The current dilemmas in primary care stem from 1) the unintended consequences of forces thought to promote primary care and 2) the "disruptive technologies of care" that attack the very function and concept of primary care itself. This paper suggests that these forces, in combination with "tiering" in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche. Evidence already exists in the marketplace for both tiering of health insurance benefits and corresponding practice changes within primary care. In the future, primary care for the top tier will cater to the affluent as "full-service brokers" and will be delivered by a wide variety of clinicians. The middle tier will continue to grapple with tensions created by patient demand and bureaucratic systems but will remain most closely aligned to primary care as a concept. The lower tier will become increasingly concerned with community health and social justice. Each primary care specialty will adapt in a unique way to a tiered world, with general internal medicine facing the most challenges. Given this forecast for the future, those concerned about primary care should focus less on workforce issues and more on macro health care financing and organization issues (such as Medicare reform); appropriate training models; and the development of a conception of primary care that emphasizes values and ethos, not just function.
"Elsewhere we have described the corporatization of doctoring: independent solo practice was rendered economically untenable with physicians increasingly forced to become full-time, salaried, bureaucratic employees (McKinlay & Arches, 1985; McKinlay & Stoeckle, 1988; McKinlay & Marceau, 2002). In any bureaucratic setting, physicians are required to go along (with performance directives concerning speedup, through-put, efficiency and profitability) if they are going to get along (St Peter, Reed, Kemper, & Blumenthal, 1999; Harrison & Ahmed 2002; Wachter & Goldman 2002; More & Showstack 2003; Sandy & Schroeder 2003). Physician performance is increasingly judged, not on some measure of the quality of care provided, but on physician adherence to organizational norms (the number of patients seen, length of the encounter, tests and procedures ordered, costs incurred, levels of client satisfaction, etc.). "
[Show abstract][Hide abstract] ABSTRACT: Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent. Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests. Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor-patient relationship). By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).
Social Science & Medicine 09/2008; 67(10):1481-91. DOI:10.1016/j.socscimed.2008.06.034 · 2.89 Impact Factor
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