The Chasm Between Intention and Achievement in Primary Care

Reuben put it well: “Primary care is on death row.”¹ A total of 21% of general internists are leaving that practice sometime in the first 10 years after completing training,² and only 6.7% of all 2007 US medical school graduates are choosing family medicine or ambulatory internal medicine.³ The net loss is worrisome because robust primary care seems to be an important component of high-performing health systems.⁴ Enhancing primary care through such models as the patient-centered medical home has been proposed as an important if incomplete part of US health system redesign.⁵ Explanations offered in both professional⁶ and popular⁷ media for the disappearance of primary care physicians have focused on salary or income differentials between primary care physicians and their specialty colleagues, differentials that in some markets have reached a factor of 3. While higher primary care incomes would be helpful, at least as large a problem affecting primary care is the lack of capacity to perform successfully the work of a generalist.