The Future of Primary Care

To the Editor.—Dr Mullan's¹ new series, Profiles in Primary Care, is well timed. Serious discussion of generalism has been minimal, and its advocacy has been sporadic rather than sustained in our medical literature. I share the author's hopes that his work "will stimulate students of medicine and the makers of policy to reflect on medical generalism."

For the past several years, policymakers in medicine and government have declared that primary care has a central role in our health care system and more primary care physicians need to be trained.² However, medicine seems ambivalent about accepting generalism into a profession that for the past several decades has been dominated by specialism. Within the medical hierarchy, primary care physicians are still accorded second-class status in most communities, and the rebirth of primary care, which seemed imminent several years ago, now appears doubtful.

Clearly, medical practice remains procedure based, and health care policy is driven mostly by specialty interests. Starting several years ago, managed care organizations provided major support for primary care, but their backing did not resonate well with medical educators in our academic health centers,³ where generalism's reception has been lukewarm. Ironically, its greatest opposition, disguised as indifference, has come from the sector that should be its greatest champion.

If primary care is delegated to nurses as independent practitioners,⁴ a dangerous precedent might be set, encouraging the use of midlevel providers as substitutes for generalists. Generalist physicians will become an anachronism. Our health care system will consist of midlevel providers referring patients to specialists. Midlevel personnel with limited training and experience acting as primary care physicians is a cost-cutting strategy, and no amount of rationalization can ever make it right. Indeed, if we allow primary care physicians to be so easily replaced by midlevel providers, it is easy to imagine a time when well-trained technicians will be doing the work of specialists. This is not farfetched considering how marketplace values are increasingly controlling medicine's destiny.

I hope that Mullan's series generates serious discussion about primary care and, in his words, makes us ponder "what should be its role as we start a new century?"