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Commentary
May 13, 2009

The Chasm Between Intention and Achievement in Primary Care

Author Affiliations

Author Affiliation: Greenhouse Internists, Philadelphia, Pennsylvania.

JAMA. 2009;301(18):1922-1924. doi:10.1001/jama.2009.558

Reuben put it well: “Primary care is on death row.”1 A total of 21% of general internists are leaving that practice sometime in the first 10 years after completing training,2 and only 6.7% of all 2007 US medical school graduates are choosing family medicine or ambulatory internal medicine.3 The net loss is worrisome because robust primary care seems to be an important component of high-performing health systems.4 Enhancing primary care through such models as the patient-centered medical home has been proposed as an important if incomplete part of US health system redesign.5 Explanations offered in both professional6 and popular7 media for the disappearance of primary care physicians have focused on salary or income differentials between primary care physicians and their specialty colleagues, differentials that in some markets have reached a factor of 3. While higher primary care incomes would be helpful, at least as large a problem affecting primary care is the lack of capacity to perform successfully the work of a generalist.

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