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Primary care: Where medicine fails
>tatcs -tIlLit one 0) ti1c t,laJor concerns 01 lilt’ S! rnpo~tunl bould be n itll varto~~s models for drug rducatlon rflorts” .At times one suspects that bullding and discardmg models becomes ;I same m Itself and :I suhstltute for arduous factlindmg. .An absence of evidence made parts of this hook [rather frustrattng. as one pushed aside successive webs of conJecture m search of the hidden treasure of fact. The Idea that Information imparted m chtldhood will mflurncr behavlour at 3 part) IOyr later 1s in Itself an act of faith which detirs measurement. Attempts to cvaluate the impact of drug rducatton ubl! reviewed by Goodstadt reveal the near impossible nature of the task and the ch;mscs observed are often trivial and inconclusive. Globetti discusses the particular problems of alcohol education in whtch no consensus exists about the ObJectIves of the tash. The dlstinctton between attitude change and action change is often overlooked. Most authors seemed more hopeful about Influencing attitudes. rather than changmg established hehawour. Inevitably the render’s thoughts turn to more fundamental questions about the nature and put-pox of educatton. and it was difficult to avoid feeling that we required a reappraisal of the adequacy of current tcuching methods as a preparation for living. Why ior IIIbtancc IS the emotional climate in one school so different from that in another in the same district’? How can we help children develop their critical abilities so that they can resist Ill-founded persuasion’? Such issues remained unanswered. perhaps they always will. This book poses man! qucsttons uhich is surely a sien of a successuI symposium. “The trcatmcnt of alcoholl opposed Much of \rhat hc 11;~sto \av .Ihout the concept of loss of control. hchav~~~u~-modilic;tt;on and teaching alcoholics to drmk nurmall~ I\ well prc\ctited and adequately rcfcrcnced. The dlscac concept 01 alcoholism is being shaken ‘II it5 foundation\ at prcs2nt a\ the author- \uggc?ts. 111,. lll11lX~\V I)r,,ll~lrIr ( ‘Ir,!,c~. R~l\~Il I.i/rlrlUrl?//r 1/f,\/“/“/. I.
t:. B. RIISON
<‘arc: Where Medicine E‘nils. cdltcd by SI+I
\~I)KIOW~I
511
Book reviews the preferred strategy. hc offers an alternative solution: “A significant amount of the funds now supporting medical education/research/administration/service might be diverted to the support of other (new) institutions designed primarily to produce primary care providers. Some of these “institutions” might be. programs preparing intermediate health workers such as physicians’ assistants or nurse practitioners”. If even this strategy proves unworkable. diverting “a significant amount of funds” often is somewhat difficult. Dr. Lewis suggests that laypersons in rural areas be trained in the use of health care protocols of the kind now employed by physicians’ assistants. He describes these individuals as “barefoot doctors carrying cookbooks for care”. The third paper in the symposium. “Primary Health Care: Suggested Organizational Structure”, is by Stanley S. Bergen, Jr., President of the College of Medicine and Dentistry of New Jersey and a former member of several health advisory panels at the city and state level, He reviews a number of efforts currently underway to improve access to primary care. He prophesizes a “gradual but persistent evolution in our primary health care delivery system”. Dr. Bergen foresees a national health insurance scheme which would rely upon existing insurance companies as fiscal intermediaries. Existing hospitals would serve as focal points for systems of primary health care facilities organized through state or regional health authorities. The number and categories of health care providers would be markedly increased. Dr. Bergen is careful to avoid any appearance of radicalism: “Any new system.. must be sensitive to the need to build on existing strengths”. He provides few details. however, as to how the changes which he envisions could be realized without substantive reform of existing institutions. One senses that he and Dr. Lewis might be at odds on this point. Furthermore. he offers no substantive rationale for favoring this relatively conservative strategy. save that it does as little as possible to upset the status quo. The final paper in this collection. “Financing Medical Care: Implications for Access to Primary Care”. examines primary care from the point of view of the economist. The author is Karen Davis, of the Brookings Institution. Washington. D.C. She sets out to answer two questions: “(1) how successful have existing financing programs been in ensuring adequate and equitable access to primary care for covered persons’! and (7) how should new financing programs be designed to help overcome remaining barriers to primary care access?” Dr. Davis defines access as the “monetary and non-monetary costs of obtaining care”. Non-monetary costs include barriers related to physical access. e.g. availability and location of facilities and personnel. as well as those related to patient and physician attitudes. e.g. consumer ignorance or provider insensitivity. In reviewing Medicare and Medicaid data. Dr. Davis makes a compelling argument for the importance of these non-monetary factors in determining the utilization of health care services, These programs provide nearly equal financial access to care for all persons covered. Despite this fact. Dr. Davis finds that blacks receive fewer benefits than whites. higher income people use services more heavily than those vvith less income and rural beneficiaries obtain less care than those in urban areas, She goes on to note. this pattern of utilization is “counter to that which would be expected on the basis of differences in “need” for medical care”. She argues that any future governmental financing scheme. which does not take account of these other barriers to access. i< likel! to systematically favor the yrime groups. Dr. Davis suggests two approaches to resolving these disparities: (1) supplementation of financing plans with direct policies to reduce non-monetary barriers to access. e.g. manpo\ver and facility development in lowincome. minority and geographically isolated areas. andjor (2) a financing program structured in such a way as to
help overcome both monetary and non-monetary barriers to access. e.g. a program of tapered benefits as income rises and higher benefits in minority and geographically isolated areas. She does admit that this latter strictly economic approach does have its limitations. particularly in the case of racial barriers to access. Here she suggests that the first strategy might be preferable. In sum, we have four authors presenting four different approaches to the problems of primary care. A community health consultant, Dr. Parker. suggests comprehensive. community-oriented health care facilities. A medical educator. Dr. Lewis, recommends that more primary care physicians be trained. A health care administrator, Dr. Bergen. proposes national entitlement and regional planning. Finally. a health economist, Dr. Davis. advocates countering non-monetary barriers to care through alterations in the prices faced by different consumers. Which approach should we choose? Like the description of the elephant offered by the blind men, we have been given some notion of the parts but no clear conception of the whole. The section of recommendations included at the end of this volume does little but restate the somewhat diverse findings of the contributors to the symposium. What would have been preferable would be some indication as to where priorities, for either private or government intervention, should lie. This is not to say that the book is not well worth examining by those concerned with the problems of primary care. Indeed, the various chapters individually contain a wealth of useful and timely material. Although this book offers no absolute solutions to the problems of primary care, it does provide the basis for a more informed discussion of the issues to be faced and is to be recommended to those with an interest in the field. Harvard John F. Harvard Boston.
Medical School. Kennedy School OJ Government, University, Massachusetts, U.S.A.
DAVID CALKINS
Psionic Medicine, by J. H. REYNERin collaboration with GEORGELAURENCEand CARL UPTON. Routledge & Kegan Paul Ltd., London, 1974. f2QO. There recently came across my desk an announcement of a symposium in New York on ways of healing, ancient and contemporary. including Chinese and American Indian The intention of the symposium was to explore the provision of alternatives to the technical orientation of Western medicine. This intent is enormously sympathetic to me. I have been intrigued and concerned with the problem of re-conceptualizing our theories of medicine to get away from the simplistic cause-and-effect model. I’ve also been concerned with the need to pay attention to the whole person and to develop a more humanistic orientation. To state my own position even more clearly. psionic medicine essentially deals with an application of extrasensory techniques to diagnosis and treatment. Once I was a member of the British Psychical Society and have for years been a critical sympathizer and an intrigued cynic. I believe that there are many things that are inexplicable by scientific method. even though much of what passes for psychical phenomena may be attributable to charlatanism or wellintentioned error. So I approached this book with sympathy toward its goals of providing alternative approaches to medicine and sympathy toward the application of ESP. It grieves me, therefore. to have to conclude that this is a sad and silly book. It comes on like a pseudo-scientific treatise which. when it comes down to it, is no more than modern scientific theology applied to back up faith healing. Not to say that faith healing does not work. for people are credulous and much disease and many problems are
t:. B. RIISON
<‘arc: Where Medicine E‘nils. cdltcd by SI+I
\~I)KIOW~I
511
Book reviews the preferred strategy. hc offers an alternative solution: “A significant amount of the funds now supporting medical education/research/administration/service might be diverted to the support of other (new) institutions designed primarily to produce primary care providers. Some of these “institutions” might be. programs preparing intermediate health workers such as physicians’ assistants or nurse practitioners”. If even this strategy proves unworkable. diverting “a significant amount of funds” often is somewhat difficult. Dr. Lewis suggests that laypersons in rural areas be trained in the use of health care protocols of the kind now employed by physicians’ assistants. He describes these individuals as “barefoot doctors carrying cookbooks for care”. The third paper in the symposium. “Primary Health Care: Suggested Organizational Structure”, is by Stanley S. Bergen, Jr., President of the College of Medicine and Dentistry of New Jersey and a former member of several health advisory panels at the city and state level, He reviews a number of efforts currently underway to improve access to primary care. He prophesizes a “gradual but persistent evolution in our primary health care delivery system”. Dr. Bergen foresees a national health insurance scheme which would rely upon existing insurance companies as fiscal intermediaries. Existing hospitals would serve as focal points for systems of primary health care facilities organized through state or regional health authorities. The number and categories of health care providers would be markedly increased. Dr. Bergen is careful to avoid any appearance of radicalism: “Any new system.. must be sensitive to the need to build on existing strengths”. He provides few details. however, as to how the changes which he envisions could be realized without substantive reform of existing institutions. One senses that he and Dr. Lewis might be at odds on this point. Furthermore. he offers no substantive rationale for favoring this relatively conservative strategy. save that it does as little as possible to upset the status quo. The final paper in this collection. “Financing Medical Care: Implications for Access to Primary Care”. examines primary care from the point of view of the economist. The author is Karen Davis, of the Brookings Institution. Washington. D.C. She sets out to answer two questions: “(1) how successful have existing financing programs been in ensuring adequate and equitable access to primary care for covered persons’! and (7) how should new financing programs be designed to help overcome remaining barriers to primary care access?” Dr. Davis defines access as the “monetary and non-monetary costs of obtaining care”. Non-monetary costs include barriers related to physical access. e.g. availability and location of facilities and personnel. as well as those related to patient and physician attitudes. e.g. consumer ignorance or provider insensitivity. In reviewing Medicare and Medicaid data. Dr. Davis makes a compelling argument for the importance of these non-monetary factors in determining the utilization of health care services, These programs provide nearly equal financial access to care for all persons covered. Despite this fact. Dr. Davis finds that blacks receive fewer benefits than whites. higher income people use services more heavily than those vvith less income and rural beneficiaries obtain less care than those in urban areas, She goes on to note. this pattern of utilization is “counter to that which would be expected on the basis of differences in “need” for medical care”. She argues that any future governmental financing scheme. which does not take account of these other barriers to access. i< likel! to systematically favor the yrime groups. Dr. Davis suggests two approaches to resolving these disparities: (1) supplementation of financing plans with direct policies to reduce non-monetary barriers to access. e.g. manpo\ver and facility development in lowincome. minority and geographically isolated areas. andjor (2) a financing program structured in such a way as to
help overcome both monetary and non-monetary barriers to access. e.g. a program of tapered benefits as income rises and higher benefits in minority and geographically isolated areas. She does admit that this latter strictly economic approach does have its limitations. particularly in the case of racial barriers to access. Here she suggests that the first strategy might be preferable. In sum, we have four authors presenting four different approaches to the problems of primary care. A community health consultant, Dr. Parker. suggests comprehensive. community-oriented health care facilities. A medical educator. Dr. Lewis, recommends that more primary care physicians be trained. A health care administrator, Dr. Bergen. proposes national entitlement and regional planning. Finally. a health economist, Dr. Davis. advocates countering non-monetary barriers to care through alterations in the prices faced by different consumers. Which approach should we choose? Like the description of the elephant offered by the blind men, we have been given some notion of the parts but no clear conception of the whole. The section of recommendations included at the end of this volume does little but restate the somewhat diverse findings of the contributors to the symposium. What would have been preferable would be some indication as to where priorities, for either private or government intervention, should lie. This is not to say that the book is not well worth examining by those concerned with the problems of primary care. Indeed, the various chapters individually contain a wealth of useful and timely material. Although this book offers no absolute solutions to the problems of primary care, it does provide the basis for a more informed discussion of the issues to be faced and is to be recommended to those with an interest in the field. Harvard John F. Harvard Boston.
Medical School. Kennedy School OJ Government, University, Massachusetts, U.S.A.
DAVID CALKINS
Psionic Medicine, by J. H. REYNERin collaboration with GEORGELAURENCEand CARL UPTON. Routledge & Kegan Paul Ltd., London, 1974. f2QO. There recently came across my desk an announcement of a symposium in New York on ways of healing, ancient and contemporary. including Chinese and American Indian The intention of the symposium was to explore the provision of alternatives to the technical orientation of Western medicine. This intent is enormously sympathetic to me. I have been intrigued and concerned with the problem of re-conceptualizing our theories of medicine to get away from the simplistic cause-and-effect model. I’ve also been concerned with the need to pay attention to the whole person and to develop a more humanistic orientation. To state my own position even more clearly. psionic medicine essentially deals with an application of extrasensory techniques to diagnosis and treatment. Once I was a member of the British Psychical Society and have for years been a critical sympathizer and an intrigued cynic. I believe that there are many things that are inexplicable by scientific method. even though much of what passes for psychical phenomena may be attributable to charlatanism or wellintentioned error. So I approached this book with sympathy toward its goals of providing alternative approaches to medicine and sympathy toward the application of ESP. It grieves me, therefore. to have to conclude that this is a sad and silly book. It comes on like a pseudo-scientific treatise which. when it comes down to it, is no more than modern scientific theology applied to back up faith healing. Not to say that faith healing does not work. for people are credulous and much disease and many problems are