The quote above points to “the writing on the wall” as the baby boomers age and the U.S. health care system faces a “perfect storm, ” where the losses are potentially great for those at the receiving and providing ends. To assume that cure is the ultimate solution is equally troubling, as great burdens are placed on practitioners and health systems to continue managing larger numbers of those living longer with chronic illnesses, even if dementia were to be eradicated. The quote is also testament to the persistent, symbolic power of “cure, ” even when its purpose and utility prove inadequate and when alternatives might exist. The issue is not whether physicians care about their patients, for they do, but how they care for them when biomedicine falls short and when the needs of patients and families reach beyond physicians’ prescriptive practices. This has ramifications for the gap between physicians’ ideas about what constitutes “proper” medical work, and their patients’ needs.
The alternative differed from the mainstream cure model, and it involved a greater emphasis on the psychosocial and emotional dimensions of health and patient experience (Benner et al., 1996
; Cancian & Oliker, 2000
; Davies, 1995a
; Ungerson, 1990
; Waerness, 1984
; Watson, 1985
). Essentially, the care alternative encompassed concerns for a patient’s quality of life and well-being, expanding the clinical imperatives of the physician role (Waitzkin & Britt, 1989
). This dissonance required symbolic work as physicians were pushed to accept the value and meaning of comfort, psychosocial emotional support, and “unskilled” work as part of their practice and professional identity. We found that PCPs reconciled the dilemma posed by dementia patients by relinquishing jurisdiction of caring to other health practitioners, and only a notable minority of PCPs effectively combined these two models. In short, PCPs collectively reinforced what has historically constituted claims to medical expertise by underscoring the preeminence of their technical interventions vis-à-vis caring more holistically. In so doing, they infused new life into the cure/care divide. The call to end the cure vs. care debate, as Jecker and Self (1991)
proposed, remains an ideal.
As we have shown, revising the guiding values central to PCPs’ practice will not come easy. This challenge must be understood in a larger social context where organizational, structural, and ideological dynamics take place. For instance, cure has historically served medicine well in advancing collective (occupational) interests, yet perhaps not against the encroachment of HMOs over the last 60 years. These structural changes in the delivery of health services have impacted primary care, which declined in status vis-à-vis increasing technical specialization. In particular, primary care has moved toward triaging and resource coordination, focusing mostly on common illness treatment and leaving the “fancy” stuff for specialists. Additionally, PCPs are among the lowest paid physicians in medicine (for a related argument, see Kim & Sakamoto, 2008
). Over the past decades there has been a continuing decline in the number of medical students entering primary care, an issue that has prompted much research and many campaigns to improve recruitment (Bodenheimer & Pham, 2010
; Tu & Ginsburg, 2006
; Walker et al., 2010
). Likewise, the unprecedented health care demands following legislative reform and a diverse aging population will further test already strained resources and the practitioner–patient relationship. In short, PCPs have become the front line of health care reform. They are “in the trenches, ” where much is at stake; where symbolic struggles over professional identity and practice have important material and territorial consequences.
We do not suggest that PCPs should be an “all-in-one” practitioner, holding the expertise of others such as nurses, social workers, or psychologists. Rather, we see the caring challenge faced by physicians working with dementia patients as underscoring the vulnerable yet potentially transformational position of primary care in the decades to come. Regarding this transformational capacity, some have proposed a participatory or partnership approach between physician and patient, a patient-centered model in which patients/families become integrally involved in the health care decision-making process. Scholars such as Davies (1995b)
have also called for a “new professionalism” in which different types of knowledge and approaches to health and healing are equally valued to advance the well-being of patients and improve the collaboration of health care practitioners (see also Holmes 1989
; Hugman, 1998a
). Calls for a new model of health care practice require “a process of situated reflection on expertise and experience which attends to the uniqueness and the uncertainty of the specific situation” (Davies, 1995b
, p. 139). Bridging curing and caring entails rejecting the hegemony of the biomedical model and focusing on a more balanced view of health provision that is based on genuine collaboration among different health care practitioners, and among practitioners, patients, families, and the community.
Because the evidence remains inconclusive on the efficacy of drug therapies for dementia, the promise of the new professionalism and/or a patient-centered model leading to the reconciliation of cure and care are equally mixed. The playing field in health care remains embedded in a hierarchical system characterized by distinctively stratified work-places where health services are provided (Apesoa-Varano, 2008
), and some models of health care practice carry more weight than others. The persistence of power differentials is still evident not only in the division of labor in health institutions but also in the relationship between “experts” and “clients, ” physicians and patients, and among health practitioners themselves (Gill, 1998
; Waitzkin, 2000
; Waitzkin, Britt, & Williams, 1994
This unequal distribution of privilege and power highlights that the cure/care divide is not simply a matter of disembodied values and beliefs. It is unquestionably grounded in structural conditions and the sociohistorical path of medicine as an occupation in the United States. Health care policy addressing these inequities is as important as returning to a Hippocratic Oath by which practitioners seek to “do no harm” rather than do “great deeds.” Practitioners might revisit their calling to the public good by considering that what is good for them must also be good for those they serve, and for society at large beyond the patient room. After all, we continue to confer great respect on highly trained medical and health professionals, and we hold them as paradigmatic of achievement and success.