From Library Journal
By the mid-20th century, the sophistication and escalation of medical knowledge led to a proliferation of medical specialists and the near extinction of the general practitioner (GP). Despite the recent advent of the primary-care physician, Mullan (pediatrics and public health, George Washington Univ.; Plagues and Politics), a contributing editor at Health Affairs, fears that the principles of "big doctoring" (coordinated, comprehensive care over time) are in danger of disappearing. Compiling and expanding the 1998-99 "Profiles in Primary Care" series of articles and interviews that appeared in the Journal of American Medicine, he maintains that general practice is an important and needed calling. In the words of GPs and other generalized caregivers, the author identifies the rewards and hassles of this type of practice. This theme has been treated in a more scholarly manner in several other publications, such as Promoting Human Wellness; however, Mullan's work, aimed at the general reader, underscores an important issue in American healthcare and makes a compelling statement. For larger public libraries.
Margaret K. Norden, Marymount Univ. Lib., Arlington, Copyright 2002 Reed Business Information, Inc.
From The New England Journal of Medicine
Fitzhugh Mullan has compiled a remarkable set of oral histories about what he calls "big doctoring," the dedication of primary care clinicians -- whether physicians, nurse practitioners, or physician's assistants -- to advancing the well-being of their patients by vigorous attempts to "treat" the systems (community, society, economics) that affect them. These are not stories about the warm relationships of old-time clinicians with their quirky patients; there are few sweet tales here of the mythic kindly country doctor. The closest we get to that is in two early chapters. One is the story told by Eugene McGregor, a retired general practitioner in his 80s who lives in Lisbon, New Hampshire. Lacking a beeper or cell phone, he says he knew he was wanted when his wife (who was the housekeeper, nurse, and telephone-answering service for his practice) left him a message or, more picturesquely, would "come out and flag down my car at times to try to stop me." Beach Conger also tells of being an internist in small-town America. A former medical civil-rights worker and leader of the house officers' association in the 1960s, he worked in the Epidemic Intelligence Service of the Centers for Disease Control, then in a methadone-maintenance clinic and a free clinic in San Francisco. He appeared to be headed for a career as an activist in community health, but while caring for patients with alcoholism and drug abuse, the homeless and disenfranchised, and an immigrant population of upwardly mobile new Americans in an urban community health center, he discovered, "I liked practicing medicine. Although public health planning had been a lot of fun, I really enjoyed patients." He wound up in private practice in Windsor, Vermont, and his story is the richest in descriptions of actual patients and what they taught their clinicians. Patients as individuals are strikingly absent in most of the other chapters. Instead, the focus is on the lives of clinicians and on the environment of care in which they practice. Among 74 oral interviews with a wide variety of generalist practitioners throughout the United States, Mullan chose 15 stories. They deal with rural medicine, the provision of care in urban ghettos, pediatric public health, managed care, teaching, and practices devoted to particularly vulnerable or needy groups of people. Few of the clinicians are in full-time practice; most of them also spend considerable time in the adjunctive administrative work they perceive as a requisite for the fulfillment of their promise. They tell of the evolution of their current roles and of the factors that motivate them (religion in one case, social activism in others, commitment to the underserved in many, and the need for system reform in most). Almost all the clinicians articulate strong opinions about the current state of health care and clinical practice in the United States and are trying to do something about it. I wonder whether those in full-time management positions or population-specific practices (e.g., homosexual patients or women) can be counted as generalist practitioners, a matter for each reader to ponder. This book presents a concept of primary care that is less patient-centered than systems-centered and makes the point that, for the medically underserved, the first is often futile without the second, echoing a current trend in thinking in some academic public health circles. I suspect that the 15 interviews were selected to emphasize this view, though this may be a misperception, and I look forward to reading the remaining 59 transcripts. Although the stories include some distressing signs of infighting (the implication by some clinicians that their way is better and more noble than anyone else's way), the importance of service is clearly deeply felt. This theme is articulated by clinicians who, though polemical and occasionally preachy, are committed activists rather than theorists, a fact that gives their opinions authenticity. Dr. Mullan, a pediatrician, concludes with a lengthy commentary in which he suggests remedies for the inequities and inadequacies in health care. These wide-ranging and controversial ideas provide much food for thought, discussion, and outright argument. The audience for this book is broad: lay and medical readers, political and community leaders, and students and professors will all find something of interest here -- and perhaps something that will inspire or inflame them. Though some may disagree with Dr. Mullan's concept of the primary objective of generalism, none can deny the harsh reality of the problems that stimulated him (and others) to attempt to promote the concept of big doctoring as a vehicle for social justice and for the equitable and frugal distribution of diminishing medical resources to increasingly needy people. The book is well worth reading and thinking about. It asks and attempts to answer, in many voices, two cardinal questions of our age: Of what value is progress in science and medicine if so many are left behind? And how can we make this better?
Faith T. Fitzgerald, M.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
