Starting point

SECOND OPINION
BY SIDNEY HARRIS

Why primary care draws fewer physicians

Two physicians lamented the decline of primary care in Yale Medicine [“Taking the e-road,” Autumn 2007]. Having been a primary care doctor for over 30 years, I felt compelled to respond.

Robert P. Gerety, M.D. ’52, correctly pointed out that the practice model of primary care began its decline as long ago as 1968. Clearly, primary care never found a comfortable fit within the medical hierarchy despite the continuous public outcry for over 50 years for more general practitioners. American medicine is research-oriented; because primary care is practice-oriented, it has received second-class status and will remain there until the focus of American medicine changes.

But there are many other reasons why primary care is attracting fewer practitioners than ever. Over the past few decades health insurers have overburdened primary care doctors with administrative hassles that consume an inordinate amount of time. Unfortunately, the doctors are not paid for the extra time they put in on administrative work. Some studies estimate that administration consumes about 20 percent of their time. Being underpaid by insurers forces primary care doctors to see large numbers of patients in order to survive. The large number and broad spectrum of patients and diseases greatly increases the physicians’ risks of making errors and intensifies their exposure to malpractice suits.

Although Gerety believes that house calls disappeared because people stopped asking for them, I think that doctors stopped making them because they were overburdened in their offices and because the complexity of modern medicine made house calls a source of medical liability. Clearly, medicine had become too complex for the family doctor to “do it all.”

The answer? A new model of primary care is needed—one that takes into account the realities of modern medical practice. The scope of the family doctor has to be redefined. Also, the medical malpractice system needs reforming. It’s too adversarial. Finally, health insurers have to be regulated. Their philosophy of profits before patients has completely transformed medicine from a profession into a business; as a result demoralization among doctors is widespread.

Family doctors can make a comeback, but their return will take work on many fronts.

Edward J. Volpintesta, M.D.
Bethel, Conn.

Uganda story rekindles memories

As I skimmed the article in Yale Medicine [“On the Wards in Uganda,” Winter 2008], I felt goose bumps. I had the most fortunate opportunity to work in Mulago Hospital for three months in 2005. I was at the Infectious Diseases Institute (IDI) next door and worked with several colleagues who were at Mulago in IT and nursing. I was sent as part of a global health fellowship with Pfizer to develop a sustainable model for facility management at the IDI. I am now the associate director of facilities for the School of Medicine and find that Yale has a program in Uganda as well. Many of the issues you speak about and pictures in the article bring back vivid memories for me; I truly miss being so close to the patients who need help so desperately. I have many lifelong friends in Kampala and such surrounding communities as Nakasera, Mukono and Jinja. I brought my wife and three daughters with me—they will never be the same.

Gary Mandelburg
Associate Director, YSM Facilities

Yale should set standards for collaborations

Being familiar with the inspiring story of the heroic doctors and nurses from Yale who risked their lives—and in some instances gave their lives—40 years ago fighting the Lassa fever outbreak in the eponymous village near Jos, Nigeria, I was disappointed by your article titled “On the Wards in Uganda,” Winter 2008. Despite your disclaimer early on that the travel of Yale doctors, residents and medical students to a hospital in Uganda was not an “exercise in medical tourism,” the subsequent narrative left me feeling that most of the program’s benefit fell to the U.S. participants. Much as I sincerely applaud the members of the Yale team for the humanitarian work they accomplished and for the considerable medical service they rendered, it is a pity that the senior physicians did not engage in serious scholarly collaboration with their Ugandan colleagues—by which I mean research and teaching. There is no reason why the United States’ partners in international biomedical collaborations between health science centers in this country and their hosts at teaching hospitals in sub-Saharan Africa can’t keep several balls in the air at a time: teaching, research, service and humanitarian work. A first-line medical school such as Yale, which I happen to hold in high regard, should be setting the standards for international collaborations.

Robert H. Glew, Ph.D.
Emeritus Professor of Biochemistry and Molecular Biology,
School of Medicine,
University of New Mexico
Albuquerque, N.M.

Starting point:

In the fall of 2006 Bayer HealthCare announced that it was closing its plant in West Haven and Orange and putting the 137-acre property on the market. By the following June the university had announced that it would buy the property for a multitude of uses still to be determined. One thing, however, was clear. With almost half a million square feet of pristine lab space at the site, the School of Medicine would have room to expand and advance its programs in medical and biomedical research.

After closing on the property last year, Provost Andrew Hamilton, Ph.D., said that the university wanted to avoid turning the space into an attic or basement that would collect the stuff no one knew where to store. In his report [“How the West was won”], Contributing Editor Marc Wortman describes how the deal came about and what is guiding the thinking of the university’s top officers as they consider the best uses for the property.

On the topic of dusty basement catchalls, a storage room underneath Harkness Dormitory has for decades been home to a treasure trove of whole human brain specimens, X-rays, patient records and photographs that document the career of Harvey Cushing, M.D., the pioneering neurosurgeon. Dennis D. Spencer, M.D., HS ’77, chair and the Harvey and Kate Cushing Professor of Neurosurgery, has been working to preserve the collection and make it accessible to a broader audience. Spencer recently published a book with colleagues at the medical school based on this collection.

By happenstance, this issue’s Capsule also includes medical images of historical interest. When medical missionary Peter Parker, an 1834 graduate of the Divinity School and what was then the Medical Institution of Yale College, opened a hospital in Guangzhou, China, he engaged a local Western-trained artist to paint preoperative portraits of his patients to document their disorders. Capsule tells the story of Parker and artist Lam Qua and their collaboration.

Finally, in our third feature we report on a visit from Hillary Rodham Clinton, J.D. ’73, who is seeking the Democratic Party’s nomination for president. On the day before the Super Tuesday primaries in February, Clinton made a campaign stop at the Child Study Center, where she had championed the rights of children and families as a law student.

John Curtis
Managing Editor