Old and Sick in America: The Journey through the Health Care System

By Muriel R. Gillick | Go to book overview

CHAPTER TWO
The Lay of the Land

The prophets of doom say that the era of small, independent medical practices that operate in a fee-for-service model is over.1 As with other similarly dire forecasts, most famously of Mark Twain’s impending death when he was alive and well, this claim may well be exaggerated. What is true is that solo practice is fading from view: thirty years ago, roughly 40 percent of American doctors were in solo practice; by 2012, only 18 percent were solo practitioners, although the majority of doctors still practice in groups of fewer than ten physicians.2 What is also true is that there are now many models of office practice other than one-or two-person private practices that charge for each service they provide. And those models vary enormously in size, ownership, reimbursement, and structure.

The most obvious difference among medical practices is their size, but size can be misleading. Small groups are often nestled within larger ones and large ones are often subdivided into semi-autonomous units. When I started out in primary care after completing my residency in internal medicine and a fellowship in geriatrics, I worked at a neighborhood health center that felt like a small group practice—we were about five internists, a comparable number of pediatricians, and a psychiatrist. But the entire center was owned by Massachusetts General Hospital (MGH), a mammoth tertiary referral center that operated a number of health centers like ours. My primary care patients got their hospital care at MGH—but there were so many internal medicine interns and residents, and the attending staff was so large, that I seldom saw a familiar face when I went to the hospital to check on them. Later, I practiced in a large, teaching nursing home where medical care was provided by what was a medium-sized group practice—we had about a dozen primary care doctors on the staff along with a number of consultants in orthopedics, neurology, and ophthalmology who saw patients several hours a week. We were affiliated with a major Boston teaching hospital, which meant our patients were hospitalized at that institution, and we each spent a few weeks every year teaching and seeing patients at the hospital. But working in our closed nursing home environment (unlike most nursing homes, we did not allow outside doctors to see patients in the facility) with the same nursing staff day after day and year after year, caring for patients who lived in the facility where we worked,

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Old and Sick in America: The Journey through the Health Care System
Table of contents

Table of contents

  • Title Page iii
  • Contents vii
  • Prelude ix
  • Abbreviations in the Text xxi
  • Part I - The Office 1
  • Chapter One - Going to the Doctor 3
  • Chapter Two - The Lay of the Land 23
  • Chapter Three - From the outside in 41
  • Chapter Four - The March of Time, 1965–2015 61
  • Part II - The Hospital 79
  • Chapter Five - Entering the Palace of Technology 81
  • Chapter Six - The Varieties of Hospital Experience 97
  • Chapter Seven - The Hospital through Other Eyes 113
  • Chapter Eight - The Transformation of the American Hospital, 1965–2015 133
  • Part III - The Skilled Nursing Facility 151
  • Chapter Nine - Going to Rehab 153
  • Chapter Ten - Different Snfs, Different Miffs 169
  • Chapter Eleven - Movers and Shapers 184
  • Chapter Twelve - Now and Then 202
  • Finale 223
  • Acknowledgments 245
  • Notes 247
  • Bibliography 267
  • Index 293
  • Studies in Social Medicine 301
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