Intended for healthcare professionals

Education And Debate

Primary care in the United States: problems and possibilities

BMJ 2005; 331 doi: (Published 08 December 2005) Cite this as: BMJ 2005;331:1400
  1. Robert L Phillips, assistant director (
  1. 1Robert Graham Center, 1350 Connecticut Ave NW, Washington DC, 20036 USA

    The UK government is hoping to improve primary care through competition. But US experience shows the difficulties created by a system reliant on market forces


    The United States has never had a more robust primary care workforce, but dysfunctional financing schemes and inability to compete for the hearts and minds of the next generation of young doctors threaten its future. Many of the problems are a direct result of the market approach to health care. Innovation is needed in how primary care functions are financed, protected, organised, and taught in order to identify options for a stable and robust health system built on primary care.

    The US undervalues family doctors

    US primary care

    Primary medical care in the US is delivered by three specialties: family medicine, general internal medicine, and general paediatrics. The specialties have a combined workforce of 222 000 doctors, whose primary function is to direct patient care. There is at least one doctor for every 1321 people in the US (table).1 In addition, more than 100 000 nurse practitioners and physician assistants work in primary care.1 Together, their offices serve as the medical home for most Americans and receive more visits than any other setting.2 It is concerning then that many recent publications have concluded that these specialties and the way they currently care for people is untenable.3 4 These publications show that people in the US are confused about the primary care specialties, sceptical about their claim to deliver comprehensive care, and unable to associate primary care with science or technology. They also indicate that the generalist specialties suffer from a lack of respect in academic circles, administrative burdens, and inflexible appointment schedules and brief visits that satisfy neither patient nor provider.

    View this table:

    Distribution of doctors in United States, 2004

    The hospitalist movement, which continues to …

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