Book Review

Doctoring: The nature of primary care medicine

N Engl J Med 1997; 337:1637November 27, 1997

Article

Doctoring: The nature of primary care medicine
By Eric J. Cassell. 206 pp. New York, Oxford University Press, 1997. $23. ISBN: 0-19-511323-3

It is Eric J. Cassell's impassioned thesis that the patient — the person, sick or well — has been pushed to the margins of 20th-century medicine by a cardinal and emblematic error, “the belief that medicine involves the application of impersonal facts to an objective problem that can be seen separately from the person who has it.” In this distorted view, he argues, diseases are categorical objects, not processes, and patients are simply containers of pathologic processes, their bodies a mechanism gone wrong. Reductionist and atomistic aspects of medical science have crowded out clinical empiricism and clinical judgment — the careful consideration of the unfolding narrative of the patient's interactions with illness, past experiences, family and environment, and the doctor. Physicians, frustrated by ambiguous illnesses that do not fit molecular explanations and intolerant of uncertainty, retreat into technology (“we have left the bedside . . . to gather around the viewbox”), which presents what is immediate but not necessarily essential.

This thesis underlies much of Cassell's earlier work in books such as The Healer's Art (Philadelphia: Lippincott, 1976) and The Nature of Suffering (New York: Oxford University Press, 1991). In Doctoring, he explores its implications with respect to the training and the daily work of physicians in what he carefully defines as primary care medicine: not entry-level, not nonspecialty, not “a lesser form of medical practice set up to pass patients on to secondary, tertiary or quaternary levels.” It is, instead, what Cassell might call quintessential: a return to

careful history taking . . . artfully enhanced by skilled questioning at every point in the illness . . . supplemented by discerning scrutiny of patients' presentation to the world, behavior, mood and feelings, environment and context . . . plus the physical examination, supplemented by the mediated investigations offered by modern tests and imaging.

Is this not just very old and rather stale wine, poured into a new bottle called primary care? Sixty-five years ago, after all, the Rappeleye Commission of the Association of American Medical Colleges observed that “students should be made to realize from the beginning of their clinical studies that the diagnosis in a large majority of illnesses can be made on the basis of a searching history, a thorough physical examination, relatively simple laboratory determinations, and the thoughtful consideration of the problem presented.” (It should be noted, however, that the word “patient” does not appear in that formulation.) And the biopsychosocial model has been a part of most medical education for decades.

Cassell is concerned with something deeper — the conceptual structure (of students and practitioners alike) that values the hard data of medical science over the soft and subjective data on the psychological, social, and ethical facts about patients. The former, he argues, are discovered by impersonal instruments and require analytic and reductionist modes of thought; the latter are discovered by “the personal instrument of the individual physician” and require synthetic, representational thought and the ability to construct a coherent narrative “in equal partnership with information about disease, pathophysiology and technology.” It is the crucial combination of both modes of thought that places the sick or well person at the center of the physician's thoughts without impairing the physician's ability to think and act scientifically.

Many medical educators and many physicians, firmly grounded in medical science yet acutely attuned to their patients' broader needs, may think this is precisely what they teach and do now. Yet, in undergraduate and graduate training that is increasingly and overwhelmingly restricted to mastery of the scientific mode, Cassell's call for a return to Oslerian medicine is a call for balance. He goes on to identify the barriers to change and to make useful suggestions as to how (and in what settings) the primary care physicians of the future should be educated and evaluated, and how they should interact with other specialists.

There is, however, a gaping flaw in his scenario — one that he recognizes but then largely ignores. How are physicians to accomplish the “rich, deep, sophisticated clinical observation of patients,” paying attention to “the patient's desires, worries, concerns, feelings and experience of the world” during the 15-minute visit dictated by many managed-care systems? How can they watch “events unfold over a long period” when hospital stays are short, patients are often arbitrarily forced to change health plans and physicians, and the sick are seen as a threat to profit centers? Cassell clearly hopes for a better future, but in today's context of health care reorganization, his humanistic vision is ironically at risk of becoming a wistful, wishful statement of what clinical medicine could be, should be, and once was, but will not be.

H. Jack Geiger, M.D.
City University of New York Medical School, New York, NY 10031