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The mess we're in: A review of Elephants in the Exam Room

Image courtesy of Bascom Hill Publishing. Over the last 40 years, medicine has experienced a radical change in the role of primary care physicians. Once captain of the health care ship, they’re now more like a funnel through which patients pass into the greater health care system.

In his book, Elephants in the Exam Room: The Big Picture Solution to Today’s Health Care “Crisis,” Medical School alumnus Wayne Liebhard, M.D. (Class of 1983), laments these changes and gives us a very personal look at how they affected the vocational life of a suburban Minnesota primary care physician. He begins with an honest description of the emotional pain he experienced when he moved from primary care to urgent care and ends with a quotation from Rousseau that encourages us all to act in concert to direct the forces shaping our world.

Along the way, Liebhard catalogs a common list of concerns with health and health care in the United States (the elephants in the exam room as it were), but a few are worth noting for the hardnosed approach he takes: lack of personal responsibility for health, the high price of prescription medications, and the growth of part-time practice.

Taking a libertarian view, Liebhard argues that people who take certain health risks ought to pay more for health insurance. He even boldly suggests that “we can limit what we wish to spend on care for irresponsible behavior.”

As for the high cost of prescription drugs, the author suggests that medications should not be covered by insurance, which would encourage both a greater use of generic drugs and more healthful living.

In perhaps his boldest move, Liebhard postulates that our primary care physician shortage is driven in part by the growing number of female primary care physicians who are choosing to practice part time. He also notes a rise in dual-physician marriages, which in some cases allow both physicians to work part time. He concludes that “people who have chosen primary care and have taken up a seat in medical school and residency need to realize that they owe a debt to society and act accordingly in their practices.”

This admonition will undoubtedly stimulate controversy and conversation, but in an era in which we are looking to such things as medical homes and accountable care organizations to rescue health care from the mess we are in, Liebhard sounds an important alarm for policymakers that this may be more hominess and accountability than the next generation of physicians is up for.

Reviewed by University of Minnesota Medical School alumnus James Hart, M.D. (Class of 1975). Hart was a general internist in Stillwater and with HealthPartners until 2005 and has been teaching public health at the University of Minnesota since then.

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