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Show of membership in the medical family." "Because membership substitutes for intimacy in this family, appearing different is too painful to be risked. Like mothers in a traditional patriarchal family, the nurses perform vital functions such as facilitating communication from a position of indirect power...in abusive families, the parent with less power may also be abused and may vent frustration in indirect ways on the children. Similarly, nurses may use their indirect power to both support and undercut students and house staff... The family of medical education often behaves in a neglectful and abusive fashion. It isolates itself from support and consultation, rigidly maintaining the training structure passed down from previous generations. Rather than supporting developing physicians, the system neglects their physical needs and trains by negative criticism rather than teaching by specific feedback... Forced to hide their uncertainties and errors, the trainees' self-esteem never matures." There is a significant gap between what the student learns during medical school and what he will be expected to do as a practicing physician. Many authors have commented on this rift, with common themes such as "he sees medical education as less a preparation for becoming a practitioner than a preparation for being a student...the gap between education and practice is due to tradition, isolation from patients who will receive care (urban versus rural, for example), teachers' overriding interest in understanding disease rather than preserving health, and assessing medical competence by academic proficiency with books and written tests rather than by the practical ability to meet needs" (Golden, Carlson, & Hagen, 1982). A biomedical model of health and illness is presented which excludes from consideration the psychosocial implications of illness, and discounts attempts to include them in health planning (Midtling, et al., 1990). For instance, during internal medicine rounds at the Veteran's Administration Hospital, we discussed an 87 year-old man recovering from a stroke. He was unable to read or perform tasks requiring fine manual dexterity, such as opening a pill bottle. He was to be discharged home because he was "medically stable." The fact that he had no one to care for him at home and was on a regimen involving some eight different medications which he could not distinguish between or open was "irrelevant to his medical condition, and therefore irrelevant to his discharge plans" according to his attending physician. Patients presenting for primary care often defy categorization, and just creating a list of problems can be a daunting task. A scenario presented at the WHO conference illustrates this: "A heavily made-up attractive young woman of 25 arrives with her 18 month-old daughter. She is sorry to trouble the doctor, but her husband has insisted that she come. The child simply will not sleep all night and insists on being brought into the parental bed." Questions raised by this seemingly simple issue include: who is the patient? Is this a pediatric problem or an adult problem? Is it physical, sexual, psychiatric, or social work in orientation? What medical and non-medical support is needed? The tertiary care model of training offers little insight into any of these issues. The Impact on Primary Care In recent years, as medical costs skyrocket and an increasing number of people find themselves unable to afford health care or insurance, many involved in health care planning believe that one major solution to the problems of cost and access is increased use of primary care services. This involves extensive preventive health care, early disease detection, and therefore (presumably) lower incidence of expensive intensive support for advanced disease. In 1964, an AMA committee studying the issue of providing expanded primary care found that the number of primary care providers had decreased due to the increasing difficulty of comprehending Utah's Health: An Annual Review 1993 95 |
