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http://www.nytimes.com/2003/01/07/health/policy/07CASE.html?tntemail0

In an Age of Specialists, One Doctor Is Primary

By ABIGAIL ZUGER, M.D.

obert is a middle-aged man with five chronic diseases and a doctor for each. He has the urologist for the prostate cancer, the rheumatologist for the arthritis, the cardiologist for the coronary artery disease, and so on.

And then, like the extra candle on the cake for luck, he has yet another doctor, the one responsible for his primary care.

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Robert was in the hospital for a few days recently, and the record of his last primary care visit accompanied him. This was its gist: "Patient was seen by hematologist. I will obtain records. Will attempt to contact rheumatologist. Will obtain record from pulmonary medicine. Will call radiotherapist. Patient to return here four weeks."

A jaundiced eye might read here a depressing postmodern portrait of what primary care has become: secretarial work with a little gatekeeping thrown in, certainly not doctoring in any traditional sense of the word.

Apparently all the standard medical care Robert gets these days — the latest tests and treatments — is provided by Doctors 1 to 5.

But if you ask Robert about Doctors 1 to 5 he shrugs, barely remembering their names. Ask him about No. 6 and a soft smile crosses his face. "I don't know what I would do without him," he says. "He's kept me alive all these years."

And there you have the continuing tangled contradictions of primary care medicine, an entity now so battered by market forces and reshaped by scientific changes that no one can quite figure out what it is anymore. Some experts are ringing its death knell, others are energetically reviving it — and in the meantime it still somehow occasionally survives in its purest form.

Which is exactly what?

It is easiest to start by enumerating what it is not any longer. It is not Norman Rockwell's gray-haired fellow slogging through blizzards with his black bag; everything from malpractice considerations to the impossibility of fitting a CAT scanner into that bag vaporized that kind of primary care long ago. It is not necessarily the doctor who oversees your health care wherever you go; more and more, hospital-based doctors called "hospitalists" take over primary care at the hospital entrance, while "intensivists" supervise stays in intensive care.

It is not necessarily even the doctor who deals with common illnesses and leaves the rarer things to specialists. Every common disease, including diabetes and athlete's foot, now has its own specialist. Further, recent studies suggest that specialists can often manage common diseases more successfully than generalists: there are fewer complications and a lower mortality rate when cardiologists manage heart attacks, for instance, or neurologists take on strokes.

If complications and mortality were all there was to medical care, that might be the end of the story — and of primary care. But anyone who has ever emerged physically intact but emotionally battered, confused, furious or appalled from an encounter with the health care system knows otherwise.

In a new book of oral history, "Big Doctoring in America" (University of California Press, 2002), 15 primary care providers from around the country describe what else is involved. They have little in common but an affirmation that primary care is "whole person care." One does his bit for the whole person in the executive offices of a managed care organization; another passes out blankets and mittens to the urban homeless. Several are not doctors at all, but nurse practitioners and physician assistants.

The book's editor, Dr. Fitzhugh Mullan, a pediatrician in Washington and a contributing editor of the health policy journal Health Affairs, traveled the country interviewing dozens of these generalists — 60 interviews not included in the book are in the National Library of Medicine's archives. Dr. Mullan calls the book a story of "the struggle to get it right in health care."

Yet even Dr. Mullan is not quite sure how to define primary care these days. He has seen it at its best in the work of the doctors in his book, at its worst in the medical care of some members of his own family, with doctors who are too detached and overcommitted even to answer his phone calls.

Primary care is "being a navigator," he said in an interview. "It's being a quarterback," knowing when to help, when to direct, when to pass. It's being "a team leader in an enterprise that's far more complicated and demanding than one person can do any more."

As policy makers scan the forest of health care, someone needs to be taking care of the trees — it's being a "tree-type."

Or as Robert will gladly tell you, primary care is whatever it takes for any patient, even the sickest, to feel cared for.

It may actually need no definition because anyone lucky enough to stumble into it knows exactly what it is.

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