Perspective
Primary Care — Will It Survive?
N Engl J Med 2006; 355:861-864August 31, 2006
- Article
The American College of Physicians recently warned that “primary care, the backbone of the nation's health care system, is at grave risk of collapse.”1 And indeed, primary care is facing a confluence of factors that could spell disaster. Patients are increasingly dissatisfied with their care and with the difficulty of gaining timely access to a primary care physician; many primary care physicians, in turn, are unhappy with their jobs, as they face a seemingly insurmountable task; the quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field.
The great majority of patients prefer to seek initial care from a primary care physician rather than a specialist,2 but their unhappiness with their primary care experience is growing.3 At the same time, primary care physicians are expressing frustration that the knowledge and skills they are expected to master exceed the limits of human capability, making it impossible to provide the best care to every patient.4 The scope of primary care extends from uncomplicated upper respiratory and urinary tract infections to the longitudinal care of elderly patients with diabetes, coronary heart disease, arthritis, and depression — who may also have limited proficiency in English.
Reimbursement based primarily on the quantity of services delivered, rather than on quality, forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians.
Contributing to this frustration is the growing set of demands placed on primary care. The preventive services that a physician either ought to provide because there is evidence of their efficacy or might provide because of the patient's preferences (which must therefore be discussed) have multiplied. The prevalence of chronic conditions — most of which are handled in primary care settings — is increasing, as are requirements for their proper management. Not only has the number of primary care tasks grown exponentially, but physician performance is being measured and physicians are even being paid according to their ability to perform these tasks reliably and consistently. It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300).4
These excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care,4 partly because half of all patients leave their office visits without having understood what the physician said.5
These problems are exacerbated by the system of physician payment.1 Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression. The median income of specialists in 2004 was almost twice that of primary care physicians, a gap that is widening. Data from the Medical Group Management Association indicate that from 1995 to 2004, the median income for primary care physicians increased by 21.4 percent, while that for specialists increased by 37.5 percent. A 2006 report from the Center for Studying Health System Change reveals that from 1995 to 2003, inflation-adjusted income decreased by 7.1 percent for all physicians and by 10.2 percent for primary care physicians. The 5 percent increase in Medicare payments for primary care announced in June 2006 is insufficient to narrow the gap.
These factors add up to an unsurprising result: fewer U.S. medical students are choosing careers in primary care.1 Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent (see line graph
Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates.). In 1998, half of internal medicine residents chose primary care; currently, about 80 percent become subspecialists or hospitalists (see bar graph
Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists.).1 These trends are occurring at a time of growing need for primary care for an aging population with an increased prevalence of chronic disease. Moreover, many nurse practitioners and physician assistants who could join the primary care workforce are instead going to work in wealthier specialty practices. Primary care practices in the United States now depend on luring physicians away from other countries.Even as primary care spirals further into crisis, studies have demonstrated that a primary care–based health care system has the potential to reduce costs while maintaining quality. The hospitalization rates for diagnoses that could be addressed in ambulatory care settings are higher in geographic areas where access to primary care physicians is more limited. States with a higher ratio of generalist to population have lower per-beneficiary Medicare expenditures and higher scores on 24 common performance measures than states with fewer generalist physicians and more specialists per capita.1
Fixing primary care requires actions on the part of primary care practices (microsystem improvement) and the larger health care system (macrosystem reform). A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.
Fortunately, microsystem improvement is taking place. Many primary care practices have instituted policies to reduce appointment delays. Learning collaboratives have catalyzed primary care practices — particularly in community health centers, integrated delivery systems, and academic medical centers — to implement components of the Chronic Care Model, effecting impressive improvements in process and outcome measures. Primary care professional societies are designing and testing new practice models.
Yet these efforts have touched only a fraction of primary care practices, with small private offices offering the greatest challenge. Moreover, these models have not sufficiently confronted the reality that primary care physicians lack the time to provide all evidence-based preventive and chronic care services for the average patient panel.4 This problem is addressed in a misguided fashion by concierge practices with small patient panels. Such practices are rarely available to lower-income patients, and if the approach were widely adopted, the primary care workforce would become grossly insufficient to care for the entire population.
A more thoughtful solution to physicians' time constraints requires a combination of team care and electronic encounters. Nonphysician team members working with Web- and e-mail–based patient portals can perform routine preventive care functions and manage less complex chronic care. However, forging cohesive and efficient teams is a challenge, and few payers adequately reimburse these services.
Unfortunately, little activity is evident at the macrosystem level. No serious proposals to narrow the income gap between primary care physicians and specialists are on the national agenda. Fee-for-service payment rewards quantity rather than quality, fostering the rushed visits that underlie primary care's shortcomings. Pay-for-performance programs appear to be insufficient to make a substantial difference; physicians could increase their income more — with less additional work — by adding one or two patient visits each day than by meeting all the quality standards in current performance-based payment programs.
Serious effort is required to develop a national primary care payment policy. Public policy on primary care does not exist; the fortunes of primary care are dictated not by the health care needs of the country but by a specialty-rich, quantity-based reimbursement system. Few legislators, particularly among those responsible for the trend-setting Medicare program, are aware that primary care is struggling. An educational campaign is needed — to explain the nature and causes of the threats to primary care's survival; to provide well-documented information on the benefits of primary care, focusing on the potential for a strong primary care–based system to control health expenditures; and to offer concrete proposals for reforming both primary care at the microsystem level and the payment scheme at the macrosystem level.
Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs. The public would benefit from microsystem improvement, with fewer appointment delays, higher quality, and more meaningful interpersonal relationships. Even specialists might recognize that they would suffer if primary care deteriorates, being forced to coordinate care and confront psychosocial issues in patients with multiple acute and chronic conditions rather than focusing on diagnosing and managing specific diseases within their scope of expertise. Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.
Source Information
Dr. Bodenheimer is a professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine, University of California, San Francisco.
- References
References
1
The impending collapse of primary care medicine and its implications for the state of the nation's health care. Washington, D.C.: American College of Physicians, January 30, 2006. (Accessed August 10, 2006, at http://www.acponline.org/hpp/statehc06_1.pdf.)
2
Grumbach K ,Selby JV ,Damberg C , et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999;282:261-266
CrossRef | Web of Science | Medline3
Safran DG . Defining the future of primary care: what can we learn from patients? Ann Intern Med 2003;138:248-255
Web of Science | Medline4
Ostbye T ,Yarnall KS ,Krause KM ,Pollak KI ,Gradison M ,Michener JL . Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3:209-214
CrossRef | Web of Science | Medline5
Roter DL ,Hall JA . Studies of doctor-patient interaction. Annu Rev Public Health 1989;10:163-180
CrossRef | Web of Science | Medline6
Garibaldi RA ,Popkave C ,Bylsma W . Career plans for trainees in internal medicine residency programs. Acad Med 2005;80:507-512
CrossRef | Web of Science | Medline
- Citing Articles (93)
Citing Articles
1
Patricia A. Murphy, Sharon G. Frazee, Jack P. Cantlin, Ed Cohen, Jay R. Rosan, Devonee E. Harshburger. (2012) Pharmacy provision of influenza vaccinations in medically underserved communities. Journal of the American Pharmacists Association 52:1, 67-70
CrossRef2
Lawrence R. Krakoff. (2011) Management of Cardiovascular Risk Factors Is Leaving the Office: Potential Impact of Telemedicine*. The Journal of Clinical Hypertension 13:11, 791-794
CrossRef3
Michèle Aubin, Lucie Vézina, René Verreault, Lise Fillion, Éveline Hudon, François Lehmann, Yvan Leduc, Rénald Bergeron, Daniel Reinharz, Diane Morin. (2011) Family physician involvement in cancer care and lung cancer patient emotional distress and quality of life. Supportive Care in Cancer 19:11, 1719-1727
CrossRef4
Lawrence S. Weisberg. (2011) The Patient-Centered Medical Home and the Nephrologist. Advances in Chronic Kidney Disease 18:6, 450-455
CrossRef5
Lyn M. Sibley, Richard H. Glazier. (2011) Evaluation of the equity of age–sex adjusted primary care capitation payments in Ontario, Canada. Health Policy
CrossRef6
Sabrina M. Chase, William L. Miller, Eric Shaw, Anna Looney, Benjamin F. Crabtree. (2011) Meeting the Challenge of Practice Quality Improvement: A Study of Seven Family Medicine Residency Training Practices. Academic Medicine1
CrossRef7
Gary S. Moak. (2011) Treatment of Late-Life Mental Disorders in Primary Care: We Can Do a Better Job. Journal of Aging & Social Policy 23:3, 274-285
CrossRef8
Dorothy L. Powell, Addie J. Price, Faith A. Burns, Eleanor S. McConnell, Cristina C. Hendrix, Leila McWhinney-Dehaney, Marilyn M. Lombardi. (2011) Pillars for the Care of Older Persons in the Caribbean. Public Health Nursingno-no
CrossRef9
Lawrence R Krakoff. (2011) Home blood pressure for the management of hypertension: will it become the new standard of practice?. Expert Review of Cardiovascular Therapy 9:6, 745-751
CrossRef10
Mark W. Friedberg, Gillian K. SteelFisher, Melinda Karp, Eric C. Schneider. (2011) Physician Groups’ Use of Data from Patient Experience Surveys. Journal of General Internal Medicine 26:5, 498-504
CrossRef11
Richard Wasserman, Janet R. Serwint, Nathan Kuppermann, Rajendu Srivastava, Benard Dreyer. (2011) The APA and the Rise of Pediatric Generalist Network Research. Academic Pediatrics 11:3, 195-204
CrossRef12
C. N. Klabunde, N. L. Keating, A. L. Potosky, A. Ambs, Y. He, M. C. Hornbrook, P. A. Ganz. (2011) A Population-Based Assessment of Specialty Physician Involvement in Cancer Clinical Trials. JNCI Journal of the National Cancer Institute 103:5, 384-397
CrossRef13
Seena L. Haines, Renee M. DeHart, Arlene A. Flynn, Karl M. Hess, Macary Weck Marciniak, Jeanine Mount, Beth Bryles Phillips, Joseph J. Saseen, S. Whitney Zatzkin. (2011) Academic pharmacy and patient-centered health care: A model to prepare the next generation of pharmacists. Journal of the American Pharmacists Association 51:2, 194-202
CrossRef14
I. John Parboosingh, Virginia A. Reed, James Caldwell Palmer, Henry H. Bernstein. (2011) Enhancing practice improvement by facilitating practitioner interactivity: New roles for providers of continuing medical education. Journal of Continuing Education in the Health Professions 31:2, 122-127
CrossRef15
Lisbeth Selby, Andrew Hoellein, John F. Wilson. (2011) Are Primary Care Providers Uncomfortable Providing Routine Preventive Care for Inflammatory Bowel Disease Patients?. Digestive Diseases and Sciences 56:3, 819-824
CrossRef16
Margaret Knight. (2011) Access to Mental Health Care Among Older Adults. Journal of Gerontological Nursing
CrossRef17
Dennis Z. Kuo, Amy J. Houtrow, Polly Arango, Karen A. Kuhlthau, Jeffrey M. Simmons, John M. Neff. (2011) Family-Centered Care: Current Applications and Future Directions in Pediatric Health Care. Maternal and Child Health Journal
CrossRef18
Nir Menachemi, Charles T Prickett, Robert G Brooks. (2011) The Use of Physician-Patient Email: A Follow-up Examination of Adoption and Best-Practice Adherence 2005-2008. Journal of Medical Internet Research 13:1,
CrossRef19
Stewart F. Babbott, Brent W. Beasley, Siddharta Reddy, F. Daniel Duffy, Mohan Nadkarni, Eric S. Holmboe. (2010) Ambulatory Office Organization for Internal Medicine Resident Medical Education. Academic Medicine 85:12, 1880-1887
CrossRef20
Jacquelyn Flaskerud. (2010) Health Care Reform and Meeting the Needs for Primary Care. Issues in Mental Health Nursing 31:12, 816-818
CrossRef21
D. Hamerman. (2010) Can Biogerontologists and Geriatricians Unite to Apply Aging Science to Health Care in the Decade Ahead?. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 65A:11, 1193-1197
CrossRef22
Annette Sofie Davidsen. (2010) To survive, general practice needs to reintroduce the psychodynamic dimension. Psychodynamic Practice 16:4, 451-461
CrossRef23
Alexander Turchin, Paul R Conlin. (2010) The doctor needs to see you now: accelerating the care of patients with uncontrolled hypertension. Expert Review of Cardiovascular Therapy 8:11, 1501-1503
CrossRef24
Francesca Zapater, Montserrat Maynegre. (2010) Cambio posible, cambio imprescindible. Atención Primaria 42:10, 496-497
CrossRef25
David Katerndahl, Michael Parchman, Robert Wood. (2010) Trends in the perceived complexity of primary health care: a secondary analysis. Journal of Evaluation in Clinical Practice 16:5, 1002-1008
CrossRef26
Hari Balasubramanian, Ritesh Banerjee, Brian Denton, James Naessens, James Stahl. (2010) Improving Clinical Access and Continuity through Physician Panel Redesign. Journal of General Internal Medicine 25:10, 1109-1115
CrossRef27
Wayne H. Bylsma, Gerald K. Arnold, Gregory S. Fortna, Rebecca S. Lipner. (2010) Where Have All the General Internists Gone?. Journal of General Internal Medicine 25:10, 1020-1023
CrossRef28
Carl G. Morris, Sarah E. Lesko, Holly A. Andrilla, Frederick M. Chen. (2010) Family Medicine Residency Training in Community Health Centers: A National Survey. Academic Medicine 85:10, 1640-1644
CrossRef29
Michael T. French, Jenny F. Homer, Shay Klevay, Edward Goldman, Steven G. Ullmann, Barbara E. Kahn. (2010) Is the United States Ready to Embrace Concierge Medicine?. Population Health Management 13:4, 177-182
CrossRef30
John W. Saultz, Peggy OʼNeill, James M. Gill, Frances E. Biagioli, Shawn Blanchard, Jean P. OʼMalley, David Brown, John C. Rogers, Patricia A. Carney. (2010) Medical Student Exposure to Components of the Patient-Centered Medical Home During Required Ambulatory Clerkship Rotations: Implications for Education. Academic Medicine 85:6, 965-973
CrossRef31
David J. Lucier, Nicholas B. Frisch, Brian J. Cohen, Michael Wagner, Deeb Salem, David G. Fairchild. (2010) Academic Retainer Medicine: An Innovative Business Model for Cross-Subsidizing Primary Care. Academic Medicine 85:6, 959-964
CrossRef32
Kurt C. Stange, Paul A. Nutting, William L. Miller, Carlos R. Jaén, Benjamin F. Crabtree, Susan A. Flocke, James M. Gill. (2010) Defining and Measuring the Patient-Centered Medical Home. Journal of General Internal Medicine 25:6, 601-612
CrossRef33
G. A. Samoutis, E. S. Soteriades, H. E. Stoffers, A. Philalithis, E. M. Delicha, C. Lionis. (2010) A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus. Family Practice 27:3, 263-270
CrossRef34
David O. Meltzer, Jeanette W. Chung. (2010) U.S. Trends in Hospitalization and Generalist Physician Workforce and the Emergence of Hospitalists. Journal of General Internal Medicine 25:5, 453-459
CrossRef35
Robin Cooper, Theresa R. Kramer. (2010) Revenue-Based Cost Assignment: A Potent but Hidden Threat to the Survival of the Multispecialty Medical Practice. Academic Medicine 85:3, 538-547
CrossRef36
Andrea Parsons Schram. (2010) Medical Home and the Nurse Practitioner: A Policy Analysis. The Journal for Nurse Practitioners 6:2, 132-139
CrossRef37
Kimberly A. Waller. (2010) Using a Symbolic Interactionist Approach to Role and Identity to Illuminate Medical Student Avoidance of Primary Care. International Quarterly of Community Health Education 31:1, 99-111
CrossRef38
J. C Crosson, P. A Ohman-Strickland, S. Campbell, R. L Phillips, M. O Roland, E. Kontopantelis, A. Bazemore, B. Balasubramanian, B. F Crabtree. (2009) A comparison of chronic illness care quality in US and UK family medicine practices prior to pay-for-performance initiatives. Family Practice 26:6, 510-516
CrossRef39
Lee K Brown. (2009) The future economic viability of sleep medicine in the United States: Götterdämmerung?. Current Opinion in Pulmonary Medicine 15:6, 529-533
CrossRef40
Lauren P. Hunter, Charles E. Weber, Anthony P. Morreale, James H. Wall. (2009) Patient satisfaction with retail health clinic care. Journal of the American Academy of Nurse Practitioners 21:10, 565-570
CrossRef41
Carrie N. Klabunde, Anita Ambs, Nancy L. Keating, Yulei He, William R. Doucette, Diana Tisnado, Steven Clauser, Katherine L. Kahn. (2009) The Role of Primary Care Physicians in Cancer Care. Journal of General Internal Medicine 24:9, 1029-1036
CrossRef42
Steven E. Wegner, Richard C. Antonelli, Renee M. Turchi. (2009) The Medical Home–Improving Quality of Primary Care for Children. Pediatric Clinics of North America 56:4, 953-964
CrossRef43
Hai Fang, Hong Liu, John A. Rizzo. (2009) Has the use of physician gatekeepers declined among HMOs? Evidence from the United States. International Journal of Health Care Finance and Economics 9:2, 183-195
CrossRef44
Kathleen Schutte, Elizabeth M. Yano, Amy M. Kilbourne, Bhagya Wickrama, JoAnn E. Kirchner, Keith Humphreys. (2009) Organizational contexts of primary care approaches for managing problem drinking. Journal of Substance Abuse Treatment 36:4, 435-445
CrossRef45
2009. Endnotes. , 141-147.
CrossRef46
Robert El-Kareh, Tejal K. Gandhi, Eric G. Poon, Lisa P. Newmark, Jonathan Ungar, Stuart Lipsitz, Thomas D. Sequist. (2009) Trends in Primary Care Clinician Perceptions of a New Electronic Health Record. Journal of General Internal Medicine 24:4, 464-468
CrossRef47
Hamel, Mary Beth, Drazen, Jeffrey M., Epstein, Arnold M., . (2009) The Growth of Hospitalists and the Changing Face of Primary Care. New England Journal of Medicine 360:11, 1141-1143
Full Text48
Daniel Bluestein, Barbara Ann Cubic. (2009) Psychologists and Primary Care Physicians: A Training Model for Creating Collaborative Relationships. Journal of Clinical Psychology in Medical Settings 16:1, 101-112
CrossRef49
Alfred L. Fisher, Elizabeth A. O'Keefe, Joseph T. Hanlon, Stephanie A. Studenski, John G. Hennon, Neil M. Resnick. (2009) A Brief, Intensive, Clinically Focused Geriatrics Course During the Third Year of Medical School. Journal of the American Geriatrics Society 57:3, 524-529
CrossRef50
(2009) How to throw the baby out with the bath water. Internal Medicine Journal 39:2, 75-76
CrossRef51
Mark W. Friedberg, Dana G. Safran, Kathryn L. Coltin, Marguerite Dresser, Eric C. Schneider. (2009) Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices. Journal of General Internal Medicine 24:2, 162-169
CrossRef52
Antoinette S. Peters, Kathleen N. Schnaidt, Kara Zivin, Sheryl L. Rifas-Shiman, Harvey P. Katz. (2009) How Important Is Money as a Reward for Teaching?. Academic Medicine 84:1, 42-46
CrossRef53
Steven J. Kravet, Heather Jones, Eric E. Howell, Scott M. Wright. (2008) Pilot study comparing patients’ valuation of health-care services with Medicare’s relative value units. Health Expectations 11:4, 391-399
CrossRef54
RICHARD L. KRAVITZ, NAIHUA DUAN, EDMUND J. NIEDZINSKI, M. CAMERON HAY, SASKIA K. SUBRAMANIAN, THOMAS S. WEISNER. (2008) What Ever Happened to N-of-1 Trials? Insiders' Perspectives and a Look to the Future. Milbank Quarterly 86:4, 533-555
CrossRef55
John McKinlay, Lisa Marceau. (2008) When there is no doctor: Reasons for the disappearance of primary care physicians in the US during the early 21st century. Social Science & Medicine 67:10, 1481-1491
CrossRef56
P Preston Reynolds. (2008) Title VII Innovations in American Medical and Dental Education: Responding to 21st Century Priorities for the Health of the American Public. Academic Medicine 83:11, 1015-1020
CrossRef57
Stephen C. Shannon. (2008) Reflections on the Impact of Title VII Funding at the University of New England College of Osteopathic Medicine. Academic Medicine 83:11, 1060-1063
CrossRef58
Stefan Timmermans. (2008) Oh look, there is a doctor after all: About the resilience of professional medicine: A Commentary on McKinlay and Marceau's ‘When there is no doctor’. Social Science & Medicine 67:10, 1492-1496
CrossRef59
Andrea C. Kronman, Arlene S. Ash, Karen M. Freund, Amresh Hanchate, Ezekiel J. Emanuel. (2008) Can Primary Care Visits Reduce Hospital Utilization Among Medicare Beneficiaries at the End of Life?. Journal of General Internal Medicine 23:9, 1330-1335
CrossRef60
Jane Zapka. (2008) Innovative Provider- and Health System-Directed Approaches to Improving Colorectal Cancer Screening Delivery. Medical Care 46:Supplement 1, S62-S67
CrossRef61
Karen E. Lasser, Steffie Woolhandler, David U. Himmelstein. (2008) Sources of U.S. Physician Income: The Contribution of Government Payments to the Specialist–Generalist Income Gap. Journal of General Internal Medicine 23:9, 1477-1481
CrossRef62
Carrie N. Klabunde, David Lanier, Helen I. Meissner, Erica S. Breslau, Martin L. Brown. (2008) Improving Colorectal Cancer Screening Through Research in Primary Care Settings. Medical Care 46:Supplement 1, S1-S4
CrossRef63
Iglehart, John K.. (2008) Medicare, Graduate Medical Education, and New Policy Directions. New England Journal of Medicine 359:6, 643-650
Full Text64
Carol E. Blixen, Noah J. Webster, Andrew J. Hund, Adam T. Perzynski, Stephanie W. Kanuch, Eleanor Palo Stoller, Richard A. McCormick, Neal V. Dawson. (2008) Communicating About Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives. Journal of General Internal Medicine 23:8, 1290-1295
CrossRef65
(2008) On the case for an interview in medical student selection. Internal Medicine Journal 38:8, 621-623
CrossRef66
Chad Boult, Colleen Christmas, Samuel C. Durso, Bruce Leff, Lisa B. Boult, Linda P. Fried. (2008) Perspective: Transforming Chronic Care for Older Persons. Academic Medicine 83:7, 627-631
CrossRef67
Karen E. Hauer, Mark J. Fagan, Walter Kernan, Matthew Mintz, Steven J. Durning. (2008) Internal Medicine Clerkship Directors’ Perceptions About Student Interest in Internal Medicine Careers. Journal of General Internal Medicine 23:7, 1101-1104
CrossRef68
(2008) Primary Care and Health Services Section: An Opportunity for Pain Medicine and Primary Care to Come Together. Pain Medicine 9:5, 487-489
CrossRef69
Jeffrey Solomon. (2008) How Strategies for Managing Patient Visit Time Affect Physician Job Satisfaction: A Qualitative Analysis. Journal of General Internal Medicine 23:6, 775-780
CrossRef70
Carla C. Keirns, Charles L. Bosk. (2008) Perspective: The Unintended Consequences of Training Residents in Dysfunctional Outpatient Settings. Academic Medicine 83:5, 498-502
CrossRef71
Kevin A. Dorrance, Gerald D. Denton, John Proemba, Jeff La Rochelle, Javed Nasir, Gregory Argyros, Steven J. Durning. (2008) An Internal Medicine Interest Group Research Program Can Improve Scholarly Productivity of Medical Students and Foster Mentoring Relationships With Internists. Teaching and Learning in Medicine 20:2, 163-167
CrossRef72
Robert E. White. (2008) Health Information Technology Will Shift the Medical Care Paradigm. Journal of General Internal Medicine 23:4, 495-499
CrossRef73
Bodenheimer, Thomas, . (2008) Coordinating Care — A Perilous Journey through the Health Care System. New England Journal of Medicine 358:10, 1064-1071
Full Text74
Carol E. Blixen, Noah J. Webster, Andrew J. Hund, Adam T. Perzynski, Stephanie W. Kanuch, Eleanor Palo Stoller, Richard A. McCormick, Neal V. Dawson. (2008) Communicating about Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives. Journal of General Internal Medicine 23:3, 242-247
CrossRef75
Lisbeth Selby, Sunanda Kane, John Wilson, Purnima Balla, Brian Riff, Christopher Bingcang, Andrew Hoellein, Smita Pande, Willem J.S. de Villiers. (2008) Receipt of preventive health services by IBD patients is significantly lower than by primary care patients. Inflammatory Bowel Diseases 14:2, 253-258
CrossRef76
MM Reidenberg. (2008) A New Look at the Profession of Clinical Pharmacology. Clinical Pharmacology & Therapeutics 83:2, 213-217
CrossRef77
Ming Tai-Seale, Thomas McGuire, Christopher Colenda, David Rosen, Mary Ann Cook. (2007) Two-Minute Mental Health Care for Elderly Patients: Inside Primary Care Visits. Journal of the American Geriatrics Society 55:12, 1903-1911
CrossRef78
Juan Gérvas, Bárbara Starfield, Sergio Minué, Concepció Violan. (2007) Algunas causas (y soluciones) de la pérdida de prestigio de la medicina general/de familia. Contra el descrédito del héroe. Atención Primaria 39:11, 615-618
CrossRef79
D. Gorman, P. Poole, Sir J Scott. (2007) On the maldistribution of the medical workforce. Internal Medicine Journal 37:10, 669-671
CrossRef80
Daniel Chen, Robert Lew, Warren Hershman, Jay Orlander. (2007) A Cross-sectional Measurement of Medical Student Empathy. Journal of General Internal Medicine 22:10, 1434-1438
CrossRef81
Bruce E. Ellerin. (2007) Debt, Demographics, and Dual Degrees: American Medicine at the Crossroads. Journal of the American College of Radiology 4:8, 537-546
CrossRef82
John A. Patti. (2007) Cost Control Is One of Radiology’s Greatest Threats. Journal of the American College of Radiology 4:7, 440-442
CrossRef83
Bruce E. Ellerin. (2007) Debt, Demographics, and Dual Degrees: American Medicine at the Crossroads. Journal of the American College of Radiology 4:7, 479-486
CrossRef84
Newhouse, Joseph P., . (2007) Medicare Spending on Physicians — No Easy Fix in Sight. New England Journal of Medicine 356:18, 1883-1884
Full Text85
Carlos Sáenz de la Calzada. (2007) Desequilibrio entre oferta y necesidades de cardiólogos en España. Revista Española de Cardiología 60:5, 556
CrossRef86
Tine Hansen-Turton, Sandra Ryan, Ken Miller, Mona Counts, David B. Nash. (2007) Convenient Care Clinics: The Future of Accessible Health Care. Disease Management 10:2, 61-73
CrossRef87
D. Gorman, P. Poole, J. Scott. (2007) On the future role of the doctor. Internal Medicine Journal 37:3, 145-148
CrossRef88
Bohmer, Richard, . (2007) The Rise of In-Store Clinics — Threat or Opportunity?. New England Journal of Medicine 356:8, 765-768
Full Text89
Magruder C. Donaldson. (2007) The care of the patient with vascular disease. Journal of Vascular Surgery 45:2, 427-432
CrossRef90
J D Gray, D Danoff, A M Shepherd. (2007) Clinical Pharmacology Education: Looking into the Future. Clinical Pharmacology & Therapeutics 81:2, 305-308
CrossRef91
N. Reed Dunnick. (2007) Expense Reduction Through Distance Learning. Academic Radiology 14:1, 1-3
CrossRef92
Edward H. Wagner, Robert J. Reid. (2007) Are Continuity of Care and Teamwork Incompatible?. Medical Care 45:1, 6-7
CrossRef93
(2006) The State of Primary Care. New England Journal of Medicine 355:24, 2595-2598
Full Text
- Letters
