Primary Care: Where Medicine Fails ed. by Spyros Andreopoulos (review)

BOOK REVIEWS Primary Care: Where Medicine Fails. Edited by Spyros Andreopoulos. New York: John Wiley & Sons, 1974. Pp. 212. $9.95. This book is based on a report of the proceedings ofa symposium on primary care which included four principal addresses, discussion, and a final summarization . The symposium was held in Idaho, June 24-30, 1973 and is one of the Sun Valley Forums. The report is the essence of the book but has been modified by addition for purposes that will be explained later in this review. As a report it is excellent, informative, and replete with many references to the literature. The decision, however, to present the report as a book has necessitated certain changes in order to accommodate to the thesis stated in the title of the book, that American medicine has failed from lack of primary care. This review points to the deviation from the original intent of the report to its use in proselytism. In a symposium, exchange of information is the principal if not the sole objective, and a report of proceedings should be largely narrative. As can be seen from the summary of the rapporteur, discussion at the symposium ranged far and wide, and no attempt was made to secure from the participants consensus, approval, recommendations, or even signatures. Many inferences can be made from the hundreds of assertions found in the proceedings, but to support a thesis, which apparently is the objective of the book's editor, one should be obliged to develop the subject material from a uniform point of view, sequentially from statement of the problem, assembly of facts, interpretation through logic to a conclusion. Symposia do not behave nicely in this regular fashion as can be seen from the report of this one; Consequently, the need to add material to supply unity and direction is evident in the book. The addition of a foreword, an introduction, new section titles grouping individual papers, and labeling a summary a list of recommendations (which it is not) does not supply the order or cohesion required to conclude with an indictment of medicine. Description and delineation of primary care is done well and exhaustively in the symposium's first paper, but it does not seem credible that the paper was actually delivered before a listening audience in such length and detail. The subsequent three speakers, utilizing the prerogative of individual essayists, presented their material in such order as suited their treatment of a given subject but not necessarily in a steady progression from problem to solution. Very likely there was no such objective at the time of presentation. While there were many direct references to problems in primary care, the strongest projections were inferential, that is, from proposals to reorganize or correct either primary care delivery or the total system of comprehensive care. The fault most frequently identified was poor access to care, the result of a great variety of barriers that may be categorized as alleged disorganization or disorien150 I Book Reviews tation of practice, lack of finances, misinformation and lack of education, inadequate facilities, geographic impediments, misdirection of professional education, poorly conceived insurance programs, and more. Obviously these are not unique to primary care. There are other considerations not aimed in any single direction but which are obligations of the book in its pursuit of its thesis. Many persons who are supportive of the primary care concept believe that we do not altogether know the extent of a primary care deficit or why it occurred, or what its potential impact on the total system is or may be. Furthermore the book does not seem to appreciate the complexities of the system or the perversities of the variety of persons involved and responsible for its success or failure. Even the approaches to investigation of manpower utilization, let alone measurement, are awesome [1]· My recommendation is that if one wishes to learn what was said at the symposium , read the book. If one wants to reinforce his belief that because of a lack of primary care medicine has failed, he may well be disappointed in the reading. REFERENCE 1. American Medical Association. Center for Health Services Research and Development . Chicago: Measuring Physician Manpower, 1973...