Primary Care: Research

The Need to Test the Patient-Centered Medical Home
Michael S. Barr, MD, Journal of the American Medical Association, August 20, 2008
"Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty. Recent workforce analyses highlight this trend and the lack of a foreseeable change in the projections for the availability of primary care physicians." Read More...

Medicare, Graduate Medical Education, and New Policy Directions
John Iglehart, New England Journal of Medicine, August 7, 2008
It has been more than a decade since Congress enacted legislation that significiantly altered the policies under which Medicare supports graduate medical education (GME). Now, the political ground under this relationship is beginning to gradually shift again, and if this development gathers momentum, it could lead to greateer support for the training of primary care physicians. Read more...
(Read the Medicare Payment Advisory Committee (MedPAC) response to this article here.)

'Bashing' of Medical Specialties: Students' Experiences and Recommendations
David Holmes, MD et al., Family Medicine, June 2008
"Exposure to non-constructive criticism of medical specialties is believed to be fairly common among medical students. Better undertanding of this "bashing" phenomenon is needed to promote greater professionalism in medical education and student interest in primary care careers." Read More...

Will Generalist Supply Meet Demands of an Increasing and Aging Population?
Jack M. Colwill, et al., Health Affairs, May/June 2008
"Projected shortages could be alleviated if the United States produced four additional generalist graduates in each family and internal medicine residency program." Read More...

United We Stand, Divided We Fall: Single Primary Care Specialty
John G. Halvorsen, MD, MS, Academic Medicine, May 2008
"Primary care as an academic discipline and key component of the U.S. health care system faces a threatened future, despite numerous studies in the United States and Cross Nationally that substantiate its health-promoting benefits." Read More...

Rural-Urban Differences in Primary Care Physicians' Practice Patterns, Characteristics, and Incomes
William B. Weeks, MD, MBA and Amy E. Wallace, MD, MPH, Journal of Rural Health, Spring 2008
"Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of of primary care physicians to rural settings." Read More...

The Residency Program in Social Medicine of Montefiore Medical Center: 37 years of Mission-Driven Interdisciplinary Training in Primary Care, Population Health and Social Medicine
Alvin H. Strelnick, MD et al., Academic Medicine, April 2008
"Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission." Read More...

Factors Associated with Medical Students' Career Choices Regarding Internal Medicine
Karen E. Hauer, MD et al., Journal of the American Medical Association, September 10, 2008
"Internists in primary care and subspecialty practice provide a large portion of the chronic care for older and medically complex patients. However, National Resident Matching Program (NRMP) data show that the number of US medical students matching into IM residency positions has declined from 3884 in 1985 to 2660 in 2008." Read More...

Improving Accountability for the Public Investment in Health Profession Education
David C. Goodman, MD, MS, Journal of the American Medical Association, September 10, 2008
"There is widespread discontent with today's health workforce and its training pipeline. Patients cannot find primary care physicians who are accepting new patients and have difficulty navigating care that is fragmented over increasingly specialized clinicians." Read More...

Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation
Diane Rittenhouse, MD, MPH et al., Annals of Family Medicine, Septeber/October 2008
"Community health centers (CHCs) are a critical component of the health care safety net. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP)." Read More...

Future Salary and US Residency Fill Rate Revisited
Mark H. Ebell, MD, MS, Journal of the American Medical Association, September 10, 2008
"The association between physician salary and residency fill rate described in 1989 has persisted. County, state, and international comparisons have consistently shown that having a greater percentage of physicians in primary care specialties is associated with better population health outcomes, including reduced all-cause, cardiovascular, infant, and cancer-specific mortality." Read More...

Educational Debt and Reported Career Plans among Internal Medicine Residents
Furman S. McDonald, MD, MPH, Annals of Internal Medicine, September 16, 2008
"Increased debt was associated with a decreased frequency of plans to pursue an internal medicine subspecialty and an increased preference for general medicine and hospitalist careers." Read More...

When Money Doesn't Change Everything
Atul Grover, MD, PhD, Annals of Internal Medicine, September 16, 2008
"The literature examining the recent trends in specialization is, at best, conflicting about why young physicians are choosing careers outside of generalism. Compensation, debt, lifestyle, prestige, personality, and demographic factors have all been identified as likely issues but their relative importance is not clear." Read More...

No Place Like Home: Testing a New Model of Care Delivery
John K. Iglehart, New England Journal of Medicine, September 18, 2008
"Seeking ways to slow the growth of Medicare spending and to better coordinate the health care it finances, the federal government is preparing to test the concept of the "medical home" in the Medicare program. In response to a mandate in the Tax Relief and Health Care Act of 2006, the staff at the Centers for Medicare and Medicaid Services (CMS) is developing a demonstration program that will operate for 3 years in rural, urban, and underserved areas in up to eight states." Read More...

Building a Medical Neighborhood for the Medical Home
Elliott S. Fisher, MD, MPH, New England Journal of Medicine, September 18, 2008
"Recent efforts to improve primary care in the United States have focused largely on the development and implementation of practice models and payment reforms intended to create a "medical home" for patients. The notion of a medical home makes intuitive sense and indeed has great promise. But unrealistic expectations about this approach abound, and insufficient attention is being paid to several important barriers to the clinical and financial success of the medical-home model." Read More...

Beyond Pay-for-Peformance - Emerging Models of Provider-Payment Reform
Meredith B. Rosenthal, PhD, New England Journal of Medicine, September 18, 2008
"Escalating costs and the growing imbalance between primary and specialty care have increased the urgency of calls for fundamental reform of the health care payment system. At the core of the problem is the fact that the dominant fee-for-service model rewards volume and intensity rather than value. But although the faults in the way we currently pay for health care are obvious, it is much less clear what feasible approach would yield better results." Read More...

Entry of U.S. Medical School Graduates Into Family Medicine Residencies: 2007-2008 and 3-year Summary
Amy L. McGaha, MD et al., Family Medicine, September 2008
"This is the 27th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs." Read More...

Results of the 2008 National Residency Matching Program: Family Medicine
Perry A. Pugno, MD, MPH, CPE et al., Family Medicine, September 2008
"The results of the 2008 National Resident Matching Program (NRMP) reflect a currently stable level of student interest in family medicine residency training in the United States. With the needs of the nation calling for the roles and services of family physicians, family medicine still matched too few graduates through the 2008 NRMP to meet the nation's needs for primary care physicians." Read More...

Reports Warn of Primary Care Shortages
Bridget M. Kuehn, Journal of the American Medical Association, October 22/29, 2008
"The United States faces a shortage of primary care physicians that could exceed 40 000 by 2025, according to a recent analysis by researchers from the University of Missouri and the Health Resources and Services Administration. The analysis adds to a growing body of evidence that US medical schools are producing too few physicians to meet the demand for medical services." Read More...

Primary Care Delivery Changes as Nonphysician Clinicians Gain Independence
Jennifer Fisher Wilson, Annals of Internal Medicine, October 2008
"To help fill gaps in the generalist physician workforce, leaders of the health reform in Massachusetts have supported the expanded use of nonphysician health care providers. Increasingly, physician assistants (PAs)and nurse practitioners (NPs) are staffing clinics and providing basic care of common conditions, screening and routine management of chronic conditions, and preventive care (such as immunizations)." Read More...

Funding for Primary Care (or Lack Thereof) and Community Health Centers: Impact of Title VII Training Programs
John J. Frey III, MD, Annals of Family Medicine, November/December 2008

The Future of Primary Care: The Need for Reinvention
Thomas H. Lee, MD, New England Journal of Medicine, November 13, 2008
"Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation's best trainees — or the chaos and inefficiency of U.S. health care will only worsen." Read more…

The Future of Primary Care: Sustaining Relationships
Katharine Treadway, MD, New England Journal of Medicine, November 13, 2008
"With its combination of care for acute, undiagnosed illness and complex, multisystem disease, as well as the provision of extensive preventive care, all in the setting of a long relationship built on mutual trust and knowledge, primary care has long been a deeply rewarding profession. But in recent years, this once-extraordinary specialty has seen its ranks diminish as doctors struggle with an increasing amount of paperwork, the explosion of therapeutic options, and a dramatic expansion in preventive care responsibilities." Read More…

The Future of Primary Care: Transforming Practice
Thomas Bodenheimer, MD, New England Journal of Medicine, November 13, 2008
"Overstressed by large patient panels, many primary care practices are performing below par. In one study, patients explaining their problem to a physician were interrupted after an average of 23 seconds. Fifty percent of patients leave office visits not understanding what the physician has told them. It would take a primary care physician 18 hours per day to provide all recommended preventive and chronic care services to a typical patient panel." Read More…

The Future of Primary Care: Reforming Physician Payment
Allan H. Goroll, MD, New England Journal of Medicine, November 13, 2008
"At the heart of the decline in primary care lie dysfunctional payment systems, from the "gatekeeper" schemes of the 1990s to the current volume-driven, fee-for-service approaches. These have proved antithetical to the goals of primary care, leaving patients unhappy, physicians demoralized, a generation of U.S. medical students shunning careers in the field, and access to care increasingly problematic — all contributing to an impending national health care crisis." Read More…

The Future of Primary Care: Refocusing the System
Barbara Starfield, MD, MPH, New England Journal of Medicine, November 13, 2008
"Robust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well." Read More…

The Future of Primary Care: Lessons from the U.K.
Martin Rolad, DM, New England Journal of Medicine, November 13, 2008
"The United Kingdom takes the importance of primary care for granted. The U.K. government is effectively the country's single payer, and successive administrations have been convinced by mounting evidence that primary care promotes high-quality, cost-effective, and equitable health care.1 If anything, the U.K. government has become more convinced over the past 15 years that strong primary care needs to be at the heart of the country's health care system — quite the reverse of the situation in the United States." Read More…

The Future of Primary Care: Redesigning Primary Care
Thomas H. Lee, MD, et al., New England Journal of Medicine, November 13, 2008
"U.S. primary care is in crisis. Primary care physicians must care for more and more patients, with more and more chronic conditions, in less and less time, for which they are compensated far less than subspecialists. They must absorb increasing volumes of medical information and complete more paperwork than ever, as they try to function in a poorly coordinated health care system. As a result, their ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields." Read More...

The Patient-Centered Medical Home Movement --- Promise and Peril for Family Medicine
John C. Rogers, MD, MPH, MEd, Journal of the American Board of Internal Medicine, September/October 2008
"Here I will review briefly what I consider family medicine's internal strengths and weakness related to the PCMH and the external opportunities and threats the PCMH movement presents to family medicine. I will end with a general action agenda." Read More...

The Medical Home: Growing Evidence to Support a New Approach to Primary Care
Thomas C. Rosenthal, MD, Journal of the American Board of Internal Medicine, September/October 2008
"Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/provider boards may be required to safeguard the public interest." Read More...

The Medical Home: Locus of Physician Information
Timothy Daaleman, DO, MPH, Journal of the American Board of Internal Medicine, September/October 2008
"The medical home has the potential to become a distinctive and specific locus of formation in which family physicians practice and habituate contextually sensitive patient care. However, the market will variably impact not only the ways in which family physicians embody the practices of caring for patients within context over time, but also how family medicine comes to represent particular activities that contribute to health and healing." Read More...

Innovation in Primary Care – Staying One Step Ahead of Burnout
Susan Okie, M.D., New England Journal of Medicine, November 27, 2008
"The general internists, family practitioners, and geriatricians who provide primary care to adults face a growing population of elderly Americans with chronic conditions. But their compensation is a fraction of what many specialists earn, and fewer and fewer U.S. medical school graduates are entering these fields — making it increasingly tough to replace primary care physicians who retire and intensifying the pressures on those who remain." Read More…

Caring for Older Patients: Current Attitudes and Future Plans of Family Medicine Residents
Margaret Helton, MD and Donald Pathman, MD, MPH, Family Medicine, November/December 2008
"Family medicine residents have limited interest in nursing home care and may generally underestimate the influence of an aging society on their future practice. Meeting the health care needs of an aging society will require innovations in reimbursement, health care delivery systems, and residency curricula." Read More…

Embracing the Ecology of Geriatrics to Improve Family Medicine Education
Kenneth Steinweg, MD, Family Medicine, November/December 2008
"Family physicians currently provide almost half of the primary care for older patients in the United States. This proportion is expected to increase as the "baby boomers" age. Current family medicine training requirements do not address these needs, and training needs to be improved." Read More…

New England Journal of Medicine Special Focus on Primary Care
New England Journal of Medicine, November 13, 2008
"U.S. primary care is in crisis. Primary care physicians must care for more and more patients, with more and more chronic conditions, in less and less time, for which they are compensated far less than subspecialists. They must absorb increasing volumes of medical information and complete more paperwork than ever, as they try to function in a poorly coordinated health care system. As a result, their ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields." Read More...

Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination
Hoangmai Pham, MD MPH et al, Annals of Internal Medicine, February 17, 2009
Coordination of care involves the integration of care across all of a patient's conditions and needs, across providers and settings, and in accordance with the preferences and capabilities of patients and their families. Coordination involves complex activities that require conscious interactions between providers and between providers and patients, including timely transfer of accurate clinical information, effective communication between the involved parties, and shared decision making. Primary care physician societies advocate support for the "advanced medical home," conceived as a physician-directed practice that provides coordinated, accessible, continuous, and comprehensive care. Read More...

Medical Students, Money, and Career Selection: Students' Perception of Financial Factors and Remuneration in Family Medicine
Dante J. Morra, MD MBA et al, Family Medicine, February 2009
"Despite the importance of family physicians to the health care system and the numerous training opportunities that exist in the field, medical students' interest in primary care has decreased. Residency positions are frequently left vacant as there is a migration by medical students to more-specialized career paths. Although there is no one variable that determines medical student career selection, studies have suggested that financial factors may influence career choice." Read More…

Primary Care: Too Important to Fail
David S. Meyers MD and Carolyn M. Clancy MD, Annals of Internal Medicine, February 17, 2009
"The U.S. primary care system is struggling. Increasing demands and expectations, coupled with diminishing economic margins, have created a challenging work environment. As the new Obama administration arrives in Washington, policy prescriptions for health care reform are being dispensed from every side. Many of them emphasize the importance of revitalizing the nation's primary care system. As a foundational element of the health care system, primary care is needed to improve quality, increase access, and contain costs. These are the principal goals of health care reform." Read More…

Ambulatory Care Provided by Office-Based Specialists in the United States
Annals of Family Medicine - March/April 2009
"This profile of the more than 1 billion ambulatory visits to office-based specialists in 2002 through 2004 showed a considerable variation across physician specialties in the patient and visit profiles, but clear patterns emerged. Routine and preventive care for patients already known to the physician accounted for one-half of visits, and most of these visits resulted in a subsequent appointment with the same physician. Referrals by other professionals accounted for less than one-third of all specialty care visits, with patients having been referred for a variety of different visit types. For patients without a referral, specialists had one-third the odds of sharing the patient's care with another physician." Read More…

How Can Primary Care Cross the Quality Chasm?
Annals of Family Medicine - March/April 2009
"The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM's chasm, major changes are needed." Read More…

Patient-Physician Connectedness and Quality of Primary Care
Annals of Internal Medicine - March 3, 2009
"Persistent deficiencies exist in the quality of health care in the United States. Because primary care physicians are the first source of health care for most patients to receive preventive and chronic illness care, efforts to measure and improve quality of care have often focused on these physicians. In practice, however, many patients receive episodic care from different physicians. Patients without a regular source of care are less likely to receive care consistent with guidelines." Read More…

Community Dimensions and HPSA Practice Location: 30 Years of Family Medicine Training
Suzanne B. Cashman, ScD et al. Family Medicine, April 2009
"In 1996, the Institute of Medicine revised the definition of primary care to include "the community context of medical practice." Shortly after, as a way to move beyond the general sentiment that community should factor into a physician's work, Pathman et al identi¬fied and defined four distinct categories of activities (sociocultural aspects of patient care, use of commu¬nity health resources, community-oriented primary care, and community participation and assimilation) through which physicians engage with communities. This framed much of the last decade's discussion about and exploration into physicians' community involvement." Read More…

Toward International Primary Care Reform
Barbara Starfield, MD MPH, Canadian Medical Journal, May 26, 2009
"Primary care reform is now a worldwide imperative. National health care systems with strong primary care infrastructures have healthier populations, fewer health-related disparities and lower overall costs for health care. In the World Health Organization's 2008 World Health Report, all countries were encouraged to orient their health care systems toward strengthened primary care. Such reforms are unlikely to improve overall population health, equalize distribution of health care resources or reduce costs unless they address both the systemic and clinical characteristics of primary care." Read More…

The Demise of Primary Care: A Diatribe From the Trenches
David D. Norenberg, MD, Annals of Internal Medicine, May 17, 2009
"Medical school graduates are avoiding primary care. The very aspects that once attracted students have been subverted. The breadth of practice that was once appealing has become the breadth of heavy-handed scrutiny, as politicians and business leaders have demanded quality—simplistically defined as dogmatic adherence to a standard. Individualized clinical judgment has been devalued; thinking has been replaced by algorithms. Generalists are spending so much time proving they are good doctors, they don't have time to be good doctors." Read More…

Commitment to Care for the Community
Catherine DeAngelis MD, Journal of the American Medical Association, May 13, 2009
"With the variety of proposed solutions to the problem of so many Americans not having access to care, in this case primary care, the common theme is commitment to care for the community. This includes commitment by physicians and other clinicians to provide the kind of care they know is best for patients, commitment by all payers—private or public—to provide the resources needed for this care, and commitment by patients to pay for what they can and not to misuse the system that provides care for them. Some individuals might believe this effort to be a pipe dream, but without the commitments by all those involved, there will never be a health system in the United States to care for all who truly need it." Read More…

Commentary: Grow the National Health Service Corps
Jonathan Saxton MD and Micheal Johns MD, Journal of the American Medical Association, May 13, 2009
"President Barack Obama has called for the renewal and expansion of volunteerism and national service so that citizens everywhere can help address serious national challenges. This call has been embraced across the country and even across party lines. Both the US House of Representatives and the US Senate have responded with bipartisan legislation designed to encourage such service. This broad initiative presents the health professions with an extraordinary opportunity to renew health professions' basis in charity while modeling service, wellness, and chronic care programs essential to health care reform. The National Health Service Corps (NHSC) could be the best place to start." Read More…

Commentary: Oversimplifying Primary Care Supply and Shortages
Gary Freed MD MPH and James Stockman MD, Journal of the American Medical Association, May 13, 2009
"Attempting to ensure an appropriate primary care workforce to meet the needs of the United States is a complex and daunting task that is vital to the ultimate health of the nation. Oversimplifying the nuances of the primary care workforce may result in policies and priorities at odds with needs. For the specialty of pediatrics, it appears that a close to appropriate proportion of trainees continues to enter the primary care arena. Certainly, an erosion of that proportion or in the absolute number of physicians entering pediatrics would require appropriate action to ensure a continued capacity to provide general and subspecialty care to children. Those concerned with workforce adequacy should continue to monitor the situation closely." Read More…

A Lifeline for Primary Care
Thomas Bodenheimer, MD, Kevin Grumbach, MD and Robert Berenson, MD, New England Journal of Medicine, June 25 2009
"Primary care in the United States needs a lifeline. In 2009, for the 12th straight year, the number of graduating U.S. medical students choosing primary care residencies reached dismally low levels.1 Overloaded primary care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care. Three major factors contribute to this crisis." Read More...

Easing the Shortage in Adult Primary Care – Is It All About Money?
Robert Steinbrook, MD, New England Journal of Medicine, June 25, 2009
"As Americans debate health care reform, it is easy to forget that success may depend as much on the availability of primary care physicians for adults as on the specifics of the reforms themselves. Access to health insurance does not ensure access to timely medical care, particularly in places where doctors are in short supply, are not accepting new patients, or are not accepting patients with some types of insurance. Effective primary care can improve the quality of care and health outcomes and save money. But to the extent that easing the shortage of primary care physicians will require additional funds, the initial costs of reform will increase." Read More…

A Health Care Cooperative Extension Service: Transforming Primary Care and Community Health
Kevin Grumbach, MD and James W. Mold, MD MPH, Journal of the American Medical Association, June 25, 2009
Primary care is the essential foundation for an effective, efficient, and equitable health care system. Calls to rebuild the crumbling primary care infrastructure in the United States are reaching receptive ears, with public and private advisory groups including the Medicare Payment Advisory Commission and the National Business Group on Health recommending increased payments for primary care. Policy makers expect that new investments will transform primary care by creating more effective and efficient patient-centered medical homes. The primary care physician community acknowledges the need for new practice models that provide accessible, comprehensive, integrated care based on healing relationships over time." Read More…

The Uncertain Future of Primary Medical Care
David Mechanic, PhD, Annals of Internal Medicine, July 7, 2009
"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. 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." Read More…

Working Conditions in Primary Care: Physicians Reactions and Care Quality
Mark Linzer, MD et al, Annals of Internal Medicine, July 7, 2009
"The primary care workplaces we studied involve many challenges for practicing physicians. Work conditions, including workflow (time pressure and a chaotic work pace), job characteristics (lack of work control), and poor organizational culture were strongly associated with adverse physician reactions. Our findings may explain current difficulties in recruiting and retaining primary care physicians but leave open the question of whether adverse work conditions influence health care quality and safety." Read More…

The Political Economy of U.S. Primary Care
July/August 2009 – Health Affairs
"Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort—a new Charter for Primary Care—is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations." Read More…

The Paradox of Primary Care
July/August 2009 – Annals of Family Medicine
"Despite rising costs, health care often is of poor quality. Current solutions to improving quality may do more harm than good if they focus more on diseases than on people. Primary care is touted as an essential building block of a high-value health care system even as it is undermined by systems attempting to improve the quality, effectiveness, and value of their health care. These contradictions plague improvement efforts in health care systems around the world, particularly the United States." Read More…

Primary Care Remuneration – A Simple Fix
Arthur Fournier, MD, The New England Journal of Medicine, August 19, 2009
"Fixing primary care is critical to health care reform but will require simultaneously fixing several problems, including those related to remuneration, the work environment, and medical education.1 The most critical of these issues is remuneration." Read More…

The PCMH: A Model for Primary Care
Journal of the American Academy of Physician Assistants, September 16, 2009
"The concept of the patient-centered medical home (PCMH) was developed by primary care physicians and large employers to encourage comprehensive health care, improve patient outcomes, and lower medical costs. The PCMH approach provides comprehensive care in a setting that facilitates a partnership with the patient, via an interdisciplinary healthcare team and community resources. The current goals of the PCMH include providing high-quality preventive care and effective chronic disease management across the life span and a reimbursement structure that includes coverage for coordination of care and documentation of patient outcomes." Read More…

American Medical Home Runs
Health Affairs, September/October 2009
"Four primary care sites in the United States constitute "medical home runs" because their patients incur 15–20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality. The sites achieved this result in a U.S. payment environment that usually penalizes physicians who invest to prevent costly near-term health crises. If the ingredients and accomplishments of these four sites spread, under- and uninsured lower-income Americans could be fully covered in the foreseeable future without increased health spending or lower quality of care. In exchange, sponsors of health benefits would gladly support additional primary care physician payment." Read More…

The End of Fee-For-Service Medicine? Proposals for Payment Reform in Massachusetts
New England Journal of Medicine, September 10, 2009
"Health care reform has multiple goals, including expanding insurance coverage, improving quality and access to care, and controlling costs. Since Massachusetts enacted reforms in 2006, the proportion of residents lacking health insurance has decreased to an estimated 2.6% — the lowest of any state. However, there are continuing concerns about quality and access, and health care costs per capita remain among the highest in the United States. A special commission has therefore proposed that Massachusetts effectively end fee-for-service medicine, the predominant form of payment for health care services, and replace it with a system of global payments that combines the approaches of risk-adjusted capitation and pay for performance with a strong focus on primary care." Read More…

Entry of US Medical School Graduates Into Family Medicine Residencies: 2008-2009 and 3-Year Summary
Family Medicine, September 2009
This is the 28th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs. Approximately 8.2% of the 16,336 graduates of US medical schools between July 2007 and June 2008 were first-year family medicine residents in 2008, compared with 8.3% in 2007 and 8.5% in 2006. Medical school graduates from publicly funded medical schools were more likely to be first-year family medicine residents in October 2008 than were residents from privately funded schools, 9.8% compared with 5.6%." Read More…

Results of the 2009 National Residency Matching Program: Family Medicine
Family Medicine, September 2009
"The results of the 2009 National Resident Matching Program (NRMP) reflect a persistently low level of student interest in family medicine residency training in the United States. Compared with the 2008 Match, 70 fewer positions (with 89 fewer US seniors) were filled in family medicine residency programs through the NRMP in 2009, at the same time that 18 fewer positions were filled in primary care internal medicine (11 fewer US seniors), one more position was filled in pediatrics-primary care (three more US seniors), and 13 more positions were filled in internal medicine-pediatrics programs (but with seven fewer US seniors)." Read More…

American Recovery and Reinvestment Act and the Expansion and Streamlining of the National Health Service Corps: A Great Opportunity for Service-Minded Family Physicians
Journal of the American Board of Family Medicine, September 2009
"President Obama has challenged Americans to improve their communities and country through service to others. There are many ways one can serve others but few ways one can do this and benefit financially from one's service. The National Health Service Corps (NHSC) offers physicians and others in health care a way to do exactly this. With a $300 million expansion from the American Recovery and Reinvestment Act and an updating of its programs, the NHSC now offers more and better opportunities than ever for rewarding and well-compensated service." Read More…

British Lessons on Health Care Reform
September 24, 2009 – New England Journal of Medicine
"So what can the United States learn from the NHS? The jewel in the NHS crown is the strength of its primary care and its general practitioners. These highly trained physicians contribute to Britain's health by focusing on the health of the whole person, rather than on a single organ; emphasizing prevention and health screening, which should reduce the life-expectancy gap between rich and poor, currently about 13 years in Britain; acting as gatekeepers, who control costs by referring only patients who truly require a specialist's opinion, since 86% of medical needs can be managed in the community; and providing continuity and coordination of care and being patients' constant companions in the domain of health care." Read More…

Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians
September 23/30, 2009 – Journal of the American Medical Association
"Primary care physicians report alarming levels of professional and personal distress. Up to 60% of practicing physicians report symptoms of burnout, defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. Physician burnout has been linked to poorer quality of care, including patient dissatisfaction, increased medical errors, and lawsuits and decreased ability to express empathy. The consequences of burnout among practicing physicians include not only poorer quality of life and lower quality of care but also a decline in the stability of the physician workforce." Read More…

Physician Assistants and Nurse Practitioners as a Usual Source of Care
Chrisinte M. Everett, MPH PA-C et al., Journal of Rural Health, September 23, 2009
"The United States (US) is faced with an aging population, projected physician shortages, and an increase in the prevalence of chronic disease, health care costs, and the number of uninsured Americans, making access to health care a leading policy issue. Since 1967, non-physician providers such as Physician Assistants (PAs) and Nurse Practitioners (NPs) have been utilized to improve access and reduce health care costs. Approximately 110,000 PAs and NPs currently practice in the United States. Fifty percent of PAs and 85% of NPs practice in primary care and are more likely than doctors to practice in rural areas and with underserved populations." Read More…

Innovation Networks: A Strategy to Transform Primary Health Care
Peter Margolis, MD PhD and Neal Halfon, MD MPH, Journal of the American Medical Association, October 7, 2009
"Upgrading primary care is key to realizing the promise of health care reform to improve access and quality while reducing costs. Promising models, such as the patient-centered medical home and new measurement systems for detecting better population outcomes, require primary care clinicians to develop innovative ways of organizing care. Because new and improved approaches are not easily transplanted directly into practice, transforming primary health care will be virtually impossible without a system for innovating, testing, and providing what works. Primary health care innovation networks can accelerate primary care transformation by harnessing the collective intelligence and motivation of the medical community." Read More…

Aspects of the Patient Centered Medical Home Currently in Place: Initial Findings from Preparing the Personal Physician for Practice
Patricia A. Carney, PhD et al., Family Medicine, October 2009
"The Patient-centered Medical Home (PCMH) is advo¬cated as an important element of health reform based on evidence of improved patient outcomes in primary care at lower cost.1-7 One study found that US states that relied more on primary care have lower Medi¬care spending, lower resource use, lower utilization rates, and better quality of care, as measured by fewer intensive care deaths and a higher composite quality score." Read More…

Ensuring Progress in Primary Care – What Can Health Care Reform Realistically Accomplish?
October 28, 2009 – New England Journal of Medicine
"Despite the apparent agreement on reforming primary care, there is no assurance that the health care reform bills currently under debate will make these consensus-based recommendations a reality. Primary care has thus far taken a back seat to the more contentious elements of the health care reform bills, such as methods of expanding insurance coverage, the institution of individual and employer mandates, financing strategies, and medical malpractice reform. In terms of augmenting the primary care workforce, the House bill is more robust than the Senate bills. Both houses would redistribute currently unused medical residency slots in favor of training for primary care practitioners. Both would also fund "teaching health centers," or ambulatory-based primary care training in, for instance, community health centers." Read More…

Primary Care and Accountable Care – Two Essential Elements of Delivery-System Reform
October 28, 2009 – New England Journal of Medicine
"With discussions about U.S. health care reform focused heavily on insurance reforms, relatively little attention has been paid to the delivery-system reforms that will be required to improve the quality and coordination of health care and slow the growth of spending. The "patient-centered medical home" (PCMH) and the "accountable care organization" (ACO) are two widely discussed models for delivery-system reform that take complementary approaches to achieving these goals." Read More…

The Primary Care Crisis and Health Care Reform
November 2009 – Journal of Healthcare for the Poor and Underserved
"Health care reform must ensure that our workforce is able to meet the demands of delivering primary care to patients. Program funding, financing mechanisms and incentives, and implementing infrastructure changes are all needed to ensure that clinicians are attracted to primary care, faculty are in place to educate health care professionals, and health care delivery is efficient and effective. Ameliorating the problems presently impeding primary care delivery involves more than just training additional doctors to become primary care physicians." Read More…

Self Directed Community Health Assessment Projects in a Required Family Medicine Clerkship: An Effective Way to Teach Community Oriented Primary Care
November/December 2009 – Family Medicine
"Community-oriented primary care (COPC) is a key teaching objective of many medical school family medicine clerkships. Though many programs are in place, little is published evalu¬ating the effectiveness of curricula." Read More…

Training Residents in Community Health Centers: Facilitators and Barriers
November/December 2009 – Annals of Family Medicine
"Family medicine residencies (FMRs) and Community Health Centers (CHCs) are confronted with 2 different aspects of the current primary care workforce crisis in the United States. FMRs suffer from declining student interest in primary care and perennial threats to financial solvency. Training family medicine residents in underserved settings, such as community health centers (CHCs), may provide a solution to the primary care workforce shortage. We sought to describe the facilitators and barriers to creating partnerships between CHCs and family medicine residencies (FMRs)." Read More…

A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs and Experiences
November 2, 2009 – Health Affairs
"In many countries, primary care clinicians serve as the foundation for health care and the "gatekeepers" for more specialized referrals. A new international survey of primary care physicians in eleven countries finds that American doctors are significantly behind many of their counterparts elsewhere in providing access to high-quality care and use of health information technology." Read More…

Redesign of the Health Care Delivery System: A Bauhaus "Form Follows Function" Approach
December 3, 2009 – Journal of the American Medical Association
"The governing design principle of the US health care system has been described as an 'edifice complex' and a 'field of dreams' complex—if the health system builds it, the patients will come. This clinician-centric approach to the design of delivery of health care is obsolete, contributing to health care of inferior quality and excessive cost. To meet the patient-centered needs of a modern health care system, the United States should consider adopting the Bauhaus design principle of 'form follows function.'" Read More…

Addressing the Primary Care Workforce Crisis for the Underserved
December 14, 2009 – Annals of Internal Medicine
"Universal coverage and multiple initiatives to improve health care delivery are crucial components of health care reform. However, the missing link has been a plan to rapidly address the primary care workforce crisis for the underserved. This can be achieved by establishing primary care teaching health centers in expanded community health centers, which have established a patient-centered medical home practice environment." Read More…

Persistent Primary Care Health Professional Areas (HPSAs) and Health Care Access in Rural America
September 2009 - WWAMI Rural Health Research Center
"This study examines the degree to which persistence of primary care HPSA designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services." Read More…

FaMeS: An Innovative Pipeline Program to Foster Student Interest in Family Medicine
January 2010 – Family Medicine
"There is a national shortage of primary care physicians; many medical school departments of family medicine are searching for new ways to attract and retain students who may be interested in primary care. In 2004, our department began a "pipeline" program targeted at entering first-year students that incorporates curricular, extracurricular, summer, and career-planning elements." Read More…

Changes in the Knowledge of and Attitudes Toward Family Medicine After Completing a Primary Care Course
January 2010 – Family Medicine
"The study's objective was to determine medical students' knowledge of and attitudes toward family medicine before and after completing a course in primary care. After completing the course, the students showed an improvement in their knowledge of and attitudes toward family medicine and primary care, but only a small percentage considered a career in family medicine as a first-choice option." Read More…

Generating the Knowledge Needed to Make the Patient-Centered Medical Home a Reality: A Collaborative Project of the Primary Care Specialties
January 2010 – Annals of Family Medicine
"There is a clear consensus that primary care needs to be at the center of a reformed US health care system. The Patient-centered Medical Home (PCMH) has emerged as the key strategy for the redesign of primary care. The PCMH model builds upon the core concepts of primary care that include accessible, accountable, coordinated, comprehensive, and continuous care in a healing physician-patient relationship over time. Added to these basic primary care concepts are features that improve quality of care, improve patient centeredness, organize care across teams, and reform the payment system to support this enhanced model of primary care." Read More…

Allies in Family Medicine Advocacy: The Patient-Centered Primary Care Collaborative
January 2010 – Annals of Family Medicine
"In 2005, IBM recognized that the health care it purchased was costly and of poor quality, mainly because there were no incentives for the provision of continuous, longitudinal care. In 2006, large employers led by IBM organized a coalition of consumer groups, quality organizations, health plans, labor unions, and physician groups to advance the principles of the Patient-Centered Medical Home (PCMH) and advocate for a model of health care compensation with the appropriate incentives. This coalition was named the Patient-Centered Primary Care Collaborative (PCPCC)." Read More…

An Idea Whose Time Has Come?
January 21, 2010 – Annals of Internal Medicine
"The timely article 'Addressing the Primary Care Workforce Crisis for the Underserved' by Rieselbach, Crouse, and Frohns (Dec. 14th) highlights the urgent workforce shortage in Community Health Centers (CHCs) and the increasing interest in the "Health Center" (THC) concept. Current language in the health reform bill provides funding for support and creation of THCs as a potential solution to the workforce for the underserved." Read More…

Just What Are Rural Premedical Students Thinking? A Report of the First 6 Years of a Pathways Program
Winter 2010 – Journal of Rural Health
"A severe, long-lasting shortage of physicians has been predicted, and this will be most severe in rural areas. Most medical schools are reacting to this by increasing class size, often as much as 30%. If present premedical education and admissions policies continue, however, the majority of the new physicians will locate in urban areas, with negligible effect on the majority of underserved Americans. A few programs have produced small numbers of rural physicians by changing admissions policies and having special programs for premedical students from underserved areas, those most likely to return to similar areas. Put simply, the most effective way to change the maldistribution of physicians is to admit the kind of students to medical school who are not currently achieving admission." Read More…

Rural Idaho Family Physicians' Scope of Practice
Winter 2010 – Journal of Rural Health
"Rural areas experience significant challenges in recruiting and retaining family physicians. The number of rural family physicians has been declining in contrast to the increasing health care needs among rural residents, who tend to be older, sicker, poorer, less educated, and living without health insurance. These challenges can materially impact local community access to health care, both for general medical care and for specific medical services such as obstetrics and emergency services. Considering the current and projected declining trends in family physicians and an increase in the number of elderly citizens, the United States must increase the number of family physicians, especially in rural areas, in order to provide adequate care to residents." Read More…

Harnessing Geographic Information Systems (GIS) to Enable Community-Oriented Primary Care
January 2010 – Journal of the American Board of Family Medicine
"Despite growing acceptance and implementation of geographic information systems (GIS) in the public health arena, its utility for clinical population management and coordination by leaders in a primary care clinical health setting has been neither fully realized nor evaluated." Read More…

Does Graduate Medical Education Also Follow Green?
February 22, 2010 – Archives of Internal Medicine
In his 2008 research letter, Ebell1 highlights the relationship between residency fill rates and physician specialty salary. Mullan referred to this as the 'white-follows-green law.' In the hope of informing these concerns that hospitals may be responding to financial incentives over workforce needs in their allocation of GME positions, we explored the relationship between physician income and 10-year growth in primary care residency positions vs those in a group traditionally noted for their 'lifestyle' appeal and higher likelihood of driving hospital revenues." Read More…

Medical Education Futures Study

George Washington University School of Public Health and Health Services

Josiah Macy Jr. Foundation

Primary Care: Research