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Practice Under Pressure

Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-first Century

Timothy Hoff
Copyright Date: 2010
Published by: Rutgers University Press
Pages: 208
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  • Book Info
    Practice Under Pressure
    Book Description:

    Through ninety-five in-depth interviews with primary care physicians (PCPs) working in different settings, as well as medical students and residents,Practice Under Pressureprovides rich insight into the everyday lives of generalist physicians in the early twenty-first centuryùtheir work, stresses, hopes, expectations, and values. Timothy Hoff supports this dialogue with secondary data, statistics, and in-depth comparisons that capture the changing face of primary care medicineùlarger numbers of younger, female, and foreign-born physicians.

    eISBN: 978-0-8135-4835-7
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-xii)
    Timothy Hoff
  4. Chapter 1 The Transformation of Primary Care in the United States
    (pp. 1-24)

    Primary care is undergoing profound change in the United States. This is evident in a sicker general population, a decreasing supply of doctors to care for that population, new alternatives to the traditional primary care physician and practice, and an economic model of primary care delivery that creates dissatisfied doctors and patients. Everyone from professional associations to the government believes that money is at the root of the problem. Primary care doctors get paid much less than other doctors, and primary care services are not valued in the same way by third-party payers as specialty services.

    Money is only part...

  5. Part I The Work of Primary Care

    • Chapter 2 A Typical Workday in Primary Care
      (pp. 27-40)

      During 2006, over 900 million medical care visits were made to doctors in the United States, with just over half made to family practitioners, internists, pediatricians, and OB/GYNs.¹ That’s over three visits per year, per person. The typical PCP works between fifty and sixty hours per week, with the majority of that time spent in direct patient care.² That’s ten to twelve hours a day, five days a week.

      The typical primary care doctor in a recent national compensation survey earned just under $200,000 per year, compared to average salaries two and three times greater for certain surgical specialties, radiology,...

    • Chapter 3 How the Primary Care Workday Has Changed
      (pp. 41-63)

      How has the typical PCP workday changed over time, besides the obvious emphasis on volume and shorter visits? Table 1 presents other meaningful aspects of the evolution of the PCP workday, identified through the study data. According to older PCPs, the most profound clinical change is that chronic-disease patients make up an increasingly larger proportion of an internist’s or family doctor’s workday. The fraction of the patient population with one or more chronic diseases ranged from half to three-quarters among PCPs in the study.

      The typical conditions I see are acute things, like upper respiratory infections and bronchitis. I see...

    • Chapter 4 Leaving Hospital Work Behind
      (pp. 64-82)

      Fewer primary care physicians do any type of hospital-based medicine today. If current trends hold, there may be no primary care physicians who provide both hospital and office-based care. Hospital medicine involves taking care of patients in the hospital when they are sick enough to warrant inpatient care and monitoring. Hospitalization may occur for a range of conditions and needed services including heart failure, general and specialty surgery, cardiac bypass surgery, infections, pneumonia, diabetes complications, falls and fractures, joint replacements, and cancer care. It also involves geriatric care for elderly patients experiencing acute episodes that require a hospital stay.


    • Chapter 5 The Routine and Nonroutine of Primary Care Work
      (pp. 83-98)

      There are strong perceptions that exist among medical students and residents that primary care work is too routine and less stimulating than specialty work. This view produces a psychological disincentive among these groups to choose a primary care specialty. To the extent primary care is imagined as lifestyle-friendly to students and residents in terms of having less intense, more flexible workdays, primary care may attract individuals looking for a healthier career choice while scaring away those who feel they deserve more given their training and personal sacrifices to become doctors. Central to this discussion is the nature of the work...

  6. Part II The People Doing Primary Care Work

    • Chapter 6 Younger and Older Physicians in Primary Care
      (pp. 101-129)

      If there is one thing on the minds of many young and aspiring physicians in the early twenty-first century, it is “lifestyle”.

      People go into a lot of specialties now, not just primary care, to have a better lifestyle. I have a friend who is in a radiology residency, and she clearly said it was because she wanted to be home with her kids at the same time every afternoon. And I said to her, “Won’t you get bored sitting in a dark room all day?” And she said, “Yeah, probably, but I’ll be home in the afternoons with my...

    • Chapter 7 Women in Primary Care
      (pp. 130-153) bills itself as “a professional and social networking site for women in medicine” and “the most active online community for women physicians, medical students and premedical students.”¹ Launched in 1999, the site contains an exhaustive array of resources, clinical information, discussion blogs, articles, job postings, products, and other features designed to help female doctors and doctors-in-training navigate their daily lives. MomMD is geared to mothers in medicine. Lots of active blogs on MomMD deal with a range of topics from family and parenting to advice about becoming a doctor to being a female medical resident. The blogs contain tens...

    • Chapter 8 International Medical Graduates in Primary Care
      (pp. 154-170)

      Brianna is a family medicine resident from India. Now in her mid-thirties, she followed her husband to the United States several years ago when he got a job as a computer programmer working for a multinational corporation. At first, Brianna worked as a research assistant in a lab, and then decided to pursue a career as a family physician. Brianna comes across as bright, energetic, and eager to have a clinical career. She has raised a young child, lived apart from her husband for significant amounts of time, studied and passed medical board exams, and actively sought out her current...

  7. Part III Fixing Primary Care

    • Chapter 9 The Medical Home: Primary Care Savior?
      (pp. 173-193)

      The most important idea currently touted as a model for revitalizing primary care is the medical home.

      The medical home label is like apple pie and motherhood. You can’t argue with it. (Skip, PCP and health plan manager)

      This idea is not new. First coined by the American Academy of Pediatrics in the late 1960s, it has been expanded upon, repackaged, and embraced tentatively by all three primary care specialties, large employers, some insurers, and by state and federal governments. In March 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic...

    • Chapter 10 No Quick Fix: An Incremental Approach to Helping Primary Care
      (pp. 194-210)

      It is impossible to imagine a return of primary care to the past, before the transactional, high-volume business model dominated. The golden age of primary care, in which the generalist physician held great sway, specialty medicine was not endemic throughout the health care system, and insurers and patients saw the generalist as a complete caregiver, is over. This decline is the result of several developments including advances in medical science and technology, a quality movement that has downplayed the generalist’s value, the media’s fixation on exotic types of care, public demands for the best, most sophisticated care possible, and insurer...

  8. Appendix How the Study Was Conducted
    (pp. 211-220)
  9. Notes
    (pp. 221-232)
  10. Index
    (pp. 233-236)
  11. Back Matter
    (pp. 237-238)