DOCTORING - The Nature of Primary Care Medicine by Eric J Cassell, MD. Oxford University Press, New York, Oxford, 1997, 206 pages, $24
Review by Del Meyer, MD
Primary care is being pushed into prominence by managed care organizations throughout the country with the gatekeeper concept. Dr Eric Cassell, a Clinical Professor of Public Health at Cornell University Medical College, begins Doctoring by pointing out how thoughtlessly rapid the restructuring of American health care has been. He contends that identifying primary care physicians as first-contact doctors, mere gatekeepers to the specialties, is a mistake. The obvious organizational advantages should not and do not make primary care medicine simple. Unless there are changes in primary care, Dr. Cassell does not feel the primary care system will prove effective in restraining costs.
Cassell traces the idea of health over 200 years as being equated with freedom from disease. The world of medicine, from this perspective, is a world of disease--peopled by those who have an acute disease, are being prevented from having a disease, are being treated for their disease, or are being rehabilitated from the effects of their disease. Organizing medicine according to disease developed at the beginning of the nineteenth century. The heavy hand of the past still prevails in medical science as it is taught to students and house officers today.
Unlike most other branches of medicine, primary care medicine is based on the centrality of the patient rather than on an organ system or a disease. The ideas that underlie current understandings of primary care medicine have been evolving since the 1920's, gaining force in the 1960's with the family physician movement, growing rapidly after its official designation as a specialty in 1970 which decried specialty medicine's concentration on the disease and sought to refocus on the patient.
No one questions the soundness of these ideas; the problem is that after a full generation of prominence they simply have not thrived within a disease-oriented, technology-driven medical establishment. For two generations we have asked doctors to focus on the patient as a person, yet, more often than not, we still see the patient's human concerns swept away by the technological imperative. If primary care is a better medical practice, why hasn't it won the field?
Cassell feels that physicians have great difficulty entering the information of the patient as a sick person into the calculus of their medical judgments so that it has equal weight with information about disease, pathophysiology, and technology. Cassell feels it is first of all the educational problem that needs to be solved. There is a deep conflict between the measurable nature of the disease--the science of medicine--and the subjective knowing of the patients as individuals.
Primary care medicine will never achieve its goals without solving the problem of technology. It is the seemingly irresistible spread of technology into every level of medicine--irresistible to doctors, patients, and the nations alike, that can be singled out as the engine of the cost inflation now occurring everywhere in the medical world. Technologies come to have a life of their own, not just because of their own properties but also because of certain universal human traits. Technologies come into being to serve the purposes of their users, but ultimately their users redefine their own goals and themselves in terms of the technologies, which are reductive, simplifying, and intolerant of ambiguity--elements not exactly conducive to healing. The ramifications for the doctor-patient relationship are disturbing. Cassell's target is not science itself but the products of science; he fears a world in which the robots rule and doctors merely attend to the efficient function and declarations of MRI and CT scanners.
Cassell emphasizes a return to careful history taking with a discerning scrutiny of the patient's behavior, mood and feelings, a physical examination, and appropriate medical tests. Deja vu!--Didn't we learn this in medical school?
Cassell fails to tells us how to accomplish the deep, sophisticated clinical observation of patients--with proper attention to their worries, concerns, and feelings--in the 10-15 minutes currently doled out by managed medicine. It's that defining word "primary." Perhaps if the primary physician could or would assume charge of the patient and be involved in every step of his or her evaluation and treatment program, we would define technology more than technology defines us--and the only managed medicine a patient would need would be from the primary care physician.
Del Meyer, MD