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

By Muriel R. Gillick | Go to book overview

CHAPTER THREE
From the Outside In

For four years, medical school steeped me in evidence-based medicine. I learned about the merits of double-blind, controlled randomized trials—and the weaknesses of observational studies. I came to understand that to shine on rounds in the hospital wards, I needed to cite data and quote the “medical literature,” as journal articles are known, though they are decidedly not literary. I was told that medicine was a science and that treatments should be subjected to rigorous testing to determine if they work. And then for three years of residency in internal medicine, when I was supposedly learning how to be a real doctor, my teachers continued to promulgate evidence-based medicine in lectures and at the bedside, even while much of the day-to-day learning was far more practical and of the “see one, do one, teach one” variety.

After eight years of education and training—following residency I spent a year doing a geriatrics fellowship—I was ready to enter the office practice of medicine. Armed with theoretical knowledge from medical school, applied knowledge from residency, and the ability to critically evaluate new information and, if it passed muster, integrate it into practice, I accepted my first job—as a primary care physician at Bunker Hill Health Center, a neighborhood clinic. I was pretty certain that I knew exactly what I was supposed to do in order to be a good doctor, not that I thought it would be easy or that I was confident I actually would be able to function well without the constant camaraderie of the hospital. Even in a group practice, where there are always colleagues down the hall, outpatient medicine is mainly a solitary pursuit. It’s all about the interaction between the doctor and the patient, with no supervising senior physician to check up on what’s happening in the privacy of the office. But I knew the drill. I subscribed to the New England Journal of Medicine, and eagerly looked forward to Thursdays when it arrived at my doorstep. I would scan the table of contents, then read the abstracts of the most interesting articles and decide which ones to read more carefully. I also subscribed to the Annals of Internal Medicine, which at the time came out monthly, and also, because I needed to keep up with my field of specialization, the Journal of the American Geriatrics Society. Every year I went to the national meeting of the American Geriatrics Society plus a few day-long courses or seminars on a topic of interest. Later, I would also have resources such as the spectacularly

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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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