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The Physician Workforce and Counting What Counts in Primary Care.

The US debate over the primary care workforce began in the 1960s with the collapse of medical student interest in general practice and the growth in specialty training. This led to the Millis Commission report on graduate medical education that identified the need for the “primary physician” to “serve as the primary medical resource and counselor to an individual or a family.”1 Nonetheless, even current workforce analyses reflect ongoing confusion regarding what primary care is, and which clinicians can provide it. This problem may contribute to conflicting assessments in several recent reports of the current and future workforce needs in primary care.2-4 The Millis report offered additional specific requirements of the primary care physician, such as “understanding and treating the whole man [sic]”; “continuing and comprehensive responsibility”; and “see that the necessary arrangements are made” for hospital or specialist physician services. In a recent review, O’Malley et al reaffirmed the continuing relevance of the core elements invoked by the Millis Commission that collectively differentiate primary care from other clinician services. These are “first-contact accessibility, continuity, comprehensiveness, coordination, and accountability for the whole person.”5 Of course it is not one element alone that achieves the primary care role envisioned in the Millis report. Neighborhood retail clinics are indeed accessible; emergency room physicians combine accessibility with comprehensive services, and hospitalist physicians retain comprehensive skills while coordinating with other clinicians to meet urgent patient needs. Both Millis and O’Malley make clear that it is not general training that characterizes primary care; it is the clinician who delivers all the features that provides primary care. Nonetheless some current workforce analyses continue to conflate training background with primary care practice. For example, some commentators arguing no shortage in primary care3 cite the Kaiser Family Foundation (KFF) report of over 456,000 US “primary care physicians.”6 However KFF includes 188,000 internal medicine physicians—many of whom are in hospitalist or other specialized roles. KFF also includes 51,000 obstetrics and gynecology physicians whose training is not designed to assure comprehensive skills in managing the multiple chronic medical conditions common in adult medicine today. The recent Association of American Medical Colleges (AAMC)-sponsored assessment of physician supply and demand narrows the relevant generalist disciplines to family medicine, general internal medicine, general pediatrics, and geriatric medicine and also excludes 28,000 of these physicians who chiefly provide hospital-based services. With this narrower set of disciplines and practice settings, the report estimates 2016 primary The Physician Workforce and Counting What Counts in Primary Care