American health care is a technological marvel. It’s also a culture-war football and an accessory to U.S. society’s grossest inequities. Three new books spotlight the dedication and dysfunction in its midst.
The family doctor represents an ideal: a physician to call our own, there for us through all our needs, the champion of our care. The role also cuts to the heart of our health care debate — 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 a field in crisis amid a system trending toward “transactional,” volume-driven, ever more “balkanized” care. Professional acumen is being usurped by algorithms, and patients’ expectations are conditioned by their experiences as consumers, Hoff writes. The family doctors he interviews are harried, careworn, buckling under administrative overheads and forced to embrace an impoverished version of the role for which they were trained. Compared to colleagues in adjacent specialties, they’re poorly remunerated.
The practitioner perspective illuminates a system antithetical to the preventive care that is family medicine’s stock-in-trade (the real money lies in intervention-intensive sick care), and Hoff’s observations about the missteps behind the field’s malaise are incisive. This emphasis will also serve to impart a sense of agency to the book’s professional readers — that redemption lies in setting their house in order. But as long as the system’s profit-driven logic remains intact, this surely represents so much tinkering around the edges.
If Hoff documents neoliberalism’s deforming effects on the medical profession, Thomas Fisher’s “The Emergency: A Year of Healing and Heartbreak in a Chicago ER” chronicles its toll on patients. Emergency rooms meet many patients where they are: without a stable job and health insurance; on public assistance if they’re lucky, but otherwise uninsured; and in chronic ill-health. They’re not arranging wellness checks with their doctor of record; instead, they show up at an ER as a last resort, often gravely sick. People of color figure disproportionately in this grim folkway, and “The Emergency” is a briskly paced, heartfelt, often harrowing year in the life of an ER doctor on Chicago’s historically Black South Side.
Much of it reads like a war report. Yet the suppurating gun wounds and gangrenous limbs are “not just a random assortment of injuries and illnesses.” Fisher’s patients have traversed a racially segregated socioeconomic topography en route to the ER. He peppers his narrative with statistics. Black people comprise 30% of Chicago’s populace, and almost 80% of Chicagoans without ready access to healthy food. Another sobering fact: Residents of the South Side’s Englewood “are nine times [likelier] to be hospitalized for diabetes” than denizens of the city’s River North. Once admitted, they must navigate a clinical environment in which “wait times are long, specialists … few, time with the doctor … short, testing and treatments … delayed, facilities … in disrepair, and amenities … absent.”
Beyond the bedside, Fisher has worked in insurance and managed care, and served as a White House fellow. He knows the system longitudinally, and the interests vested in its status quo.
“Executives, vendors, physicians, insurers, pharmaceutical companies, and suppliers of medical technology — the entire medical-industrial complex grows fat as long as nothing changes,” he writes.
One thing U.S. medicine excels in is technologically advanced complex care. Sovereign here are surgeons, and surgeon-writer Ira Rutkow’s “Empire of the Scalpel: The History of Surgery” romps through the field’s development from rude “sawbones” trade to meticulous professional discipline.
Rutkow has a raconteur’s touch, and he is especially good on the rugged, difficult, obstinate characters that propelled the field’s advance during a heroic age of medicine.
He’s also notably generous. Perhaps to a fault. Academic papers, a congressional inquiry and a New York Times investigation in the 1970s finding a surfeit of surgeons performing unnecessary operations (2.4 million in 1974, according to the congressional report) contributed to “a confusing time for the nation’s knife bearers,” he allows.
Of the oblivion that befell a 1976 American College of Surgeons study finding surgeons underemployed and recommending training be scaled back, Rutkow glumly observes, “Why the surgical establishment refused to endorse the major findings of its own study is cloaked in almost five decades of obscurity.”
This seems rather obtuse. A quick internet search shows oversold services remain a concern; how could they not? The dynamics impelling them have only grown more entrenched: a fee-for-service model that incentivizes procedures, asymmetry of information between patient and surgeon, professional turf stoutly defended by surgeons’ organizations, and ever-quickening specialization in which “knife-wielders” become nail-seeking hammer-wielders.
There’s much to marvel at in surgery’s history, but its practitioners today command status and prestige; they’re richly rewarded from the public purse, and their work is sufficiently socially important that they can stand more scrutiny from one of their own.
Searching for the Family Doctor: Primary Care on the Brink
By Timothy J. Hoff
(Johns Hopkins University Press; 288 pages; $39.95)
The Emergency: A Year of Healing and Heartbreak in a Chicago ER
By Thomas Fisher; foreword by Ta-Nehisi Coates
(One World; 272 pages; $27)
Empire of the Scalpel: The History of Surgery
By Ira Rutkow
(Scribner; 416 pages; $29.99)