Monthly Archives: January 2013

Re-Visioning Primary Care

Existing approaches to the looming crisis of primary care are like Congressional approaches to our fiscal crisis.  They have been, and will continue to be, unavailing because they shy away from structural change that would promote equity.  I suggest the time has come to think outside the financial box of subsidization and loan repayment for medical students and residents who agree to serve the medically underserved for a few years.  Here are my propositions and proposals:

  1. We should redefine “primary care” in a way that gives primary care physicians (PCPs) a fighting chance of actually functioning as specialists. This means eliminating “family medicine” altogether.  The effort to make the family physician (FP) (until 2003, the “family practitioner”) a specialist among specialists was tried in the 70s and by and largely failed – not for FP patients, certainly, but for FPs themselves, who, by most accounts, failed to achieve the academic stature and clinical privileges associated with specialist standing.  It is time to face this hard fact and acknowledge that the era of modern general practice/family medicine, as it took shape in the 1940s and came to fruition in the quarter century following World War II, is at an end.  Yet another round of financial incentives that make it easier for medical students and residents to “specialize” in family medicine will fail.  “Making it easier” will not make it easy enough, nor will it overcome a specialist mentality that has been entrenched since the 1950s.  Further policy-related efforts to increase the tenability of family medicine, such as increasing Medicare reimbursement for primary care services or restructuring Medicare to do away with primary care billing costs, will be socioeconomic Band-Aids that cover over the professional, personal, familial, and, yes, financial strains associated with family medicine in the twenty-first century.  Vague and unenforceable “mandates” by state legislatures directing public medical schools to “produce” more primary care physicians have been, and will continue to be, political Band-Aids.[1]
  2. As a society, we must re-vision generalist practice as the province of internists and pediatricians.  We must focus on developing incentives that encourage internists and pediatricians to practice general internal medicine and general pediatrics, respectively.  This reconfiguring of primary care medicine will help advance the “specialty” claims of primary care physicians.  Historically speaking, internal medicine and pediatrics are specialties, and the decision-making authority and case management prerogatives of internists and pediatricians are, in many locales, still those of specialists. General internists become “chief medical officers” of their hospitals; family physicians, with very rare exceptions, do not.  For a host of pragmatic and ideological reasons, many more American medical students at this juncture in medical history will enter primary care as internists and pediatricians than as family physicians.
  3. Part of this re-visioning and reconfiguring must entail recognition that generalist values are not synonymous with generalist practice.  Generalist values can be cultivated (or neglected) in any type of postgraduate medical training and implemented (or neglected) by physicians in any specialty. There are caring physicians among specialists, just as there are less-than-caring primary care physicians aplenty.  Caring physicians make caring interventions, however narrow their gaze.  My wonderfully caring dentist only observes the inside of my mouth but he is no less concerned with my well-being on account of it.  The claim of G. Gayle Stephens, one of the founders of the family practice specialty in the late 1960s, that internists, as a class, were zealous scientists committed to “a mechanistic and flawed concept of disease,” whereas family physicians, as a class, were humanistic, psychosocially embedded caregivers, was specious then and now.[2]  General internists are primary care physicians, and they can be expected to be no less caring (and, sadly, no more caring) of their patients than family physicians.  This is truer still of general pediatrics, which, as far back as the late nineteenth century, provided a decidedly patient-centered agenda for a cohort of gifted researcher-clinicians, many women physicians among them, whose growth as specialists (and, by the 1920s and 30s, as pediatric subspecialists) went hand-in-hand with an abiding commitment to the “whole patient.”[3]
  4. We will not remedy the primary care crisis by eliminating family medicine and developing incentives to keep internists and pediatricians in the “general practice” of their specialties.  In addition, we need policy initiatives to encourage subspecialized internists and subspecialized pediatricians to continue to work as generalists.  This has proven a workable solution in many developed countries, where the provision of primary care by specialists is a long-established norm.[4]   And, in point of fact, it has long been a de facto reality in many smaller American communities, where medical and pediatric subspecialists in cardiology, gastroenterology, endocrinology, et al. also practice general internal medicine and general pediatrics.  Perhaps we need a new kind of mandate:  that board-certified internists and pediatricians practice general internal medicine and general pediatrics, respectively, for a stipulated period (say, two years) before beginning their subspecialty fellowships.

Can we remedy the shortage of primary care physicians through the conduits of internal medicine and pediatrics?  No, absolutely not.  Even if incentive programs and mandates increase the percentage of internists and pediatricians who practice primary care, they will hardly provide the 44,000-53,000 new primary care physicians we will need by 2025.[5]  Nor will an increase in the percentage of medical students who choose primary care pull these new providers to the underserved communities where they are desperately needed.  There is little evidence that increasing the supply of primary care physicians affects (mal)distribution of those providers across the country.  Twenty percent of the American population lives in nonmetropolitan areas and is currently served by 9% of the nation’s physicians; over one third of these rural Americans live in what the Health Resources and Services Administration of the U.S. Department of Health and Human Services designates “Health Professional Shortage Areas” (HPSAs) in need of primary medical care.[6]  Efforts to induce foreign-trained physicians to serve these communities by offering them J-1 visa waivers have barely made a dent in the problem and represent an unconscionable “brain drain” of the medical resources of developing countries.[7]  The hope that expansion of rural medicine training programs at U.S. medical schools, taken in conjunction with increased medical school enrollement, could meet the need for thousands of new rural PCPs is not being borne out.  Graduating rural primary care physicians has not been, and likely will not be, a high priority for most American medical schools, a reality acknowledged by proponents of rural medicine programs.[8]

Over and against the admirable but ill-fated initiatives on the table, I propose two focal strategies for addressing the primary care crisis as a crisis of uneven distribution of medical services across the population:

  1. We must expend political capital and economic resources to encourage people to become mid-level providers, i.e., physician’s assistants (PAs) and nurse practitioners (NPs), and then develop incentives to keep them in primary care.  This need is more pressing than ever given (a) evidence that mid-level practitioners are more likely to remain in underserved areas than physicians,[9] and (b) the key role of mid-level providers in the team delivery systems, such as  Accountable Care Organizations and Patient-Centered Medical Homes, promoted by the Patient Protection and Affordable Care Act of 2010.  Unlike other health care providers, PAs change specialties over the course of their careers without additional training, and since the late 1990s, more PAs have left family medicine than have entered it.  It has become incumbent on us as a society to follow the lead of the armed forces and the Veterans Health Administration in exploiting this health care resource.[10]  To wit, (a) we must provide incentives to attract newly graduated PAs to primary care in underserved communities and to pull specialty-changing “journeyman PAs” back to primary care,[11] and (b) we must ease the path of military medics and corpsmen returning from Iraq and Afghanistan into PA programs by waiving college-degree eligibility requirements that have all but driven them away from these programs.[12]  Although the Physician Assistant profession came into existence in the mid-1960s to capitalize on the skill set and experience of medical corpsman returning from Vietnam, contemporary PA programs, with few exceptions, no longer recruit military veterans into their programs.[13]
  2. Finally, and most controversially, we need a new primary care specialty aimed at providing comprehensive care to rural and underserved communities.  I designate this new specialty Procedural Rural Medicine (PRM) and envision it as the most demanding – and potentially most rewarding – primary care specialty.  PRM would borrow and enlarge the recruitment strategies employed by the handful of medical schools with rural medicine training programs.[14]  But it would require a training curriculum, a residency program, and a broad system of incentives all its own.

In the next installment of this series, I will elaborate my vision of Procedural Rural Medicine and explain how and why it differs from family medicine as it currently exists.

[1] D. Hogberg, “The Next Exodus: Primary-Care Physicians and Medicare,” National Policy Analysis #640 (; C S. Weissert & S. L. Silberman, “Sending a policy signal: state legislatures, medical schools, and primary care mandates,” Journal of Health Politics, Policy and Law, 23:743-770, 1998.

[2] G. G. Stephens, The Intellectual Basis of Family Practice (Tucson, AZ: Winter Publishing, 1982), pp. 77, 96.

[3] See E. S. More, Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995 (Cambridge: Harvard University Press, 1999), pp. 170-72.  Edith Dunham, Martha Eliot, Helen Taussig, Edith Banfield Jackson, and Virginia Apgar stand out among the pioneer pediatricians who were true generalist-specialists.

[4] See W. J. Stephen, An Analysis of Primary Care: An International Study (Cambridge: Cambridge University Press, 1979) and B. S. Starfield, Primary Care: Concept, Evaluation and Policy (Oxford : Oxford University Press, 1992).

[5] The percentile range denotes the different protocols employed by researchers.  See M. J. Dill & E. S. Salsberg, “The complexities of physician supply and demand: projections through 2025,” Association of American Medical College, 2008 (,%202008.pdf); J. M. Colwill, et al., Will generalist physician supply meet demands of an increasing and aging population?  Health Affairs, 27:w232-w241, 2008;  and S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10: 503-509, 2012.

[6] See the Federal Office of Rural Health Policy, “Facts about . . . rural physicians” ( ) and J. D. Gazewood, et al., “Beyond the horizon: the role of academic health centers in improving the health of rural communities,” Acad. Med., 81:793-797, 2006.  In all, the federal government has designated 5,848 geographical areas HPSAs in need of primary medical care (

[7] These non-immigrant visa waivers, authorized since 1994 by the Physicians for Underserved Areas Act (the “Conrad State 30” Program), allow foreign-trained physicians who provide primary care in underserved communities for at least three years to waive the two-hear home residence requirement.  That is, these physicians do not have to return to their native countries for at least two years prior to applying for permanent residence or an immigration visa.  On the negative impact of this program on health equity and, inter alia, the global fight against HIV and AIDS, see V. Patel, “Recruiting doctors from poor countries: the great brain robbery?, BMJ, 327:926-928, 2003; F. Mullan, “The metrics of the physician brain drain,” New Engl. J. Med., 353:1810-1818, 2005; and N. Eyal & S. A. Hurst, “Physician brain drain:  can nothing be done?, Public Health Ethics, 1:180-192, 2008.

[8] See H. K. Rabinowitz, et al., “Medical school programs to increase the rural physician supply: a systematic review,” Acad. Med., 83:235-243, at 242:  “It is, therefore, unlikely that the graduation of rural physicians will be a high priority for most medical schools, unless specific regulations require this, or unless adequate financial resources are provided as incentives to support this mission.”

[9] U. Lehmann, “Mid-level health workers: the state of evidence on programmes, activities, costs and impact on health outcomes,” World Health Organization, 2008 (

[10] R. S. Hooker, “Federally employed physician assistants,” Mil. Med., 173:895-899, 2008.

[11] J. F. Cawley & R. S. Hooker, “Physician assistant role flexibility and career mobility,” JAAPA, 23:10, 2010.

[12] D. M. Brock, et al., “The physician assistant profession and military veterans,” Mil. Med., 176:197-203, 2011.

[13] N. Holt, “’Confusion’s masterpiece’:  the development of the physician assistant profession,” Bull. Hist. Med., 72:246-278, 1998; Brock, op cit., p. 197.

[14]H. K. Rabinowitz, et al., “Critical factors  for designing programs to increase the supply and retention of rural primary care physicians,” JAMA, 286:1041-48, 2001; H. K. Rabinowitz, et al., “The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later,” Acad. Med., 87:493-497, 2012; H. K. Rabinowitz, et al., “The relationship between matriculating medical students’ planned specialties and eventual rural practice outcomes,” Acad. Med., 87:1086-1090, 2012.

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.