The Essential Role of Generalists in Health Care Systems

To manage a system effectively, you might focus on interaction of the parts rather than their behavior taken separately. Russell L. Ackoff, systems theorist (1) Health care is an essential means for promoting human development. By expanding people's capability to pursue lives that they valuefree from premature death or treatable illnesshealth care reduces deprivation and enhances freedom (2). But to achieve these social objectives, a society must be able to distribute the benefits of health care across its entire population. Because it delivers health care to populations with both equity and efficiency, primary care is an essential component of a rational health care system (3). Given such broad aspirations, realizing the potential of primary care is universally challenging, but it has been especially difficult in the United States (4). Without an organized system of health care delivery, or even a financing mechanism that ensures universal access, the fragmented system that has evolved presents many obstacles to primary care (5-9). Some recent assessments of primary care's future have become increasingly dystopian (8, 10, 11), standing in stark contrast to the thorough account of primary care's benefits published by the Institute of Medicine's Committee on the Future of Primary Care less than a decade ago (3). Many of the warnings about primary care's possible demise take a market perspective (10-12), arguing that if primary care is faltering because of consumer choice, then the invisible hand has performed its duty to regulate demand and supply. But the market is subject to well-known failingsthe so-called externalitiesin which decisions to produce or consume a good or service have consequences beyond the participants in the transaction (13). In such cases, the aggregate effect of many self-interested decisions causes public harm in domains such as social well-being, public health, and environmental protection (14). A classic example is the polluter, who saves money by indiscriminately disposing of wastes, while others pay the costs in the form of a degraded environment (15). Certain population benefits of primary care are at risk for being eroded by externalities in the current U.S. health care marketplace. For example, free access to specialists may be an individual psychic good, but if it comes at the expense of a rational system of matching population needs with health care resources, and promoting generalistspecialist interdependence, then free access to specialists may endanger long-term health system sustainability. It is easy to overlook many of the important benefits of primary care if one views it as merely another clinical services niche in the marketplace. Only a systems view illuminates the real value of primary care: First, primary care is best understood as an essential part of an effective, efficient, and equitable health care system, even in a de facto system such as exists in the United States (16). Second, within the broader systemthe naturalistic ecology (17, 18) of patients nested within health care systems nested within communitiesprimary care provides essential services at each level of organization. Important aggregate effects of primary careover and above its benefits for individual patientsarise at higher organizational levels, representing new system behaviors not necessarily predictable from lower-level effects (19, 20). We describe these essential system functions that primary care performs for health care organizations and populations. We have attempted to build on previous systems thinking (16, 21, 22), by explicitly considering a set of primary care functions that contribute to the effectiveness and overall integrity of the health care system, including triage of undifferentiated symptoms, improving the efficiency and appropriateness of specialty care, and reducing socioeconomic and geographic disparities. We hope that a focus on these primary care functions will not only place the debate on primary care's future in a sufficiently broad context but will also guide transformations that will enable primary care to fully realize its promise. Many of the transformations involve strengthening generalists' role as key connections in the network of patients, clinicians, and communities. Scaling Up from Individuals to Systems In trying to understand complex systems like ecosystems, economies, or health care, a central issue is how large-scale system features and patterns emerge from small-scale interactions (23-25). For example, what driving forces across millions of doctorpatient interactions cause disparities by race and ethnicity in the use of preventive and therapeutic interventions (26)even among insured populations (27)to emerge independently in so many communities across the United States? To address such questions, 3 characteristics of complex systems must be understood (28): 1) the number and diversity of interacting components, 2) how the components interact to generate system behavior, and 3) the mechanisms that feed back to the components the outcomes of their interactions. Each characteristic can sway the performance of the overall system. Most intuitively, an increase in 1 type of component relative to the others will change system behavior. Thus, continuing with the health care disparities example, if physicians from minority groups provide less disparate care, then each incremental increase in the minority physician workforce would be expected to incrementally reduce health service disparities. Beyond a critical threshold of minority physician workforce, however, the larger medical culture may evolve so that patient interactions change across all providers, thus sharply reducing disparities. Such emergent effects often follow nonlinear paths, illustrating the principle that quantitative change of a sufficient magnitude becomes qualitative change. The feedback mechanism motivating physician behavior change could be very explicit (tracking measures of disparate care) or more implicit (heightened awareness of disparities prompts physicians to question their assumptions when they care for minorities). Primary Care Functions Primary care provides essential functions for patients, health systems, and populations. Because patient-level services have been extensively discussed in the primary care literature, we discuss them here only to emphasize that they are the fundamental units of primary care activity and the necessary prerequisites for the emergence of many higher-level functions (Table, top). For example, although not unique to primary care, a strong emphasis on person-focused care (29, 30) projects beyond the patientphysician dyad to support important system goals such as quality of care (31, 32) and efficient use of services (33, 34). Person-focused care also helps caregivers reach decisions that meet the needs of the patient rather than the health care system (35). This entails careful consideration of procedures that may be driven by availability rather than benefit (36); self-perpetuating cascades of diagnostic or therapeutic interventions (37); and interventions aimed at reducing clinician rather than patient uncertainty. Table. Health Care Functions Provided by Primary Care Functions for Health Care Systems Primary care provides essential functions for health systems, whether the de facto system of care in the United States or the more centrally organized health systems elsewhere (Table, middle). As the point of entry into the health system, primary care enhances the efficiency of downstream providers in several ways. First, primary care is a mechanism to evaluate patients with undifferentiated symptoms, so that, for example, patients with chest pain from panic disorder do not end up in the angiography laboratory, while those with chest pain from angina do. This benefit accrues not only to patients; the aggregate effect of this triage function at the health system level is to match patients' needs with system resources, thus minimizing potential overtreatment or undertreatment (38). Part of the triage effect emerges from the mathematics of clinical epidemiology. Specialist testing strategies for ruling in serious disease function well only when the prior probability of disease is reasonably high; primary care can ensure that this is so with appropriate screening of referrals (39, 40). Another part of the triage effect stems from the different severity of illness usually seen by generalists rather than specialists. Dealing with complex, high-risk cases, specialists often use maximin strategies (41) designed to make the best of the worst-case scenario, strategies that may be inappropriate for patients with less severe illness (42). On the other hand, patients with complex illnesses often require specialist care, and primary care triage helps to ensure that specialists spend most of their time applying their skills where they are critically needed. In the case of illnesses such as major depressive disorder, primary care also provides a major source of system capacity for a disorder that would otherwise overwhelm the supply of specialist mental health clinicians. Some patients present with problems that the health care system cannot diagnose or solve (43). Often, after a string of specialty evaluations excludes various organ systems as the cause, the patient is left feeling confused, frightened, and forsaken. Because of its commitment to persons rather than problems, primary care does not dismiss these patients, but continues to hold them in the system and manage their problems. The continuing prevalence of undiagnosable illness in medical practice (44) makes this holding function an important system service. Another function of primary care is to enhance the mutual understanding of patient and health system. Using the knowledge gained from personal relationships, primary care clinicians can anticipate and address patients' concerns about diagnostic tests, procedure