Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century

Abstract

Reviewed by: Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century Heather J. Carmack, PhD (bio) Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century, by Timothy Hoff. New Brunswick, NJ: Rutgers University Press, 2009. 208 pp. Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century by Timothy Hoff is an in-depth sociological study of the changing nature of primary care work. Hoff, an associate professor of health policy and management at the University of Albany School of Public Health, uses this shifting nature of care as the impetus for recommendations to transform the current U.S. health care system. Ultimately, Hoff calls for a re-envisioning of health care to privilege patient-centered care and encourage primary care physicians to be accountable for the care they provide. In order to demonstrate a need for reform, Hoff uses the first two-thirds of the book to describe the historical development of primary care and the ways physicians practice it. The first section of the book explores the structuring of primary care practice. Hoff chronicles the average day for a primary care physician, pointing out how primary care practice has changed over time. For contemporary primary care physicians, the practice of medicine is dictated by the cost of treatment and insurance coverage. The reality of primary care practice for the physicians interviewed by Hoff is one of short patient visits, writing referrals to specialists, and relying on nurses, nurse practitioners, and physicians assistants to treat patients (pp. 27-39). The focus on medicine as a business has affected the care patients receive; however, as Hoff points out, changes have come from patients as well, as they presently visit primary care physicians about chronic illnesses and mental health issues more frequently than at any time in the past. These two changes underscore the change in the routine care primary care physicians provide. The physicians in Hoff's study point out an interesting tension: primary care is becoming more basic and narrow, while simultaneously becoming more complicated by chronic illness and mental health issues (pp. 86-95). Primary care is no longer simply preventative and acute care. This tension also highlights how education for primary care physicians has changed, especially for behavioral health. The young physicians interviewed discuss how, during medical school and internships, they focus on behavioral health, knowing that increasing numbers of patients report behavioral issues. One of the biggest changes in primary care practice is the phasing out of hospital practice and the introduction and reliance on hospitalists. Once an important part of the everyday practice of primary medicine, today's primary care physicians hardly, if at all, treat patients in the hospital. Many of the physicians interviewed talked about how this transition to hospitalists is the result of DRGs (diagnostic relating groups) and residency training that emphasizes hospital medicine while deemphasizing primary care, which ultimately results in decreased numbers of medical students deciding to practice primary care. Ultimately, the use of hospitalists results in primary care physicians [End Page 1412] with fewer skills (p. 68). Although the physicians interviewed saw the benefits of using hospitalists (as one physician said, "Who wants to get up at 2 a.m. in the morning to go to the hospital?" [p. 69]), they also recognized that using hospitalists encourages primary care physicians to lessen their ability to "perform a variety of jobs, losing occupational prestige and autonomy as a result" (p. 69). The use of hospitalists also changes the patient-physician relationship, as patients will not see their primary care physician until after a hospital visit. This fragmentation in care could affect patients' perceived quality of care; however, as Hoff points out, the research on patients' satisfaction with hospitalists and primary care physicians is inconclusive (p. 79). The second part of the book focuses on the changing demography of primary care physicians. As Hoff argues, "The game has changed. It is perfectly reasonable to expect the players to change with it" (p. 129). This section of the book is divided along three demographic lines: age, gender, and nationality. This section is of particular importance to patients because...