Doctoring: The Nature of Primary Care Medicine

The book contains no figures.

American medicine attracts some of the brightest and most motivated people the country has to offer, and it boasts the most advanced medical technology in the world, a wondrous parade of machines and techniques such as PET scans, MRI, angioplasty, endoscopy, bypasses, organ transplants, and much more besides. And yet, writes Dr. Eric Cassell, what started out early in the century as the exciting conquest of disease, has evolved into an overly expensive, over technologized, uncaring medicine, poorly suited to the health care needs of a society marked by an aging population and a predominance of chronic diseases. In Doctoring: The Nature of Primary Care Medicine, Dr. Cassell shows convincingly how much better fitted advanced concepts of primary care medicine are to America's health care needs. He offers valuable insights into how primary care physicians can be better trained to meet the needs of their patients, both well and sick, and to keep these patients as the focus of their practice.
Modern medical training arose at a time when medical science was in ascendancy, Cassell notes. Thus the ideals of science—objectivity, rationality—became the ideals of medicine, and disease—the target of most medical research—became the logical focus of medical practice. When clinicians treat a patient with pneumonia, they are apt to be thinking about pneumonia in general—which is how they learn about the disease—rather than this person's pneumonia. This objective, rational approach has its value, but when it dominates a physician's approach to medicine, it can create problems. For instance, treating chronic disease—such as rheumatoid arthritis, diabetes, stroke, emphysema, and congestive heart failure—is not simply a matter of medical knowledge, for it demands a great deal of effort by the patients themselves: they have to keep their doctor appointments, take their medication, do their exercises, stop smoking. The patient thus has a profound effect on the course of the disease, and so for a physician to succeed, he or she must also be familiar with the patient's motivations, values, concerns, and relationship with the doctor. Many doctors eventually figure out how to put the patient at the center of their practice, but they should learn to do this at the training level, not haphazardly over time. To that end, the training of primary care physicians must recognize a distinction between doctoring itself and the medical science on which it is based, and should try to produce doctors who rely on both their scientific and subjective assessments of their patients' overall needs. There must be a return to careful observational and physical examination skills and finely tuned history taking and communication skills. Cassell also advocates the need to teach the behavior of both sick and well persons, evaluation of data from clinical epidemiology, decision making skills, and preventive medicine, as well as actively teaching how to make technology the servant rather than the master, and offers practical tips for instruction both in the classroom and in practice.
Most important, Doctoring argues convincingly that primary care medicine should become a central focus of America's health care system, not merely a cost-saving measure as envisioned by managed care organizations. Indeed, Cassell shows that the primary care physician can fulfill a unique role in the medical community, and a vital role in society in general. He shows that primary care medicine is not a retreat from scientific medicine, but the natural next step for medicine to take in the coming century.

Daniel J. Brauner

This is a book of essays about primary care medicine written by a prolific physician well known for his important contributions regarding humanistic aspects of patient care. Dr. Cassell uses historical and philosophical perspectives as well as his extensive clinical experience and patient vignettes to show the problems with current ideas about primary care and to lay the foundation for a new discipline based on patient-centered care. Dr. Cassell's purpose is to show how a novel notion of primary care, one which puts the patient at the center of the endeavor, will enable us to better care for our patients. He shows how this approach requires learning skills which have not traditionally been stressed in medical school or residency training programs but which must be learned if primary care is to evolve into the ascendant specialty he envisions. This is an extremely timely and important book in response to the rapidly changing nature of health care. With many of these changes formed by administrators looking at the bottom line, appreciating Dr. Cassell's perspective as a thoughtful practitioner becomes vitally important. This book will be most useful for those in primary care medicine, but its messages are much more universal. Readers could include most health professionals caring for, learning to care for, or considering caring for patients. It would also be interesting and important to those who teach students to care for patients, as well as to those involved in health care policy. Dr. Cassell uses a broad array of references from historical treatises on medicine to current physician thinkers and from early twentieth century philosophers to those of modern-day. It is wellreferenced and indexed. I heartily recommend this book. Dr. Cassell's insights into caring for patients in the late twentieth century are sharp and cogent. His well reasoned plan for change should form the nucleus of a revolution in how we care for patients.

Eric J. Cassell, M.D., is Clinical Professor of Public Health at Cornell University Medical College. He is the author of a number of books, including The Nature of Suffering, of which the Journal of the American Medical Association wrote "should be read by everyone in medical practice or considering a career in medicine."