LANGUAGE
Throughout Big Doctoring, I use the terms “generalist” or “generalist physician” and “primary care,” “primary care provider,” or “primary care clinician” more or less interchangeably. I do this knowing that I am blurring certain professional lines of demarcation. There certainly are distinctions that can be drawn between these terms, and there are activities or clinicians that are typically designated by one or another of the labels. Generalism as a term has broad implications and links to concepts well beyond medicine and, as such, has particular importance to certain discussions, whereas primary care has a more specific applicability to health care and, therefore, a special role in other discussions. Yet the commonality of the work of generalist practitioners substantially outweighs the differences in nomenclature that complicate the domain of primary care, and the message of Big Doctoring is one of ecumenicism, not of schism. Therefore, at each opportunity I have attempted to choose the term that makes most substantive sense and avoids semantic awkwardness.
These linguistic issues are enriched and complicated by the arrival of clinicians from backgrounds other than medicine in the primary care sector—specifically, nurse practitioners and physician assistants. Nurses, in particular, have well-developed identities and a long tradition of nursing practice, so that their new presence in the realm of “medical practice” has created multiple challenges of language. Words such as “provider” and “clinician” have to some extent taken the place of “doctor” or “physician.” In some circles the very word “medical” is considered both exclusionary
In choosing the title Big Doctoring, I concede from the start that I am not going to try to force my view and experience with the world of primary care into a language that might be topical but does not talk to the public as a whole. The title “Big Providing,” for instance, simply didn't work. Throughout the book I have followed this same convention. I consider nurse practitioners and physician assistants core members of the primary care family, and my interviews and writings include them in significant numbers. But the work that they do falls under the banner of what for centuries society has considered to be doctoring. I have tended to use language that welcomes them to that role, in the spirit of collegial embrace and in the hopes of an increasingly unified world of big doctoring.
Some readers will undoubtedly raise questions about my selection of primary care disciplines. The boundaries of primary care are not uniformly defined, and there are many professional disciplines within health care that regularly or, on occasion, identify themselves as primary care providers. Common examples include obstetrician/gynecologists, dentists, and podiatrists. Others lay claim to practicing primary care under certain circumstances, such as oncologists who sometimes treat noncancerous conditions of cancer patients. While the contributions of these clinicians to the delivery of primary care is important, in Big Doctoring I chose to limit my interviews to five categories of health professionals whose educational programs are designed to prepare them to care for most of the problems that trouble most people most of the time and whose practices reflect that training. These are family physicians, general internists, general pediatricians, nurse practitioners, and physician assistants.
It is my hope that Big Doctoring will help make the work of primary care more discernible to the public as a whole as well as to practitioners and students of medicine and the health professions. These lives tell a great deal about healers whose specialty is knowing and treating people over time and helping them navigate the opportunities and the hazards of an ever more complex health care system. Taken together, they make an eloquent case that primary care is a fascinating, important, and precious calling.