Examining American family medicine in the New World Order - A study of 5 practices

BACKGROUND. In the last decade managed care has become the major form of he alth care delivery in the United States. Though some persons believe that m anaged care is the salvation of family practice, critics claim that it thre atens many of the core concepts of primary care. We systematically examined 5 US family practices, to provide a microanalysis of the current situation , particularly from the viewpoint of the care providers. METHODS. During 1997 and 1998, case studies were conducted at 5 sites using long interviews, focus groups, and extensive participant-observation of pr ovider-patient and provider-staff interactions. Participants included 54 he alth care providers, 18 administrators, 45 nurses or nursing assistants, an d 30 ancillary staff at the sites. RESULTS. We found dominant themes of rapid change, disruption, increased de mands, interference in clinical decision making, and adaptation. Health car e providers have the perception of being in the midst of a revolution with disruptions of key relationships and local knowledge. The clinicians in the study feel a loss of certainty, control, and autonomy. CONCLUSIONS. There appears to be a rampant ideologic competition occurring between business and beneficence for the moral sensibilities of family medi cine providers. This is potentially hazardous to feelings of trust in the p rovider-patient relationship. The focus of much of the warring has been on managed care, though many of today's problems either predated its developme nt or were peripheral to it. More empirical and observational studies are n eeded to document the fundamental changes taking place in today's health ca re environment.