Training in Primary Care

Abstract

Training in primary care has received limited attention in medical schools despite state and federal funding to increase its emphasis. Departments of internal medicine, which have been responsible for most training in primary care, have shifted their interests to the medical subspecialties. Departments of family practice, which have been established by most medical schools in response to government pressure, have had a limited role in the undergraduate curriculum. Residency programs in family practice have become widespread and popular with medical students. Primary care has been defined as that type of medicine practiced by the first physician whom the patient contacts. Most primary care has involved well-patient care, the treatment of a wide variety of functional, acute, self-limited, chronic, and emotional disorders in ambulatory patients, and routine hospital care. Primary care physicians have provided continuing care and coordinated the treatment of their patients by specialists. The major specialties providing primary care have been family practice, general internal medicine, and pediatrics. General and family physicians in particular have been major providers of ambulatory care. This was shown in a study of diaries kept in 1977–1978 by office-based physicians in a number of specialties. General and family physicians treated 33 percent or more of the patients in every age group from childhood to old age. They delivered at least 50 percent of the care for 6 of the 15 most common diagnostic clusters and over 20 percent of the care for the remainder. The 15 clusters, which accounted for 50 percent of all outpatient visits to office-based physicians, included activities related to many specialties, including pre- and postnatal care, ischemic heart disease, depression/anxiety, dermatitis/eczema, and fractures and dislocations. According to the study, ambulatory primary care was also provided by many specialists who have not been considered providers of primary care. A substantial part of the total ambulatory workload of general surgeons involved general medical examinations, upper respiratory ailments, and hypertension. Obstetricians/ gynecologists performed many general medical examinations. The work activities of these and other specialists have demonstrated that training in primary care has been essential for every physician who provides patient care, not just those who plan to become family physicians, general internists, or pediatricians.