10
PRIMARY CARE: SOME ISSUES* DAVID E. ROGERS, M.D. President, The Robert Wood Johnson Foundation Princeton, N.J.
I SHALL try to set some boundaries around the subject of primary care and offer a definition of the problems the United States faces in developing a more satisfactory system for the delivery of primary care. This is difficult to do effectively; most medical people hear more than they wish to about primary care, and the rhetoric on the subject has become monotonous and repetitious. There are, however, some clear pressures for change in the way in which we train our medical manpower and how we distribute the fruits of our achievements in biomedical research to those who want them. I do not believe that these pressures will go away. How can we, as a nation and as health professionals, adapt our educational programs and services to fulfill more adequately the general needs for medical care at a cost which is tolerable? This is one of the major challenges of our times. To set the stage, I shall first offer a definition of what I have come to include in the term primary care. Next, I shall document briefly the current mismatch between needs-either real or perceived-and the care we now are supplying, and list a few of the pros and cons to be examined in considering whether it is reasonable to attempt to construct a better system of primary care when so many social needs are competing for funds and attention. I shall then offer some possible ways in which the health-care system might be modified to improve primary-care services if it is agreed that we should make that effort. WHAT IS PRIMARY CARE?
The term primary care has become a shorthand term for the kind of care traditionally delivered by community-based physicians. It is first-contact medicine. However, it has some additional dimensions. First, it is care of a continuing, longitudinal nature. It also implies continuing medical responsibility for groups of people, and not just for individuals who seek a physician. It has integrationist qualities in that it must combine *Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
PRIMARY
CARE:
SOME
II
11
concern for social and psychological factors which contribute to illness with concern for factors that are physiologic and disease-oriented. This care might be provided by internists, pediatricians or obstetricians and gynecologists, and most certainly by family practitioners. It also could involve care given by other kinds of health professionals. WHAT MUST A PRIMARY CARE SYSTEM DELIVER?
Any system of primary care must have certain basic capabilities. The following have seemed most important.1 1) It must provide ready access to the physician or some other health professional who can cope effectively with ordinary medical problems. 2) It must be able to separate from the many innocent-appearing situations those few that are potentially serious and it must provide properly for them. 3) It must provide scientific, humanistic support to those that it serves. 4) It must provide care on a continuing basis. 5) It must be distributed with reasonable equity. 6) As a system, it must be stable and self-renewing, i.e., those who work in it must enjoy it and others must wish to enter the field. 7) It must have a proper fit with the way of life or the culture of those it serves, and this will vary widely by background, culture, and locale in our diverse and far-flung country. 8) It must be able to receive support in competition with other real needs of our society. How DID WE REACH OUR PRESENT STATE?
The development of specialists with progressively narrower orientations was a logical response to advancing knowledge about human illness and the rapidly multiplying therapeutic technologies. The recognition in the 19th century of the microbial etiology of many diseases, the discovery of anesthesia, and the realization at the time of World War I that we were not adequately training doctors to care for our troops all started the shift. The march of science-based medicine, heralded in the 1920s by the discovery of insulin and proceeding through to the development of antimicrobial drugs and of potent agents for the management of high blood pressure, congestive heart failure, and malignancies put powerful tools in the hands of the individual physician. These advances, coupled with the shifts in medical education which followed the Flexner Report of 19 1 0, the increasing focus on hospitalized patients, and Vol. 53, No. 1, January-February 1977
12
12
D. E. ROGERS
the freedom of so many medical schools each able to pursue its own ends has contributed to our current dilemma. WHAT HAS BEEN THE RESULT?
The result of these many forces is the subject at issue of this conference. First, there is a worrisome lack of correlation between the kinds of physicians we need and those that we produce. It has been estimated that 60 to 70% of the problems which bring people to doctors are straightforward problems in primary care. Yet, until recently only about 1% of our postgraduate residency-training opportunities have been directed toward primary-care careers. Thus, since the early 1950s we have had a progressive decline in the number of physicians who function as generalists and a marked increase in the number who treat special problems. Second, we have wide geographic variations in the number of health professionals available to those seeking care. That there are five-fold or greater differences between the numbers of physicians available in some wealthy areas, e.g., sections of New York City, and other less wealthy parts of the United States is causing many to worry about our responsiveness to health needs. The fact that the well-to-do have much more ready access to physicians than the poor do also is disturbing at a time when we are trying to correct social inequities in many sectors. These data suggest that something has gone awry. SHOULD WE Do SOMETHING ABOUT IT?
Clearly, one of the questions facing the medical profession and society in general is whether we should do something about the situation. During the period of the great society of the 1960s we attempted to correct many social inequities. This period was discouraging to many people; it has come to be viewed as a time of throwing money at social problems with disappointing results. Thus, it is now often heard that the world is inequitable in most areas. It is inequitable in housing, nutrition, income, and many other areas. People ask if it is reasonable to strive for more equity in medical care. Second, many worry that we have oversold what medical care can do to improve health. Simply providing more medical care does not, of itself, insure good health. The millions of dollars spent on mental health have not decreased the incidence of schizophrenia, and there are precious few adultonset diseases we can prevent simply with more medical care. The heavy Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
PRIMARY
CARE:
13 13
expenses versus probable benefits now are being debated in many quarters. Finally, the inherent contradictions in the design of any system of primary care are troubling many thoughtful students of the health-care system. The maintenance of the kinds of technical and scientific skills we ask of a physician today requires considerable experience with complex diseases. If we design a system in which physicians assume medical-care responsibilities for defined groups of a certain size, we run the hazard of letting these skills atrophy. To illustrate: one physician probably can take care of or relate in a meaningful way to between 2,500 and 4,000 people. Numerous studies permit us to predict what kinds of disease processes will be encountered in a group of this size composed of people of differing ages. I can assure you that the number is very few. Thus, such a physician may see five patients with appendicitis a year. The physician might see a carcinoma of the cervix every three years. A child with a congenital heart lesion will be encountered perhaps five times in the physician's practicing lifetime. One of the basic capabilities that I listed as important in a primary-care system-to separate innocentappearing situations from those few that are potentially serious-clearly requires some continuing experience with complex illness to keep those skills sharpened. The dilemma could be likened to what we face in our peace-time navy, where we ask sailors to maintain a whole set of skills that we hope they will never have to use. Thus, we face a problem in designing a system which will deliver prompt and effective primary care while at the same time permitting maintenance of the kinds of expertise that we ask of the modem physician. There is, however, another side to the coin. First, it is clear that more adequate primary care can, under certain circumstances, make a difference in health. We should be cautious about the conventional wisdom of the moment which says that it does not. For example, after the introduction of maternal and infant-care centers in poor areas during the 1960s there was a profound reduction in infant mortality in these areas. In Omaha, for example, infant mortality dropped from 33.4 per thousand to 13.9 in less than four years. 2 That is a remarkable advance. The same was true in areas which initiated health-care programs for children and teen-agers. When viewed collectively these programs reduced serious illness; hospitalization of youngsters decreased by 60%. The costs of child-health care went down by a similar amount. 3 A second reason for developing a more adequate system of primary care is
Vol. 53, No. 1, January-February 1977
14
D. E. ROGERS 14~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
simply the cost factor. Despite increasing efficiencies, hospital costs will continue to escalate; they must do so, for they are labor-intensive, hightechnology centers. Consequently, major attention must be directed to managing more illnesses outside hospitals. As an example, if we had been able to foreshorten hospitalization for everyone hospitalized in the United States last year by one day, it would have saved this country $2 billion. This seems deserving of attention. Finally, there is the human need part of the equation. With the fragmentation of families, church ties, and other social support structures medicine is increasingly viewed as a potent coping force needed by many. The management of straightforward illness, the effective management of chronic disease, and the relief of anxiety are important human needs. Thus, I would guess that whether it is cost-effective or not, as a nation we shall move to put a better system in place. WHAT ARE THE OPTIONS?
The options for developing a stronger system for general care are finite. They must be considered against the backdrop of our times, our culture, and realistic limits of present social choice. Broadly speaking, one can go one of two ways, depending on one's prejudices. There are a series of options which derive from the view that the profound decline in the selection of generalist careers results from our present system of medical education. This thesis holds that we have not admitted the right people to medicine and that we have not designed the curriculum properly to show aspiring physicians the values of a generalist career. The second premise holds that the large-scale avoidance of generalist careers is a permanent phenomenon. This view is based on the premise that the advance of science-based technology and the requirements for practising as a modern physician are so complex that the days of the generalist are past. If this is so, we must develop other mechanisms for coping with the generalist's function. Dr. Walsh McDermott and others of the Robert Wood Johnson Foundation have come up with a number of options. 1 The first four stem from the thesis that we have chosen the wrong people and have not properly designed our medical school or residency-career experiences to keep the generalist role attractive. 1) Recast the criteria for admission to medical school to select some candidates who would be interested in generalist careers. A number of institutions are moving in this direction. Some studies suggest that if we chose
Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
15
15
different kinds of people with different values and aspirations more of them might enter generalist careers. 2) Train two kinds of physicians. It has been suggested that a shorter, faster system of education could be developed for those who would become generalists and a longer educational experience for those who would specialize. This idea has been advanced intermittently over many years. It presents major philosophic problems in our society. Americans have been very reluctant to move to a two-tiered physician system. This inevitably would lead to viewing the graduates as either first-class or second-class physicians, based upon the length of education, with the generalists the losers. 3) Restructure the graduate training of physicians so that we materially increase the opportunities for young men and women to gain experience with primary care. This would require sharply limiting the number of opportunities to go into specialties and increasing the number of training opportunities for generalists. The experience which differentiates the doctor is his postgraduate residency training. To increase generalist postgraduate opportunities has been one of the options selected by the federal government; it is supporting an increasing number of family-practice residencies. Similarly, many academic centers are expanding the primary-care opportunities for residents in medicine and pediatrics. 4) Use economic incentives to encourage entry into primary or general medical careers. This has been done with considerable success in Great Britain and Canada. We have tried it tentatively in the past by indenturing students for subsequent service in particular areas with discouraging results, but it deserves broad consideration. The remaining options stem from the other thesis: that a generalist career is no longer a viable lifetime career for many who are now entering medical school. 5) Consider general medical practice as a stage in the physician's development or career. This would dictate that young physicians could not go into specialty training until they had devoted a period of time to experience as generalists. This system worked quite well in the United States before and during World War II. Many young men put in at least two years as generalists before turning to other kinds of careers. It is the way our National Health Service Corps is now functioning. It delivers medical care of quite acceptable quality. It would fall short of the ideal system in that it would not offer care of a continuing nature by the same physician. 6) Use other kinds of health professionals, such as nurse-practitioners or
Vol. 53, No. 1, January-February 1977
1616
D. D. E. E. ROGERS ROGERS~~~~~~~~~~~~
physician assistants to cover the bulk of primary medical care. Under such an option the physician simply would leave primary care to others and play a supervisory role. At present such a system alone would not be acceptable to many Americans. 7) Use foreign medical graduates for the bulk of general medical care. I have added this option largely for the sake of completeness, because I have heard it suggested. It is totally unrealistic. It flies in the face of the career patterns that FMGs elect since they essentially have the same preferences as American graduates. Further, I think it would be socially unacceptable in this country. It clearly would create some major problems if one of our objectives is to develop the kind of care which fits the life-style and culture of those being served. 8) Rely on the "hidden system" of general medical care that we now have and fill in the gaps by the creation of special subsystems for those people not now covered. Although most specialists deny it in a survey, many provide a great deal of general medical care. However, only select patients get into this system. Internists or pediatricians spend a great deal of their time in primary care. The surgeon whose patients initially come because of a surgical problem such as that involving a gall bladder or a hernia often will continue to provide these patients with some general medical care. It works, but it fails to offer a clear, easily understood way of entering into the system. 9) Develop free-standing multispecialty groups to serve the primary-care function. With such a strategy we would continue to train specialists in the hope that they would, in groups and in certain kinds of constellations, subserve the primary-care function as a group function. 10) Develop a strategy in which primary-care groups work through linkages to public and private hospitals. We now have some 7,000 community hospitals and it seems reasonable to consider linking a primary-care system to this existing network. WHAT SHALL WE Do? Obviously, the question is which way will the United States go? My predictions would include a bit of all of the directions I have suggested. At this time I would guess that we shall move with a series of positive incentives-the carrot rather than the stick approach-although this is being debated at a national level and the situation may change. I expect that health care will become an increasingly regulated industry. However, I do not believe that this will include regulation of the careers of physicians themselves. I think that is politically unlikely in the United States today. Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
17
Our major efforts probably will go to emphasizing the hidden system. I believe we shall see changes in the training of internists and a dramatic change in the training of pediatricians. Obstetrician-gynecologists may become generalist physicians for women. Clearly, we shall expand the number of family practitioners. I think we also shall continue to experiment with the use of other kinds of health professionals, particularly in areas which simply cannot logically sustain a physician's practice. Thus, it seems likely that nurse-practitioners, physician assistants, and other kinds of health professionals will play increasingly important roles. I expect to see a number of experiments which will use the existing network of community hospitals to link groups with a primary-care orientation to that base. We probably shall see the increasing basing of specialists in hospitals; new physicians will choose either primarily in-hospital or out-of-hospital careers, although, obviously, there will continue to be an overlap. We have a mandate to do a more adequate job of delivering prompt, effective, and humanistic care of straightforward problems to people who sleep in their own beds at night. It is clear that we are capable of doing so and I hope that we shall. The fact that the New York Academy of Medicine has chosen to devote attention to this topic gives me encouragement. The Robert Wood Johnson Foundation, which I represent, is also working to help in this effort. REFERENCES 1. McDermott, W.: General medical care. Acad. Sciences, 1973. Identification and analysis of alternative 3. Minnesota Systems Research: Children and Youth Projects Report, Service 18 approaches. John Hopkins Med. J. and 20, Quarterly Summary Reports. 135:292, 1974. April-June 1972 and October-December 2. Kessner, D.S.: Injant Death: An Analysis 1972. of Material Risk and Health Care. Washington, D. C., Inst. of Medicine, Nat.
Vol. 53, No. 1, January-February 1977
PRIMARY CARE: SOME ISSUES* DAVID E. ROGERS, M.D. President, The Robert Wood Johnson Foundation Princeton, N.J.
I SHALL try to set some boundaries around the subject of primary care and offer a definition of the problems the United States faces in developing a more satisfactory system for the delivery of primary care. This is difficult to do effectively; most medical people hear more than they wish to about primary care, and the rhetoric on the subject has become monotonous and repetitious. There are, however, some clear pressures for change in the way in which we train our medical manpower and how we distribute the fruits of our achievements in biomedical research to those who want them. I do not believe that these pressures will go away. How can we, as a nation and as health professionals, adapt our educational programs and services to fulfill more adequately the general needs for medical care at a cost which is tolerable? This is one of the major challenges of our times. To set the stage, I shall first offer a definition of what I have come to include in the term primary care. Next, I shall document briefly the current mismatch between needs-either real or perceived-and the care we now are supplying, and list a few of the pros and cons to be examined in considering whether it is reasonable to attempt to construct a better system of primary care when so many social needs are competing for funds and attention. I shall then offer some possible ways in which the health-care system might be modified to improve primary-care services if it is agreed that we should make that effort. WHAT IS PRIMARY CARE?
The term primary care has become a shorthand term for the kind of care traditionally delivered by community-based physicians. It is first-contact medicine. However, it has some additional dimensions. First, it is care of a continuing, longitudinal nature. It also implies continuing medical responsibility for groups of people, and not just for individuals who seek a physician. It has integrationist qualities in that it must combine *Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
PRIMARY
CARE:
SOME
II
11
concern for social and psychological factors which contribute to illness with concern for factors that are physiologic and disease-oriented. This care might be provided by internists, pediatricians or obstetricians and gynecologists, and most certainly by family practitioners. It also could involve care given by other kinds of health professionals. WHAT MUST A PRIMARY CARE SYSTEM DELIVER?
Any system of primary care must have certain basic capabilities. The following have seemed most important.1 1) It must provide ready access to the physician or some other health professional who can cope effectively with ordinary medical problems. 2) It must be able to separate from the many innocent-appearing situations those few that are potentially serious and it must provide properly for them. 3) It must provide scientific, humanistic support to those that it serves. 4) It must provide care on a continuing basis. 5) It must be distributed with reasonable equity. 6) As a system, it must be stable and self-renewing, i.e., those who work in it must enjoy it and others must wish to enter the field. 7) It must have a proper fit with the way of life or the culture of those it serves, and this will vary widely by background, culture, and locale in our diverse and far-flung country. 8) It must be able to receive support in competition with other real needs of our society. How DID WE REACH OUR PRESENT STATE?
The development of specialists with progressively narrower orientations was a logical response to advancing knowledge about human illness and the rapidly multiplying therapeutic technologies. The recognition in the 19th century of the microbial etiology of many diseases, the discovery of anesthesia, and the realization at the time of World War I that we were not adequately training doctors to care for our troops all started the shift. The march of science-based medicine, heralded in the 1920s by the discovery of insulin and proceeding through to the development of antimicrobial drugs and of potent agents for the management of high blood pressure, congestive heart failure, and malignancies put powerful tools in the hands of the individual physician. These advances, coupled with the shifts in medical education which followed the Flexner Report of 19 1 0, the increasing focus on hospitalized patients, and Vol. 53, No. 1, January-February 1977
12
12
D. E. ROGERS
the freedom of so many medical schools each able to pursue its own ends has contributed to our current dilemma. WHAT HAS BEEN THE RESULT?
The result of these many forces is the subject at issue of this conference. First, there is a worrisome lack of correlation between the kinds of physicians we need and those that we produce. It has been estimated that 60 to 70% of the problems which bring people to doctors are straightforward problems in primary care. Yet, until recently only about 1% of our postgraduate residency-training opportunities have been directed toward primary-care careers. Thus, since the early 1950s we have had a progressive decline in the number of physicians who function as generalists and a marked increase in the number who treat special problems. Second, we have wide geographic variations in the number of health professionals available to those seeking care. That there are five-fold or greater differences between the numbers of physicians available in some wealthy areas, e.g., sections of New York City, and other less wealthy parts of the United States is causing many to worry about our responsiveness to health needs. The fact that the well-to-do have much more ready access to physicians than the poor do also is disturbing at a time when we are trying to correct social inequities in many sectors. These data suggest that something has gone awry. SHOULD WE Do SOMETHING ABOUT IT?
Clearly, one of the questions facing the medical profession and society in general is whether we should do something about the situation. During the period of the great society of the 1960s we attempted to correct many social inequities. This period was discouraging to many people; it has come to be viewed as a time of throwing money at social problems with disappointing results. Thus, it is now often heard that the world is inequitable in most areas. It is inequitable in housing, nutrition, income, and many other areas. People ask if it is reasonable to strive for more equity in medical care. Second, many worry that we have oversold what medical care can do to improve health. Simply providing more medical care does not, of itself, insure good health. The millions of dollars spent on mental health have not decreased the incidence of schizophrenia, and there are precious few adultonset diseases we can prevent simply with more medical care. The heavy Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
PRIMARY
CARE:
13 13
expenses versus probable benefits now are being debated in many quarters. Finally, the inherent contradictions in the design of any system of primary care are troubling many thoughtful students of the health-care system. The maintenance of the kinds of technical and scientific skills we ask of a physician today requires considerable experience with complex diseases. If we design a system in which physicians assume medical-care responsibilities for defined groups of a certain size, we run the hazard of letting these skills atrophy. To illustrate: one physician probably can take care of or relate in a meaningful way to between 2,500 and 4,000 people. Numerous studies permit us to predict what kinds of disease processes will be encountered in a group of this size composed of people of differing ages. I can assure you that the number is very few. Thus, such a physician may see five patients with appendicitis a year. The physician might see a carcinoma of the cervix every three years. A child with a congenital heart lesion will be encountered perhaps five times in the physician's practicing lifetime. One of the basic capabilities that I listed as important in a primary-care system-to separate innocentappearing situations from those few that are potentially serious-clearly requires some continuing experience with complex illness to keep those skills sharpened. The dilemma could be likened to what we face in our peace-time navy, where we ask sailors to maintain a whole set of skills that we hope they will never have to use. Thus, we face a problem in designing a system which will deliver prompt and effective primary care while at the same time permitting maintenance of the kinds of expertise that we ask of the modem physician. There is, however, another side to the coin. First, it is clear that more adequate primary care can, under certain circumstances, make a difference in health. We should be cautious about the conventional wisdom of the moment which says that it does not. For example, after the introduction of maternal and infant-care centers in poor areas during the 1960s there was a profound reduction in infant mortality in these areas. In Omaha, for example, infant mortality dropped from 33.4 per thousand to 13.9 in less than four years. 2 That is a remarkable advance. The same was true in areas which initiated health-care programs for children and teen-agers. When viewed collectively these programs reduced serious illness; hospitalization of youngsters decreased by 60%. The costs of child-health care went down by a similar amount. 3 A second reason for developing a more adequate system of primary care is
Vol. 53, No. 1, January-February 1977
14
D. E. ROGERS 14~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
simply the cost factor. Despite increasing efficiencies, hospital costs will continue to escalate; they must do so, for they are labor-intensive, hightechnology centers. Consequently, major attention must be directed to managing more illnesses outside hospitals. As an example, if we had been able to foreshorten hospitalization for everyone hospitalized in the United States last year by one day, it would have saved this country $2 billion. This seems deserving of attention. Finally, there is the human need part of the equation. With the fragmentation of families, church ties, and other social support structures medicine is increasingly viewed as a potent coping force needed by many. The management of straightforward illness, the effective management of chronic disease, and the relief of anxiety are important human needs. Thus, I would guess that whether it is cost-effective or not, as a nation we shall move to put a better system in place. WHAT ARE THE OPTIONS?
The options for developing a stronger system for general care are finite. They must be considered against the backdrop of our times, our culture, and realistic limits of present social choice. Broadly speaking, one can go one of two ways, depending on one's prejudices. There are a series of options which derive from the view that the profound decline in the selection of generalist careers results from our present system of medical education. This thesis holds that we have not admitted the right people to medicine and that we have not designed the curriculum properly to show aspiring physicians the values of a generalist career. The second premise holds that the large-scale avoidance of generalist careers is a permanent phenomenon. This view is based on the premise that the advance of science-based technology and the requirements for practising as a modern physician are so complex that the days of the generalist are past. If this is so, we must develop other mechanisms for coping with the generalist's function. Dr. Walsh McDermott and others of the Robert Wood Johnson Foundation have come up with a number of options. 1 The first four stem from the thesis that we have chosen the wrong people and have not properly designed our medical school or residency-career experiences to keep the generalist role attractive. 1) Recast the criteria for admission to medical school to select some candidates who would be interested in generalist careers. A number of institutions are moving in this direction. Some studies suggest that if we chose
Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
15
15
different kinds of people with different values and aspirations more of them might enter generalist careers. 2) Train two kinds of physicians. It has been suggested that a shorter, faster system of education could be developed for those who would become generalists and a longer educational experience for those who would specialize. This idea has been advanced intermittently over many years. It presents major philosophic problems in our society. Americans have been very reluctant to move to a two-tiered physician system. This inevitably would lead to viewing the graduates as either first-class or second-class physicians, based upon the length of education, with the generalists the losers. 3) Restructure the graduate training of physicians so that we materially increase the opportunities for young men and women to gain experience with primary care. This would require sharply limiting the number of opportunities to go into specialties and increasing the number of training opportunities for generalists. The experience which differentiates the doctor is his postgraduate residency training. To increase generalist postgraduate opportunities has been one of the options selected by the federal government; it is supporting an increasing number of family-practice residencies. Similarly, many academic centers are expanding the primary-care opportunities for residents in medicine and pediatrics. 4) Use economic incentives to encourage entry into primary or general medical careers. This has been done with considerable success in Great Britain and Canada. We have tried it tentatively in the past by indenturing students for subsequent service in particular areas with discouraging results, but it deserves broad consideration. The remaining options stem from the other thesis: that a generalist career is no longer a viable lifetime career for many who are now entering medical school. 5) Consider general medical practice as a stage in the physician's development or career. This would dictate that young physicians could not go into specialty training until they had devoted a period of time to experience as generalists. This system worked quite well in the United States before and during World War II. Many young men put in at least two years as generalists before turning to other kinds of careers. It is the way our National Health Service Corps is now functioning. It delivers medical care of quite acceptable quality. It would fall short of the ideal system in that it would not offer care of a continuing nature by the same physician. 6) Use other kinds of health professionals, such as nurse-practitioners or
Vol. 53, No. 1, January-February 1977
1616
D. D. E. E. ROGERS ROGERS~~~~~~~~~~~~
physician assistants to cover the bulk of primary medical care. Under such an option the physician simply would leave primary care to others and play a supervisory role. At present such a system alone would not be acceptable to many Americans. 7) Use foreign medical graduates for the bulk of general medical care. I have added this option largely for the sake of completeness, because I have heard it suggested. It is totally unrealistic. It flies in the face of the career patterns that FMGs elect since they essentially have the same preferences as American graduates. Further, I think it would be socially unacceptable in this country. It clearly would create some major problems if one of our objectives is to develop the kind of care which fits the life-style and culture of those being served. 8) Rely on the "hidden system" of general medical care that we now have and fill in the gaps by the creation of special subsystems for those people not now covered. Although most specialists deny it in a survey, many provide a great deal of general medical care. However, only select patients get into this system. Internists or pediatricians spend a great deal of their time in primary care. The surgeon whose patients initially come because of a surgical problem such as that involving a gall bladder or a hernia often will continue to provide these patients with some general medical care. It works, but it fails to offer a clear, easily understood way of entering into the system. 9) Develop free-standing multispecialty groups to serve the primary-care function. With such a strategy we would continue to train specialists in the hope that they would, in groups and in certain kinds of constellations, subserve the primary-care function as a group function. 10) Develop a strategy in which primary-care groups work through linkages to public and private hospitals. We now have some 7,000 community hospitals and it seems reasonable to consider linking a primary-care system to this existing network. WHAT SHALL WE Do? Obviously, the question is which way will the United States go? My predictions would include a bit of all of the directions I have suggested. At this time I would guess that we shall move with a series of positive incentives-the carrot rather than the stick approach-although this is being debated at a national level and the situation may change. I expect that health care will become an increasingly regulated industry. However, I do not believe that this will include regulation of the careers of physicians themselves. I think that is politically unlikely in the United States today. Bull. N.Y. Acad. Med.
PRIMARY CARE: SOME ISSUES
17
Our major efforts probably will go to emphasizing the hidden system. I believe we shall see changes in the training of internists and a dramatic change in the training of pediatricians. Obstetrician-gynecologists may become generalist physicians for women. Clearly, we shall expand the number of family practitioners. I think we also shall continue to experiment with the use of other kinds of health professionals, particularly in areas which simply cannot logically sustain a physician's practice. Thus, it seems likely that nurse-practitioners, physician assistants, and other kinds of health professionals will play increasingly important roles. I expect to see a number of experiments which will use the existing network of community hospitals to link groups with a primary-care orientation to that base. We probably shall see the increasing basing of specialists in hospitals; new physicians will choose either primarily in-hospital or out-of-hospital careers, although, obviously, there will continue to be an overlap. We have a mandate to do a more adequate job of delivering prompt, effective, and humanistic care of straightforward problems to people who sleep in their own beds at night. It is clear that we are capable of doing so and I hope that we shall. The fact that the New York Academy of Medicine has chosen to devote attention to this topic gives me encouragement. The Robert Wood Johnson Foundation, which I represent, is also working to help in this effort. REFERENCES 1. McDermott, W.: General medical care. Acad. Sciences, 1973. Identification and analysis of alternative 3. Minnesota Systems Research: Children and Youth Projects Report, Service 18 approaches. John Hopkins Med. J. and 20, Quarterly Summary Reports. 135:292, 1974. April-June 1972 and October-December 2. Kessner, D.S.: Injant Death: An Analysis 1972. of Material Risk and Health Care. Washington, D. C., Inst. of Medicine, Nat.
Vol. 53, No. 1, January-February 1977
