Berkeley: University of California Press; 2002. California/Milbank
Books on Health and the Public. Hardcover: ISBN: 0-520-22670-4.
275 pages; $40.00 (Paperback: ISBN: 0-520-24331-5. $19.95) |
Big
Doctoring in America: Profiles in Primary Care |
to pdf >>
by
Fitzhugh Mullan, MD; Photographs by John Moses
Review by Linn Getz, MD
|
The title
Big Doctoring in America provoked my curiosity, partly because
I am situated in Iceland--the geological and cultural bridge between
Europe and the USA and a place from where the condition of American
medicine is followed with great interest. The US system is widely believed
to be the best in the world despite consuming a higher portion of the
national gross domestic product than in any other country and despite
a World Health Organization report1 ranking it as only 37th
among the health care systems of 191 countries. Gro Harlem Brundtland
(WHO Director-General at the time) acknowledged that "there is
wide variation in performance, even among countries with similar levels
of income and health expenditure" and asserted that "[i]t
is essential for decision-makers to understand the underlying reasons
so that system performance, and hence the health of populations, can
be improved."2
Coming
from a Nordic country where general practice has a strong tradition,
I suspect that part of the American problem is the absence of a comprehensive
primary health care system. The subtitle of the book--Profiles in
Primary Care--therefore increased my interest even further.
What is
it like to deliver temperate, deliberate primary health care in contemporary
America in the shadow of compartmentalized, expensive, expansive high-tech
medicine? Is doing so worth the effort? Big Doctoring in America
aims to answer these questions. The book acquaints us with 15 devoted,
visionary, experienced primary health care professionals whose mission,
in their view, is to deliver affordable, humanistic, comprehensive health
care. We also learn what has inspired or compelled these clinicians
to show admirable determination, courage, and generosity.
The author,
Fitzhugh Mullan--a professor of pediatrics and public health--presents
the 15 narratives within a trustworthy theoretical framework. The book
opens by introducing the professional ideology and mindset underlying
primary health care at its best. Next, the author adds "flesh and
blood" to the ideology of primary care by presenting the histories
of devoted and determined clinicians. The accompanying photographs enhance
our familiarity with these people and our feeling of learning from them.
This phenomenon reminds me of the Aristotelian idea that we teach virtue
by the practice of virtue.
The stories
in Big Doctoring are purposefully selected from a total of 74
interviews, five of which previously appeared in JAMA (Profiles
in Primary Care, 1998-9).3-7 The stories are recorded with
impressive simplicity and sensitivity, reflecting the mind of an experienced,
gifted clinician-writer equipped with a strong sense of the big and
small issues that matter in people's lives. The author also presents
a good overview of the organization and history of the American health
care system. The narratives reflect the development from generalist
to super-specialist medicine in the 20th century, introduction of new
financial steering systems, and the profound challenge of balancing
professional autonomy and managed care.8
The author
also has a clear vision for tomorrow's health care system. Mullan
delivers the well-founded argument that primary care clinicians are
the leading actors in any sensible health care system: "Big
Doctoring is about a way of medical life, an approach to health
care ... 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 ... [providing] a foundation for health care that
blends good science with good judgment." 9:p1 Mullan
closes by suggesting concrete policy strategies to strengthen primary
health care in America. Although some readers might consider this important
book controversial and polemical, I would recommend it to any serious
health care professional at any career stage and to nonmedical readers
interested in politics, public health, or philosophy of health care.
The book is so well written and so enlightening that even clinicians
in countries where primary health care is considered a self-evident
necessity and specialty can expect to boost their professional inspiration
and self-esteem.
"...
at every moment of our lives, we all have one foot in a fairy tale and
the other in the abyss ..." writes Paulo Coelho in the opening
of his new novel, Eleven Minutes.10:p1 These words
remind me that ultimately, medicine is a moral enterprise. The primary
care professional's mission is to establish a firm relationship with
patients and to help them to make sense of the system as they face illness
or death. Fitzhugh Mullan has got it right: Cost-effective, humane health
care is best delivered in a context where people have access to a generalist
trained--and well paid--to be their "navigator, personal coach,
and medical friend." 9:p229
References
- World
Health Organization. The world health report, 2000: health systems:
improving performance [monograph on the Internet]. Geneva: World Health
Organization; 2000 [cited 2005 Jan 31]. Available from: www.who.int/whr/2000/en.
- World
Health Organization. Press release WHO/44: World Health Organization
assesses the world's health systems [monograph on the Internet]. 2000
Jun 21 [cited 2005 Jan 31]. Available from: www.who.int/inf-pr-2000/en/pr2000-44.html.
- Mullan
F. Eugene McGregor, MD: a legacy of general practice. JAMA 1998 Apr
8;279(14):1117-20.
- Mullan
F. Connie Adler, MD: living rural medicine. JAMA 1998 Jun 10;279(22):1833-6.
- Mullan
F. Linda Headrick, MD: seeking a common language in primary care.
JAMA 1998 Aug 19;280(7):655-8.
- Mullan
F. Selma Deitch, MD, MPH: children first. JAMA 1998 Dec 2;280(21):1867-71.
- Mullan
F. Sam Ho, MD: idealist, innovator, entrepreneur. JAMA 1999 Mar 10;281(10):947-51.
- May
WF. Beleaguered rulers: the public obligation of the professional.
Louiseville (KY): Westminster John Knox Press; 2001.
- Mullan
F. Big doctoring in America: profiles in primary care. Berkeley (CA):
University of California Press; 2002.
- Coelho
P. Eleven minutes: a novel. Translated from the Portuguese by MJ Costa.
New York: HarperCollins Publishers; 2004.
Linn
Getz, MD, is a Norwegian general practitioner
who works as an occupational physician at the National University Hospital
of Iceland, Reykjavik. She is also a PhD candidate in community medicine
at the Norwegian University of Science and Technology, Trondheim, Norway.
E-mail: linngetz@med.is
