Summer 1996

The Two Faces of Primary Care

by Eric J. Cassell

Primary care is a more effective medicine not only for people with simple ailments but for those with illnesses that are serious and complex.

Among the cost cutters who are overseeing the rapid and often thoughtless restructuring of the American health-care system, "primary care’’ medicine has become a panacea. To the executives and physicians who run the managed-care organizations that increasingly dominate America’s health-care landscape, primary care seems to offer promising solutions to many of the problems of modern high-cost medicine. They see the primary care physician as a combination low-cost general practitioner and "gatekeeper’’ to the rest of the health-care system, reducing the flow of patients into more specialized and expensive forms of medicine.

Within medicine, however, primary care has long had a different meaning. While its name suggests simplicity, primary care is in fact a very sophisticated response to problems created by high-cost, high-technology, highly specialized modern medicine. It has been evolving as a distinct field for several decades. Primary care emphasizes a more comprehensive view of patients and their treatment than does today’s standard medicine. It seeks to aid the vast majority of patients who are not best served by the high-technology, superspecialized medicine at which the American healthcare system excels, especially the poor, the chronically ill, the aged, and the disabled. Consider the plight of a poorly educated 58-year-old woman, a diabetic for 20 years. Her mother and her son both died of the disease, and she lives in constant fear of its complications. Yet she seems almost completely unable to follow the regimen of diet, exercise, and medications prescribed by a specialist. Without the added attention to the psychological and social elements of her illness that primary care provides, there is little hope of helping her.

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