The Uncertain Future of Primary Medical Care

The United States needs a strong primary medical care capacity as we engage the challenges of health care reform, expand insurance coverage, and constrain medical costs without sacrificing quality. Research over decades has repeatedly demonstrated that primary care services that provide continuing access to care are associated with superior population health outcomes (1, 2). Nonetheless, the future of U.S. primary care is uncertain, many clinicians report high levels of frustration and dissatisfaction, and careers in primary care are increasingly unattractive to new medical graduates. In this issue, Linzer and colleagues (3) studied 422 family practitioners and general internists in 119 ambulatory clinics. They report high levels of unhappiness about time pressure and practice pace, little sense of control over work conditions, and deficient organizational culture. Other data indicate substantial deficiencies on measures of quality outcomes and neglect of care processes.

Three themes persist across time, place, and practice arrangements (4). First, primary care physicians persistently report time pressures and insufficient time for patients, but practice disorganization substantially limits their ability to cope (4, 5). Second, primary care physicians dislike intrusions on their clinical autonomy by managers and are particularly dissatisfied when their remuneration depends on successfully constraining the clinical choices they can offer their patients (6). Finally, physicians want remuneration to meet their expectations and reflect the intensity of their efforts (7). Each of these themes will be …