With accelerating growth of medical technologies, specialization and sub-specialization since World War II, the U.S. now has 24 specialty boards and more than 135 certified subspecialties. As a result, a unified voice from the profession about how best to serve patients in a rational health care system has largely disappeared. At the same time, tensions and jurisdictional disputes have increased between generalists and specialists, as well as among specialists themselves. It is not surprising, then, that confusion, myths and misperceptions have developed over the role of primary care—the purview of generalists—both within the profession and the lay public.
We are indebted to the late Dr. Barbara Starfield of the Johns Hopkins School of Public Health for this basic definition of the four pillars of primary care: (1) first-contact care; (2) longitudinal continuity over time; (3) comprehensiveness, with capacity to provide care for the majority of health problems; and (4) coordination of care with other parts of the health care system. (Starfield, B. Is primary care essential? The Lancet 344 (8930): 1129-33, 1994) Dealing as they do with a broad spectrum of patients’ problems, generalist primary care physicians necessarily think and practice differently than specialists, who deal with a deeper level of knowledge and skills in a far narrower area.
These are some of the most common myths and misperceptions about the generalist primary care role in the U.S. today, together with brief responses to clarify them.
1. As a generalist, it’s impossible to know everything.
This is true—nobody can know everything. But the generalist’s knowledge is different from that of the specialist, both in kind, breadth and depth. This widespread sentiment reveals a fundamental misunderstanding about the nature of knowledge and information. It is based on the faulty assumption that all specialized knowledge must be vertical, in-depth knowledge about a narrow subject. Dr. Gayle Stephens, an early pioneer in the evolution of family medicine since the 1960s, reminds us that:
“None of the certifiable medical specialties were established on epistemological grounds. Most of them sprang up like Topsy and exist by virtue of political, economic, and technological factors that have little to do with a theory of knowledge. . . All of medicine is derivative, secondary, and applied.” (Stephens, GG. The Intellectual Basis of Family Practice. Tucson. Winter Publishing Company, Inc, 1982, p3)
2. Primary care deals with trivial content and problems.
Generalist physicians are attracted to the front-line nature of their work, dealing as they do with a wide spectrum of care spanning the entire life cycle (in the case of family medicine), medical emergencies, screening and prevention, diagnosis and management of acute and chronic illnesses, counseling and long-term care. They are prepared to definitively manage the majority of the problems brought to them, arrange for consultation with appropriate specialists when necessary, and then co-manage many patients with consulting specialists thereafter. A recent study comparing the relative complexity of patient encounters in three fields—general/family practice, cardiology and psychiatry—concluded that the practice of generalists is one-third more complex than that of cardiologists and five times more so than that of psychiatrists. (Katerndahl, D, Wood, R, Jaen. CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Amer Board Fam Med 24 (1): 6-15, 2011)
3. Anyone can do primary care.
Many specialists, with little experience, knowledge or understanding of primary care practice, denigrate it as “simple” and nowhere near as challenging or complex as their own specialty. Such a self-serving attitude often dates back to their own experiences in medical school, where they heard similar sentiments from some of their sub-specialist mentors with little of no experience in community practice.
In fact, generalist physicians today have three or more years of residency training after medical school, are willing and able to cope with the intellectual challenges and ambiguity of primary care practice, enjoy working closely with people, and have a mindset looking for patterns of illness beyond the shackles of arbitrary specialty boundaries.
4. Specialist care is better than generalist care.
Since our culture tends to worship technology and specialization, it follows that many Americans naturally assume that specialty care is of higher quality than that provided by generalists. A major review of the literature in 2007 attempted to answer this question, but yielded mixed results. Forty-nine studies compared the quality of care provided by generalists vs. specialists, but were limited by their focus on single discrete medical conditions, thereby advantaging specialists over generalists. We still don’t have a solid answer to this important question, since these studies failed to deal with multiple chronic conditions, little attention was paid to coordination and integration of care, case-mix adjustment was often inadequate, and characteristics of physicians’ practice settings (such as use of clinical practice guidelines and electronic medical records) were ignored. (Smetana, GW, Landon, BE, Bindman, AB, Burstin, H, Davis, RB et al. A comparison of outcomes from generalist vs. specialist care for a single discrete medical condition. Arch Intern Med 167 (1):10-20, 2007) At the macro level, however, a 2005 analysis of 100 ecological studies of the relative benefits of generalist vs. specialist care in various health care systems concluded that “primary care helps prevent illness and death . . .and . . . that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations.” (Starfield, B, Shi, L, Macinko, J. Contribution of primary care to health systems and health. Millbank Q 83: 457, 2005)
5. Since medicine has become so specialized, generalists are no longer needed.
Actually, there has never been a greater need in this country for generalist physicians rebuilding the deteriorating primary care infrastructure. Current projections call for a shortage of 45,000 primary care physicians by 2020 (Krupa, C. Physician shortage projected to soar to more than 91,000 in a decade. American Medical News. Amednews.com, October 11, 2010). If the 2009 health care reform legislation ever gets fully implemented, some 32 million Americans will be newly covered by health insurance (including 16 million on expanded Medicaid) in 2014. But replacements of our dwindling supply of primary care physicians are nowhere in sight. Already, only 42 percent of patients’ annual visits to physicians for acute medical problems are made to their personal physicians; all the rest are made to emergency rooms (28 percent), to specialists (20 percent), or to hospital outpatient departments (7 percent), often with difficulty in arranging follow-up care. (Pitts, SR, Carrier, ER, Rich, EC, Kellerman, AL. Where Americans get acute care: Increasingly, it’s not at their doctor’s office. Health Affairs 29 (5): 1620-28, 2010) So we’re facing a growing crisis in having generalist primary care physicians available for patients to see that they know. More to be expected—continued growth in the numbers of patients without a primary care physician who are forced to seek care from strangers through emergency rooms, urgent care centers and other facilities without access to the full benefits of primary care.
Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Health Care, 2011.
John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program