Primary Care, Generalism, Public Good: Déjà vu? Again!

Developing the supplement on the future of generalism in medicine in this issue caused us to have a collective sense of déjà vu (1-5). Many of the ideas and arguments presented in this supplement echo the calls for revitalization in recent “special reports” by groups in family medicine (6), pediatrics (7, 8), and internal medicine (9, 10) and harken back to the 1970s (11-13). During the reviewing and editing process, we felt like we have been through all this before. And, in fact, we have. Admittedly, there are important differences between the mid-1970s, when the primary care movement emerged (11), and today. Costs are far greater than anyone would have anticipated. Science and technology and the acceptance of evidence-based principles are much further developed. Medical care is even more complex and occurs in more sites, with more exchanges, than we would have imagined possible 30 years ago. And, of course, advances in information systems have transformed modern society and are transforming medicine in ever more powerful ways. Indeed, the very notion that resources for medical care are finite is being called into question. However, medicine in the United States has still not developed into anything resembling a system—much less a system based on the model that seemed so promising 30 years ago, a model organized around a generalist principle or primary care physician. For most Americans, this ideal of patients receiving most of their care based on a relationship with a personal physician or personal team of clinicians located in the patient's community remains just that—an ideal.

Given that conventional wisdom and good evidence indicate that a primary care physician is essential to good medical care (14) and a primary care–based system is the ideal system, why then hasn't the United States developed one? Why …