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Big Doctoring in America: Profiles in Primary Care

Fitzhugh Mullan
Photographs by John Moses
Copyright Date: 2002
Edition: 1
Pages: 275
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  • Book Info
    Big Doctoring in America
    Book Description:

    The general practitioner was once America's doctor. The GP delivered babies, removed gallbladders, and sat by the bedsides of the dying. But as the twentieth century progressed, the pattern of medical care in the United States changed dramatically. By the 1960s, the GP was almost extinct. The later part of the twentieth century, however, saw a rebirth of the idea of the GP in the form of primary care practitioners. In this engrossing collection of oral histories and provocative essays about the past and future of generalism in health care, Fitzhugh Mullan-a pediatrician, writer, and historian-argues that primary care is a fascinating, important, and still endangered calling. In conveying the personal voices of primary care practitioners, Mullan sheds light on the political and economic contradictions that confront American medicine. Mullan interviewed dozens of primary care practitioners-family physicians, internists, pediatricians, nurse practitioners, and physician assistants-asking them about their lives and their work. He explains how, during the last forty years, the primary care movement has emerged built on the principles of "big doctoring"--coordinated, comprehensive care over time. This book is essential reading for understanding core issues of the current health care dilemma. As our country struggles with managed care, market reforms, and cost containment strategies in medicine,Big Doctoring in Americaprovides an engrossing and illuminating look at those in the trenches of the profession.

    eISBN: 978-0-520-93841-0
    Subjects: Health Sciences, Sociology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Foreword
    (pp. ix-x)
    Daniel M. Fox and Samuel L. Milbank

    The Milbank Memorial Fund is an endowed national foundation that engages in nonpartisan analysis, study, research and communication on significant issues in health policy. The Fund makes available the results of its work in meetings with decision-makers, reports, articles, and books.

    This is the fifth of the California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the Press seeks to encourage the synthesis and communication of findings from research that could contribute to more effective health policy.

    Fitzhugh Mullan uses the methods of oral history and personal journalism to humanize the phrases “primary care” and...

  4. Introduction
    (pp. xi-xx)

    Big Doctoringis a book about the generalist in America, the practitioner of primary care medicine in the United States at the opening of the twenty-first century. Big doctoring is what the generalist does: doctoring that embraces the whole person, that values comprehensiveness and continuity, that welcomes the richness and the complexity of the complete human being. I set about writing this book because I am a primary care physician, a pediatrician, and I am, by turns, puzzled, fascinated, and troubled by what is happening to health care in this country.

    I chose medicine as a career because, I realize...

  5. CHAPTER ONE Primary Care Roots
    (pp. 1-16)

    Big Doctoringis about a way of medical life, an approach to health care and healing, a skill set, and a mind set that is called primary care. It is about doctoring that is humanist, comprehensive, efficient, and flexible, doctoring that builds on the legacy of the past and the rich tradition of care in medicine and nursing. To that it adds the science and technology of the contemporary world, applied in a measured, evidence-based, and coordinated fashion. In our current culture of medical care—noteworthy for its sophistication of technology, its inexorable cost increases, the absence of uniform access...

  6. CHAPTER TWO The New GPs: The Family Physician Comes of Age
    (pp. 17-54)

    In 1940, three-quarters of America’s physicians were still general practitioners. World War II provided a huge boost for specialization, as board-certified physicians received higher rank, more pay, and, in consequence, higher status in the military. Following the war, the G.I. Bill covered medical education, providing an instant subsidy for young doctors pursuing specialty training. The rapid development of employment-based health insurance in the postwar period also stimulated specialty practice by providing much of the population with a payment system for care that was increasingly procedure-oriented and hospital-based. By 1970 only 20 percent of America’s physicians counted themselves as GPs.


  7. CHAPTER THREE Roots Rediscovered: The Internist and the Pediatrician as Generalists
    (pp. 55-94)

    The philosophical difference between “medicine” and “surgery” is a time-honored one. Surgeons have long been distinguished by their use of knives for manually removing disease from the body. In contrast, practitioners of medicine have relied on their powers of observation and analysis to make decisions about therapeutic interventions. Early in the twentieth century, as medical science progressed and the tendency toward specialty training and practice gained momentum, several important developments occurred. The first was the formalization of the distinct professional identities, organizations, and, eventually, certifications for medicine and surgery with the founding of the American College of Surgeons in 1913...

  8. CHAPTER FOUR The New Clinicians: Nurse Practitioners and Physician Assistants
    (pp. 95-134)

    Well past the middle of the twentieth century, every state had a medical practice act that granted qualified physicians a license to practice “medicine and surgery,” with little in the way of further requirements or definitions. At the same time that these acts ushered physicians onto the terrain of medical practice, they served to keep the rest of the world out. There was, in theory, a clear division between what doctors did and what, say, nurses did, though in practice there was always some amount of overlap, which tended to increase in areas with fewer doctors.

    Two phenomena in the...

  9. CHAPTER FIVE The System Doctors: Managed Care and Primary Care
    (pp. 135-178)

    When the idea of primary care first became topical in the 1960s and 1970s, managed care as it exists today was not part of the American health scene. The first health maintenance organizations began as prepaid group health schemes in the 1930s and 1940s, cooperative health arrangements that were marginal in impact and generally considered subversive and off-limits by mainstream medicine. It was the Nixon administration in the early 1970s that first promoted health maintenance organizations, based on the persuasive rationale of Dr. Paul Ellwood, the Minnesota physician who coined the term HMO. The incentive structure in American medicine was...

  10. CHAPTER SIX The Quixote Factor: Generalists Doing Special Battle
    (pp. 179-219)

    The medical generalist is really a “clinician for all seasons.” Broadly educated and given to big-picture concerns, generalists find their way into unusual areas of the medical enterprise. Add a sense of cause or moral purpose that motivates and nourishes many generalists, and some truly remarkable stories emerge—stories of medical Don Quixotes.

    In the late 1970s, William Kapla, M.D., was a family physician concerned with the health issues of the gay community in San Francisco. Then AIDS erupted underneath him. The past twenty years of his life have been spent on the front lines of this new epidemic, grappling...

  11. CHAPTER SEVEN Building a Better Future: The Case for Primary Care
    (pp. 220-238)

    The stories of the men and women ofBig Doctoringpaint a portrait of primary care as it has been practiced in the latter part of the twentieth century. They are a committed group, partisans of generalism, practitioners of a revitalized, redefined field of medicine. Their work and their lives throw down the gauntlet for the twenty-first century.

    Where is primary care headed? Where, indeed, is the health system—which represents one-seventh of the nation’s economy—headed? Fifty years from now, would the speakers in this book look back with a sense of satisfaction that their legacy had been valued...

  12. Acknowledgments
    (pp. 239-242)
  13. Notes
    (pp. 243-246)
  14. Index
    (pp. 247-255)
  15. Back Matter
    (pp. 256-256)