Larry A. Green, MD

Two US state-based reports in this issue of JFP focus attention on relationships between primary care physicians and those in other specialties. From California¹ the results of a mailed survey show that specialists’ attitudes were mixed regarding primary care physicians as gatekeepers. Approximately half of the responding specialists viewed the involvement of a primary care gatekeeper as a hindrance to their patient care. These attitudes differed significantly, however, depending on the specialists’ practice setting and payment plan. Those physicians who were paid a salary or paid by capitation and those working in larger, more organized practice settings had more favorable views toward the role of gatekeeper. Although this study confirms associations, not causes, it emphasizes the value that medical specialists placed on the gatekeeping role in health care systems structured to control costs. These findings show that specialists’ attitudes toward primary care are sensitive to their perception of risk for loss of referrals and income. This is consistent with anecdotal experiences of large group practices in which responsibility for a condition is viewed as belonging squarely in primary care if a specialty is capitated, but that the condition probably needs a referral if the specialty is paid on a fee-for-service basis.

From Florida,² an ecologic analysis shows another reason that we should care about the relationships between primary care and other specialties. Assigning patients with colorectal cancer to their county of residence, this careful analysis found that the incidence and mortality of colorectal cancer decreased in Florida counties that had a greater number of primary care physicians (primary care defined as family practice, general practice, obstetrics/gynecology, or general internal medicine). Although this association at a population level may be different at the level of individual patients, the findings are consistent with a large body of established literature about the value of primary care^3,4 and its effect on important things like mortality.^5-7 The ability of primary care clinicians to provide better screening and earlier diagnoses may explain the association. Strikingly, overall physician supply was not a significant predictor of any of the outcomes examined. The authors rightly conclude that their findings suggest that a balanced work force is probably necessary to achieve the best outcomes.

The call for a balanced approach to the organization of health care services is neither new⁸ or outdated.⁹ Given that the United States has many physicians and spends more money than any other country on health care (more $1.3 trillion; almost $300 billion for physician services in 2000)¹⁰ for mediocre results (37th in overall health system performance according to the World Health Organization’s ranking of nations),¹¹ it makes sense to look at the mix of physicians and the way they work together—or do not work together—for opportunities to enhance performance.

As of the middle of 2000, the proportion of physicians in primary care (defined here as family practice, general practice, general internal medicine, and general pediatrics) ranged from lows of 27.8% (District of Columbia) and 31.6% (Connecticut) to highs of 42.9% (Alaska) and 41.7% (Iowa), with Florida nestled in the middle at 33.5%.¹² This relatively small proportion of primary care physicians is different from other countries, such as the Australia and the United Kingdom, where approximately 44% and 63% of physicians, respectively, are in primary care.¹³ This is widely believed to be a contributing factor to the relatively poor performance of the health care system of the United States. The paper by Roetzheim and colleagues² should direct attention to the deployment of a skilled workforce to achieve the primary care function because it matters to people.

Fretting over money should be expected when so much of it is at stake. In 1997 United States primary care physicians reported average annual incomes after expenses, but before taxes, of $156,061 when working an average of 45.4 hours per week.¹⁴ This compared with $229,447 for physicians in other specialties providing direct patient care and working an average of 47.6 hours per week. Thus, the income of primary care physicians was approximately 68% as much as other physicians directly caring for patients, while working approximately 95% as many hours. California physicians reported a similar pattern, but net incomes for both primary care and other specialties were approximately 14% less in California than in the United States overall, with a slightly shorter work week in California for both groups.

These statistics are not news, of course, but they provide a context for the views of California physicians reported by Peña-Dolhun and coworkers.¹ They suggest how there could be feelings of inequity among primary care physicians and feelings of threat among some hard-working specialists who trained longer than most physicians doing primary care. These income differentials offer an explanation for why students might find primary care practice relatively unrewarding financially. They also show why the public lacks sympathy for physicians squabbling about money.

Using different foci and methods (and coming from both sides of the country) these 2 reports contribute to the growing awareness of the urgent need to redesign medical care and medical education in the United States.¹⁵ What will it take to move from our current expensive but inadequate approach that overemphasizes disease-oriented subspecialty medicine to a balanced sustainable patient-centered health care model that optimizes the capacities of an abundant well-trained health care workforce? To answer this question physicians — especially primary care physicians at the frontlines of medicine — will need to work together on behalf of the well-being of the people of the United States.

Two US state-based reports in this issue of JFP focus attention on relationships between primary care physicians and those in other specialties. From California¹ the results of a mailed survey show that specialists’ attitudes were mixed regarding primary care physicians as gatekeepers. Approximately half of the responding specialists viewed the involvement of a primary care gatekeeper as a hindrance to their patient care. These attitudes differed significantly, however, depending on the specialists’ practice setting and payment plan. Those physicians who were paid a salary or paid by capitation and those working in larger, more organized practice settings had more favorable views toward the role of gatekeeper. Although this study confirms associations, not causes, it emphasizes the value that medical specialists placed on the gatekeeping role in health care systems structured to control costs. These findings show that specialists’ attitudes toward primary care are sensitive to their perception of risk for loss of referrals and income. This is consistent with anecdotal experiences of large group practices in which responsibility for a condition is viewed as belonging squarely in primary care if a specialty is capitated, but that the condition probably needs a referral if the specialty is paid on a fee-for-service basis.

From Florida,² an ecologic analysis shows another reason that we should care about the relationships between primary care and other specialties. Assigning patients with colorectal cancer to their county of residence, this careful analysis found that the incidence and mortality of colorectal cancer decreased in Florida counties that had a greater number of primary care physicians (primary care defined as family practice, general practice, obstetrics/gynecology, or general internal medicine). Although this association at a population level may be different at the level of individual patients, the findings are consistent with a large body of established literature about the value of primary care^3,4 and its effect on important things like mortality.^5-7 The ability of primary care clinicians to provide better screening and earlier diagnoses may explain the association. Strikingly, overall physician supply was not a significant predictor of any of the outcomes examined. The authors rightly conclude that their findings suggest that a balanced work force is probably necessary to achieve the best outcomes.

The call for a balanced approach to the organization of health care services is neither new⁸ or outdated.⁹ Given that the United States has many physicians and spends more money than any other country on health care (more $1.3 trillion; almost $300 billion for physician services in 2000)¹⁰ for mediocre results (37th in overall health system performance according to the World Health Organization’s ranking of nations),¹¹ it makes sense to look at the mix of physicians and the way they work together—or do not work together—for opportunities to enhance performance.

As of the middle of 2000, the proportion of physicians in primary care (defined here as family practice, general practice, general internal medicine, and general pediatrics) ranged from lows of 27.8% (District of Columbia) and 31.6% (Connecticut) to highs of 42.9% (Alaska) and 41.7% (Iowa), with Florida nestled in the middle at 33.5%.¹² This relatively small proportion of primary care physicians is different from other countries, such as the Australia and the United Kingdom, where approximately 44% and 63% of physicians, respectively, are in primary care.¹³ This is widely believed to be a contributing factor to the relatively poor performance of the health care system of the United States. The paper by Roetzheim and colleagues² should direct attention to the deployment of a skilled workforce to achieve the primary care function because it matters to people.

Fretting over money should be expected when so much of it is at stake. In 1997 United States primary care physicians reported average annual incomes after expenses, but before taxes, of $156,061 when working an average of 45.4 hours per week.¹⁴ This compared with $229,447 for physicians in other specialties providing direct patient care and working an average of 47.6 hours per week. Thus, the income of primary care physicians was approximately 68% as much as other physicians directly caring for patients, while working approximately 95% as many hours. California physicians reported a similar pattern, but net incomes for both primary care and other specialties were approximately 14% less in California than in the United States overall, with a slightly shorter work week in California for both groups.

These statistics are not news, of course, but they provide a context for the views of California physicians reported by Peña-Dolhun and coworkers.¹ They suggest how there could be feelings of inequity among primary care physicians and feelings of threat among some hard-working specialists who trained longer than most physicians doing primary care. These income differentials offer an explanation for why students might find primary care practice relatively unrewarding financially. They also show why the public lacks sympathy for physicians squabbling about money.

Using different foci and methods (and coming from both sides of the country) these 2 reports contribute to the growing awareness of the urgent need to redesign medical care and medical education in the United States.¹⁵ What will it take to move from our current expensive but inadequate approach that overemphasizes disease-oriented subspecialty medicine to a balanced sustainable patient-centered health care model that optimizes the capacities of an abundant well-trained health care workforce? To answer this question physicians — especially primary care physicians at the frontlines of medicine — will need to work together on behalf of the well-being of the people of the United States.

Two US state-based reports in this issue of JFP focus attention on relationships between primary care physicians and those in other specialties. From California¹ the results of a mailed survey show that specialists’ attitudes were mixed regarding primary care physicians as gatekeepers. Approximately half of the responding specialists viewed the involvement of a primary care gatekeeper as a hindrance to their patient care. These attitudes differed significantly, however, depending on the specialists’ practice setting and payment plan. Those physicians who were paid a salary or paid by capitation and those working in larger, more organized practice settings had more favorable views toward the role of gatekeeper. Although this study confirms associations, not causes, it emphasizes the value that medical specialists placed on the gatekeeping role in health care systems structured to control costs. These findings show that specialists’ attitudes toward primary care are sensitive to their perception of risk for loss of referrals and income. This is consistent with anecdotal experiences of large group practices in which responsibility for a condition is viewed as belonging squarely in primary care if a specialty is capitated, but that the condition probably needs a referral if the specialty is paid on a fee-for-service basis.

From Florida,² an ecologic analysis shows another reason that we should care about the relationships between primary care and other specialties. Assigning patients with colorectal cancer to their county of residence, this careful analysis found that the incidence and mortality of colorectal cancer decreased in Florida counties that had a greater number of primary care physicians (primary care defined as family practice, general practice, obstetrics/gynecology, or general internal medicine). Although this association at a population level may be different at the level of individual patients, the findings are consistent with a large body of established literature about the value of primary care^3,4 and its effect on important things like mortality.^5-7 The ability of primary care clinicians to provide better screening and earlier diagnoses may explain the association. Strikingly, overall physician supply was not a significant predictor of any of the outcomes examined. The authors rightly conclude that their findings suggest that a balanced work force is probably necessary to achieve the best outcomes.

The call for a balanced approach to the organization of health care services is neither new⁸ or outdated.⁹ Given that the United States has many physicians and spends more money than any other country on health care (more $1.3 trillion; almost $300 billion for physician services in 2000)¹⁰ for mediocre results (37th in overall health system performance according to the World Health Organization’s ranking of nations),¹¹ it makes sense to look at the mix of physicians and the way they work together—or do not work together—for opportunities to enhance performance.

As of the middle of 2000, the proportion of physicians in primary care (defined here as family practice, general practice, general internal medicine, and general pediatrics) ranged from lows of 27.8% (District of Columbia) and 31.6% (Connecticut) to highs of 42.9% (Alaska) and 41.7% (Iowa), with Florida nestled in the middle at 33.5%.¹² This relatively small proportion of primary care physicians is different from other countries, such as the Australia and the United Kingdom, where approximately 44% and 63% of physicians, respectively, are in primary care.¹³ This is widely believed to be a contributing factor to the relatively poor performance of the health care system of the United States. The paper by Roetzheim and colleagues² should direct attention to the deployment of a skilled workforce to achieve the primary care function because it matters to people.

Fretting over money should be expected when so much of it is at stake. In 1997 United States primary care physicians reported average annual incomes after expenses, but before taxes, of $156,061 when working an average of 45.4 hours per week.¹⁴ This compared with $229,447 for physicians in other specialties providing direct patient care and working an average of 47.6 hours per week. Thus, the income of primary care physicians was approximately 68% as much as other physicians directly caring for patients, while working approximately 95% as many hours. California physicians reported a similar pattern, but net incomes for both primary care and other specialties were approximately 14% less in California than in the United States overall, with a slightly shorter work week in California for both groups.

These statistics are not news, of course, but they provide a context for the views of California physicians reported by Peña-Dolhun and coworkers.¹ They suggest how there could be feelings of inequity among primary care physicians and feelings of threat among some hard-working specialists who trained longer than most physicians doing primary care. These income differentials offer an explanation for why students might find primary care practice relatively unrewarding financially. They also show why the public lacks sympathy for physicians squabbling about money.

Using different foci and methods (and coming from both sides of the country) these 2 reports contribute to the growing awareness of the urgent need to redesign medical care and medical education in the United States.¹⁵ What will it take to move from our current expensive but inadequate approach that overemphasizes disease-oriented subspecialty medicine to a balanced sustainable patient-centered health care model that optimizes the capacities of an abundant well-trained health care workforce? To answer this question physicians — especially primary care physicians at the frontlines of medicine — will need to work together on behalf of the well-being of the people of the United States.

Tympanometry has been assessed and is sometimes promoted as a useful tool in the management of children with ear infections and effusions.^1-6 Recently a group at the Centers for Disease Control and Prevention⁷ recommended tympanometry as a procedure of value when the diagnosis of acute otitis media is uncertain. It provides an objective assessment of the status of the middle ear^8-10 and for some children correlates with hearing loss.^11-12 The feasibility of using hand-held tympanometers in family practice has been established,^3-13 but the accuracy of the interpretations of tympanograms made by primary care physicians is unknown.¹⁴ We report the level of agreement of interpretations of tympanograms between practicing primary care physicians and experts.

Methods

As part of a study of acute otitis media, 131 primary care physicians obtained 6358 tympanograms from 1773 children aged 6 to 180 months during 3179 routine practice visits: 2236 in the Netherlands, 1594 in the United Kingdom, and 2528 in North America. Data from Canada and the United States were combined, because the practices were united in one network (The Ambulatory Sentinel Practice Network), and followed the same study standards. Visits occurred either at the time of the diagnosis of a new episode of acute otitis media, or at 2- or 5-month study follow-up visits. Diagnostic criteria for acute otitis media included either otoscopic evidence of a bulging tympanic membrane, drainage of pus, or a red ear accompanied by ear pain.

A study coordinator trained each physician in the otoscopic examination of the ear, the use of the Welch Allyn Micro Tymp 2 (Skaneateles Falls, NY), and tympanogram interpretation. The study physicians were observed and coached as necessary until they were able to demonstrate competence to the study coordinator. The physicians were provided with a calibrated tympanometer and printer. The Modified Jerger Classification¹ which includes 5 categories (A, C1, C2, B, and uninterpretable) was used. This established classification is based primarily on the pressure at which acoustic admittance is greatest (A: -99 to 200 daPa; C1: -199 to -100 daPa; C2: -399 to -200 daPa; B: less than -399, seen as a flat tracing)

Tympanograms were forwarded to national data centers and blindly reinterpreted by 1 of 3 national study coordinators. The study coordinators identified difficult to interpret tympanograms, reached agreement about rules to be used in their interpretation, and informed the participating physicians of these rules during the ongoing study. These national coordinators and the criterion referee interpreted a set of 52 tympanograms randomly selected from a pool of difficult to interpret tympanograms. The k statistic, a chance-corrected measure of agreement, was calculated using SPSS software (Chicago, Ill) to determine inter-rater agreement.¹⁵ A k of 0.75 or greater represents excellent agreement beyond chance, and values between 0.40 and 0.75 represent fair to good agreement. Kappas for expert interrater reliability ranged from 0.77 to 0.95. Conflicts among the interpretations of the expert national study coordinators were resolved by the most experienced investigator, who served as the study’s criterion standard.¹³

Data from the interpretations of the tympanograms were organized by country (Canada and the United States were combined as North America), age of child (6-12,13-24, and 25-180 months),¹⁶ and type of visit (initial, follow-up at 2 months, follow-up at 5 months). On the basis of established cut-points related to sensitivity and specificity, C1 and A interpretations were categorized as normal and C2 and B as abnormal. The interpretation of individual tympanograms is important in determining test performance. However, treatment decisions affect the whole child and depend on assessment of the combined interpretation of tympanograms from both ears obtained from a child during a visit. Therefore, both individual and bilateral sets of tympanograms obtained for a child at a visit were used as units of analyses.

Significance testing of differences is not reported because of small standard deviations associated with most of the observations.

Results

The expert national coordinators interpreted 35.8% of the tympanograms as A curves, 30% as B curves, 15.5% as C1 curves, and 12% as C2 curves. Only 6.8% of the curves were considered uninterpretable, ranging from a high of 9.5% at initial visits to a low of 3.0% at 5-month visits. The distribution of the interpretations by country, age group, and visit type is shown in Table 1.

From a clinical perspective decisions are made on the basis of individuals, not ears. As shown in Table 2, 37.8% of the visiting children were classified as normal (A or C1 classification of both ears), 55.6% as abnormal (B or C2 classification of at least one ear), and 6.6% could not be classified. The distribution varied by country, age, and type of visit. The Netherlands had the largest percentage of children with abnormal tympanograms. A majority of children had an abnormal tympanogram at the initial visit, but there was little difference among children in the 3 age groups.

There was a high level of agreement between primary care physicians and the experts as shown in Table 3. Agreement in interpretation of the tympanograms in both type of curve (A, C1, C2, B) and classification of children as normal or abnormal was high in all countries, in all the age groups, and at all types of visits. Similarly, agreement was high in all countries, age groups, and visit types for classification of children at visits as normal or abnormal on the basis of tympanograms of both ears, with the lowest k (0.58) for children at their initial visits, and kappas of 0.76 and 0.75 at follow-up visits.

Discussion

The need for primary care research in practice settings is established.¹⁷ Some researchers, however, question the accuracy of the data gathered and reported by busy primary care clinicians in their practice settings. Our findings demonstrate that primary care physicians can obtain and accurately interpret tympanograms during daily practice. A high level of agreement with experts was found in the Netherlands, the United Kingdom, and North America for infants and older children and at initial as well as follow-up visits for children with acute otitis media. High levels of agreement persisted when analyzed as bilateral sets of tympanograms obtained at a visit. This analysis suggests agreement at the level most relevant to clinical decision making in primary care.

The lower—but still high—level of agreement in interpretations by child at initial visit may relate to physiological, anatomic, and behavioral aspects present at the early stages of acute otitis media as seen in the primary care setting. The higher levels of agreement at follow-up are reassuring, given the role of tympanometry in assessing effusion as a potential complication of acute otitis media.

Conclusions

The results of our study are unique and important because they are robust and based on large numbers of tympanograms obtained from both infants and older children in primary care practices in the Netherlands, the United Kingdom, the United States, and Canada. Our findings support the assertion that primary care physicians can successfully use tympanometry but offer no data to verify the relevance of tympanometry in the management of acute otitis media or other middle ear disease in primary care. Tympanometry is feasible in primary care practice, and the results obtained by physicians trained in the use of the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

Acknowledgments

Our work was supported by the Agency for Health Care Policy and Research grant no. RO1 HS07035-03. The tympanometers were purchased at a discounted rate from Welch Allyn. The participating physicians were: Ambulatory Sentinel Practice Network (United States and Canada): Arlis Adolf, Jules Amer, John Anderson, Robert Baker, Gordon Blakeman, Brian Caplan, Paul Collins, Bill Davis, Richard Douglass, Patricia Fibiger, Stephen Fischer, Ed Friedler, Ronald Gagne, Thomas Gilbert, Susan Girardeau, John Glennon, Gary Gray, Cindy Hansen, Terry Hankey, Michael Hartsell, Joseph Hildner, Robert Howse, Jr., Robert James, Roger Kimber, Gary Knaus, Paula Leonard-Schwartz, Mary Maguire, Kim Manning, Kathleen McGarr, Doreen McMahon, Jasmine Moghissi, Michael Mulligan, William Nietert, Spiro Papadopoulos, Donya Powers, Thomas Overholt, Steve Perry, Paul Schmitt, John Scott, Susan Shapiro, Brian Siray, Kimball Spence, Jon Sternburg, Linda Stewart, Lynne Studebaker, James Wickerath, Elizabeth Wise, and Lloyd Wollstadt. Surrey GP Network (the United Kingdom): Nick Barrie, G. Bennett, S. Brown, Jace Clarke, Mark Cornbloom, I. Davies, Niall Ferguson, N. Fisher, Richard France, Paul Grob, Mark Hanan, Robert Harvey, John Healey, David William Holwell, R. N. Jeffery, Murdo Macleod, Mather, Philip Moore, Julia Oxenbury, Margaret Palmer, C. A. Pearson, C. Pidgeon, M. Pujara, David Skipp, A. Smith, K. Tarrant, Chris Tibbott, Brett J. Whitby-Smith, Hamish Whitaker, Mary Anne Whitehead, P. R. Wilks, Sidney Worthington, and J. Young. University of Utrecht Network (the Netherlands): Atyvan Aarnhem, G. Ploosvan Amstel, D. B. van Baarda, Marja Baeten, P. J. van Beek, H. C. V. Berkum, R. Bohm, J. C. M. van Campen, J. W. Cirkel, H. J. R. Dorman, J. H. Duistermaat, H. van Es, N. Goudswaard, N. de Grunt, Ax. M. E. J. Hoeberichts, M. E. van der Hoek, J. M. P. M. Janssen, E. G. A. de Jong, L. Klaphake, A. W. K. Kramer, J. Kuiper, N. Kwakernaak, Hans Kootte, Jaap R. van der Laan, O. J. M. Lackamp, C. G. Lameris, Marjan Lamers, H. C. de Lathouder, P. J. Luyendijk, G. A. M. Maathuis, R. H. L. Morshuis, W. P. G. Mulder, P. L. W. Pijman, F. G. Pingen, Pricleer, Liesbeth Redeke, M. J. G. van Roosmalen, C. J. Rovers, S. H. A. Schmeets, J. F. Scholte, B. P. Schreuder, T. Steenkamer, Jette Timmer-Martijn, F. Trip, de Vries, Christine Weenink, H. C. P. M. van Weert, P. Willems, Boes Willemse, and P. van de Woestijne.

Tympanometry has been assessed and is sometimes promoted as a useful tool in the management of children with ear infections and effusions.^1-6 Recently a group at the Centers for Disease Control and Prevention⁷ recommended tympanometry as a procedure of value when the diagnosis of acute otitis media is uncertain. It provides an objective assessment of the status of the middle ear^8-10 and for some children correlates with hearing loss.^11-12 The feasibility of using hand-held tympanometers in family practice has been established,^3-13 but the accuracy of the interpretations of tympanograms made by primary care physicians is unknown.¹⁴ We report the level of agreement of interpretations of tympanograms between practicing primary care physicians and experts.

Methods

As part of a study of acute otitis media, 131 primary care physicians obtained 6358 tympanograms from 1773 children aged 6 to 180 months during 3179 routine practice visits: 2236 in the Netherlands, 1594 in the United Kingdom, and 2528 in North America. Data from Canada and the United States were combined, because the practices were united in one network (The Ambulatory Sentinel Practice Network), and followed the same study standards. Visits occurred either at the time of the diagnosis of a new episode of acute otitis media, or at 2- or 5-month study follow-up visits. Diagnostic criteria for acute otitis media included either otoscopic evidence of a bulging tympanic membrane, drainage of pus, or a red ear accompanied by ear pain.

A study coordinator trained each physician in the otoscopic examination of the ear, the use of the Welch Allyn Micro Tymp 2 (Skaneateles Falls, NY), and tympanogram interpretation. The study physicians were observed and coached as necessary until they were able to demonstrate competence to the study coordinator. The physicians were provided with a calibrated tympanometer and printer. The Modified Jerger Classification¹ which includes 5 categories (A, C1, C2, B, and uninterpretable) was used. This established classification is based primarily on the pressure at which acoustic admittance is greatest (A: -99 to 200 daPa; C1: -199 to -100 daPa; C2: -399 to -200 daPa; B: less than -399, seen as a flat tracing)

Tympanograms were forwarded to national data centers and blindly reinterpreted by 1 of 3 national study coordinators. The study coordinators identified difficult to interpret tympanograms, reached agreement about rules to be used in their interpretation, and informed the participating physicians of these rules during the ongoing study. These national coordinators and the criterion referee interpreted a set of 52 tympanograms randomly selected from a pool of difficult to interpret tympanograms. The k statistic, a chance-corrected measure of agreement, was calculated using SPSS software (Chicago, Ill) to determine inter-rater agreement.¹⁵ A k of 0.75 or greater represents excellent agreement beyond chance, and values between 0.40 and 0.75 represent fair to good agreement. Kappas for expert interrater reliability ranged from 0.77 to 0.95. Conflicts among the interpretations of the expert national study coordinators were resolved by the most experienced investigator, who served as the study’s criterion standard.¹³

Data from the interpretations of the tympanograms were organized by country (Canada and the United States were combined as North America), age of child (6-12,13-24, and 25-180 months),¹⁶ and type of visit (initial, follow-up at 2 months, follow-up at 5 months). On the basis of established cut-points related to sensitivity and specificity, C1 and A interpretations were categorized as normal and C2 and B as abnormal. The interpretation of individual tympanograms is important in determining test performance. However, treatment decisions affect the whole child and depend on assessment of the combined interpretation of tympanograms from both ears obtained from a child during a visit. Therefore, both individual and bilateral sets of tympanograms obtained for a child at a visit were used as units of analyses.

Significance testing of differences is not reported because of small standard deviations associated with most of the observations.

Results

The expert national coordinators interpreted 35.8% of the tympanograms as A curves, 30% as B curves, 15.5% as C1 curves, and 12% as C2 curves. Only 6.8% of the curves were considered uninterpretable, ranging from a high of 9.5% at initial visits to a low of 3.0% at 5-month visits. The distribution of the interpretations by country, age group, and visit type is shown in Table 1.

From a clinical perspective decisions are made on the basis of individuals, not ears. As shown in Table 2, 37.8% of the visiting children were classified as normal (A or C1 classification of both ears), 55.6% as abnormal (B or C2 classification of at least one ear), and 6.6% could not be classified. The distribution varied by country, age, and type of visit. The Netherlands had the largest percentage of children with abnormal tympanograms. A majority of children had an abnormal tympanogram at the initial visit, but there was little difference among children in the 3 age groups.

There was a high level of agreement between primary care physicians and the experts as shown in Table 3. Agreement in interpretation of the tympanograms in both type of curve (A, C1, C2, B) and classification of children as normal or abnormal was high in all countries, in all the age groups, and at all types of visits. Similarly, agreement was high in all countries, age groups, and visit types for classification of children at visits as normal or abnormal on the basis of tympanograms of both ears, with the lowest k (0.58) for children at their initial visits, and kappas of 0.76 and 0.75 at follow-up visits.

Discussion

The need for primary care research in practice settings is established.¹⁷ Some researchers, however, question the accuracy of the data gathered and reported by busy primary care clinicians in their practice settings. Our findings demonstrate that primary care physicians can obtain and accurately interpret tympanograms during daily practice. A high level of agreement with experts was found in the Netherlands, the United Kingdom, and North America for infants and older children and at initial as well as follow-up visits for children with acute otitis media. High levels of agreement persisted when analyzed as bilateral sets of tympanograms obtained at a visit. This analysis suggests agreement at the level most relevant to clinical decision making in primary care.

The lower—but still high—level of agreement in interpretations by child at initial visit may relate to physiological, anatomic, and behavioral aspects present at the early stages of acute otitis media as seen in the primary care setting. The higher levels of agreement at follow-up are reassuring, given the role of tympanometry in assessing effusion as a potential complication of acute otitis media.

Conclusions

The results of our study are unique and important because they are robust and based on large numbers of tympanograms obtained from both infants and older children in primary care practices in the Netherlands, the United Kingdom, the United States, and Canada. Our findings support the assertion that primary care physicians can successfully use tympanometry but offer no data to verify the relevance of tympanometry in the management of acute otitis media or other middle ear disease in primary care. Tympanometry is feasible in primary care practice, and the results obtained by physicians trained in the use of the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

Acknowledgments

Our work was supported by the Agency for Health Care Policy and Research grant no. RO1 HS07035-03. The tympanometers were purchased at a discounted rate from Welch Allyn. The participating physicians were: Ambulatory Sentinel Practice Network (United States and Canada): Arlis Adolf, Jules Amer, John Anderson, Robert Baker, Gordon Blakeman, Brian Caplan, Paul Collins, Bill Davis, Richard Douglass, Patricia Fibiger, Stephen Fischer, Ed Friedler, Ronald Gagne, Thomas Gilbert, Susan Girardeau, John Glennon, Gary Gray, Cindy Hansen, Terry Hankey, Michael Hartsell, Joseph Hildner, Robert Howse, Jr., Robert James, Roger Kimber, Gary Knaus, Paula Leonard-Schwartz, Mary Maguire, Kim Manning, Kathleen McGarr, Doreen McMahon, Jasmine Moghissi, Michael Mulligan, William Nietert, Spiro Papadopoulos, Donya Powers, Thomas Overholt, Steve Perry, Paul Schmitt, John Scott, Susan Shapiro, Brian Siray, Kimball Spence, Jon Sternburg, Linda Stewart, Lynne Studebaker, James Wickerath, Elizabeth Wise, and Lloyd Wollstadt. Surrey GP Network (the United Kingdom): Nick Barrie, G. Bennett, S. Brown, Jace Clarke, Mark Cornbloom, I. Davies, Niall Ferguson, N. Fisher, Richard France, Paul Grob, Mark Hanan, Robert Harvey, John Healey, David William Holwell, R. N. Jeffery, Murdo Macleod, Mather, Philip Moore, Julia Oxenbury, Margaret Palmer, C. A. Pearson, C. Pidgeon, M. Pujara, David Skipp, A. Smith, K. Tarrant, Chris Tibbott, Brett J. Whitby-Smith, Hamish Whitaker, Mary Anne Whitehead, P. R. Wilks, Sidney Worthington, and J. Young. University of Utrecht Network (the Netherlands): Atyvan Aarnhem, G. Ploosvan Amstel, D. B. van Baarda, Marja Baeten, P. J. van Beek, H. C. V. Berkum, R. Bohm, J. C. M. van Campen, J. W. Cirkel, H. J. R. Dorman, J. H. Duistermaat, H. van Es, N. Goudswaard, N. de Grunt, Ax. M. E. J. Hoeberichts, M. E. van der Hoek, J. M. P. M. Janssen, E. G. A. de Jong, L. Klaphake, A. W. K. Kramer, J. Kuiper, N. Kwakernaak, Hans Kootte, Jaap R. van der Laan, O. J. M. Lackamp, C. G. Lameris, Marjan Lamers, H. C. de Lathouder, P. J. Luyendijk, G. A. M. Maathuis, R. H. L. Morshuis, W. P. G. Mulder, P. L. W. Pijman, F. G. Pingen, Pricleer, Liesbeth Redeke, M. J. G. van Roosmalen, C. J. Rovers, S. H. A. Schmeets, J. F. Scholte, B. P. Schreuder, T. Steenkamer, Jette Timmer-Martijn, F. Trip, de Vries, Christine Weenink, H. C. P. M. van Weert, P. Willems, Boes Willemse, and P. van de Woestijne.

Tympanometry has been assessed and is sometimes promoted as a useful tool in the management of children with ear infections and effusions.^1-6 Recently a group at the Centers for Disease Control and Prevention⁷ recommended tympanometry as a procedure of value when the diagnosis of acute otitis media is uncertain. It provides an objective assessment of the status of the middle ear^8-10 and for some children correlates with hearing loss.^11-12 The feasibility of using hand-held tympanometers in family practice has been established,^3-13 but the accuracy of the interpretations of tympanograms made by primary care physicians is unknown.¹⁴ We report the level of agreement of interpretations of tympanograms between practicing primary care physicians and experts.

Methods

As part of a study of acute otitis media, 131 primary care physicians obtained 6358 tympanograms from 1773 children aged 6 to 180 months during 3179 routine practice visits: 2236 in the Netherlands, 1594 in the United Kingdom, and 2528 in North America. Data from Canada and the United States were combined, because the practices were united in one network (The Ambulatory Sentinel Practice Network), and followed the same study standards. Visits occurred either at the time of the diagnosis of a new episode of acute otitis media, or at 2- or 5-month study follow-up visits. Diagnostic criteria for acute otitis media included either otoscopic evidence of a bulging tympanic membrane, drainage of pus, or a red ear accompanied by ear pain.

A study coordinator trained each physician in the otoscopic examination of the ear, the use of the Welch Allyn Micro Tymp 2 (Skaneateles Falls, NY), and tympanogram interpretation. The study physicians were observed and coached as necessary until they were able to demonstrate competence to the study coordinator. The physicians were provided with a calibrated tympanometer and printer. The Modified Jerger Classification¹ which includes 5 categories (A, C1, C2, B, and uninterpretable) was used. This established classification is based primarily on the pressure at which acoustic admittance is greatest (A: -99 to 200 daPa; C1: -199 to -100 daPa; C2: -399 to -200 daPa; B: less than -399, seen as a flat tracing)

Tympanograms were forwarded to national data centers and blindly reinterpreted by 1 of 3 national study coordinators. The study coordinators identified difficult to interpret tympanograms, reached agreement about rules to be used in their interpretation, and informed the participating physicians of these rules during the ongoing study. These national coordinators and the criterion referee interpreted a set of 52 tympanograms randomly selected from a pool of difficult to interpret tympanograms. The k statistic, a chance-corrected measure of agreement, was calculated using SPSS software (Chicago, Ill) to determine inter-rater agreement.¹⁵ A k of 0.75 or greater represents excellent agreement beyond chance, and values between 0.40 and 0.75 represent fair to good agreement. Kappas for expert interrater reliability ranged from 0.77 to 0.95. Conflicts among the interpretations of the expert national study coordinators were resolved by the most experienced investigator, who served as the study’s criterion standard.¹³

Data from the interpretations of the tympanograms were organized by country (Canada and the United States were combined as North America), age of child (6-12,13-24, and 25-180 months),¹⁶ and type of visit (initial, follow-up at 2 months, follow-up at 5 months). On the basis of established cut-points related to sensitivity and specificity, C1 and A interpretations were categorized as normal and C2 and B as abnormal. The interpretation of individual tympanograms is important in determining test performance. However, treatment decisions affect the whole child and depend on assessment of the combined interpretation of tympanograms from both ears obtained from a child during a visit. Therefore, both individual and bilateral sets of tympanograms obtained for a child at a visit were used as units of analyses.

Significance testing of differences is not reported because of small standard deviations associated with most of the observations.

Results

The expert national coordinators interpreted 35.8% of the tympanograms as A curves, 30% as B curves, 15.5% as C1 curves, and 12% as C2 curves. Only 6.8% of the curves were considered uninterpretable, ranging from a high of 9.5% at initial visits to a low of 3.0% at 5-month visits. The distribution of the interpretations by country, age group, and visit type is shown in Table 1.

From a clinical perspective decisions are made on the basis of individuals, not ears. As shown in Table 2, 37.8% of the visiting children were classified as normal (A or C1 classification of both ears), 55.6% as abnormal (B or C2 classification of at least one ear), and 6.6% could not be classified. The distribution varied by country, age, and type of visit. The Netherlands had the largest percentage of children with abnormal tympanograms. A majority of children had an abnormal tympanogram at the initial visit, but there was little difference among children in the 3 age groups.

There was a high level of agreement between primary care physicians and the experts as shown in Table 3. Agreement in interpretation of the tympanograms in both type of curve (A, C1, C2, B) and classification of children as normal or abnormal was high in all countries, in all the age groups, and at all types of visits. Similarly, agreement was high in all countries, age groups, and visit types for classification of children at visits as normal or abnormal on the basis of tympanograms of both ears, with the lowest k (0.58) for children at their initial visits, and kappas of 0.76 and 0.75 at follow-up visits.

Discussion

The need for primary care research in practice settings is established.¹⁷ Some researchers, however, question the accuracy of the data gathered and reported by busy primary care clinicians in their practice settings. Our findings demonstrate that primary care physicians can obtain and accurately interpret tympanograms during daily practice. A high level of agreement with experts was found in the Netherlands, the United Kingdom, and North America for infants and older children and at initial as well as follow-up visits for children with acute otitis media. High levels of agreement persisted when analyzed as bilateral sets of tympanograms obtained at a visit. This analysis suggests agreement at the level most relevant to clinical decision making in primary care.

The lower—but still high—level of agreement in interpretations by child at initial visit may relate to physiological, anatomic, and behavioral aspects present at the early stages of acute otitis media as seen in the primary care setting. The higher levels of agreement at follow-up are reassuring, given the role of tympanometry in assessing effusion as a potential complication of acute otitis media.

Conclusions

The results of our study are unique and important because they are robust and based on large numbers of tympanograms obtained from both infants and older children in primary care practices in the Netherlands, the United Kingdom, the United States, and Canada. Our findings support the assertion that primary care physicians can successfully use tympanometry but offer no data to verify the relevance of tympanometry in the management of acute otitis media or other middle ear disease in primary care. Tympanometry is feasible in primary care practice, and the results obtained by physicians trained in the use of the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

Acknowledgments

Our work was supported by the Agency for Health Care Policy and Research grant no. RO1 HS07035-03. The tympanometers were purchased at a discounted rate from Welch Allyn. The participating physicians were: Ambulatory Sentinel Practice Network (United States and Canada): Arlis Adolf, Jules Amer, John Anderson, Robert Baker, Gordon Blakeman, Brian Caplan, Paul Collins, Bill Davis, Richard Douglass, Patricia Fibiger, Stephen Fischer, Ed Friedler, Ronald Gagne, Thomas Gilbert, Susan Girardeau, John Glennon, Gary Gray, Cindy Hansen, Terry Hankey, Michael Hartsell, Joseph Hildner, Robert Howse, Jr., Robert James, Roger Kimber, Gary Knaus, Paula Leonard-Schwartz, Mary Maguire, Kim Manning, Kathleen McGarr, Doreen McMahon, Jasmine Moghissi, Michael Mulligan, William Nietert, Spiro Papadopoulos, Donya Powers, Thomas Overholt, Steve Perry, Paul Schmitt, John Scott, Susan Shapiro, Brian Siray, Kimball Spence, Jon Sternburg, Linda Stewart, Lynne Studebaker, James Wickerath, Elizabeth Wise, and Lloyd Wollstadt. Surrey GP Network (the United Kingdom): Nick Barrie, G. Bennett, S. Brown, Jace Clarke, Mark Cornbloom, I. Davies, Niall Ferguson, N. Fisher, Richard France, Paul Grob, Mark Hanan, Robert Harvey, John Healey, David William Holwell, R. N. Jeffery, Murdo Macleod, Mather, Philip Moore, Julia Oxenbury, Margaret Palmer, C. A. Pearson, C. Pidgeon, M. Pujara, David Skipp, A. Smith, K. Tarrant, Chris Tibbott, Brett J. Whitby-Smith, Hamish Whitaker, Mary Anne Whitehead, P. R. Wilks, Sidney Worthington, and J. Young. University of Utrecht Network (the Netherlands): Atyvan Aarnhem, G. Ploosvan Amstel, D. B. van Baarda, Marja Baeten, P. J. van Beek, H. C. V. Berkum, R. Bohm, J. C. M. van Campen, J. W. Cirkel, H. J. R. Dorman, J. H. Duistermaat, H. van Es, N. Goudswaard, N. de Grunt, Ax. M. E. J. Hoeberichts, M. E. van der Hoek, J. M. P. M. Janssen, E. G. A. de Jong, L. Klaphake, A. W. K. Kramer, J. Kuiper, N. Kwakernaak, Hans Kootte, Jaap R. van der Laan, O. J. M. Lackamp, C. G. Lameris, Marjan Lamers, H. C. de Lathouder, P. J. Luyendijk, G. A. M. Maathuis, R. H. L. Morshuis, W. P. G. Mulder, P. L. W. Pijman, F. G. Pingen, Pricleer, Liesbeth Redeke, M. J. G. van Roosmalen, C. J. Rovers, S. H. A. Schmeets, J. F. Scholte, B. P. Schreuder, T. Steenkamer, Jette Timmer-Martijn, F. Trip, de Vries, Christine Weenink, H. C. P. M. van Weert, P. Willems, Boes Willemse, and P. van de Woestijne.

This year the American Academy of Family Physicians (AAFP) opened a new policy center in Washington, DC. The idea for this center can be traced back to AAFP Executive Vice President Robert Graham, MD, who envisioned a research unit focused on family practice and primary care policy in the relatively small community of health policy advocates in Washington.

In 1996, several officers and staff of the AAFP agreed that a policy center in Washington could fit into a framework focused on building the infrastructures necessary to support family practice and primary care. Concurrently, the membership and leadership of the Academy rediscovered the critical role of research in strengthening family practice, and the concepts of research and a policy center converged.

When the idea was taken to the AAFP Board of Directors for formal action, the board approved the policy center without controversy and directed the staff to proceed. Key leaders supported a comprehensive plan to enhance research capacity and included a policy center with other strategies for achieving this goal. There was agreement that effective advocacy requires facts and that the envisioned policy center would have to be sufficiently independent to be credible. And there was agreement that the center should be located in Washington, DC, to affirm family practice and primary care and react to vagaries of health care policy at a federal level.

A favorable financial position permitted immediate movement toward implementation. By the end of 1998, the first director was designated and the exact location of the Center was determined. Ideas about the work and focus of the Center were elicited from practicing family physicians and other leaders within and beyond the primary care community. The Center for Policy Studies in Family Practice and Primary Care opened for business on June 8, 1999. The Center operates according to a set of assumptions which are outlined in the Table 1

Initial structure and function

The Center is structured to operate as an independent unit working under the personnel and financial policies of the AAFP. The initial staff of 5 (supplemented with consultative relationships) have knowledge and skills in the areas of primary care, family practice, epidemiology, statistics, research design, and data/information management. These individuals share leadership and responsibility for various projects and activities and coordinate their efforts with the help of an office administrator. Because the policy of the Center is to use existing data sets and the study results of researchers worldwide whenever possible, the Center’s staff will only do primary data collection when necessary.

The staff of the Center is accountable to the Director, who reports to the Vice President of Socioeconomic Affairs. There are no lines of accountability to the various AAFP commissions and committees. The AAFP Board decided that the Center would have editorial independence to pursue and publish work according to traditional academic and peer-review standards. A formally constituted advisory board advises the Center. This volunteer group does not have administrative authority but provides commentary on the Center’s direction and work on a regular basis. The Center relies on the AAFP’s Washington office and other AAFP divisions for assistance in detecting relevant policy opportunities, guidance about the Washington environment, and decisions about communication strategies.

Issues from the field

The United States is spending much more for health care than other countries, with relatively mediocre results. The commitment of this huge amount of wealth is accompanied by widespread dissatisfaction among patients, physicians, nurses, psychologists, hospital administrators, employers, and governments. Indeed, there are those who suggest that the marriage of medicine and the market has left medicine purposeless and adrift.³ Something is terribly wrong.

Starting a new health policy center in Washington, DC, in this context will be challenging. As a way of grounding the Center in its stated purpose of bringing a family practice and primary care perspective to health policy issues, the initial staff of the Center sought advice from those people most committed to family practice and primary care from a provider perspective. From the autumn of 1998 to the winter of 1999, approximately 400 individuals responded to queries about what the important health policy issues are for family practice and primary care. Among these respondents were officers of all of the national family medicine organizations, officers of national internal medicine and pediatric organizations, the chairmen of academic departments of family medicine, family practice residency directors, participants in a national meeting concerning practice-based research networks, leaders of safety-net organizations, members of the Institute of Medicine, faculty at medical schools (including those working primarily with medical students), international health workers, state legislators and activists, Robert Wood Johnson Generalist Scholars, and several early leaders of family medicine in the United States. Practicing family physicians and the staff of the AAFP were also polled. The various committees of the Academic Family Medicine Organization, directors of other health policy centers, staff working in agencies of the US Department of Health and Human Services, and a few deans of nursing and medical schools also provided their perspectives.

Most of the concerns expressed by these individuals can be summarized into 3 themes: The Functional Domain (Scope of Practice), Investing in Primary Care Infrastructures, and Universal Health Coverage.

The Functional Domain (Scope of Practice)

An overcommitment to reductionistic specialism has fragmented the health care system and left patients in a confusing maze of health services. An abundance of health professionals and would-be health care providers seeking their place and revenue stream from the trillion-dollar health care economy creates constant border disputes. In addition, there are expansive rules for various health plans, and there is confusion about what should be bought and who should pay for it.

These circumstances threaten the implementation of robust primary care and the sensible totality of family practice. Many family physicians wonder if they will have the opportunity to provide comprehensive care that matches the needs of their communities. They fear their scope of practice will be reduced, defined by a restricted set of services, a particular setting, or the problems that are left after various specialty groups secure their piece of contemporary practice.

The promise of improved health care and health status associated with integrated comprehensive, longitudinal, person-centered care seems elusive. It may not be possible to define the complimentary interfaces among primary care, public health, and tertiary care without more clearly establishing the scope of primary care. Areas of concern include mental health services, preventive care, chronic disease management, care of the aged, and care of the dying.

Current unrest and dissatisfaction in large segments of the population also impede the development of the definition of a sensible scope of primary care practice. There is widespread suspicion of the motives of physicians and others involved in health care; which suggests patients no longer trust the social contract that requires providers to put patients’ interests first. This has stimulated efforts to protect health care, consumers from physicians, health plans, and insurance companies and sorely tests the personal relationship that is central to primary care. Instead of a safe haven where a sustained partnership exists between the patient and the physician, primary care practices have become battlefields where the scope of practice is contested on a daily basis.

These circumstances should provoke a sense of urgency when juxtaposed with what is known about the salutary effects of primary care.⁴

Investing in Primary Care Infrastructures

Primary care is often misunderstood to be cheap and easy, requiring no infrastructures of its own because it derives its intellectual basis and practical applications from other fields. There is little recognition of the need to develop key undergirding to sustain primary care and propel it forward with constant improvements. Primary care clinicians are frustrated in their attempts to enhance health status by a lack of intentional investment in primary care research, training, and technology.

The country’s huge investment in disease-oriented research offers occasional opportunities to extend discovery into the situations and problems most relevant in the primary care setting. Often, however, the processes for obtaining research funding from institutions operating from a different perspective distort the fundamental phenomena and questions of primary care, and compromise the commitment to understanding from the perspective of primary care how people remain healthy, become sick, recover, or remain ill. There is no adequate place for an investigator to go to develop the tools necessary to study primary care and ask the questions essential for achieving its goals. The enthusiasm of foundations and agencies with commitments to primary care research is admirable, but it is constrained by lack of investment capital.

The country’s huge investment in graduate medical education is driven by a set of arcane rules that do not result in the training of the right workforce. Children are relatively neglected by the current system built around Medicare, and this system continues to emphasize hospitals and their problems instead of other settings of greater importance and relevance to the public. The point of view taken by most hospital administrators is that primary care is an economic loss. They often believe that if primary care has value in the hospital setting, it is primarily in what it can do to stimulate or protect the profitable enterprises; and these enterprises, not primary care, must be taught, defended, and financed by our major teaching institutions. Technologies for teaching and demonstrating best practice, such as computerized support systems and telemedicine, could make primary care training more relevant and more efficient if investments were directed appropriately. The best primary care is delivered by teams of various sizes and structures, but we do not currently finance the education and training of the members of the team in a manner that encourages collaborative practice on the behalf of patients.

The country’s huge investment in technology has not yet targeted the primary care setting, perhaps because the people directing those funds believe that technology and primary care are antithetical instead of complimentary. Indeed, many working in primary care now recognize that information management technologies are integral to robust primary care, but the cost of information systems capable of defining populations under care, monitoring their health status, measuring results, and improving quality are far beyond the resources available for primary care. Many of the procedures known to relieve suffering and improve the probability of staying healthy are performed competently in primary care but have not been widely implemented because of disorganization and perverse financial arrangements. Breakthrough technologies for teaching, such as virtual reality training centers, could make primary care training more efficient, but financial requirements exceed the revenue-generating capacity of primary care.

This pervasive lack of funding for primary care is one explanation for why it is a relatively powerless, awaiting its full manifestation as the foundation of an affordable and effective health care system.

Universal Health Coverage

Universal coverage—the inclusion of all people in the primary care system—has emerged as a major issue for those attempting to achieve the best primary care for our country. Accompanying a belief in this policy is a disbelief that the United States has the political will to do what is necessary to implement such coverage. Its affordability is doubted, but some policymakers suggest that primary care is an essential part of a sustainable inclusive solution. Indeed, as medicine and society create each other, universal coverage and primary care are also interdependent.

Because it is situated between the community and the rest of medicine, primary care is exposed to a broad spectrum of patients’ troubles and aspirations. When segments of the community are explicitly or functionally excluded, they are disadvantaged by not having access to the benefits of primary care, and they often eventually need to rely on health care and social services that may be inappropriate, too expensive, or too late. Not only are the excluded individuals disadvantaged, but so are their neighbors who experience less obvious losses and risks because of the neglect of significant numbers of their cohabitants.

Primary care provides a sensible link between individuals in the community and medical care. The ability to put primary care into practice, however, is compromised in the United States because of distortions and distractions created by selective inclusion. Without commitment to universal coverage, the value of primary care erodes, and the return on investment seems to diminish. To fully realize the benefits of primary care, universal coverage is necessary.

Preliminary plan of action

These themes provide a framework but not the focused explicit plan of action that is needed. To stay focused will be a continuing challenge for those seeking to bring a family practice and primary care perspective to health policy. To face this challenge, the Center initially will pursue the following 5 objectives.

Facilitate cooperative relationships with others interested in health policy. There is a vibrant health policy community in Washington, but it lacks a critical mass of primary care advocates. The initial strategies will include personal visits with various individuals and organizations, the establishment of an advisory board, an open house for the new Center, and an ongoing primary care forum in Washington for those interested in primary care health policy.

Develop mechanisms to communicate ideas about primary care. The Center will establish a Web site and and publish 1-page reports as ongoing methods for engaging others and reporting its work. The AAFP’s publications will be used to disseminate information when appropriate. Results of specific studies will be submitted to relevant journals. Occasionally, the Center will author a monograph focused on an issue of particular importance to family practice and primary care. Members of the Center will present ideas at selected meetings and in response to invited commentary.

Create a capacity to evaluate contemporary health policy issues from a family practice and primary care perspective. The time frame for policy issues ranges from moments to years. Sometimes, relatively immediate information is necessary for evidence-based advocacy. The Center will acquire and link multiple data sets to create a capacity to evaluate issues in short time frames using existing data. Cooperative relationships with other research centers and specific individuals will be explored. A catalog detailing useful data sets will be assembled. A rotating internship program will be tested, with interns functioning as essential members of the Center’s team. The topics evaluated will depend on the current issues that concern family practice and primary care.

Support self-initiated investigations. These investigations are intended to inform health policy and result in peer-reviewed publication. An early investigation will focus on updating the distribution of problems and services in the health care system, stratified by level of care. Others will examine the concerns of patients and clinicians about family practice and primary care. The Center intends to always have at least one investigation underway that studies disadvantaged populations.

Seek reality check points. The ideas of health care policy can lose touch with the reality of clinical practice, and clinical practice is at risk of failing to define relevant health policy. The physician members of the Center work on a limited basis as family physicians while working at the Center. All members of the Center will use the available opportunities to learn from practicing internists, pediatricians, family physicians, nurse practitioners, physician assistants, mental health professionals, and others engaged in daily service to patients at the level of primary care.

Conclusions

The Center for Policy Studies in Family Practice and Primary Care is now a reality. It is dedicated to improving the health of individuals and populations through enhanced primary care, and it aspires to achieve this goal by informing health policy with evidence from family practice and primary care. Expectations for an immediate large impact are unrealistic. However, this new Center can gradually become a credible and enduring piece of the Washington landscape. It aspires to be identified with those who put patients first and who advocate relentlessly for improved family practice and primary care for all.

This year the American Academy of Family Physicians (AAFP) opened a new policy center in Washington, DC. The idea for this center can be traced back to AAFP Executive Vice President Robert Graham, MD, who envisioned a research unit focused on family practice and primary care policy in the relatively small community of health policy advocates in Washington.

In 1996, several officers and staff of the AAFP agreed that a policy center in Washington could fit into a framework focused on building the infrastructures necessary to support family practice and primary care. Concurrently, the membership and leadership of the Academy rediscovered the critical role of research in strengthening family practice, and the concepts of research and a policy center converged.

When the idea was taken to the AAFP Board of Directors for formal action, the board approved the policy center without controversy and directed the staff to proceed. Key leaders supported a comprehensive plan to enhance research capacity and included a policy center with other strategies for achieving this goal. There was agreement that effective advocacy requires facts and that the envisioned policy center would have to be sufficiently independent to be credible. And there was agreement that the center should be located in Washington, DC, to affirm family practice and primary care and react to vagaries of health care policy at a federal level.

A favorable financial position permitted immediate movement toward implementation. By the end of 1998, the first director was designated and the exact location of the Center was determined. Ideas about the work and focus of the Center were elicited from practicing family physicians and other leaders within and beyond the primary care community. The Center for Policy Studies in Family Practice and Primary Care opened for business on June 8, 1999. The Center operates according to a set of assumptions which are outlined in the Table 1

Initial structure and function

The Center is structured to operate as an independent unit working under the personnel and financial policies of the AAFP. The initial staff of 5 (supplemented with consultative relationships) have knowledge and skills in the areas of primary care, family practice, epidemiology, statistics, research design, and data/information management. These individuals share leadership and responsibility for various projects and activities and coordinate their efforts with the help of an office administrator. Because the policy of the Center is to use existing data sets and the study results of researchers worldwide whenever possible, the Center’s staff will only do primary data collection when necessary.

The staff of the Center is accountable to the Director, who reports to the Vice President of Socioeconomic Affairs. There are no lines of accountability to the various AAFP commissions and committees. The AAFP Board decided that the Center would have editorial independence to pursue and publish work according to traditional academic and peer-review standards. A formally constituted advisory board advises the Center. This volunteer group does not have administrative authority but provides commentary on the Center’s direction and work on a regular basis. The Center relies on the AAFP’s Washington office and other AAFP divisions for assistance in detecting relevant policy opportunities, guidance about the Washington environment, and decisions about communication strategies.

Issues from the field

The United States is spending much more for health care than other countries, with relatively mediocre results. The commitment of this huge amount of wealth is accompanied by widespread dissatisfaction among patients, physicians, nurses, psychologists, hospital administrators, employers, and governments. Indeed, there are those who suggest that the marriage of medicine and the market has left medicine purposeless and adrift.³ Something is terribly wrong.

Starting a new health policy center in Washington, DC, in this context will be challenging. As a way of grounding the Center in its stated purpose of bringing a family practice and primary care perspective to health policy issues, the initial staff of the Center sought advice from those people most committed to family practice and primary care from a provider perspective. From the autumn of 1998 to the winter of 1999, approximately 400 individuals responded to queries about what the important health policy issues are for family practice and primary care. Among these respondents were officers of all of the national family medicine organizations, officers of national internal medicine and pediatric organizations, the chairmen of academic departments of family medicine, family practice residency directors, participants in a national meeting concerning practice-based research networks, leaders of safety-net organizations, members of the Institute of Medicine, faculty at medical schools (including those working primarily with medical students), international health workers, state legislators and activists, Robert Wood Johnson Generalist Scholars, and several early leaders of family medicine in the United States. Practicing family physicians and the staff of the AAFP were also polled. The various committees of the Academic Family Medicine Organization, directors of other health policy centers, staff working in agencies of the US Department of Health and Human Services, and a few deans of nursing and medical schools also provided their perspectives.

Most of the concerns expressed by these individuals can be summarized into 3 themes: The Functional Domain (Scope of Practice), Investing in Primary Care Infrastructures, and Universal Health Coverage.

The Functional Domain (Scope of Practice)

An overcommitment to reductionistic specialism has fragmented the health care system and left patients in a confusing maze of health services. An abundance of health professionals and would-be health care providers seeking their place and revenue stream from the trillion-dollar health care economy creates constant border disputes. In addition, there are expansive rules for various health plans, and there is confusion about what should be bought and who should pay for it.

These circumstances threaten the implementation of robust primary care and the sensible totality of family practice. Many family physicians wonder if they will have the opportunity to provide comprehensive care that matches the needs of their communities. They fear their scope of practice will be reduced, defined by a restricted set of services, a particular setting, or the problems that are left after various specialty groups secure their piece of contemporary practice.

The promise of improved health care and health status associated with integrated comprehensive, longitudinal, person-centered care seems elusive. It may not be possible to define the complimentary interfaces among primary care, public health, and tertiary care without more clearly establishing the scope of primary care. Areas of concern include mental health services, preventive care, chronic disease management, care of the aged, and care of the dying.

Current unrest and dissatisfaction in large segments of the population also impede the development of the definition of a sensible scope of primary care practice. There is widespread suspicion of the motives of physicians and others involved in health care; which suggests patients no longer trust the social contract that requires providers to put patients’ interests first. This has stimulated efforts to protect health care, consumers from physicians, health plans, and insurance companies and sorely tests the personal relationship that is central to primary care. Instead of a safe haven where a sustained partnership exists between the patient and the physician, primary care practices have become battlefields where the scope of practice is contested on a daily basis.

These circumstances should provoke a sense of urgency when juxtaposed with what is known about the salutary effects of primary care.⁴

Investing in Primary Care Infrastructures

Primary care is often misunderstood to be cheap and easy, requiring no infrastructures of its own because it derives its intellectual basis and practical applications from other fields. There is little recognition of the need to develop key undergirding to sustain primary care and propel it forward with constant improvements. Primary care clinicians are frustrated in their attempts to enhance health status by a lack of intentional investment in primary care research, training, and technology.

The country’s huge investment in disease-oriented research offers occasional opportunities to extend discovery into the situations and problems most relevant in the primary care setting. Often, however, the processes for obtaining research funding from institutions operating from a different perspective distort the fundamental phenomena and questions of primary care, and compromise the commitment to understanding from the perspective of primary care how people remain healthy, become sick, recover, or remain ill. There is no adequate place for an investigator to go to develop the tools necessary to study primary care and ask the questions essential for achieving its goals. The enthusiasm of foundations and agencies with commitments to primary care research is admirable, but it is constrained by lack of investment capital.

The country’s huge investment in graduate medical education is driven by a set of arcane rules that do not result in the training of the right workforce. Children are relatively neglected by the current system built around Medicare, and this system continues to emphasize hospitals and their problems instead of other settings of greater importance and relevance to the public. The point of view taken by most hospital administrators is that primary care is an economic loss. They often believe that if primary care has value in the hospital setting, it is primarily in what it can do to stimulate or protect the profitable enterprises; and these enterprises, not primary care, must be taught, defended, and financed by our major teaching institutions. Technologies for teaching and demonstrating best practice, such as computerized support systems and telemedicine, could make primary care training more relevant and more efficient if investments were directed appropriately. The best primary care is delivered by teams of various sizes and structures, but we do not currently finance the education and training of the members of the team in a manner that encourages collaborative practice on the behalf of patients.

The country’s huge investment in technology has not yet targeted the primary care setting, perhaps because the people directing those funds believe that technology and primary care are antithetical instead of complimentary. Indeed, many working in primary care now recognize that information management technologies are integral to robust primary care, but the cost of information systems capable of defining populations under care, monitoring their health status, measuring results, and improving quality are far beyond the resources available for primary care. Many of the procedures known to relieve suffering and improve the probability of staying healthy are performed competently in primary care but have not been widely implemented because of disorganization and perverse financial arrangements. Breakthrough technologies for teaching, such as virtual reality training centers, could make primary care training more efficient, but financial requirements exceed the revenue-generating capacity of primary care.

This pervasive lack of funding for primary care is one explanation for why it is a relatively powerless, awaiting its full manifestation as the foundation of an affordable and effective health care system.

Universal Health Coverage

Universal coverage—the inclusion of all people in the primary care system—has emerged as a major issue for those attempting to achieve the best primary care for our country. Accompanying a belief in this policy is a disbelief that the United States has the political will to do what is necessary to implement such coverage. Its affordability is doubted, but some policymakers suggest that primary care is an essential part of a sustainable inclusive solution. Indeed, as medicine and society create each other, universal coverage and primary care are also interdependent.

Because it is situated between the community and the rest of medicine, primary care is exposed to a broad spectrum of patients’ troubles and aspirations. When segments of the community are explicitly or functionally excluded, they are disadvantaged by not having access to the benefits of primary care, and they often eventually need to rely on health care and social services that may be inappropriate, too expensive, or too late. Not only are the excluded individuals disadvantaged, but so are their neighbors who experience less obvious losses and risks because of the neglect of significant numbers of their cohabitants.

Primary care provides a sensible link between individuals in the community and medical care. The ability to put primary care into practice, however, is compromised in the United States because of distortions and distractions created by selective inclusion. Without commitment to universal coverage, the value of primary care erodes, and the return on investment seems to diminish. To fully realize the benefits of primary care, universal coverage is necessary.

Preliminary plan of action

These themes provide a framework but not the focused explicit plan of action that is needed. To stay focused will be a continuing challenge for those seeking to bring a family practice and primary care perspective to health policy. To face this challenge, the Center initially will pursue the following 5 objectives.

Facilitate cooperative relationships with others interested in health policy. There is a vibrant health policy community in Washington, but it lacks a critical mass of primary care advocates. The initial strategies will include personal visits with various individuals and organizations, the establishment of an advisory board, an open house for the new Center, and an ongoing primary care forum in Washington for those interested in primary care health policy.

Develop mechanisms to communicate ideas about primary care. The Center will establish a Web site and and publish 1-page reports as ongoing methods for engaging others and reporting its work. The AAFP’s publications will be used to disseminate information when appropriate. Results of specific studies will be submitted to relevant journals. Occasionally, the Center will author a monograph focused on an issue of particular importance to family practice and primary care. Members of the Center will present ideas at selected meetings and in response to invited commentary.

Create a capacity to evaluate contemporary health policy issues from a family practice and primary care perspective. The time frame for policy issues ranges from moments to years. Sometimes, relatively immediate information is necessary for evidence-based advocacy. The Center will acquire and link multiple data sets to create a capacity to evaluate issues in short time frames using existing data. Cooperative relationships with other research centers and specific individuals will be explored. A catalog detailing useful data sets will be assembled. A rotating internship program will be tested, with interns functioning as essential members of the Center’s team. The topics evaluated will depend on the current issues that concern family practice and primary care.

Support self-initiated investigations. These investigations are intended to inform health policy and result in peer-reviewed publication. An early investigation will focus on updating the distribution of problems and services in the health care system, stratified by level of care. Others will examine the concerns of patients and clinicians about family practice and primary care. The Center intends to always have at least one investigation underway that studies disadvantaged populations.

Seek reality check points. The ideas of health care policy can lose touch with the reality of clinical practice, and clinical practice is at risk of failing to define relevant health policy. The physician members of the Center work on a limited basis as family physicians while working at the Center. All members of the Center will use the available opportunities to learn from practicing internists, pediatricians, family physicians, nurse practitioners, physician assistants, mental health professionals, and others engaged in daily service to patients at the level of primary care.

Conclusions

The Center for Policy Studies in Family Practice and Primary Care is now a reality. It is dedicated to improving the health of individuals and populations through enhanced primary care, and it aspires to achieve this goal by informing health policy with evidence from family practice and primary care. Expectations for an immediate large impact are unrealistic. However, this new Center can gradually become a credible and enduring piece of the Washington landscape. It aspires to be identified with those who put patients first and who advocate relentlessly for improved family practice and primary care for all.

This year the American Academy of Family Physicians (AAFP) opened a new policy center in Washington, DC. The idea for this center can be traced back to AAFP Executive Vice President Robert Graham, MD, who envisioned a research unit focused on family practice and primary care policy in the relatively small community of health policy advocates in Washington.

In 1996, several officers and staff of the AAFP agreed that a policy center in Washington could fit into a framework focused on building the infrastructures necessary to support family practice and primary care. Concurrently, the membership and leadership of the Academy rediscovered the critical role of research in strengthening family practice, and the concepts of research and a policy center converged.

When the idea was taken to the AAFP Board of Directors for formal action, the board approved the policy center without controversy and directed the staff to proceed. Key leaders supported a comprehensive plan to enhance research capacity and included a policy center with other strategies for achieving this goal. There was agreement that effective advocacy requires facts and that the envisioned policy center would have to be sufficiently independent to be credible. And there was agreement that the center should be located in Washington, DC, to affirm family practice and primary care and react to vagaries of health care policy at a federal level.

A favorable financial position permitted immediate movement toward implementation. By the end of 1998, the first director was designated and the exact location of the Center was determined. Ideas about the work and focus of the Center were elicited from practicing family physicians and other leaders within and beyond the primary care community. The Center for Policy Studies in Family Practice and Primary Care opened for business on June 8, 1999. The Center operates according to a set of assumptions which are outlined in the Table 1

Initial structure and function

The Center is structured to operate as an independent unit working under the personnel and financial policies of the AAFP. The initial staff of 5 (supplemented with consultative relationships) have knowledge and skills in the areas of primary care, family practice, epidemiology, statistics, research design, and data/information management. These individuals share leadership and responsibility for various projects and activities and coordinate their efforts with the help of an office administrator. Because the policy of the Center is to use existing data sets and the study results of researchers worldwide whenever possible, the Center’s staff will only do primary data collection when necessary.

The staff of the Center is accountable to the Director, who reports to the Vice President of Socioeconomic Affairs. There are no lines of accountability to the various AAFP commissions and committees. The AAFP Board decided that the Center would have editorial independence to pursue and publish work according to traditional academic and peer-review standards. A formally constituted advisory board advises the Center. This volunteer group does not have administrative authority but provides commentary on the Center’s direction and work on a regular basis. The Center relies on the AAFP’s Washington office and other AAFP divisions for assistance in detecting relevant policy opportunities, guidance about the Washington environment, and decisions about communication strategies.

Issues from the field

The United States is spending much more for health care than other countries, with relatively mediocre results. The commitment of this huge amount of wealth is accompanied by widespread dissatisfaction among patients, physicians, nurses, psychologists, hospital administrators, employers, and governments. Indeed, there are those who suggest that the marriage of medicine and the market has left medicine purposeless and adrift.³ Something is terribly wrong.

Starting a new health policy center in Washington, DC, in this context will be challenging. As a way of grounding the Center in its stated purpose of bringing a family practice and primary care perspective to health policy issues, the initial staff of the Center sought advice from those people most committed to family practice and primary care from a provider perspective. From the autumn of 1998 to the winter of 1999, approximately 400 individuals responded to queries about what the important health policy issues are for family practice and primary care. Among these respondents were officers of all of the national family medicine organizations, officers of national internal medicine and pediatric organizations, the chairmen of academic departments of family medicine, family practice residency directors, participants in a national meeting concerning practice-based research networks, leaders of safety-net organizations, members of the Institute of Medicine, faculty at medical schools (including those working primarily with medical students), international health workers, state legislators and activists, Robert Wood Johnson Generalist Scholars, and several early leaders of family medicine in the United States. Practicing family physicians and the staff of the AAFP were also polled. The various committees of the Academic Family Medicine Organization, directors of other health policy centers, staff working in agencies of the US Department of Health and Human Services, and a few deans of nursing and medical schools also provided their perspectives.

Most of the concerns expressed by these individuals can be summarized into 3 themes: The Functional Domain (Scope of Practice), Investing in Primary Care Infrastructures, and Universal Health Coverage.

The Functional Domain (Scope of Practice)

An overcommitment to reductionistic specialism has fragmented the health care system and left patients in a confusing maze of health services. An abundance of health professionals and would-be health care providers seeking their place and revenue stream from the trillion-dollar health care economy creates constant border disputes. In addition, there are expansive rules for various health plans, and there is confusion about what should be bought and who should pay for it.

These circumstances threaten the implementation of robust primary care and the sensible totality of family practice. Many family physicians wonder if they will have the opportunity to provide comprehensive care that matches the needs of their communities. They fear their scope of practice will be reduced, defined by a restricted set of services, a particular setting, or the problems that are left after various specialty groups secure their piece of contemporary practice.

The promise of improved health care and health status associated with integrated comprehensive, longitudinal, person-centered care seems elusive. It may not be possible to define the complimentary interfaces among primary care, public health, and tertiary care without more clearly establishing the scope of primary care. Areas of concern include mental health services, preventive care, chronic disease management, care of the aged, and care of the dying.

Current unrest and dissatisfaction in large segments of the population also impede the development of the definition of a sensible scope of primary care practice. There is widespread suspicion of the motives of physicians and others involved in health care; which suggests patients no longer trust the social contract that requires providers to put patients’ interests first. This has stimulated efforts to protect health care, consumers from physicians, health plans, and insurance companies and sorely tests the personal relationship that is central to primary care. Instead of a safe haven where a sustained partnership exists between the patient and the physician, primary care practices have become battlefields where the scope of practice is contested on a daily basis.

These circumstances should provoke a sense of urgency when juxtaposed with what is known about the salutary effects of primary care.⁴

Investing in Primary Care Infrastructures

Primary care is often misunderstood to be cheap and easy, requiring no infrastructures of its own because it derives its intellectual basis and practical applications from other fields. There is little recognition of the need to develop key undergirding to sustain primary care and propel it forward with constant improvements. Primary care clinicians are frustrated in their attempts to enhance health status by a lack of intentional investment in primary care research, training, and technology.

The country’s huge investment in disease-oriented research offers occasional opportunities to extend discovery into the situations and problems most relevant in the primary care setting. Often, however, the processes for obtaining research funding from institutions operating from a different perspective distort the fundamental phenomena and questions of primary care, and compromise the commitment to understanding from the perspective of primary care how people remain healthy, become sick, recover, or remain ill. There is no adequate place for an investigator to go to develop the tools necessary to study primary care and ask the questions essential for achieving its goals. The enthusiasm of foundations and agencies with commitments to primary care research is admirable, but it is constrained by lack of investment capital.

The country’s huge investment in graduate medical education is driven by a set of arcane rules that do not result in the training of the right workforce. Children are relatively neglected by the current system built around Medicare, and this system continues to emphasize hospitals and their problems instead of other settings of greater importance and relevance to the public. The point of view taken by most hospital administrators is that primary care is an economic loss. They often believe that if primary care has value in the hospital setting, it is primarily in what it can do to stimulate or protect the profitable enterprises; and these enterprises, not primary care, must be taught, defended, and financed by our major teaching institutions. Technologies for teaching and demonstrating best practice, such as computerized support systems and telemedicine, could make primary care training more relevant and more efficient if investments were directed appropriately. The best primary care is delivered by teams of various sizes and structures, but we do not currently finance the education and training of the members of the team in a manner that encourages collaborative practice on the behalf of patients.

The country’s huge investment in technology has not yet targeted the primary care setting, perhaps because the people directing those funds believe that technology and primary care are antithetical instead of complimentary. Indeed, many working in primary care now recognize that information management technologies are integral to robust primary care, but the cost of information systems capable of defining populations under care, monitoring their health status, measuring results, and improving quality are far beyond the resources available for primary care. Many of the procedures known to relieve suffering and improve the probability of staying healthy are performed competently in primary care but have not been widely implemented because of disorganization and perverse financial arrangements. Breakthrough technologies for teaching, such as virtual reality training centers, could make primary care training more efficient, but financial requirements exceed the revenue-generating capacity of primary care.

This pervasive lack of funding for primary care is one explanation for why it is a relatively powerless, awaiting its full manifestation as the foundation of an affordable and effective health care system.

Universal Health Coverage

Universal coverage—the inclusion of all people in the primary care system—has emerged as a major issue for those attempting to achieve the best primary care for our country. Accompanying a belief in this policy is a disbelief that the United States has the political will to do what is necessary to implement such coverage. Its affordability is doubted, but some policymakers suggest that primary care is an essential part of a sustainable inclusive solution. Indeed, as medicine and society create each other, universal coverage and primary care are also interdependent.

Because it is situated between the community and the rest of medicine, primary care is exposed to a broad spectrum of patients’ troubles and aspirations. When segments of the community are explicitly or functionally excluded, they are disadvantaged by not having access to the benefits of primary care, and they often eventually need to rely on health care and social services that may be inappropriate, too expensive, or too late. Not only are the excluded individuals disadvantaged, but so are their neighbors who experience less obvious losses and risks because of the neglect of significant numbers of their cohabitants.

Primary care provides a sensible link between individuals in the community and medical care. The ability to put primary care into practice, however, is compromised in the United States because of distortions and distractions created by selective inclusion. Without commitment to universal coverage, the value of primary care erodes, and the return on investment seems to diminish. To fully realize the benefits of primary care, universal coverage is necessary.

Preliminary plan of action

These themes provide a framework but not the focused explicit plan of action that is needed. To stay focused will be a continuing challenge for those seeking to bring a family practice and primary care perspective to health policy. To face this challenge, the Center initially will pursue the following 5 objectives.

Facilitate cooperative relationships with others interested in health policy. There is a vibrant health policy community in Washington, but it lacks a critical mass of primary care advocates. The initial strategies will include personal visits with various individuals and organizations, the establishment of an advisory board, an open house for the new Center, and an ongoing primary care forum in Washington for those interested in primary care health policy.

Develop mechanisms to communicate ideas about primary care. The Center will establish a Web site and and publish 1-page reports as ongoing methods for engaging others and reporting its work. The AAFP’s publications will be used to disseminate information when appropriate. Results of specific studies will be submitted to relevant journals. Occasionally, the Center will author a monograph focused on an issue of particular importance to family practice and primary care. Members of the Center will present ideas at selected meetings and in response to invited commentary.

Create a capacity to evaluate contemporary health policy issues from a family practice and primary care perspective. The time frame for policy issues ranges from moments to years. Sometimes, relatively immediate information is necessary for evidence-based advocacy. The Center will acquire and link multiple data sets to create a capacity to evaluate issues in short time frames using existing data. Cooperative relationships with other research centers and specific individuals will be explored. A catalog detailing useful data sets will be assembled. A rotating internship program will be tested, with interns functioning as essential members of the Center’s team. The topics evaluated will depend on the current issues that concern family practice and primary care.

Support self-initiated investigations. These investigations are intended to inform health policy and result in peer-reviewed publication. An early investigation will focus on updating the distribution of problems and services in the health care system, stratified by level of care. Others will examine the concerns of patients and clinicians about family practice and primary care. The Center intends to always have at least one investigation underway that studies disadvantaged populations.

Seek reality check points. The ideas of health care policy can lose touch with the reality of clinical practice, and clinical practice is at risk of failing to define relevant health policy. The physician members of the Center work on a limited basis as family physicians while working at the Center. All members of the Center will use the available opportunities to learn from practicing internists, pediatricians, family physicians, nurse practitioners, physician assistants, mental health professionals, and others engaged in daily service to patients at the level of primary care.

Conclusions

The Center for Policy Studies in Family Practice and Primary Care is now a reality. It is dedicated to improving the health of individuals and populations through enhanced primary care, and it aspires to achieve this goal by informing health policy with evidence from family practice and primary care. Expectations for an immediate large impact are unrealistic. However, this new Center can gradually become a credible and enduring piece of the Washington landscape. It aspires to be identified with those who put patients first and who advocate relentlessly for improved family practice and primary care for all.