and indeed such a system would be antithetical to the committee's future vision of primary care.

First contact with a primary care clinician may lead to referrals to other resources—for example, to a nurse practitioner for diabetic counseling or to a cardiologist for subspecialty care. In some cases, self-referral by a patient may be appropriate—for example, for recurrent problems previously treated by another specialist or subspecialist or refractions for eyeglass prescriptions. Information about these encounters should be provided to the primary care clinician.

The descriptor first contact is not, however, a sufficient or unique attribute for defining primary care. It is not unique because some first contact events do not represent primary care—for example, those that occur through an occupational health service, an emergency room, or at a health fair booth for cholesterol screening. Such encounters can be integral to the patient 's health care, and information gathered should be communicated to the primary care practice.

Furthermore, first contact is not sufficient to define primary care. Insofar as it has come to imply the restriction of primary care to a triage function, it neglects the other characteristics of primary care included in this report, specifically, comprehensiveness.

A derivative term is gatekeeper. In many circles, the term gatekeeper has been used to describe the function of using the experience and judgment of the primary care clinician to determine whether diagnostic tests are necessary, whether a patient's problem can be handled by the primary care practice, or whether a person needs to be evaluated or treated by another specialist or subspecialist. Patients view gatekeeping with suspicion because they fear that efforts to control use of services and to manage costs may ultimately work to the detriment of their health. By contrast, many managers, benefits officers, and policymakers view gatekeeping with enthusiasm because they see it as a way of rationalizing, if not restricting, the use of health care resources. The term gatekeeper, therefore, has come to have a pejorative connotation when primary care is reduced to the function of managing costs and especially when it implies that the gate is kept closed most of the time. This committee categorically rejects the view that the primary care clinician acts mainly or exclusively as a gatekeeper.

The Scope of Primary Care. Comprehensive care is intended to mean care of any health problem at a given stage of a person's life. It includes ongoing care of patients in various care settings (e.g., hospitals, nursing homes, clinicians' offices, community sites, schools, and homes). Ideally, the primary care clinician listens to the patient, evaluates, makes diagnoses, manages, and screens for other health care problems. He or she educates and communicates with the patient and others who may be involved. He or she involves other specialists when

Front Matter (R1-R6)

Contents (R7-R8)

Summary (1-2)

Part 1: Introduction (3-7)

Part 2: Earlier Definitions of Primary Care: A Review (8-14)

Part 3: The New Definition and an Explanation of Terms (15-33)

Part 4: Achieving the Goals of Primary Care as Defined (34-34)

Part 5: Issues to be Addressed in the Full Report (35-38)

References (39-40)

Appendix: Characteristics of Primary Care Described in the First IOM Report (IOM 1978) (41-42)