Intended for healthcare professionals

Feature Christmas 2010: Primary Care

A modest proposal

BMJ 2010; 341 doi: (Published 09 December 2010) Cite this as: BMJ 2010;341:c6605
  1. Philip A Mackowiak, professor, vice chairman1, chief2
  1. 1Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
  2. 2Medical Care Clinical Center, VA Maryland Health Care System, Baltimore, Maryland
  1. Correspondence to: philip.mackowiak{at}
  • Accepted 15 November 2010

“For Preventing Primary Care Physicians in America From Being a Burden to Their Profession or Country, and For Making Them Beneficial to the Publick.” A solution to America’s healthcare crisis inspired by Jonathan Swift’s “A Modest Proposal” (1729)

Once President Obama has at last put the US healthcare insurance crisis to bed, he must then figure out what to do about primary care providers, who are crucial (as those who have more expertise in such matters than I believe) to the success of his healthcare programme. Roughly reckoned, there are some 300 000 to 350 000 of them.1 The question is: how do we continue to train, equip, and maintain this number, much less provide for the even larger number that others have suggested is needed to care for our ageing population?2 The current crop is already hard pressed to cover their overheads, to say nothing of supporting their spouses and children, who, given current levels of compensation for primary care services, are soon sure to become wards of the state.

Fixing the primary care problem (Howard Pyle’s “Walking the plank”)

As to my own qualifications for offering advice on this weighty matter, I have for years read and ruminated over the subject, carefully weighed the myriad solutions offered by others (including but not limited to: comparative effectiveness research, accountable care organisations (ACOs), patient centred medical homes, capitated/global payment schemes, and sentinel networks) and found each of them grossly mistaken in concept. These prior proposals, concocted mostly by PhDs and other nonclinicians, have focused on the primary care physician as the solution to America’s healthcare crisis. I believe a broader perspective is indicated, one in which the primary care physician is recognised not just as the solution to the problem, but also its cause.

In all humility, I offer for …

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