This article examines the future and primary care. Discussing the future does not mean the future can be seen with certainty. Imagine the following scenario. A reasonably talented scientist in the 22nd century extracts from termite amber the DNA of an extinct primary care practitioner. Primary Care Park, like Jurassic Park, is created where we can visit and see the physician generalist comforting an ill child, making diagnoses about common events, making house calls, and being available for patients at all hours. This physician is a well respected citizen of his/her community, and a physician who knows his/her patients over time.
The extinct generalist came about because of failures in education in the last half of the 20th century. This was a time of trouble around issues of health-care finance, of medical care organization, and the number and kinds of clinicians this country wanted. These were the issues that were discussed as part of major health-care reform. The question for the future of primary care is whether Primary Care Park is a fantasy or will it happen?
Using a typology originally presented by A.R. Tarlov, public attitudes and policies can be examined as a means of understanding society's willingness to make important decisions about health, which require change (unpublished data, 1984). The public policy periods identified include: 1 ) Flexner reforms, 2) American Medical Association (AMA) restraint, 3) public awareness, and 4) turmoil and change with the future to be determined by 5) a new consensus.
The Flexnerian reforms occurred at a time when medical education in the United States was in crisis. The rapidity with which Flexnerian reforms were accepted and implemented indicate what can occur when consensus is achieved. The AMA restraint period followed World War I and the great depression. At this time, the AMA was in control of both the education and practice of medicine, and little change occurred. World War II intervened, and in the 1960s our nation rediscovered poverty. Turmoil in the health field is a reasonable description of the current scene, and most of us expect change. Finally, the nature of the change will depend on whether we can forge a new consensus.
In each of the first three periods, a powerful group defended or advocated for a position that became popular and effective without regard for the long-term consequences. The existence of turmoil suggests that today a number of powerful interests have divergent views of what changes should occur and we have not reached a consensus.
Will we achieve a new consensus about primary care? Nesbitt and Aburdeni1 have provided a methodology for assessing the future through the use megatrends. Megatrends are large and important issues that shape the future. If we can successfully identify medical education megatrends and act accordingly, we could anticipate and plan accordingly for the future. In 1974, Hoekelman in an editorial in JAMA2 gave his megatrends. These were: less serious disease, change in reproductive behavior, dramatic and new therapies, and sharing with other health professionals responsibilities for health-care service delivery. His final megatrend was increased consumer control and the larger voice patients would have with respect to medical care issues and decision making. in 1974 we had acted with consensus using Hoekelmans megatrends, we would have made decisions that would have been implemented by 1993. We might have prevented our present shortage of generalists.
Pediatrie megatrends that provide signposts for the 21st century are: changing morbidity, children at risk, spending limits, and practicing generalists.
First, we will continue to see changing morbidity. The change in morbidity will involve diseases lifestyle. Examples of changing morbidity are disordered learning, obesity, alcohol, drug abuse, and violence. More morbidity will be psychosocial and will be managed largely through the interventions provided by behavioral and developmental pediatrics. This morbidity will be shaped as much by forces outside the traditional field of medicine (eg, the environment) as within it.
The second trend is children at risk, which means that children will face a broad range of social, behavioral, and economic issues. While most children can succeed despite these risks, it is the family's economic state that will determine the impact and outcome of many illnesses. For example, crowded housing and the difficult conditions imposed by poverty will continue to place poor children at increased risk for diseases such as lead poisoning and injuries. Developmental delay, learning disabilities, and inadequate nutrition will affect larger numbers of poor children.
The third megatrend is spending limits. Fewer dollars will be available for pediatrie health services. Within the health services field, we will compete with others for service dollars. Costs will have to be managed through choices and spending caps will be part of the future. Finally, if the generalist megatrend is correct, the future of primary care is secure as generalists will be practicing.
Why is primary care basic to the practice of medicine? Primary care is the foundation of the medical profession's contract with society. We have had that contract for a long time but we didn't always call it primary care; we have used other descriptive terms. The primary care function was described in the 1930s and before as general practice.3 Medical schools existed to produce generalists. In the 1940s at Johns Hopkins, Richardson wrote about the whole patient. Reader at Cornell and Kerr and Hammond at Colorado in the 1950s used the term comprehensive care. In the 1960s, general practice was replaced by family practice. General practice, at least in academic circles, had become a pejorative term. At Harvard and Case Western Reserve, programs were established in family care. In the 1960s, a series of reports, of which the Millis report4 was representative, charged medicine to function as a social, preventative discipline delivering personal medical services through the skills and expertise of well-trained primary care physicians. The phrase primary care became widely used in the 1970s, fry, in England, and White, in the United States, described primary care as part of the organization of delivery of health-care services, along with secondary and tertiary care. The term generalist resurfaced in the 1980s, and in the 1990s, the term community physician has reappeared.
In 1973, Alpert and Chamey3 defined primary care as having four anchoring points: first contact, coordinated, integrated, and family-focused care. In its first-contact function, primary care is concerned with the interface between the patient and the physician and the patient's outreach, follow-up, and compliance. Primary care includes coordinated and longitudinal responsibility for a patient regardless of the presence or absence of disease. The primary care physician, with his or her colleagues, is available at all times and functions in a broad range of settings delivering care. The third anchoring point is integration of services. When other professional help or resources are called for, the primary care physician manages, to the limit of his or her capacity, the physical and psychological and social aspects of patient care. Finally, these services are delivered to families either directly or with a family focus. The fundamental unit of living in our society is the family, and reports of the death of the family as a functional unit, as Mark Twain said of his death, are premature and exaggerated. Primary care, as defined, is the cornerstone of personal health services.
MEDICAL EDUCATION AND PRIMARY CARE
Why in the 1990s are we in an increasingly severe primary care crisis? The answer may be placed at the doorstep of medical education. Medical education generally has had two goals. These goals are first to provide knowledge and second to provide access to services.
Medical institutions have succeeded with the knowledge goal brilliantly. However, these same institutions have failed at providing access even though medical schools and their affiliated hospitals have had two ongoing opportunities to provide access. The first opportunity is through the delivery of services in the hospital setting using the emergency room and outpatient departments often serving the nearby urban community. The second opportunity is to educate physicians who will enter practice and thereby provide service.
Because the physician has always been the major educational product of medical schools, why have we failed to educate physicians, especially as generalists? The answer may be found as a by-product of US medicine, which has many strengths. These include modern facilities, high technology, outstanding biomedical research, and, some would say, a world standard of graduate education. This education has largely been hospital-based specialty education.
However, there are also important weaknesses. Part of the reason that we are in the stage of turmoil and change today is because of these weaknesses. Our medical care is expensive. There are financial barriers when needed services are to be received. We have too many subspecialists, especially surgeons and other procedurally driven specialists, and of course too few generalists. We have not learned much from other countries where costs of medical care are associated with the numbers of generalists who practice with clinical freedom. In England, 70% of practicing physicians are generalists and 6% of the gross national product (GNP) is spent on health care. In Canada, also with a commitment to a generalist service, 50% of practicing physicians are generalists and 9% of the GNP is spent on health care. In the United States, 30% of physicians are generalists and 14% of the GNP is being spent on health, and the percentage devoted to health for 1993 is approaching 17%, while the percentage of generalists continues to fall. Without change, the percentage of US generalists will shortly decrease to 15%, and in the 21st century, we will have Primary Care Park.
Barriers to primary care education exist in the academic environment. Most obvious is academic arrogance. In the teaching hospital, the generalist is referred to as local medical doctor or the referring physician, and medical students who want to be generalists are told that as generalists, they would have wasted their careers.
The hospital environment where education takes place was never designed for primary care. A specialized full-time medical faculty supported by grants became teachers replacing the clinical practicing faculty. Financial incentives rewarded the subspecialists as did lifestyle. Although review of training regulations by the pediatrie residency review committee is again underway, the history of regulation has been to place restrictions on primary care. Controversy continues in internal medicine where 70% of practicing internists have a subspecialty, and the internists argue about whether the internist is a generalist or a subspecialist. Pediatricians debate the same issue and experience the tension as to whether pediatrics is a primary care or a specialist discipline.
PRIMARY CARE STRATEGIES
What can we do to correct the primary care crisis? There are short-term strategies. There are too many subspecialists so let us retrain them. Let us increase the nonphysician role and educate more advanced nurse practitioners and physicians' assistants to de' liver primary care. These are logical actions considering the present crisis but they will fall short. Using nonphysicians instead of the generalists should not be seen as a replacement but as an addition to the generalist physician. We also need to support generalists who are willing to stay in practice.
There is another set of short-term strategies that have little to do with education. Let us rapidly improve the work environment. We must have insurance reform and simplified billing. We must increase the income of the generalist. These actions would definitely decrease entry into the specialties and expand the pool of generalists.
If we succeed, Primary Care Park will have specialists driving the tour buses. If it is true that generalists in some California Health Maintenance Organizations are starting with salaries of $145 000 and there are no openings for specialists, the hoped for changes may be beginning.
Hoekelman provided us an educational prescription in 1974 that, in combination with his megatrends, would have addressed today's issues. He advised us to change medical education and to make it pertinent to practice. He wanted us to have an interdisciplinary approach. Once again, we have experiments in medical education. The latest efforts are supported by the Kellogg, PEW, and Robert Wood Johnson foundations. Tliese experiments are impor tant, but like most experiments, will end when funding ends. If past history is a guide and medical education is left to its own devices, little will change, and the experiments will continue to come and go, as does their funding.
Society may expect medical education to reduce costs, increase access, and have more generalists. If we accept the view that primary care is the foundation of the medical profession's contract with society and we achieve consensus, we will determine that the future for medicine is primary care. It may be that we will not or should not be allowed the luxury of making our own decision. Long-term proposals to increase generalists are emerging from not only educational but also from other groups. The Physician Payment Review Commission, the Council on Graduate Medical Education, and the Rockefeller Commission have proposed a national physician workforce commission that would set national targets implemented through direct financing of graduate medical education. One mechanism to accomplish this goal would be by increasing reimbursement for primary care residencies and not funding subspecialty training.
Whether we like these ideas or not, it appears certain that the future of primary care will be determined not just by what happens within the medical school setting, but also by what happens outside. This means that complex and large medical and social issues must be addressed. Careful attention must be paid to our professional relationships with local, state, and national government as well as other professional groups about children's issues to ensure wise, longterm decisions. The absence of universal health coverage is a crisis that is now being debated through health-care reform. Achieving the financial timetable will be determined by political considerations, as perhaps will the resolution of the primary care crisis. However, our shame as the only industrialized western nation without a national health insurance program must change and so must the shame of inadequate numbers of generalists be corrected.
Primary care is about the intimate contact that takes place when a patient comes to the physician because that individual is concerned that he OT she, son or daughter, parent or grandparent is sick, or is well and wants to stay well. Our history has been that we have paid attention to important problems but we have missed so far on primary care as a megatrend. As noted, one of our most important societal megatrends is poverty and how poverty places children at risk. Poverty and primary care are linked. The reality that all of our citizens do not have access to primary care is not just our failure but it is society's as well.
We pediatricians face many problems. In developing solutions, historically our profession has never lost sight of the fact that we are a helping and caring discipline. We are an advocate for the poor, advocates for children, advocates for community, and that is a large job. But the challenge is real, and we do not have much time. Now is not the time to be timid. We need to achieve consensus, accepting and acting on the megatrend of securing the future for primary care.
1. Nesbitt J, Aburdeni P Megatrends: Ten New Dnecoom Traru/brmingOur LHCI. New York, NY: Warner Bodts; 1982.
2. Hoekelman RA. A prognosis for pediatrics. JAMA. 1974;228:1274-I275.
3. Alpen j], Chamey E The Eduaow of Physiaans for Pnrnaiy Catr Washington, DC: US Dept of Health, Education, and Wfelfere; 1973- DHEW publican«! (HRA) 74-3113.
4. MiUu JS. The Graduate Educano« of Pkjadtms Repart of die Cunáis Cananaàon an Graduar Medica! Education- Chicago, UL American Medical Associât ion r 1966.