Primary Care and Physician Shortages

Primary Care and Physician Shortages

DOI: 10.4018/978-1-4666-6355-8.ch002


In this chapter, the author provides an overview of the primary care system. Primary care is the backbone of healthcare systems and is defined as “the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Donaldson, 1996, p. 1). The primary care system in the United States is stricken with chronic systematic problems related to access, cost, and provider shortages. The chapter explicates the impact of recent legislation, including the Patient Protection and Affordable Care Act (PPACA) on these issues. It also highlights some solutions to increase access such as Community Health Centers (CHCs), the restructuring of care models to foster teamwork, the use of information technology, the provision of after-hours care, as well as the use of non-physician providers such as nurse practitioners and physician assistants.
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The idealized version of primary health care envisions a kindly gentleman-black tote bag in hand-visiting his patient’s home, admonishing the patient for his or her naïveté, and offering a prescription with the proverbial “take two and call me in the morning.” Yet this rose-colored account of access to primary care fails to reflect reality for most residents of the United States who need health care. Many residents do not have a primary care doctor, and the ones that do may experience the rushing through a primary care examination that often took weeks to schedule.— Hansen-Turton, Ware, & McClellan, 2010)


1. Definition And Functions Of Primary Care

The term “primary care” is thought to have first appeared in a British official white paper called the Dawson Report and published around 1920 (Starfield, Shi and Macinko, 2005). The Report mentioned “primary health care centers” as the core of regional healthcare services in the United Kingdom. Subsequently, primary care started to play an increasingly important role in that country as well as many others, but not in the United States (U.S.), where specialization of the physician workforce was in full strength. Many U.S. general practitioners (generalists) took advantage of the GI Bill of Rights after returning from service in World War II and obtained additional training in other specialties. In response, family physicians reacted to this disproportionate increase in specialization by instituting credentialing standards for family practice. Therefore, in the 1960s-1970s, primary care came to include general internal medicine and general pediatrics, and required longer post-graduate training. These developments led the way to the recognition of primary care as separate “specialty” (Starfield, Shi and Macinko, 2005).

Nowadays, primary care can be defined as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community”(Donaldson, 1996, p.1). In addition to primary care, healthcare systems are comprised of secondary care, tertiary care and emergency care. Secondary care is consultative, short-term, and mainly aims to assist primary care providers with diagnostic or therapeutic decisions, whereas tertiary care is care for patients with unusual disorders that primary care providers are not experienced enough to treat (Starfield, 1994). Emergency care is care provided to stabilize and treat patients with acute illnesses or injuries (See Chapter 1) (Marx, 2010).

Primary care can be understood in three different ways: as the specialty of individual providers, as a specified set of functions, and as a general orientation of healthcare delivery systems (Friedberg, Hussey and Schneider, 2010). First, as a specialty, primary care providers are identified based on their training as general pediatricians, general internists, family physicians, or other generalists, including non-physician providers. According to this definition, specialists cannot serve primary care functions (Friedberg, Hussey and Schneider, 2010). The Health Resources and Services Administration (HRSA, 2013) adopts a broader definition of primary care services as basic health services which consist of “health services related to family medicine, internal medicine, pediatrics, obstetrics, or gynecology, that are furnished by physicians and where appropriate, physician assistants, nurse practitioners, and nurse midwives”; diagnostic laboratory and radiologic services; preventive health services; preventive dental services; emergency medical services; and pharmaceutical services (HRSA).

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