The future of primary care in America

Author: Fitzhugh Mullan
Date: Oct, 1991

In the period following World War II, the U.S. medical care system was composed principally of generalists, with almost two-thirds of the physicians identifying themselves as general practitioners. Today, that statistic is reversed, with roughly two-thirds of practicing physicians identifying themselves as subspecialists. Comparatively, Canada and Great Britain--two countries similar to ours in culture and general health status--currently have primary care physician bases of 50 and 70 percent, respectively.

Moreover, the erosion in the primary care infrastructure of this country is evidenced by the declining numbers of medical students indicating an interest in primary care and by the subsequent decline in the National Resident Matching Program match rate in primary care disciplines (i.e., family practice, general internal medicine and general pediatrics). In 1989, only 25 percent of medical students indicated an interest in primary care, compared with nearly 40 percent in 1981. [1] In family medicine, the match rate had declined from 85 percent in 1984 to 65 percent in 1991. [2] Even as we graduate more medical students, the lure of subspecialization draws young physicians away from the practice of primary care. For example, almost two-thirds of the internal medicine residents in the 1980s chose subspecialties rather than general internal medicine. [3]

Not surprisingly, the problems with the infrastructure of primary care are reflected in pimrary care programs that strive to provide health care access to disadvantaged populations. The Federal Community Health Center Program, the National Health Service Corps, the Indian Health Service, rural health programs and state or locally financed access projects tend to focus on primary care in the sense of access to basic health and medical care for populations who have difficulty obtaining such care through conventional means. In a recent survey, 45 of the 50 governors indicated that primary care manpower was a significant problem in their states. The supply of primary care physicians in rural areas is particularly problematic. [4] The federal health professions shortage area (HPSA) designation system measures primary care manpower shortage areas throughout the country and tracks the number of physicians needed to bring these areas to a minimum staffing level. With the help of the National Health Service Corps, the physician deficit diminished slightly, from 4,500 in 1984 to 4,100 in 1988, but has begun to climb again and is now at 4,200. [5]

If a system of health care firmly built on a foundation of primary care is the most effective way to provide excellent, broad-based services at a reasonable cost to the entire population--disadvantaged and not disadvantaged--reversal of the erosion in our system of primary care training and practice is essential. Improving the status and opportunities for primary care teaching in medical schools is important. Augmenting the reimbursement for primary care services as proposed under the resource-based relative value scale (RBRVS) is critical, as is a general strengthening of the continuum of primary care teaching, training and practice.

The Health Resources and Services Administration of the Public Health Service is developing an overall strategy to focus attention on the primary care needs of the nation and to increase efforts to fulfill these needs. The following interrelated concepts may help to bolster primary care:

National Health Service Corps. The scholarship and loan repayment program of the National Health Service Crops could be revitalized to target the hardest-to-staff underserved areas.

Minority health professionals. Continued emphasis in federal funding could be placed on programs aimed at preparing and training health professionals from minority and disadvantaged backgrounds.

Primary care research. Research in primary care could be expanded, funded principally by the Agency for Health Care Policy and Research.

Primary care training. A priority could be placed on programs for primary care graduate medical education that provide explicit preparation for work with underserved populations.

Service-linked education programs. Service-linked education programs, such as area health education centers, geriatric education centers and AIDS education and training centers, could continue, with increased emphasis on program training activities dedicated to primary care providers for work with underserved populations.

Nonphysician providers. Support could be given to nonphysician providers in the delivery of primary care services, and the roles of these providers could be more clearly delineated.

Public health practice. Training for public health practice could link the work of public health practitioners to the provision of primary care services.

Health Care Financing Administration. HCFA, in its administration of the Medicare trust fund, will spend $4.7 billion on graduate medical education in 1991. Despite recent efforts of HCFA to increase reimbursement for primary care training, this money is policy-neutral and does nothing to address the erosion of primary care. A collaborative undertaking between HCFA and the Public Health Service in support of primary care training activities could bring an important new emphasis and source of support for efforts to improve primary care teaching, training and practice.

To achieve these goals, the primary care community needs an organizational means that will enable family medicine, general internal medicine, general pediatrics, nurse practitioners and nurse midwives to talk to one another and speak to the world as a whole on certain key, common issues. Without a potent and unified voice from the primary care education and practice communities, efforts to improve access to health care will be far less effective. A common forum for discussing ideas and voicing opinions would be an enourmous step toward strengthening family medicine and primary care as a whole. The time for such a forum has come; let us hope it can become a reality.


[1] AAMC Data Book. Washington, D.C.: Association of American Medical Colleges, 1990.

[2] National Resident Matching Program (U.S.) NRMP data. Evanston, Ill.: National Resident Matching Program, 1991.

[3] Barnett PG, Midtling JE. Public policy and the supply of primary care physicians. JAMA 1989;262:2864-8.

[4] States' assessment of health personnel shortages: issues and concerns. Hyattsville, Md.: U.S. Department of Health and Human Services, 1990; DHHS publication no. HRC-P-OD 90-6.

[5] U.S. Department of Health and Human Services. HRSA's long range action plan: report on access to primary care for all. Report to the Assistant Secretary for Health, June 7, 1990.

COPYRIGHT 1991 American Academy of Family PhysiciansCOPYRIGHT 2004 Gale Group

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