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Books, Journals, New Media
June 4, 2003

Ambulatory Medicine

Author Affiliations

Books, Journals, New Media Section Editor: Harriet S. Meyer, MD, Contributing Editor, JAMA; David H. Morse, MS, University of Southern California, Norris Medical Library, Journal Review Editor.

JAMA. 2003;289(21):2872-2873. doi:10.1001/jama.289.21.2872

Is primary care in trouble? There is disquieting evidence that it might be. The number of senior medical students pursuing residency training in primary care specialties is dropping. The salaries of practicing generalist physicians are declining, and tales of such practitioners leaving the field altogether are depressingly common.

Concern about the health of primary care is intense enough that the Robert Wood Johnson Foundation sponsored a recent conference of generalist leaders.1 At the core of the angst is what might be called the current primary care paradox. Providers are being asked at many levels to do more with less—more paperwork, more administrative tasks unrelated to direct patient care, more continuing self-education as the pace of new scientific discovery inexorably increases, more care of complex, chronically ill patients—but with less time, control, continuity, income, and respect. At academic centers, generalists continue to be asked to provide a significant share of medical student and resident education, to provide direct or supervised care to the medically uninsured or under-insured, and to labor to earn salaries in the context of an unfavorable payer mix and flat or falling levels of reimbursement. At the same time, the claim of generalists that they provide continuous, comprehensive care is being undermined by the rise of hospitalist medicine, geriatrics, women's health, adolescent medicine, and sports medicine and the increasing presence of nurse practitioners and physician's assistants in primary care settings (particularly but not exclusively ambulatory).

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