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.