Out of Practice

Out of Practice: Fighting for Primary Care Medicine in America

Frederick M. Barken
Copyright Date: 2011
Edition: 1
Published by: Cornell University Press,
Pages: 264
https://www.jstor.org/stable/10.7591/j.ctt7zgn8
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  • Book Info
    Out of Practice
    Book Description:

    Primary care medicine, as we know and remember it, is in crisis. While policymakers, government administrators, and the health insurance industry pay lip service to the personal relationship between physician and patient, dissatisfaction and disaffection run rampant among primary care doctors, and medical students steer clear in order to pursue more lucrative specialties. Patients feel helpless, well aware that they are losing a valued close connection as health care steadily becomes more transactional than relational. The thin-margin efficiency, rapid pace, and high volume demanded by the new health care economics do not work for primary care, an inherently slower, more personal, and uniquely tailored service.

    In Out of Practice, Dr. Frederick Barken juxtaposes his personal experience with the latest research on the transformations in the medical field. He offers a cool critique of the "market model of medicine" while vividly illustrating how the seemingly inexorable trend toward specialization in the last few decades has shifted emphasis away from what was once the foundation of medical practice. Dr. Barken addresses the complexities of modern practice-overuse of diagnostic studies, fragmentation of care, increasing reliance on an array of prescription drugs, and the practice of defensive medicine. He shows how changes in medicine, the family, and society have left physicians to deal with a wide range of geriatric issues, from limited mobility to dementia, that are not addressed by health care policy and are not entirely amenable to a physician's prescription. Indeed, Dr. Barken contends, the very survival of primary care is in jeopardy at a time when its practitioners are needed more than ever.

    Illustrated with case studies gleaned from more than twenty years in private practice and data from a wide range of sources, Out of Practice is more than a jeremiad about a broken system. Throughout, Dr. Barken offers cogent suggestions for policymakers and practitioners alike, making clear that as valuable as the latest drug or medical device may be, a successful health care system depends just as much on the doctor-patient relationship embodied by primary care medicine.

    eISBN: 978-0-8014-6060-9
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. ACKNOWLEDGMENTS
    (pp. ix-xii)
    Frederick M. Barken
  4. INTRODUCTION: THE DOCTOR IS OUT
    (pp. 1-6)

    On June 30, 2007, at the relatively young age of fifty-one, I left the practice of medicine. After nearly a quarter of a century spent building and managing a busy, locally well respected and successful private practice in primary care, I chucked it all and walked away from my professional career. Was I the victim of burnout, a vague but insidious ailment common to busy older physicians that renders them indifferent and inured to patientsʹ problems and pains? I donʹt think so. Rather, it was a resignation. In chess, after a wearying and protracted battle, there comes a moment, shortly...

  5. 1 A FIRST VISIT WITH THE DOCTOR
    (pp. 7-28)

    Compassionate, high-quality primary care medicine, both affordable and accessible, is fundamental to U.S. health care. It is the right of every American, and it is a national moral imperative. It is the cornerstone of care and our best defense against the human misery of disease, dysfunction, and frailty. Elections, geopolitical crises, and economic upheavals may come and go, but the essential need for a good primary care doctor is here to stay.

    This is not news. Other nations throughout the world, rich and poor, have designed health care systems that prominently feature ready access to effective and efficient primary care...

  6. 2 “TELL HIM NOT TO DRIVE”
    (pp. 29-48)

    Mr. A is an eighty-eight-year-old former World War II bomber pilot who miraculously beat the odds by surviving multiple missions over Germany. His pluck and self-confidence are still evident today, even if his hearing, vision, and reaction time are no longer up to par.

    One day Mr. A elects to drive alone from upstate New York to New England to visit family. His six- or seven-hour ʺmissionʺ starts off, though, with a critical miscalculation. Mr. A confuses a.m. and p.m. on his digital alarm clock at home, and he consequently sets out on his journey already quite late in the...

  7. 3 POLYPHARMACY: THE PROBLEM WITH PILLS
    (pp. 49-71)

    We are a nation of pill poppers. In the United States, it is culturally acceptable, if not expected, that one should turn outward (i.e., take a drug) to relieve the pain, suffering, or bodily dysfunction that stems from within. A drug is an exogenous substance (from outside the body), ingested or infused, smeared or inhaled, that changes us in some way. Since all drugs, even a lone aspirin tablet, have side effects, it would be more proper to say that every drug affects us in some ways. Our modern pharmacopoeia, the full collection of our chemical bag of tricks, is...

  8. 4 POLY-DOCTORING: A DOCTOR FOR EVERY DISEASE
    (pp. 72-91)

    To the toga-clad physician of classical Rome or his chiton-wearing counterpart of ancient Greece, all of medicine was encompassed by a balancing act of the four humors: black bile, blood, phlegm, and yellow bile. A preponderance of one of these four bodily humors resulted in a patient who was melancholic, sanguine, phlegmatic, or choleric, respectively. Treatment involved countering the excessive and offending humor. Fever, for example, was thought to be a hot and dry disorder, due to an excess of yellow bile, and it therefore was treated with cold baths. Conveniently, for the physician-philosopher of the time, the four humors...

  9. 5 A BUBBLE OFF
    (pp. 92-110)

    Todayʹs two oʹclock appointment is with Mrs. E, a seventy-nine-year-old woman who returns for follow-up of a recent complaint of abdominal pain. At her last office visit, one month ago, she and I discussed her symptoms, and we elected to obtain a CT scan if her pain did not resolve spontaneously after two weeks. She called me last week and indicated that her pain had persisted. The CT was performed, and the films sit on my desk. She is scheduled to return today to discuss those results.

    I have cared for Mr. and Mrs. E for about three years, since...

  10. 6 ON THE ROAD AGAIN
    (pp. 111-130)

    Mrs. G failed to show for her doctorʹs appointment. She was to have been seen that day in 1981 at the rural health center in bucolic Orange, Virginia, a regional satellite office of the Medical Center of Mr. Jeffersonʹs University of Virginia in nearby Charlottesville. She was due to see me, an overwhelmed and anxious new intern. Since I didnʹt feel like a physician, it didnʹt strike me as odd that she hadnʹt appeared for her doctorʹs appointment. In fact, I was relieved. In the first months of internship, well before my metamorphosis from book-smart medical student to barely competent...

  11. 7 THE SUPPLY SIDE
    (pp. 131-150)

    At the dawn of the twentieth century, the education of young doctors was, like the old Wild West, a rough and unregulated territory. There were no standards of excellence established by accrediting organizations or by law, and the concepts of physician credentialing and quality assurance were alien. Before the advent of the large, technologically sophisticated modern teaching hospital of today, medical education, as with other trades, was by apprenticeship. Today, physicians may joke that surgical procedures are taught in the manner of ʺsee one, do one, teach one,ʺ but one hundred years ago that was standard practice. Since most medical...

  12. 8 ALL IN THE FAMILY
    (pp. 151-169)

    Only weeks earlier, Mrs. I had been an independent, self-sufficient, and active woman. In her mid-eighties and a longtime widow, she was accustomed to living on her own. She had navigated bereavement and widowhood successfully, just as she had triumphed over the childhood hardships of the Great Depression and the personal sacrifices demanded of her during World War II, two traumatic events that uniquely tempered her generation. Now she faced another challenge: she was very sick. Mrs. I had suffered a massive heart attack, which, in the seeming blink of an eye, had transformed her from a fully functional ʺyoung-oldʺ...

  13. 9 PRACTICE/MALPRACTICE
    (pp. 170-189)

    A stranger enters my office. Three or four of my usual geriatric patients, contentedly marking time in the waiting room, track the stranger surreptitiously, while they pretend to read well-worn dated copies of Newsweek or People magazine. Who is this man? He is middle-aged and somber, not likely to be a pharmaceutical representative. Drug reps are young and bubbly, and they come emblazoned with drug logos and carrying goody bags of drug samples. The stranger is dressed casually, unlike the dark-suited funeral director who carries a freshly typed death certificate in need of the doctorʹs quick signature before burial can...

  14. 10 YOU GET WHAT YOU PAY FOR
    (pp. 190-212)

    Accompanied by his father, a small boy comes reluctantly to see the local dermatologist for the minor management of a few warts on the back of his right hand. For the skin specialist, making the diagnosis is a trivial matter; treating the child, however, proves to be an ordeal. Blood-curdling screams fill the air as each little wart is eradicated with the brief touch of a cotton applicator laden with subzero liquid nitrogen. Kicking and screaming, the boy wiggles and writhes despite the viselike grip of his dad, who has the boy in a paternal full nelson hold, and in...

  15. EPILOGUE
    (pp. 213-218)

    The year: 2030. Twenty years have elapsed since former president Barack Obamaʹs speech to Congress in which he vowed, alas unsuccessfully, to be the last American president to take up the cause of health care for all, a political tradition inaugurated by Teddy Roosevelt a full century before.¹ For the Obama administration, addressing health care meant tackling health insurance. They grappled with a well-entrenched private insurance industry, recalcitrant Republicans who championed laissez-fare and the status quo, and righteous liberals who demanded universal coverage as a national moral imperative. They confronted physicians who bristled when chastised for achieving less-than-stellar outcomes for...

  16. NOTES
    (pp. 219-226)
  17. REFERENCES
    (pp. 227-240)
  18. INDEX
    (pp. 241-244)