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Primary Care Primary care in the United States

Innovations in primary care in the United StatesCommentary: What can primary care in the United States learn from the United Kingdom?

BMJ 2003; 326 doi: (Published 12 April 2003) Cite this as: BMJ 2003;326:796

Innovations in primary care in the United States

  1. Thomas Bodenheimer, clinical professor (
  1. Department of Family and Community Medicine, University of California at San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
  2. a Primary Care Research Unit, School of Public Policy, University College London, London WC1H 9EZ
  3. b Departments of Medicine, Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA 94118, USA
  • Accepted 11 February 2003

It has been said that primary care in the United States faces the worst of times and the best of times.1 Why the worst of times? Primary care was catapulted into prominence by the advent of health maintenance organisations; many of such organisations' 80 million patients were required to gain permission from their primary care physician to access laboratory, radiology, and specialty services. Because the number of people enrolled in health maintenance organisations is declining, more patients are free to move around the healthcare system. The United States may revert to its previous dispersed system of care, in which patients enter the specialty-dominated system through a variety of doors rather than through a single primary care entrance.

When health maintenance organisations moved primary care to a central position in health care, they expected primary care physicians to do far more for their patients than before,2 yet they paid little more, if at all, for these additional tasks. Primary care physicians were looking more and more like the “hamsters on a treadmill” described in an article in the BMJ.3 In California, the proportion of primary care physicians very satisfied with their work dropped from 48% in 1991 to 36% in 1996.4 In the past few years, medical students have become less interested in making a career in primary care because of the long hours, high stress, and relatively low reimbursement of generalist physicians.5

Summary points

Primary care in the United States is facing difficult times: doctors are overworked and dissatisfied with it, and medical students are not very interested in it

Primary care is unable to deliver everything expected of it and offers neither timely access to acute care nor state of the art chronic care

A redesign of the primary care sector that addresses these problems …

Correspondence to: A Majeed

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