the European HCS. It began in the 1980s, when large numbers of specialists were employed by polyclinics, which are the major providers of both primary care and outpatient specialty care. Today, large urban polyclinics employ 15–20 categories of specialists, and polyclinics in small towns 3–5 categories. The generalist who serves for the catchment area (district doctors) is limited in the scope of services they provide. Multidisciplinary practices are built through employing new specialists, while in European countries mainly through nurses and other categories of staff. Specialists in Russian polyclinics do not supplement, but essentially replace district doctors: they accounted for 66% of visits in 2019. Footnote 1

The scope of district doctors’ services is limited: at least 30–40% of initial visits end with referrals to a specialist or to a hospital, while in Europe only 5–15% [ 35 , 36 ]. Gatekeeping is promoted, but district doctors are overloaded and not interested in expanding the scope of their services. Specialists in polyclinics have insufficient training and poorly equipped, e.g. urologists do not do ureteroscopy and ophthalmologists do not practice surgery.

Since the 1990s, some regions started replacing district doctors and pediatricians with general practitioners. But this initiative has not been supported by the federal Ministry of Health, therefore the institution of a general practitioner is not accepted throughout the country. Currently, the share of general practitioners in the total number of generalists serving a catchment area is only 15% (Fig.  1 ). The model of general practice is used only in some regions. The main part of the primary care in the country is provided by district doctors and pediatricians, whose task profile remains narrower than that of general practitioners. The division of primary care for children and adults is preserved. The family is not a whole object of medical care. This division is actively defended by Russian pediatricians with references to specific methods of managing child diseases.

Distribution of generalists in Russia by categories in 2000, 2019. Source: Calculated from RRIH [ 22 , 37 ]

The prevailing trend in all European HCS is to increase the role of nurses. In Russia, the participation of nurses in medical care is limited to fulfilling doctors’ prescriptions and performing ancillary functions.

The transformation of inpatient care

Due to increased costs, technological advances in diagnosis and treatment, there were changes in patterns of diseases and patients treated in hospitals. A substantial amount of inpatient care has been moved to outpatient settings with a respective decrease in bed capacity. This is an almost universal trend in European HCS [ 19 ].

Hospitals continue to be centers of high-tech care, which concentrate most difficult cases and intensify inpatient care with a corresponding decrease in the average length of stay. These changes have been promoted by the move to diagnostic related groups based payment systems and a growing integration with other sectors of service delivery.

In many European countries, most hospitals no longer act as discrete entities and have become units of hospital-physician systems which are multi-level complex adaptive structures [ 3 ]. A new function of hospital specialists is their involvement in chronic disease management in close collaboration with general practitioners, outpatient specialists, and rehabilitative and community care providers [ 38 ].

Over the past two decades the treatment of relatively simple cases and preoperative testing have gradually moved to day care wards and polyclinics. In annual health funding, the federal government sets decreasing targets of inpatient care which are obligatory and which regions use to plan their inpatient care. However, inpatient care discharges per 100 people have been almost stable (21.9 in 2000 and 22.4 in 2018) in contrast to the EU 19 members Footnote 2 (18.4 in 2000 and 16.9 in 2018) [ 18 ]. The pressure of decreasing targets resulted in a drop in the average length of hospital stays (Fig.  2 ) and the total bed-days per person (Fig.  3 ). These indicators, along with bed supply (Fig.  4 ), decreased even faster than in the EU.

Average length of stay in hospital in EU members and Russia (days). Note: Calculated for EU 19 member states (see Methods). The EU 19 average length of hospital stay estimates are calculated as the sum of the products of inpatient care discharges by the average length of stay for each country, weighted average by the total inpatient care discharges. Source: OECD Health Statistics [ 18 ]

Number of bed-days per person in the EU and Russia. Note: Calculated for EU 19 member states (see Methods). EU 19 estimates are calculated as the sum of the products of inpatient care discharges by the average length of stay for each country weighted by the total population. Source: OECD Health Statistics [ 18 ]

Hospital beds per 1000 people in the EU and Russia. Note: Calculated as the average for all EU 28 members weighted by the total population. Source: World Bank [ 20 ]

At the same time, the intensity of medical care processes in hospitals in Russia remains significantly lower than in European countries. An indicator of this is the gap in the number of hospital employees per 1000 discharged (Table  1 ).

Over the past 20 years, significant efforts have been made to deploy day wards, both in hospitals and polyclinics, to reduce the burden on hospitals. As a result, the proportion of patients treated in day wards in the total number of patients treated in hospitals increased from 7.6% in 2000 to 20.8% in 2016 [ 21 ]. However, there is fragmentary evidence that this figure is still noticeably lower than in Europe. The share of cataract surgery carried out as ambulatory cases varies in most European countries between 80 to 99% [ 24 ] but is negligible in Russia.

Despite these positive trends, the health system remains hospital centered. The number of bed-days per person remains nearly twice as high as the EU average (Fig. 3 ).

An important trend is the increasing concentration of hospitals. The number of hospitals halved between 2000 and 2018, mostly due to mergers, but also due to the closures of inadequately equipped hospitals. This process has led to an increase in the average size of hospitals from 156 beds in 2000 to 223 beds in 2018 [ 21 ]. This figure is higher today than in Western countries with large territories. The average hospital size in France was 130 beds in 2018 and in Germany 215 beds in 2017 [ 18 ]. In Russia, with its very low population density, the reduction in the number of small rural hospitals resulted in some accessibility problems.

At the same time, the incorporation of previously independent polyclinics into hospitals is under way. The proportion of independent polyclinics in the total number of polyclinics has decreased from 35% in 2000 to 19% in 2014 [ 36 ].

The development of long-term care

Over the last 20 years, most European countries have increasingly developed the public provision of long-term care. The number of nursing and elderly home beds per 100,000 people in the EU increased from 581.7 in 2000 to 748.3 in 2014 [ 19 ], although the pace of changes, the coverage of citizens in need of long-term care, and its organization and funding differ substantially across countries [ 39 ]. Many countries control costs by keeping people in their homes longer and shifting the responsibility for non-institutional forms of care to communities [ 40 ]. An expected outcome of investment in long-term care is the reduction of informal care utilization.

Compared to European HCS, long-term care is underdeveloped in Russia. The number of nursing care beds declined from 14.7 per 100,000 people in 2011 to 10.6 in 2019 [ 22 ]. The share of citizens over working age and people with disabilities receiving outpatient and inpatient care within the long-term care system in the total number of citizens over working age and people with disabilities in need of long-term care, was only 2.9% in 2019 [ 41 ].

In contrast to the European HCS, Russia has not built a strong long-term care sector with the capacity to reduce the workload of acute inpatient care settings. Hospitals have to keep some patients longer resulting in a relatively higher length of stay. Palliative care as another sector of the long-term care which started to develop only a few years ago.

Driving forces and tools of structural changes in the Russian health care system

These changes have been driven by the federal and regional governments. They use two main tools to manage structural changes: 1) setting health care targets for the entire country and for regions, and 2) implementing vertical health care programs.

Since 1998, the federal government has annually approved a program of benefit packages for health (the Program). It sets targets for the utilization of medical care for each sector of service delivery, as well as unit cost targets. The Program is designed to balance the volumes of care with the amount of public funding. The annual versions of the Program gradually reduced the targets for inpatient care to encourage a shift to outpatient care. The federal targets are used in regional health planning. In the first decade of using the Program, the changes in the actual volume of medical care were small, but in the second decade, pressure from the federal center on the regions increased, and the gap between the federal targets and the actual utilization of care has noticeably narrowed (Table  2 ).

The development of the legislation on the delimitation of responsibility between levels of government, carried out in the last two decades, has consistently strengthened the regional governments role in restructuring medical care delivery. In 2012, almost all resources of health care governance were transferred from the municipal to the regional level (including the governance of primary health care. During the period 2000–2019 the number of public hospitals has decreased by 2.2 times, the number of hospital beds by 1.5 times, polyclinics 1.3 times, feldsher-obstetric posts 1.3 times. Footnote 3

When oil prices increased, the federal government poured additional resources into vertical programs. They are administered by the federal Ministry of Health and regional governments. The major programs: the ‘Priority national health project’ (2004–2012), the Prophylactic Program (2008 – ongoing), and regional programs for the modernization of health care (2011–2013). All additional and some basic resources are earmarked in an attempt to develop the highest priority activities: preventive care, obstetric care, cardiovascular surgery, oncology, etc.

The role of the centralized administration of these priority programs is controversial. The federal government initiated them, provided regions with additional funding, and made the program’s targets a priority of health policy. According to interviews with federal and regional officials, the implementation of programs is heavily controlled by the federal government: practically all decisions on specific activities, target indicators and resource allocation are approved on the federal level. The Russian regions have low flexibility to respond to local needs such as variation in disease incidence, the capacity of health care, or vulnerable population groups.

Structural changes in the provision of inpatient care were prompted by the introduction of a diagnostic related groups based payment system in the early 2010s. This was initiated by the federal government and implemented with the participation of the World Bank experts. It makes more profitable for hospitals to reduce the duration of hospitalizations and to complicate the structure of inpatient treatment [ 44 ].

We found that despite significant differences in health care organization, some structural changes in Russia have followed the general European trends. A similar rise in the coverage of the population with screenings is underway in Russia. There is a clear tendency to replace some inpatient care with day care. The volume of inpatient care is reducing —mostly due to a significant decrease in the length of stays, while the rate of hospital admission remains relatively stable. As in the most European HCS, the concentration of medical organizations and the formation of large outpatient and inpatient complexes is developing.

However, there are some substantial differences: the development of prevention programs is relatively less focused on the most vulnerable target groups and on local needs; primary care specialization is much stronger than in European HCS; the role of first contact generalists is waning; the worldwide tendency of increasing the role of nurses is almost invisible in Russia; long-term care is starting to develop but is still at a very low level and palliative care is in its infancy; integration in the health system are much less pronounced—both at the level of individual medical organizations and between health sectors.

The reasons for these differences are rooted in the specific features of health governance in Russia.

The Semashko model, by virtue of its genesis, reproduces the state administration patterns of a planned economy. The main driving force of changes is the bureaucracy. Its managerial activities are guided by the mechanism described by J. Kornai: ‘postponement, putting out the fire, postponement’ [ 45 ]. The governance focuses on mobilizing and distributing available resources to solve or mitigate the most pressing problems - ‘fire fighting’. This is what determines the fragmentation of structural changes in Russian health care compared to structural changes in European countries.

Materials of interviews with heads of federal and regional health authorities suggest that in the existing governance system each of its levels must demonstrate the success of its activity exclusively to the higher levels of management. It is easier to achieve success when solving problems of optimizing the volume of medical care and the organizational structure of medical institutions, and much more difficult when solving problems of improving the efficiency of all elements of medical care system, which requires changes in their functionality and ways of interaction. It requires more financial resources and better management at all levels of health governance.

A number of deeply rooted limitations for carrying out structural transformations in Russian health care can be highlighted.

Firstly, the low capacity of primary care providers and to some extent the unwillingness of patients to replace inpatient care with outpatient treatment prevents a shift of patients from hospitals to polyclinics.

Secondly, a feature of the Russian health care system is the weak development of horizontal links between medical organizations related to different levels of medical care, and between medical workers within medical organizations working in different departments [ 36 , 46 , 47 ]. The interaction of different providers is carried out mostly through vertical channels. This is a serious obstacle to the development of horizontal integration [ 36 ].

Thirdly, democratic institutions for the development of health care are historically underdeveloped in Russia and this influences the choice of health policy priorities. According to interviews with heads of regional health authorities, the role of local communities is negligible, and the role of the medical community is marginal. Professional organizations are rarely involved in decision-making on health issues. The input of public councils to government bodies is largely imitative. Information about the activities of the system as a whole and of individual medical organizations is restricted for public use. This enables health authorities to focus on achievements in their reports, while hiding shortcomings. Feedback from patients, and society as a whole, is poorly expressed.

Conclusions

Russian health care, whose genetic basis was the Soviet Semashko model, after a difficult ‘survival’ period in the 1990s, underwent significant structural changes over the next two decades. To a large extent, the directions of these changes have coincided with European trends. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care was accompanied by an intensification of inpatient treatment and a decrease in the average length of stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. Structural changes in primary care are much less pronounced. The resources and competences of providers and the governance of primary care are still not enough to abolish the hospital-centered model of service delivery. Russia has intensively implemented vertical health care programs to develop the priority activities, but still significantly lags in the level of development of horizontal ties among services providers.

Specific structural changes in Russia are rooted in the organization and governance of service delivery. The interests of federal and regional bureaucracies, which act as the main drivers of changes, are pushing them to prioritize the changes in volumes of medical care and organizational structure of health care providers and not spend a lot of effort on improving their functionality and modes of interaction between providers of medical care. An important role is also played by the low capacity of primary care units to provide quality care.

To respond effectively to modern global challenges, reduce mortality, and improve the health of the population, structural transformations in Russian health care must be intensified with the focus on strengthening primary care, the further integration of care, and an accelerated development of new structures that mitigate the dependence on inpatient care.

Availability of data and materials

The data used and analysed during the current study are publicly available.

Calculated using data from [ 34 ].

See Methods.

Calculated using data from [ 21 ].

Abbreviations

European Union

Health Care System

Organization for Economic Co-operation and Development

World Health Organization

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Sergey Shishkin – DSc in Economics, Director, Centre for Health Policy, HSE University.

Igor Sheiman – PhD in Economics, Professor, Health Economics and Management Department, HSE University.

Vasily Vlassov – DSc in Internal Diseases, Professor, Health Economics and Management Department, HSE University.

Elena Potapchik – PhD in Economics, Leading Research Fellow, Centre for Health Policy, HSE University.

Svetlana Sazhina – MPA, Leading Analyst, Centre for Health Policy, HSE University.

The study was funded by the grant provided by the Ministry of Science and Higher Education of the Russian Federation (Grant Agreement No. 075–15–2020-928).

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Sergey Shishkin conceptualized, designed the study and supervised the work. All authors collected, analyzed and interpreted the data. Elena Potapchik, Svetlana Sazhina made statistical analysis. Sergey Shishkin, Igor Sheiman and Vasily Vlassov wrote a first draft of the manuscript. All authors critically reviewed the draft. All authors read and approved the final manuscript.

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Shishkin, S., Sheiman, I., Vlassov, V. et al. Structural changes in the Russian health care system: do they match European trends?. Health Econ Rev 12 , 29 (2022). https://doi.org/10.1186/s13561-022-00373-z

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Modern Development Problems of Russian Healthcare (Part 1)

V. n. ivanov.

Institute of Economic Forecasting, Russian Academy of Sciences, Moscow, Russia

A. V. Suvorov

Abstract—.

The paper (part 1) analyzes the dynamics of indicators characterizing the state of health of the Russian population. A comparative analysis of the development of healthcare in Russia and other countries is carried out. The conclusion is confirmed that the main problem in the development of Russian healthcare is the insufficient volume of public funding. The drawbacks and limited potential of the adopted funding model are assessed. A possible way to increase public funding is proposed. It is shown that the availability of medical care is reduced as a result of the so-called optimization of healthcare. A possible way to improve the territorial organization of medical services is considered. The effectiveness of the Russian healthcare system in the fight against the coronavirus pandemic is assessed.

The current state of the national healthcare system raises justified concern. The high morbidity and mortality of the population of Russia persist. Sociological studies record a low level of satisfaction of the population with the quality and level of accessibility of medical care. Representatives of the medical community are increasingly criticizing the government’s policy in the field of healthcare, the adopted directions of reforming the industry. At the same time, many of the shortcomings of the implemented strategy for organizing healthcare have been clearly manifested during the epidemic of coronavirus infection COVID-19 and caused significant damage to the socio-economic development of the country.

The state of health of the population. According to official data, in 2018 the total number of registered diseases in the country’s residents amounted to 240 mln, i.e., on average, 1.6 diseases per person. 1 Every fourth person has a disease of the circulatory system; in a population sample of 100 people, 13 were diagnosed with diseases of the musculoskeletal system, 12 had diseases of the genitourinary system, 11 had digestion diseases, 10 had eye diseases, 8 had diseases of the endocrine system, and 5 had neoplasms.

The fastest growing morbidity in the Russian population was observed in the first half of the 1990s during the period of change in the social system, which was characterized by a sharp drop in the level and deterioration of living conditions of the population. An increase in morbidity was observed in relation to almost all classes of diseases, including curable diseases, which were considered almost completely eliminated in the Soviet period. So, for example, in comparison with 1991, the number of patients with a diagnosis of active tuberculosis established for the first time in their life increased by the mid-1990s by more than two times, and the number of patients with a diagnosis of syphilis grew 30 times.

In the 2000s, as compared to the previous decade, the rate of growth in the incidence of diseases of the circulatory system (the number of registered diseases in patients diagnosed for the first time in their lives) increased, while it decreased in many other classes of diseases ( Table 1 ). At the same time, the incidence rate in 2019 was lower than in 1991 only for infectious diseases. Meanwhile, over the past almost thirty years, the number of detected diseases of the endocrine system has increased three and a half times, the number of detected diseases of the circulatory system has grown more than three times, and the number of neoplasms has twice increased. The last two classes of diseases as well as external causes (accidents, traffic injuries, homicides and suicides) are currently the main causes of mortality in the population.

Table 1.  

The incidence rate for main classes of diseases (registered diseases in patients with a diagnosis established for the first time in life), thousands

The dynamics of the mortality rate of the population include three time intervals: 1991–1995, 1995–2005, and 2005–2019. In the early 1990s, there was a maximum increase in the overall mortality of the population, which was due, first of all, to a significant deterioration in the socio-economic situation in the country: a deep economic recession, a sharp drop in the standard of living for the majority of the population and an accompanying increase in socio-psychological tension as a result of the inability adapt to new economic conditions [ 1 ]. Moreover, this inability was most characteristic of the younger age cohorts of the population. This is confirmed by the significantly higher growth in mortality at the working age ( Table 2 ).

Table 2.  

Mortality from the main death causes (deaths from all causes per 100 000 people)

The increase in mortality in 1991–1995 was noted for all major classes of death causes, while the increase in mortality from external causes was the greatest, which was a direct consequence of the growth of socio-psychological tension. In this regard, it should be noted that social and psychological stress is recognized by WHO experts as main among socioeconomic factors that negatively affect the health of the population and lead to the development of cardiovascular diseases, an increase in mortality from accidents, homicides and suicides; at the same time, this influence is most pronounced in the countries that are carrying out accelerated economic transformations without an adequate social policy [ 2 ].

The degradation of the medical care system also contributed to the growth in mortality in the first half of the 1990s. As radical economic transformations began, funding for Russian healthcare collapsed. The reduction in funding and the deterioration of the material and technical support of the healthcare system resulted in the transition to simplified medical technologies, which in many cases did not provide the previously achieved quality of medical care. This could not but lead to a decrease in its effectiveness.

During the next time interval (1995–2005), the growth rate of total mortality decreased significantly. At the same time, mortality from external causes, primarily in the working age, had a clear tendency to decrease, while mortality from cardiovascular diseases (the main cause of mortality in the population) continued to grow and increased by almost one and a half times compared with 1991. It is due to mortality from diseases of the circulatory system that the increase in the total mortality of the population occurred in the period under review.

It became possible to reverse the growth trend in mortality only in the middle of the 2000s as a result of both an improvement in the socio-economic situation and living conditions of the population and improvement in the medical care system. The latter was facilitated primarily by implementing measures for strengthening the material and technical base of healthcare within the framework of the “Health” national project, which was launched in 2006: large-scale procurement of modern medical equipment, and introduction of modern medical technologies.

Over the past 15 years (2005–2019), the rate of mortality from diseases of the circulatory system and external causes has decreased most significantly. As the socio-economic situation in the country began to improve, mortality from external causes began to decline rapidly and decreased by a third by 2019 compared to 1991. The reduction in mortality from diseases of the circulatory system must be attributed—in contrast to the decrease in mortality from external causes—to achievements of healthcare as a result of the modernization of the system of medical care for patients with cardiovascular diseases: the organization of a network of vascular centers and vascular departments of hospitals, a multiple increase in the number of surgeries on the heart and blood vessels. At the same time, it should be noted that mortality from diseases of the circulatory system in Russia continued to remain at a significantly higher level compared to most economically developed countries [ 3 ]. There is also reason to believe that the rate of mortality from diseases of the circulatory system officially registered in recent years is artificially underestimated. Experts explain this by the fact that the achievement of the target rates of mortality from cardiovascular diseases defined by the 2012 presidential decrees in May is one of the criteria for assessing the performance of regional leaders. As a result, the regions often indicate another concomitant disease of the patient as the cause of death at the suggestion of their leaders [ 4 ]. This is probably the reason for the hard-to-explain increase in mortality from “other diseases” just in elderly patients who usually have several diseases (see Table 2 ).

A generalizing characteristic of the mortality rate and one of the main indicators for assessing the health of the population and the effectiveness of the functioning of the healthcare system is the indicator of average life expectancy (life expectancy at birth). The dynamics of the average life expectancy indicator also include three time intervals ( Table 3 ).

Table 3.  

Average life expectancy (years)

In the early 1990s, there was a sharp decline in life expectancy, which was unprecedented in peacetime, primarily for men (see Table 2 ). From the mid-1990s to the mid-2000s, the values of this indicator remained almost unchanged. The observed insignificant increase in the average life expectancy with a simultaneous growth in the total mortality of the population during this period is mainly explained by the decrease in mortality from external causes during this period due to the significantly lower average age of death in comparison with other death causes.

During 2005–2019, the average life expectancy grew, while the difference in the average life expectancy between men and women also decreased due to the higher growth rates for men (see Table 3 ). A significant increase in average life expectancy during this period was primarily due to a decrease in mortality from cardiovascular diseases and mortality from external causes. At the same time, the decrease in mortality from external causes not only made a significant contribution to the growth of average life expectancy, but also largely determined the decrease in the difference in the average life expectancy between women and men due to the lower average age of death from this cause with a fourfold excess of its level in men compared to women. Along with the reduction in mortality from diseases of the circulatory system, a significant decrease in infant mortality must be attributed to the unconditional achievements of domestic healthcare, which contribute to an increase in average life expectancy. The infant mortality rate (the number of children who died under one year of age per 1000 live births) decreased almost three times: from 11.0 in 2005 to 4.1 in 2019.

Despite the observed upward trend in the average life expectancy of the population, Russia is still among the second hundred countries of the world in the WHO ranking for this indicator [ 5 ]. In most developed countries, the average life expectancy of the population is eight to ten years higher than in Russia, and the difference in the life expectancy between women and men is two times less ( Table 4 ). The reasons for Russia’s lag behind other developed countries have a more than half a century history and are explained, first of all, by insufficient financing of the Russian healthcare system.

Table 4.  

Life expectancy (in 2019) in Russia and in a number of developed countries, years

Health financing. A global trend is a change in the so-called epidemiological revolutions. By the middle of the 20th century, developed countries almost completed the first epidemiological revolution, which was characterized by significant successes in the fight against diseases that are curable in nature. One of the main results was a significant decrease in mortality, primarily in infant mortality and mortality in working age. As a result, average life expectancy increased by 1960 to about 70 years in most developed countries.

The second epidemiological revolution meant a replacement of the strategy of “treatment up to recovery” with the strategy of prevention and “postponement of fatal complications” of chronic diseases (atherosclerosis, diseases associated with metabolism, etc.), i.e., “moving deaths from these causes to older ages, an increase in the average age of death from them, and, ultimately, a significant increase in life expectancy” [ 6 ].

The implementation of such a strategy requires the development and introduction of new medical technologies, diagnostic and therapeutic equipment, an increase in the number of people employed in healthcare, and the development of pharmaceutical production. All this leads to a significant rise in the cost of medical care and, accordingly, to a significant increase in healthcare costs.

As a result, the dynamics of spending on healthcare have become an indicator of the dynamics of the volume of medical services of the quality required to solve the problems of the second epidemiological revolution. At the same time, it is considered that one of the most adequate indicators of not only the quality, but also the availability of medical care for the population is the value of public expenditures on healthcare and, in particular, the indicator of the share of these expenditures in the gross domestic product (GDP), which allows for cross-country comparisons, including comparison of countries with different levels of economic development. This indicator to the greatest extent reflects the state of health of the population, mortality rate and average life expectancy.

As the analysis shows, there has been a rapid increase in healthcare expenditures since the 1960s in almost all foreign developed countries. At the same time, the growth rates of public healthcare financing significantly exceeded the rates of economic growth of the countries; as a result, the share of these expenditures in GDP increased by no less than 2–3 times by 1990 compared to 1960. Simultaneously, the average life expectancy increased by 5–7 years in most developed countries (see Table 4 ).

In our country, the problems of the first epidemiological revolution were solved quite successfully. As a result, life expectancy increased from 43 years in 1926–1927 (data for the European part of the Russian Soviet Federative Socialist Republic) up to 68.8 years in 1960. The country entered the top twenty countries of the world by this indicator, being only slightly inferior to the leading countries. However, in the next 30 years, the average life expectancy did not increase and in 1990 it was equal to only 69.2 years. At the same time, as calculations show, the amount of public health spending that was calculated as a share of GDP remained almost unchanged. This indicator ( Table 5 ) in 1990 remained at the level of spending in most developed countries in the 1960s.

Table 5.  

Public health spending (% of GDP) and average life expectancy (years) in the Soviet Union and other countries in 1960–1990*

* The data for the Russian Soviet Federative Socialist Republic barely differed from the data for the Soviet Union. Data for foreign countries were calculated according to [ 7 , 8 ].

The development of domestic healthcare in the period under review followed the path of building up the network of medical institutions and increasing the training of medical personnel. As a result, the number of hospital beds and the number of doctors in the Russian Soviet Federative Socialist Republic increased more than twice. Given the size of the country’s territory and the nature of the population’s settlement, such an extensive direction of healthcare development seems to be a fully justified way of ensuring universal access to medical care. At the same time, insufficient funding did not make it possible to ensure an improvement in the quality of medical care by the technical and technological re-equipment of domestic healthcare, which was necessary to solve the problems of the second epidemiological revolution. Calculations show, in particular, that the cost of purchasing equipment in total healthcare spending in the period under review was only about 2% [ 9 ].

As a result of insufficient funding, the provision of medical organizations with modern diagnostic and treatment equipment, the use of advanced medical technologies remained at an extremely low level. The provision of modern medicines was also very low. In addition, insufficient funding led to low wages in healthcare. Despite the high educational and professional levels of people employed in this sector, the average salary in healthcare was a quarter lower than the average for the national economy. Our country also lagged significantly behind other developed countries in terms of the ratio of the average wages in healthcare to the this indicator in the economy as a whole.

In the early 1990s, there was a collapse in funding for Russian healthcare. The scale of the fall in public spending is evidenced, first of all, by a sharp decline in wages for people employed in healthcare, which is the main item of expenditure of medical organizations. Calculations show that this indicator decreased in constant prices three times in the first year of radical reforms, and in 1995 it amounted to 47% of the 1991 level. Due to the unreliability of statistics on the values of the deflator of GDP elements in 1992, it is difficult to give an accurate estimate of the magnitude of the fall in total public health spending from 1991 to 1995. According to our calculations with corrections of data for 1992, public health financing decreased about twice over this period.

Table 6 shows the dynamics of the indicator of public health spending for the period from 1995 to 2018 in constant prices, which was calculated on the basis of the deflator of final consumption as an element of the use of GDP.

Table 6.  

Public health spending (at constant 1995 prices) and average life expectancy

* In 1995—bln Rubles.

As can be seen from the cited data, public health spending continued to decline in the second half of the 1990s, and the 2000s brought about an increase in financing for healthcare along with the growth of the economy. Given the two-fold drop in funding in the first half of the 1990s, this growth is a recovery growth. The level of funding in 1991 was achieved only in 2010. It is interesting to note that the indicator of average life expectancy in 2010 (68.9 years) became exactly the same as in 1991.

In the second half of the 2000s at a relatively high growth rate of public expenditures (average annual growth was 2.8%), the state of the material and technical base of healthcare improved. The coefficient of renewal of fixed assets increased several times—up to 6% in 2010. At the same time, the share of machinery and equipment in the structure of fixed assets grew (up to 39% in 2010). As noted above, large-scale purchases of modern diagnostic and treatment equipment were carried out during these years within the implementation of the “Health” national project, which made it possible to switch to the use of advanced medical technologies, at least at some medical organizations. First of all, this applies to federal specialized medical centers, the network of which significantly increased, including through the creation of such centers outside Moscow and St. Petersburg.

In general, all this led to an improvement in the quality of medical care and, accordingly, to an increase in its effectiveness. For the first time in Russian history, average life expectancy exceeded the 70‑year threshold in the 2010s and continued to grow until recently. At the same time, the success of the Russian healthcare system significantly lags behind the majority of developed foreign countries. Russia’s lag behind these countries in terms of life expectancy not only has not decreased, but has increased over the past three decades. A similar trend is also observed for the difference in public health expenditures calculated as a share of these expenditures in GDP. As for per capita public spending in comparable prices at purchasing power parity (PPP), the scale of Russia’s lag behind most developed countries is especially large. In terms of per capita financing, Russia lags almost three times behind the average financing for the countries of the Organization for Economic Cooperation and Development (OECD) and 3.5–5 times behind the countries such as Austria, Germany, Canada, Norway, France, and Japan ( Table 7 ).

Table 7.  

Public health spending and average life expectancy in the Russian Federation and other countries in 2018*

* Data for the OECD countries are given according to [ 10 ]. ** Per capita spending is calculated using PPP of final consumption in GDP.

Against the background of low public funding in post-Soviet Russia, private spending on healthcare began to grow rapidly: household spending on the purchase of medicines and medical supplies, payments for medical services, and contributions to voluntary medical insurance increased. For the period 1995–2018 in comparable prices, spending for the purchase of medicines and medical goods increased almost 12 times, and spending for payments for medical services grew almost seven times. An advancing growth in private spending was accompanied by an increase in its share in total expenditures on healthcare.

As can be seen from Table 8 , the commercialization of Russian healthcare has become an obvious trend.

Table 8.  

Structure of healthcare expenditures and their share in GDP in 1995 and 2018

At the same time, the vector of development was directly opposite to that observed in most developed foreign countries. Historically, the improvement of healthcare systems in these countries followed the path of strengthening the role of the state, the transition from private to public funding. As a result, the current share of private financing in total health spending in developed foreign countries (23% in Belgium and France, 22% in Germany, 21% in Great Britain, 16% in Japan, 15% in Norway [ 10 ]) is significantly lower than in Russia (39%).

As many years of world experience have shown, public funding not only ensures universal access to healthcare, but also allows more efficient use of health resources. In Russia, this experience was ignored, including the conclusions of experts that “private financing of healthcare threatens its values and is ineffective in comparison with public financing” [ 11 ]. In this regard, it should be noted that healthcare is the most costly in the United States, where private funding dominated until recently. Thus, total expenditures on healthcare in the United States in 2018 amounted to 16.9% of GDP, which is almost twice more than the average for OECD countries [ 10 ]. At the same time, the United States occupies one of the last places in terms of average life expectancy (78.6 years) among the countries with a high level of economic development.

The commercialization of Russian healthcare has resulted in the increased inequality in the availability of medical care for the population due to the lack of funds for paid medicine among the majority of the population, especially among its poorest strata. So, for example, according to the data from a sample survey of households cited by Federal State Statistics Service, in 2018 20% of the wealthiest citizens accounted for 70% of paid medical services and 20% of the poorest people accounted for less than 1.5%, or a share almost 50 times less. According to sample studies, every seventh resident of the country and every fifth pensioner could not purchase the medicines necessary for treatment due to a lack of funds.

At the beginning of the period under review, a reform of public health financing took place: in addition to state budget financing, a compulsory health insurance system (CHI) was introduced in 1993, which provides for employers paying insurance premiums for employees to the state federal and territorial CHI funds. It should be emphasized that financing through the CHI, i.e., financing by the introduction of compulsory payments for the working population was originally regarded precisely as an addition to financing from the state budget in the context of a sharp decline in the incomes of the latter. This made it possible to dampen the drop in budget financing to a certain extent.

However, later the CHI system began to be considered as the main model for financing healthcare. A transition was made to a one-channel system of financing, in which the budgets of the constituent entities of the Russian Federation transfer certain amounts (contributions) for the nonworking population to the territorial CHI funds. Territorial funds that also receive employers’ insurance contributions from the federal CHI fund transfer the accumulated funds to private insurance companies that finance the activities of medical organizations. Meanwhile, some types of medical care as well as capital expenditures, including the purchase of expensive equipment, are financed exclusively from the state budget.

The above-described complex and contradictory scheme of healthcare financing (public expenditures are carried out by private insurance companies) is only one of the characteristics of the adopted CHI model. Leaving aside for now the assessment of all the negative consequences of the application of this model, we note two important circumstances. First, as international comparative studies show, the CHI model is more costly compared to the system of financing from the state budget and, moreover, does not provide greater efficiency of medical care, in particular, reduction in the mortality rate of the population (for example, see [ 12 ]).

Second, despite the declared transition to universal compulsory health insurance, the main source of public funding for healthcare is still the state budget rather than personalized insurance premiums for each insured person, as in other countries applying the CHI model. As calculations show, employers’ insurance premiums for employees at a statutory rate amounted in 2018 to just over a third (36%) of public health spending despite the increase in this rate from 3.6% during the introduction of CHI to 5.1% in recent years, and budgetary appropriations accounted for the remaining almost two-thirds (calculations were made according to [ 13 ]).

Proceeding from these two facts, a natural question arises about the expediency of maintaining funding according to the adopted CHI model. Recently, proposals to return to the state budget financing system have been increasingly formulated by many experts (see, for example, [ 14 – 16 ]), including due to the ineffectiveness of the CHI model under the conditions of the coronavirus pandemic. In 2020, the state allocated additional budgetary funding for the development of a network of covid hospitals and additional payments to doctors working with coronavirus patients. At the same time, due to a sharp decrease in the number of patients in polyclinics and noncovid hospitals under the conditions of the pandemic, their financing through compulsory medical insurance decreased, which resulted in large accounts payable of medical organizations to insurance companies that pay for their services under compulsory medical insurance [ 17 ].

Summarizing the above, one cannot but agree with the experts’ conclusion that the fundamental limitation of the financial capabilities of the CHI system is becoming more and more obvious [ 16 ]. Moreover, to restore economic growth, it is necessary to increase consumer demand at the expense of the growth in household incomes. Therefore, it seems reasonable to reduce the insurance burden on the wages of employees. In such a situation, in our opinion, the abandonment of the CHI model and the transition to a system of budgetary financing must be considered fully justified.

Under these conditions, an urgent task is to increase significantly state budget spending on healthcare, which is necessary not only to compensate for falling insurance payments, but also to achieve an acceptable level of financing for healthcare in general. The way to solve this problem is also obvious—the state budget revenues must be increased. Until recently, the revenues of the RF consolidated budget amounted to only 35% of the GDP. This is significantly less than in most developed countries: this figure is 45% on average for the EU countries, and in Belgium, Denmark and Finland it exceeds 50% [ 18 ].

It is currently recognized that one of the main problems of economic development is an increase in the income gap with an increasing concentration of income among one percent of the population. The importance of solving this problem was acknowledged by the President of the Russian Federation in his speech at the last Davos Forum [ 19 ].

In developed foreign countries, a decrease in income concentration is stimulated by high tax rates on incomes of the richest citizens from work and property. As a result, one percent of taxpayers account for most of the collected income tax (in the United States, for example, more than 40% [ 20 ]), which is one of the main items of state budget revenues.

In our opinion, the introduction of a high income tax rate in Russia similarly to developed countries in relation to the incomes of the richest citizens must be considered the first step in solving the problem of increasing the incomes of the consolidated budget of the Russian Federation and, accordingly, increasing public spending on healthcare. The relevance of such a solution is defined as extremely high. According to available estimates, the concentration of income in Russia for one percent of the Russian population corresponds to that in the United States. In both countries, especially in Russia, the authorities are realizing the urgent need to reduce this concentration.

It should be emphasized that we are not talking about the introduction of progressive taxation with a multilevel scale of tax rates in Russia. Objections to the introduction of such a system are to a certain extent justified, given the low income of the vast majority of citizens and the complexity of the administration of such taxation. It is proposed not to go beyond the establishment of an increased tax rate on that part of the income of the richest taxpayers, which exceeds a certain threshold value with maintaining the existing tax rate on all incomes below the established threshold, i.e., incomes of the absolute majority of the population. The amount of the threshold income, above which an increased rate must be applied, as well as the amount of this rate can be determined taking into account the experience of taxation in developed foreign countries: the maximum tax rate they use for that part of an individual’s income that exceeds the established threshold. The corresponding calculations for a number of countries [ 21 – 23 ] are given in Table 9 .

Table 9.  

The maximum personal income tax rate and the amount of the annual income above which the maximum rate is applied

* Based on the results of international comparisons for 2017.

1 Here and below, if a specific reservation is not made, the indicators are based on the data of the Federal State Statistics Service published in the “Russian Statistical Yearbook,” statistical collections “Healthcare in Russia,” “Demographic Yearbook of Russia,” “Social Position and Living Standard of the Population of Russia,” and “Regions of Russia.”

Translated by L. Solovyova

Essay on Hospital

500 words essay on  hospital.

Hospitals are institutions that deal with health care activities. They offer treatment to patients with specialized staff and equipment. In other words, hospitals serve humanity and play a vital role in the social welfare of any society. They have all the facilities to deal with varying diseases to make the patient healthy. The essay on hospital will take us through their types and importance.

Types of Hospitals

Generally, there are two types of hospitals, private hospitals and government hospitals. An individual or group of physicians or organization run private hospitals. On the other hand, the government runs the government hospital.

There are also semi-government hospitals that a private and organization and government-run together. Further, there are general hospitals that deal with different kinds of healthcare but with a limited capacity.

General hospitals treat patients from any type of disease belonging to any sex or age. Alternatively, there are specialized hospitals that limit their services to a particular health condition like oncology, maternity and more.

The main aim of hospitals is to offer maximum health services and ensure care and cure. Further, there are other hospitals also which serve as training centres for the upcoming physicians and offer training to professionals.

Many hospitals also conduct research works for people. The essential services which are available in a hospital include emergency and casualty services, OPD services, IPD services, and operation theatre.

Importance of Hospitals

Hospitals are very important for us as they offer extensive treatment to all. Moreover, they are equipped with medical equipment which helps in the diagnosis and treatment of many types of diseases.

Further, one of the most important functions of hospitals is that they offer multiple healthcare professionals. It is filled with a host of doctors, nurses and interns. When a patient goes to a hospital, many doctors do a routine check-up to ensure maximum care.

Similarly, when there are multiple doctors in one place, you can take as many opinions as you want. Further, you will never be left unattended with the availability of such professionals. It also offers everything under one roof.

For instance, in the absence of hospitals, we would have to go to different places to look for specialist doctors in their respective clinics. This would have just increased the hassle and waste energy and time.

But, hospitals narrow down this search to a great level. Hospitals are also a great source of employment for a large section of society. Apart from the hospital staff, there are maintenance crew, equipment handlers and more.

In addition, they also provide cheaper healthcare as they offer treatment options for patients from underprivileged communities. We also use them to raise awareness regarding different prevention and vaccination drives. Finally, they also offer specialized treatment for a particular illness.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Hospital

We have generally associated hospital with illness but the case is the opposite of wellness. In other words, we visit the hospital all sick and leave healthy or better than before. Moreover, hospitals play an essential role in offering consultation services to patients and making the population healthier.

FAQ of Essay on Hospital

Question 1: What is the importance of hospitals?

Answer 1: Hospitals are significant as they treat minor and serious diseases, illnesses and disorders of the body function of varying types and severity. Moreover, they also help in promoting health, giving information on the prevention of illnesses and providing curative services.

Question 2: What are the services of a hospital?

Answer 2: Hospitals provide many services which include short-term hospitalization. Further, it also offers emergency room services and general and speciality surgical services. Moreover, they also offer x-ray and radiology and laboratory services.

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Our Physician Advisors will help you brainstorm content while our Writing Advisors will help you refine that content, paying special attention how you are showcasing your experiences, organizing your narrative, and developing your unique “voice.” After some careful editing and proofreading from your Writing Advisor and a final review by your Physician Advisor, you will have a compelling and authentic essay that will help you stand out.

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After a few drafts, your Writing Advisor will refine your prose and correct smaller writing errors that stand in the way of excellence. Your Physician Advisor will then approve the final product.

With the help of your team of advisors, you will craft a primary application that will get you secondary application invites, and lead to an acceptance to medical school.

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A trailblazing physician and advocate, Dr. Ng has spearheaded LGBT health initiatives, founded Ohio's first LGBT-focused PRIDE Clinic, and achieved numerous accolades for his work in healthcare diversity and inclusion. Dr. Ng was an assistant dean and member of the Case Western Reserve University School of Medicine Admissions Committee.

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Young Surgeons: Submit Essays for History and Archives Committee Competition

September 17, 2024

The ACS History and Archives Committee offers a Young Surgeons Essay Competition that is intended to recognize and support young surgeons who are interested in the historical roots of the surgical profession and are dedicated to studying it. The objective is to produce a scholarly essay for publication using original historical research that will advance knowledge of the past, thus promoting both young surgeon historians and the history of surgery itself.

Young surgeons are invited to submit an essay on a historical topic of their choosing. The winner and runner up will be invited to publish their paper in a surgical journal, with publication costs covered, if accepted.

Entries are invited from young surgeons who must be the first and primary author.

Young surgeons are defined as:

• Fellows 45 or younger
• Associate Fellows 45 or younger
• Resident members
• Medical student members, who must be the first and primary author

Fellows older than 45 years of age may serve as additional or senior authors.

Submissions for the 2025 essay competition are now open, and the deadline to submit an entry is January 10, 2025. View the guidelines for the essay contest, including how and to whom to submit, and contact ACS Archivist Michael Beesley at [email protected]  for more information. 

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Healthcare system

Healthcare Basics

The healthcare system in Russia

Discover how the Russian healthcare system works and how to find a Russian pharmacy, doctor, or hospital in the country.

By Gary Buswell

Updated 13-8-2024

Important notice from the Editor in Chief

Maintaining our Russian site is a delicate matter during the war. We have chosen to keep its content online to help our readers, but we cannot ensure that it is accurate and up to date. Our team endeavors to strike the right balance between giving information to those who need it, and respecting the gravity of the situation.

The Russian healthcare system might seem similar to other systems elsewhere in Europe, with both state and private health insurance available for accessing healthcare in Russia. In truth, though, understanding how the Russian healthcare system works and ensuring you have adequate health insurance coverage for Russia can be a confusing and time-consuming business for expats relocating to Russia.

This guide to Russian healthcare includes:

The Russian healthcare system

Who can access healthcare in russia , costs of healthcare in russia .

Health insurance in Russia

Medical check-ups for expats in Russia

Since late 2021, Russia has required foreigners and long-term visitors to provide biometric information and undergo compulsory health check-ups .

These checks apply to anyone staying in Russia for longer than 90 days, with the exception of diplomats, members of international organizations (and their families), children under six years old, and Belarusian nationals. You will need to take the tests within 30 days of arriving in Russia or when you apply for your work permit. It isn’t yet clear how often foreigners will need to renew their tests, so it’s important to keep an eye on the Ministry of Internal Affairs website .

The medical checks aim to detect narcotics and psychoactive substances, as well as dangerous infectious diseases such as leprosy, HIV, COVID-19 , tuberculosis, and sexually transmitted infections. The process can potentially include:

• Blood tests
• Urine analysis
• Chest X-ray

When you attend your appointment, you will need your ID, migration card, and registration. The tests usually cost 4,200 to 6,600 p. Depending on your results, you will receive a medical report which includes a certificate to say that you have been examined and a certificate of absence of HIV.

Once you receive your documents from your medical examination, you will need to submit your biometrics; i.e. your fingerprints and photograph. This is possible through either the Ministry of Internal Affairs or another authorized organization. You will also need to present your ID and certificate showing that you do not have HIV and have passed the other medical tests.

Notably, these medical tests are only valid if they are carried out in an approved medical center. There are currently very few of these centers, and it is not always clear where valid tests are possible. For example, some suggest that the only option in the Moscow region is at the Sakharovo migration center , while others claim it is possible elsewhere . With this in mind, it is advisable to check with your employer to find out where other expats have conducted their tests.

If you don’t take the tests in time, then you may find that the authorities limit your stay. Importantly, if your tests reveal drug use or infectious diseases, you might be banned from entering or staying in Russia.

Unsurprisingly, the new process for foreigners living in Russia has come under fire for being ‘ xenophobic ,’ ‘disappointing, and outrageous.’ There have also been complaints from workers that the tests are invasive .

Haven’t quite mastered Russian yet? Don’t worry, here are some basic medical terms to help you if you need them:

• Help! –  Pomogitye!
• Call an ambulance! –  Pozvonitye v skoruyu pomosh’!
• Hospital –  bolnitsa
• Excuse me, I need help! –  Izvinitye, mnye nuzhna pomosh’!
• Doctor –  vrach
• General Practitioner (GP) –  terapevt, semeynoy
• Duty doctor   –  dezhurniy vrach
• Dentist –  zubnoiy vrach
• Pharmacy –  apteka
• Medicine –  lekarstvo
• Prescription –  ryetsyept
• Health centre –  polyklinika
• Insurance (s) –  strakhovka
• Ministry of Health of the Russian Federation

Gary Buswell

About the author

Based in London, Gary has been freelancing for  Expatica  since 2016. He’s had various past lives as a community worker, a record store owner, and even a brief stint as a postman before pursuing a career as a writer/editor.

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Why Medical Properties Trust Rallied Today

• Medical Properties Trust reached an interim settlement yesterday with bankrupt tenant Steward Health.
• The troubled saga has forced Medical Properties to slash its dividend twice in a year.
• But new operators agreed to lease terms for 15 of Steward's 23 facilities.
• Motley Fool Issues Rare “All In” Buy Alert

Medical Properties Trust

The company reached a settlement with the troubled Steward Health and inked new lease agreements with new operators for most of its facilities.

Shares of Medical Properties Trust ( MPW -4.81% ) were rallying 16.8% in Thursday trading as of 12:45 p.m. ET.

The medical property real estate investment trust (REIT) has a depressed stock price, as rising interest rates and problems with its largest tenant, Steward Health Care, forced the company to slash its dividend nearly in half over the summer -- the second 50% dividend cut in a year.

But with the stock beaten down, news of a final legal settlement with Steward sent the stock rebounding today.

New operators taking over for Steward

The most important part of the settlement agreement for shareholders was MPT reaching new lease deals with four hospital operators that will take over 15 of Steward's 23 troubled sites.

MPT won't collect rent from the new operators this year, but will start receiving lease payments in Q1 2025, then ramping up to fully stabilized rent of $160 million annually by Q4 2026. Of note, MPT said that would amount to 95% of what it would have gotten from Steward in 2026 based on the original lease deal with escalators.

Management also noted it was in active discussions with other parties regarding two under-construction hospitals and six other closed or impaired hospitals. MPT has agreed to sell three of the troubled hospitals in Florida, with most of the proceeds going to Steward. But after that, Steward will relinquish all rights to claims on any value from the other facilities. Steward sued MPT in August accusing it of blocking Steward's attempted sales of the hospitals. Of note, MPT actually owns the land for most of these facilities, while Steward owned the facilities themselves.

A relief rally

Hopefully, these new operators will be superior to Steward, which got into trouble after its former private equity owner saddled it with debt and high lease obligations.

At its current reduced dividend, Medical Properties stock yields about 5.8% after today's rally. But as the company gets closer to putting the Steward Health fiasco behind it and new operators get ready to pay their leases next year, hopefully there won't be any more cuts to the payout.

Billy Duberstein and/or his clients have no position in any of the stocks mentioned. The Motley Fool has no position in any of the stocks mentioned. The Motley Fool has a disclosure policy .

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