Book Review

Primary Care: America's health in a new era

N Engl J Med 1997; 336:1615May 29, 1997

Article

Primary Care: America's health in a new era
Edited by Molla S. Donaldson, Karl D. Yordy, Kathleen N. Lohr, and Neal A. Vanselow. 395 pp. Washington, D.C., National Academy Press, 1996. $42.95. ISBN: 0-309-05399-4

The recent increase in the proportion of medical school graduates choosing primary care is an encouraging response to market signals and educational reforms. But having more graduates in family medicine, general pediatrics, and general internal medicine will not by itself ensure access to high-quality primary care services. This report by the Institute of Medicine's Committee on the Future of Primary Care assesses American primary care and offers 31 recommendations for its improvement.

Written by a distinguished, multidisciplinary panel of 16 experts and the Institute of Medicine's excellent staff, the report is based on an extensive review of the literature and other available evidence, a public hearing, two workshops, and three site visits. It offers a valuable bench mark for primary care policy at a critical time in the history of American medicine.

The most fundamental contribution of this road map to improved primary care is the redefinition of the term. Building on previous definitions, including that of the Institute of Medicine's 1978 report, this report defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

According to this new definition, primary care is a function, “not just a label for a set of clinicians.” By defining primary care in functional terms, the Institute of Medicine emphasizes relationships and collaboration rather than boundaries between specialties and disciplines. The new definition also “emphasizes the need for the primary care clinician not only to manage a given health concern and address issues of preventive health care, but also to act as an advocate for the patient in a larger health system so that the patient knows who is directing and coordinating his or her care.” The emphasis is on the clinician's role as the patient's partner and advocate. Primary care means more than just first-contact care or entry-level care, a “triage function in which patients are then passed on to a higher level of care.” Instead, the word “primary” is understood in its sense of “chief, principal, or main.” Primary care is a multidimensional function that is essential to high-quality health care.

One essential function of primary care is to provide continuity of care, and this report broadens that concept by emphasizing that continuity may be provided by a clinical team, perhaps more effectively than by one clinician, and that continuity of the medical record will help ensure timely communication.

After critically reviewing the convincing evidence that a system with effective primary care provides higher quality care (decreased mortality, fewer emergency visits, lower rates of preventable hospital admissions, and more appropriate care), as well as lower costs, the authors of the report offer their recommendations. The themes of the recommendations are familiar and very important. First, education should be based on the core competencies required in primary care, emphasize the associated evaluative sciences (e.g., clinical epidemiology and evidence-based medicine), and be shifted to primary care (not just ambulatory) settings. Second, new systems of care, particularly those being developed in the private sector, should be used as sites for education in primary care, particularly those that offer timely integrated care and are not just marketing devices to attract referrals to the hospital. Academic hospitals that aspire to become academic health care systems will need to view primary care not as a feeder to tertiary care but as a central mission of the system. Third, primary care should be provided by teams that bring “different kinds of expertise . . . to bear on the patient's needs through collaborative activity, and . . . permit the delegation of some tasks by broadening the range of professionals involved in primary care.” Fourth, new financing mechanisms will be needed to support both the education of primary care clinicians and access to high-quality primary care for all Americans. This need could be met by an all-payer fund for graduate medical education and by enhancement of payment for primary care, such as continued improvements of the resource-based relative-value payment system to recognize practice costs in ambulatory care. Fifth, effective coordination of care will require improved information systems, as well as new organizational arrangements. Finally, the knowledge base necessary for effective primary care will require enhanced clinical epidemiology and health services research. The need for better measures of performance and enhanced evidence to guide decision making suggests the need for support of practice-based primary care research networks and improved standards for data collection.

This report by the Institute of Medicine addresses the full breadth of primary care policy and delivery and succeeds in providing a road map for improvement. The report is weaker in describing the demand side of primary care than it is in describing the supply side, however, which suggests that we need to know more about patients' needs, preferences, and values. In addition, the report gives short shrift to the need for primary care clinicians to understand the biologic and clinical science of common diseases and advances in basic biology in order to apply such knowledge to clinical care.

The Institute of Medicine has again thrown down the gauntlet in primary care. Progress since its 1978 report on primary care education includes an expansion of the primary care professions (e.g., advanced nursing practice), development of the intellectual and methodologic framework for primary care research, and reorganization of integrated systems of care. This new report challenges the public and private sectors to meet the need for affordable, high-quality primary care in the United States.

John M. Eisenberg, M.D.
Agency for Health Care Policy and Research, Rockville, MD 20852