American health care is a technological marvel. It’s also culture war football and an accessory to the most glaring inequalities in American society. Three new books shine a light on the dedication and dysfunction within it.
The family doctor represents an ideal: a doctor who is our own, there for us through all our needs, the champion of our care. The role is also at the heart of our debate over health care – a mainstay of socialized medicine, it is increasingly untenable within America’s patchwork of mostly private insurers.
In “Searching for the Family Doctor: Primary Care on the Brink,” management professor Timothy J. Hoff depicts an area in crisis within a system moving toward increasingly volume-oriented, “transactional” care. more “balkanized”. Professional insight is usurped by algorithms, and patients’ expectations are conditioned by their experiences as consumers, Hoff writes. The family physicians he interviews are harassed, fatigued, bent under administrative overhead, and forced to embrace an impoverished version of the role they were trained for. Compared to their colleagues in neighboring specialties, they are poorly paid.
The practitioner’s perspective illuminates a system antithetical to preventive care that is family medicine’s business (the real money is in intensive interventional health care), and Hoff’s observations of the missteps behind the discomfort of the domain are incisors. This emphasis will also serve to impart a sense of agency to professional readers of the book – that redemption lies in getting their homes in order. But as long as the profit-driven logic of the system remains intact, it surely represents so many tinkering around the edges.
If Hoff documents the distorting effects of neoliberalism on the medical profession, Thomas Fisher’s “The Emergency: A Year of Healing and Heartbreak in a Chicago ER” chronicles its impact on patients. The emergency departments meet many patients where they are: without stable employment or health insurance; on public assistance if they are lucky, but otherwise they are uninsured; and chronically ill health. They do not arrange wellness checks with their GP; instead, they show up to the emergency room as a last resort, often seriously ill. People of color feature disproportionately in this dark folkloric lane, and “The Emergency” is a fast-paced, heartfelt, and often heartbreaking year in the life of an emergency room doctor on Chicago’s historically black South Side.
Much of it reads like a war report. Yet festering gunshot wounds and gangrenous limbs are “not just a random assortment of wounds and illnesses.” Fisher’s patients traversed a racially segregated socioeconomic topography en route to the ER. He sprinkles his story with statistics. Blacks make up 30% of Chicago’s population, and nearly 80% of Chicagoans don’t have easy access to healthy food. Another sobering fact: the residents of Englewood on the south side “are nine times [likelier] being hospitalized for diabetes” than residents of River North. Once admitted, they must navigate a clinical environment in which “wait times are long, specialists…few, time with the doctor…short, tests and treatments…delayed, facilities…in poor condition. and conveniences…absent”.
Beyond the bedside, Fisher has worked in insurance and managed care, and served in the White House. He knows the system longitudinally and the interests related to its status quo.
“Leaders, salespeople, doctors, insurers, pharmaceutical companies and medical technology providers – the entire medical-industrial complex grows as long as nothing changes,” he writes.
American medicine excels in technologically advanced complex care. Here, surgeons are king, and writer-surgeon Ira Rutkow’s “Empire of the Scalpel: The History of Surgery” charts the development of the field from the crude trade of “sawbones” to a professional discipline. meticulous.
Rutkow has a storyteller’s touch, and he’s especially good at the tough, tough, stubborn characters that propelled the field forward in a heroic age of medicine.
He is also particularly generous. Maybe a fault. Academic papers, a Congressional investigation, and a New York Times survey in the 1970s revealing a glut of surgeons performing unnecessary operations (2.4 million in 1974, according to the Congressional report) contributed to “a confusing time for the knife bearers of the nation,” he admits. .
Of the oblivion that struck a 1976 American College of Surgeons study that found surgeons were underemployed and recommended cutting training, Rutkow gloomily observes: “Why does the establishment Surgical refused to endorse the key findings of his own study is masked by nearly five decades of obscurity. ”
It seems rather obtuse. A quick internet search shows that oversold services remain a concern; how could they not? The dynamic that drives them has only taken root: a fee-for-service model that encourages procedures, an asymmetry of information between the patient and the surgeon, a professional terrain fiercely defended by surgeons’ organizations and ever-faster specialization in which “knife-wielders” become hammer-wielders in search of nails.
There is something to marvel at in the history of surgery, but its practitioners today enjoy status and prestige; they are richly rewarded with the public purse, and their work is socially important enough that they can withstand closer scrutiny from one of their own.
In Search of the Family Doctor: Primary Care on the Brink
By Timothy J. Hoff
(Johns Hopkins University Press; 288 pages; $39.95)
The ER: A year of healing and grief in a Chicago ER
By Thomas Fisher; preface by Ta-Nehisi Coates
(One world; 272 pages; $27)
The empire of the scalpel: the history of surgery
By Ira Rutkow
(Scribner; 416 pages; $29.99)