The Role of Subspecialists in Primary Medical Care

THE ROLE OF SUBSPECIALISTS IN PRIMARY MEDICAL CARE LOIS SIGEL* and BERNARD SIGELf At a time of significant concern regarding shortages of primary care resources, emphasis has been placed on reversing the trend toward subspecialization in medicine and encouraging the development of primary care physicians. The content of the Millis report (1966) stimulated interest in graduate medical education programs directed toward producing more primary care specialists [I]. Governmental incentives for maximizing numbers of primary care practitioners ensued. At the national level both the Health Manpower Act of 1971 (P.L. 92-157) and the more recent Health Professions Educational Assistance Act of 1976 (P.L. 94-484) encouraged medical schools to initiate programs that would increase the number of medical graduates entering primary care specialties . States, too, have assumed this approach to meeting the need for more primary care. As ofJanuary 1, 1977, 20 states have passed special legislation aimed at promoting and funding family practice residency programs [2]. In spite of these major efforts, it is not likely that they alone will rapidly achieve the objectives of providing sufficient primary care for the American population. There are at least two reasons why this approach may not in itself achieve the goal in a reasonably short time. The first of these is the problem of sheer numbers. Schoenfeld et al. suggest that approximately 133 primary care physicians are required per 100,000 people. They estimate that fewer than half that number are available now [3]. Thus recent efforts to develop enough physician manpower for primary care by stimulating the production of primary care specialists cannot be expected to make up the estimated deficit in the near future. *Assistant professor, Community Health Services Department, School of Public Health, University of Illinois at the Medical Center, 2121 West Taylor Street, Chicago, Illinois 60612. tProfessor, Department of Surgery, Abraham Lincoln School of Medicine, College of Medicine, University of Illinois, 1853 West Polk Street, Chicago, Illinois 60612.© 1980 by The University of Chicago. 0031-5982/8l/2401-0l7l$01.00 122 I Lois Sigel and Bernard Sigel ¦ Subspecialists in Primary Medical Care The second reason relates to career choice regarding patient care responsibilities. There is evidence that the initial intent of many physicians to become primary care specialists is often diverted. Wechsler et al. recently reported a follow-up of residents starting in primary care fields. They found that only one in four internal medicine residents surveyed remained in full-time primary care [4]. Providing greater encouragement for physicians to enter and stay in primary care, enabling primary care physicians to work more efficiently, and developing more nonphysician health professionals for primary care are all approaches which need to be pursued further. A recent Institute of Medicine study deals with these issues [5]. This report recommends policies which would give greater financial incentives for primary care physicians and reduce the amount of primary care provided by subspecialists. It is generally recognized that medical subspecialists do engage in many activities categorized as primary care. Cooper in his opening remarks at the AAMC Institute on Primary Care in 1974 acknowledged the significant involvement of some subspecialists "in broad continuing care" not related to their subspecialty [6]. Benson in his presidential address before the American Gastroenterological Association in 1978 stated that the third commonest disorder seen by the gastroenterologist is essential hypertension [7]. Haggerty, while recognizing that much of primary care is provided by highly specialized internists, pediatricians, and surgical subspecialists, believes that this "is more by accident than design" [8]. The purpose of this paper is to examine the role of subspecialists functioning as providers of primary care. This is done in the belief that while there are many instances in which these functions are best performed by primary care specialists, there are other circumstances in which the subspecialist may be the most appropriate physician to provide these services. If this contention is true, certain functions of subspecialists may offer a supplemental source of manpower in primary medical care which may help to meet the needs for these services. To examine this issue further, we need to consider the definition of primary care medicine, its relation to the various provider functions, and the application of provider...