• The care provided by certain clinicians—the Clinton administration's Health Security Act, for example, named the medical specialties of primary health care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants (OTA, 1986; Pew Commission, 1994).

  • A set of activities whose functions define the boundaries of primary care—such as curing or alleviating common illnesses and disabilities;

  • A level of care or setting—an entry point to a system that includes secondary care (by community hospitals) and tertiary care (by medical centers and teaching hospitals) (Fry, 1980); ambulatory versus inpatient care;

  • A set of attributes, as in the 1978 IOM definition—care that is accessible, comprehensive, coordinated, continuous, and accountable—or as defined by Starfield (1992)—care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;

  • A strategy for organizing the health care system as a whole—such as community-oriented primary care, which gives priority to and allocates resources to community-based health care and places less emphasis on hospital-based, technology-intensive, acute-care medicine (IOM, 1984).

No one category incorporates all the dimensions that people believe are denoted by the term, and this has resulted in a lack of clarity and consensus about the meaning of the term. A clue to the difficulty lies in an ambiguity of the word primary, as noted in a background paper prepared for this report by Safran (1994). If primary is understood in its sense of first in time or order, this leads to a relatively narrow concept of primary care as “first contact, ” the entry point, or ground floor of health care delivery. This meaning of primary can connote only a triage function in which patients are then passed on to a higher level of care. If, on the other hand, primary is understood in its sense of chief, principal, or main, then primary care is better understood as central and fundamental to health care. This idea of primary care supports the multidimensional view of primary care envisioned by this IOM committee.

This IOM committee thus reaffirms the importance of continuing to define primary care as multidimensional; it cannot be defined on the basis of a single dimension, as attractive as this might be for policymakers who formulate workforce policy and must decide who does or does not provide primary care. This exigency, faced by policymakers, has led to reliance on criteria based on, for example, residency training, care setting, or level of care (e.g., first contact). While fully acknowledging the need for a clearer sense of primary care to guide policymaking at the national and state level, the committee believes a careful but multidimensional view of primary care will permit a far richer discussion of organizational opportunities, professional development and satisfaction, health curricula reform, and improved health care than any single-dimension definition.



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