In this article, I review the present precarious status of primary care in the United States, discuss primary care’s proven value to individuals and society, explain why the present three primary care disciplines should become one, and outline a plan for achieving that goal.
The Present Status of Primary Care in the United States
Primary care as an academic discipline and as a key component of the United States’ health care system faces a threatened future and confronts a critical crossroads in its history.1–5 Phillips,6 writing in the British Medical Journal, summarizes the dilemma well:
By some measures of sufficiency, the primary care workforce in the United States has never been more capable of caring for people. Is it just in time to witness its demise, or just in time to retool and transform its clinical models and role in the health care system?
The data collected by perceptive observers of the U.S. health care system indicate that very real threats to primary care presently arise from (1) falling reimbursement,6–17 (2) an eroding scope of practice,6,10,18 (3) dissatisfaction with practice,6,7,17 (4) a less favorable lifestyle,6,7,14,17 and (5) diminished medical student interest in primary care careers.7,8,14–17
Despite these threats, however, a host of other contemporary studies substantiate primary care’s proven value and its considerable benefit to individuals and to society at large. Starfield and colleagues19 have extensively documented the health-promoting influence of primary care in preventing illness and death and in more equitably distributing health across major population subgroups.
Cross-national comparisons of primary care infrastructures and their beneficial population-health outcomes also substantiate primary care’s benefits. Starfield and colleagues20–22 published a series of studies during a 20-year span, documenting that the stronger a nation’s primary care infrastructure was, the lower the rates were of premature mortality, deaths from treatable conditions, and neonatal and perinatal mortality, even after accounting for differences in demographics and gross domestic product. Case studies from Sweden, Finland, and Spain also attest to the fact that an emphasis on primary care is correlated with lower cost, more appropriate use of health care services, better continuity, and increased patient satisfaction.23,24 In the United States, the Veterans Administration reorganized itself in 1995 to enhance primary care. Since that time, it has also observed enhanced continuity of care, higher rates of preventive services, fewer hospitalizations, and lower death rates.25
Data from Starfield and others26–29 also demonstrate that adding more specialists to the health care workforce may not benefit the health of populations but may actually produce more spending with less high-quality, effective care. For example, states with more generalists have more effective care and lower spending, whereas those with more specialists have higher costs and lower quality of care.26 Evidence from the county level also supports these findings. Counties with more primary care physicians demonstrate lower mortality rates than counties with a greater percentage of specialists.27–29
The U.S. health care system today confronts an ironic paradox—the risk of primary care’s demise comes at a time when the health system is finally beginning to recognize its value. Universal health care for all Americans is an increasingly strong priority for many state and federal planners. Most suggest plans organized around a primary care systems model and specify a primary medical home for all Americans. Given the current size, structure, deployment, and reimbursement of the primary care workforce, however, meeting this expectation may be impossible. The state of Massachusetts, which enacted a universal health care plan for its citizens, now faces this exact dilemma. The Wall Street Journal has tracked the progress of this plan and recently noted that
the dearth of primary care providers threatens to undermine the Massachusetts health care initiative. Newly insured patients are expected to avail themselves of primary care because the insurance covers it. And with the primary care system already straining, some providers say they have no idea how they will accommodate an additional half-million patients seeking check-ups and other routine care.30
The United States remains the only Western industrialized nation that delivers its primary medical care through three major specialty disciplines—general internal medicine, family medicine, and general pediatrics—rather than delivering it through a single primary medical specialty. The fragmented, and often competing, model of primary care that evolved from this diversity has not improved the overall health of the U.S. population when compared with health outcomes in those countries where the health care system is based on primary care and coordinated through a single primary discipline.27 Further indicators of system failure include other disturbing findings: at last count, more than 50 million Americans lacked health insurance, a factor directly correlated with increased morbidity and mortality31; the U.S. health care system demonstrates considerable waste, duplication, and overuse32; and, although the United States spends more money on health care than any other nation, patients receive only 55% of recommended care for prevention, acute illness, and chronic disease.33
Fragmentation also creates confusion about the content of primary care, who provides it, and its appropriate role in the U.S. health care system. For example, a significant finding from the population-based research conducted during the Future of Family Medicine Study was the fact that patients had a “hard time differentiating family medicine from other primary physician specialties, notably between family medicine and internal medicine. Indeed the words ‘family’ and ‘practitioner’ were often found to confuse people.”34
In addition to primary care’s lack of an evident, recognizable identity, another outcome of fragmentation is that primary care, as a discipline, lacks a clear, unified voice. Although the three major primary disciplines willingly interact at the intellectual level, agree on primary care’s value, and band together when they perceive a common threat, they continue to compete for academic and professional status, resources, medical school curricular time, research and training program funding, patients, and reimbursement for services. Commenting on this present state of affairs, Geyman and Bliss35 note that
The United States remains unique among Western industrialized nations in having multiple generalist specialties [and]…continues to see competition among three generalist specialties (four if obstetrics–gynecology is included), as well as a “hidden” system of primary care provided by physicians in the more limited specialties. By comparison, general practice is the unambiguous foundation of primary care in other Western industrialized countries.
Geyman and Bliss also observe that although the three primary disciplines have much in common, they
remain distinct tribes on parallel but separate courses. [They] still have largely separate educational programs, read different literature, and are organizationally more separated than collaborative—from each other and from family medicine.
A Time to Merge
Confronting the beleaguered status of primary care in the United States, and transforming it into a powerful force in U.S. medicine that can guide the critical macrosystem changes necessary to reform our systems for providing health care, financing health care, and educating the health care workforce, will require cohesive support from the medical profession; committed, disciplined leadership; and many intermediate steps. Creating a unified primary care discipline can enable that cohesion and can help to prepare the leadership and to set the directional focus that our current fragmented system lacks.
Perkoff36 prophetically recognized the need for a unified discipline 18 years ago when he wrote, “Logically, a united front in primary care could be a much more important force in American medicine than the present warring groups ever could be.” Grumbach and Bodenheimer37 also note that a 21st-century model of primary care in the United States will need two things to succeed: a more unified primary care specialty for physicians, which would result in a stronger, more focused primary care specialty in the United States; and integrated primary care teams that build on the complementary strengths of physicians and nonphysicians in primary care fields. Geyman and Bliss,35 commenting on the future of family medicine, wrote, “First, and most importantly, we should work to establish linkages among the current primary care specialists to accomplish development of a unified primary care generalist discipline by 2030.” DeGruy38 also endorsed this concept:
Family medicine, general internal medicine, and general pediatrics. Three disciplines separated by a common agenda. If ever there were three sisters with good reason to link arms, here they are. We are Venn diagrams with way more overlapping than unique territory, and we are continuing to converge!…Up to this point, we have squandered opportunities to borrow strength and ideas from each other and form a more perfect primary care. Our inability to produce a coherent primary care represents one of our greatest political failures—a naiveté about how to transform existing resources and impetuses into something new and greater.
Creating “something new and greater” is more necessary now than ever before. The time has come to end theoretical discussions. Rapid evolution in health care technology; inequities in health care financing; the combined burdens of health care costs, access, morbidity, and mortality; and the perilous future of generalism and primary care in the United States all support the need for united, strategic action to revitalize primary care on many fronts. Merging the primary care disciplines is one strategic action that can enable that entire process.
The task of unification will face many obstacles, but it can ground itself in the common history and the common values, skills, and behaviors that general medicine, general pediatrics, and family medicine embrace. Internal medicine, pediatrics, and family medicine all trace their origins to a common progenitor—the general practice physician. In the United States, pediatrics began to differentiate from this common origin in the mid-1800s, influenced by several important factors: (1) the growing recognition that infants and children were not just small adults but that, because of their unique physiology, biochemistry, and pathology, they had special needs, (2) the infant and child welfare movement, which began to promote the concept that child health was a public responsibility that included attention to prenatal care, infant mortality, school inspections, and child labor laws and, (3) the social reform movements that recognized the relationship between child and maternal health and the need to improve both.39 The American Academy of Pediatrics, however, was not organized until 1930, and it wasn’t until 1933 that the American Board of Pediatrics began certification in the specialty.
Internal medicine arose from a German medical discipline, innere medizin, that became popular in the late 1800s. This term was adopted by physicians who combined the science of the laboratory with care for patients. Early in the 20th century, many U.S. physicians studied in Germany and returned to practice in the United States, committed to teaching and practicing science-based medicine that was rooted in the academic university as opposed to the extant proprietary, apprentice-based medical training and practice. The American College of Physicians was incorporated in 1915 as the American Congress of Internal Medicine, with the “purpose of facilitating scientific intercourse among physicians interested in internal medicine,”40 and the American Board of Internal Medicine administered its first certifying examinations in 1936 for general internal medicine.41
Family medicine differentiated from the general practice model much later, facilitated by two major studies commissioned by the American Medical Association (AMA) and published in 1966: (1) The Graduate Education of Physicians: The Report of the Citizen’s Commission on Graduate Medical Education (popularly known as the Millis Commission Report),42 and (2) Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council of Medical Education (also known as the Willard Committee).43 These seminal studies emphasized the need to train a new type of physician who could provide personalized, comprehensive, and continuing care; who could reassemble the fragmenting components of the patient-care system; and who could practice both scientific and humanistic medicine as a new kind of specialist. They also emphasized the need for residencies that were based in a model practice; for departments and curricula in all medical schools; for incorporating behavioral science into residency training; and for continuing medical education and lifelong learning. The American Board of Family Practice (now the American Board of Family Medicine) administered its first certifying examination in 1969, and in 1971 the American Academy of General Practice became the American Academy of Family Physicians (AAFP).
In addition to a common origin, these three primary disciplines also share many common values on which to build a unified future. All are committed to the attributes of medical professionalism that are so well articulated in the American Board of Internal Medicine’s Project Professionalism—altruism, accountability, excellence, duty, honor, integrity, and respect for others.44 All are committed to the critical components of primary care, as defined by the National Academy of Science Institute of Medicine—integration (encompassing comprehensiveness, coordination, continuity, and team-based care), accessibility and accountability (encompassing quality, satisfaction, efficiency, and ethical behavior), partnerships with patients, and practice within the context of families and communities.45 All are committed to
- providing a “patient-centered medical home” for every person living in the United States—a concept that originated in pediatrics and was further developed in the AAFP’s Future of Family Medicine Project report34;
- creating a universal health care system that is built on a strong primary care foundation;
- ensuring that every single person in the United States can access affordable health care;
- developing integrated primary care/specialty care teams that build on the complementary strengths of multiple providers and use the primary physician as a key coordinator;
- using advanced information-management systems to increase efficiency, improve quality, and reduce medical errors; and
- promoting health care system reform.
Although they share much in common, each discipline also possesses unique attributes that it can bring to a unified model—attributes that will enhance the model and expand the breadth and depth of the new discipline, increasing its clinical scope. Internal medicine brings strong traditions in intellectual and methodological rigor; a focus on pathophysiology; the priority for integrating scientific discovery into clinical medicine (evidence-based medicine); skill in managing complex, chronic, multisystem diseases; skill in providing high-quality, hospital-based care; and a reputation for evaluating difficult and complex diagnostic dilemmas.
Pediatrics also brings strong traditions: advocacy for children; an understanding of hereditary and genetic diseases, developmental disorders, and behavioral problems in children; skilled hospital care for children; the ability to manage complex pediatric illnesses; and the priority for understanding the unique physiology, biochemistry, and pathophysiology of children.
Family medicine brings strong traditions in ambulatory training and medical care, community-oriented primary care, integration of the biopsychosocial model into clinical practice, performance of office-based procedures, emphasis on lifelong disease prevention and health promotion, and a commitment to providing/coordinating comprehensive care continuously throughout a person’s lifetime.
All three disciplines also share the common challenge to reinvent themselves and are laboring to define new methods that will transform their primary care educational and clinical models. They have all examined their disciplines in great depth and have issued independent reports (discussed below). This simultaneous self-evaluation process suggests that they now have a prime opportunity to learn from each other, to integrate their discoveries, and to create a new identity to which all can contribute.
Family medicine recently completed an intensive self-study, published as The Future of Family Medicine: A Collaborative Project of the Family Medicine Community,34 that proposes a new model of practice and a “process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health of the nation.”
In 2000, the Pediatric Generalists of the Future Workgroup published its final report presenting a vision for the role and scope of the pediatrician of the future and the core attributes, skills, and competencies pediatricians caring for infants, children, adolescents, and young adults will need in the 21st century.46
The Society of General Internal Medicine (SGIM) recently published two seminal reports outlining recommendations for its future. The 2004 SGIM Task Force on the Domain of General Internal Medicine47 report examined the present and anticipated future of general internal medicine, described its core values and competencies, and made recommendations that include “recommitting the field to its core values, paradigm shifts in the practice of internal medicine, and changes in training and research.” Subsequently, another task force examined the current state of residency education and provided recommendations for the future, publishing its results in a report that focused on “structures and processes of four specific areas of residency reform: inpatient education, ambulatory education, health disparities and cultural competence, and life long learning skills.”48
At a time when the nation needs a new and better primary care, and at a time when all three primary care disciplines are considering their own transformation, a portal in history has opened to finally focus that transformation on unification.
Merging these three parallel disciplines would substantially benefit medical student education, graduate medical education, health care systems and services, health care policy, and research.
At the medical school level, the benefits derived from a single, large, primary medicine department would include
- eliminating competition for patients, money, and academic influence within the school;
- creating a cohesive and integrated curriculum that would eliminate duplication and allow for more extensive, focused primary care contact and visibility with students;
- creating efficiencies of scale in caring for patients and delivering the curriculum;
- facilitating communication and action to implement common primary care goals and objectives; and
- creating greater cohesion, less fragmentation, and greater influence in meeting challenges within the academic environment.
In graduate medical education, the previously referenced reports from general pediatrics, general internal medicine, and family medicine indicate a need for curricular revision in the training programs of all three primary disciplines. A striking feature of these recommendations is how much they share in common, rather than how much they diverge.
Advantages of merged training would include infusing the unique attributes of each discipline into a new model of training that could extend both the breadth and depth of that training and, by extension, the scope of primary medical practice. Furthermore, merged training would result in a common professional identity, a unified faculty for role modeling, and a common practice setting with common policy, procedures, practice guidelines, and electronic systems. Additional efficiencies could be gained through a common curricular model, a common set of educational goals, objectives, and evaluation systems, and a single set of residency training requirements from the Accreditation Council for Graduate Medical Education. Furthermore, combining currently divided and scarce training funds could help to increase the level of support for training a primary physician workforce.
A single primary discipline would also result in beneficial changes in health systems and services. Integrating and expanding primary care graduate training programs would provide a primary physician workforce equipped to manage both a greater breadth (more problems) and depth (greater complexity) of service. A unified discipline would establish common standards of practice, result in less service duplication, establish common goals for quality and safety, create a uniform model for delivering primary care services, and establish a uniform reimbursement policy for those services. Because the new discipline would provide continuous, comprehensive health care for an individual through his or her entire lifetime, it would naturally incorporate models and processes of care that integrate the known effects of genetic factors, health risks, lifestyle choices, prenatal and natal factors, and disease processes over a person’s complete lifespan. From a professional perspective, additional efficiency and cost saving would also be gained by creating a single set of standards and mechanisms for initial board certification and continued maintenance of certification.
A larger, single-specialty body of primary physicians would also demonstrate greater political strength. A stronger voice emanating from a more cohesive discipline that was supported by one large professional academy could be a more persuasive advocate for an increased primary care emphasis in our academic centers. It could also more effectively influence government agencies that are concerned with reimbursement systems, health care education, health care policy, and health care research, and it would more effectively communicate the value of primary care and the rationale for equitable reimbursement for primary services to corporate America and to the insurance industry.
A unified primary care would also benefit research. A stronger primary discipline could more likely wield the influence required to establish an Institute for Primary Care at the National Institutes of Health that could increase research funding in the discipline and that would support primary care research as a prominent national priority. A unified primary care incorporating a network of nationwide practice locations that were operating under similar evidence-based guidelines and measures for quality and safety, and that were linked together with common electronic systems and shared disease registries, could serve as a powerful and robust research laboratory to study health services, systems, and outcomes and to translate basic research discoveries into clinical practice.
A Plan to Act
How might we implement this process? One suggested initial step would be to convene a forum where representatives from the three generalist disciplines could begin a focused dialog on the topic of unification. The purpose of this initial forum would be threefold: (1) to critically, and without bias, examine the advantages and disadvantages of a merging into a single discipline, (2) to explore the forces that are driving primary care toward unification and those that are restraining it from unification, and (3) to begin establishing/strengthening working relationships and linkages between the disciplines that are necessary for unification. The representatives to this forum would also need to confront their own fears about the process, including the very real fear that they will lose a measure of their own identity. Realistically, identities would change. The challenge, however, would be to create a new and valued professional identity woven together from the collective strengths of each discipline.
Which organization should lead?
Which organization could best serve to initiate and to shepherd this process? Ideally, it should possess several key attributes.
- It should serve as “common ground” for all three primary disciplines. Incorporating all three in its membership and demonstrating a history of all three working collaboratively within the organization would help to establish legitimacy and trust.
- It should demonstrate impartiality toward each discipline. All three disciplines would enter this process concerned about loss of identity and influence, potentially restraining their commitment to the process. An organization that has treated each discipline fairly could reassure them that it will protect the interests of all.
- It should exert broad influence over medical education and research. The ideal organization should demonstrate an extensive and intensive commitment to medical education at the predoctoral and graduate level as well as the ability to influence the direction of medical research. Furthermore, it must have the ability to empower the required changes.
- It should provide access to the resources that are needed to support and to enable the process. Resources are the fuel that will drive the change engine.
- Through its stated values and actions, it should demonstrate a commitment to the attributes of medical professionalism. These include altruism, honor, and integrity; caring and compassion; respect; responsibility; accountability; excellence and scholarship; and leadership.
- The U.S. public must trust this organization to act on behalf of their welfare over its own. This is critically important. A key attribute that defines a profession is autonomy—the ability of the profession to define and to control its own work. Society will honor that autonomy as long as the profession continues to serve the public’s interest. If medicine wishes to retain its autonomy and its ability to self-regulate, then it must demonstrate public accountability. It must critically analyze itself and determine the degree to which it is serving society’s needs over its own. If it is falling short, then it must demonstrate the will to change, and it must impose upon itself the necessary discipline to do so.
- It should demonstrate the ability to actually implement change. Many commissions and task forces have conducted critical analyses and prepared reports that recommend change. These help to define the nature and the extent of the task and help to create the future vision, but they don’t empower the process. The organization that commits to the task of unifying primary care must be able to act.
Several organizations could be considered for the role of shepherding and implementing the unification process, including a citizen’s commission; a government agency; organized medicine, acting through the AMA or through one or more physician specialty organizations; and the Association of American Medical Colleges (AAMC). Each organization possesses unique strengths and weaknesses.
A citizens’ commission?
The previously referenced Millis Commission Report42 was created by a prototypical citizens’ commission that provided a detailed and profound external review of graduate medical education. This report influenced change in graduate medical education, including recommendations for a “commission on graduate medical education” and for new graduate training programs that would prepare a skilled, comprehensive physician workforce. Forty years after its publication, although its vision and many of its recommendations remain relevant, its potential impact is only partially realized. The physician workforce today is even more fragmented by specialization, even more people lack access to health insurance and to primary medical services, and the attraction to comprehensive medical practice is at its nadir among medical students.
The fact that a citizens’ commission functions as an external body is both a strength and a weakness. As an external body, it is less constrained in its review process, and its recommendations are less likely influenced by inherent bias. The fact that it does not possess the power, the infrastructure, or the resources to implement its recommendations is a major weakness. Another is the fact that, because it remains external to the profession, the profession may question its legitimacy, may challenge its assessment, and may obstruct its ability to influence change. Profound and lasting change will more likely originate from within the profession as it voluntarily accepts its responsibility for professional self-assessment.
A government agency?
A government agency is another possible change agent. A new or existing government agency could be given the power and the resources to implement (perhaps coerce) change. Through financial controls and legislation, it could direct medical education, influence the course of medical research, and mandate the composition of the physician workforce. Were that to occur, medicine would have truly lost a measure of status as a profession. When society must act through a government agency to implement change in the profession of medicine, then it has determined that the profession no longer holds society’s welfare foremost, that the profession cannot regulate itself, and that society must limit the profession’s autonomy by removing its ability to control its own work. In the preface to the Millis Commission Report,42 Millis wrote:
For any learned profession there are but two alternatives for establishing standards of practice and education. Responsibility can be assumed by society as a whole, acting through government, or can be assumed by the organized profession through a voluntarily accepted self-discipline.
A physicians’ organization?
Organized medicine, acting through the AMA or through one or more physicians’ societies, provides another option for leading the unification process. The AMA incorporates all three primary disciplines, it has demonstrated the ability to influence the direction of medical education and research, it controls considerable resources, and it honors professional values. The major concern with the AMA and the specialty societies rests on the degree to which the U.S. public trusts them to act in society’s best interest rather than their own. The AMA and the specialty societies were formed in large part to represent and to advocate on behalf of their members.
A likely leader
Among all potential professional physician organizations that could initiate and shepherd this process, the AAMC most closely embodies all the core attributes of the ideal organization. All three primary disciplines are voluntarily incorporated into its membership and have already established dialog and collaboration around common interests. The AAMC has welcomed all three disciplines, with no inherent bias toward them. As a large, multidisciplinary association, it exerts profound influence over the content and delivery of medical education and of medical research in this country. Through its extensive association of medical schools, teaching hospitals, and academic societies, it can access the resources required to implement the process. It is an organization that the U.S. public trusts to act on its behalf, and it is one that has established a record of honoring the highest standards of medical professionalism and public accountability. Among all potential organizations, the AAMC is best positioned to lead the unification process.
To initiate that process, the AAMC could convene a multidisciplinary primary care summit, inviting representatives from the following bodies:
- The primary care professional physician organizations (the American College of Physicians, the AAFP, and the American Academy of Pediatrics)
- The specialty-certifying boards (the American Board of Internal Medicine, the American Board of Family Medicine, and the American Board of Pediatrics)
- The Accreditation Council for Graduate Medical Education’s residency review committees in internal medicine, family medicine, and pediatrics
- The academic organizations of department heads and chairs and of residency program directors in internal medicine, family medicine, and pediatrics
- The AAMC
After this initial summit (or perhaps several), the representatives would need to determine whether they have the will and the commitment to proceed with unification. If they do, then they would need to identify a committed group of individuals from their respective disciplines to lead the transformation process. This leadership coalition should include individuals from each discipline who hold positions of influence within their respective disciplines, and who demonstrate expertise, credibility, and leadership ability.
The first task of the leadership coalition would be to create a clear and compelling vision to guide the unification process, and then to communicate that vision widely, clearly, and often. It would also need to create task forces charged to examine a number of critical change issues, including how unification would affect medical school education, graduation medical education (including pathways to specialization), professional identity (including the potential for a new physician organization), the process of initial board certification and maintenance of certification, research in primary care, the content and process of health care, and health policy, including the role of a unified primary care in reforming the health care delivery system. On the basis of the reports of these task forces, the leadership coalition would outline a process and a strategy to accomplish the vision, including plans on how to take advantage of forces driving them toward the vision, and how to overcome forces restraining them from that goal. It would also need to specify the milestones that must be reached during the unification process, and a timeline for reaching those milestones and for achieving the final goal.
A Public Good Worth Attaining
In his inaugural address to the 117th Annual Meeting to the AAMC in 2006, AAMC President Darrel Kirch, MD,49 presented a compelling case to argue that “our social values demand that we come together to preserve one of our greatest ideals—the principle of the ‘public good.’”
In his concluding remarks, he stated that
we all share a commitment to certain goals: ensuring enough caring, skilled, and culturally competent doctors for the years ahead; providing better support for their practice by advancing science; and giving them a health care system that works equally well for everyone.
Ensuring access to high-quality, vibrant, state-of-the-art, affordable primary care for all Americans is a critical public good that is a necessary requirement for a transformed U.S. health care system. Coming together to create a single primary discipline can help to ensure and to energize primary care’s future and, in so doing, to ensure the health of the U.S. population.
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