The Future of Primary Care
http://www.100md.com
《新英格兰医药杂志》
This book contains 15 contributions that were prepared for a meeting that was held in October 2001 in Glen Cove, New York, sponsored by the Robert Wood Johnson Foundation, and attended by 45 invited persons. Revised versions of four of these papers were published in a supplement to the February 4, 2003, issue of the Annals of Internal Medicine.
The question, therefore, is: Was it worthwhile to publish a book about discussions that took place two and a half years earlier and have already partly been published? The answer, clearly, is yes. Primary care is in crisis, and this book contains a lot of information that contributes to the discussion of how it got there and how it can move forward. The book is well organized, nicely presented, and complemented by useful subject and name indexes.
The chapters by Larry A. Green and Barbara Starfield show convincingly that the poor performance of the U.S. health care system (which was ranked 37th worldwide by the World Health Organization in 2000) is due, at least in part, to the weakness in primary care. Why is this specialty doing so badly? Despite the fact that primary care was promoted by the managed-care movement from the 1970s to the 1990s, the U.S. health care system continues to be characterized by consumerism: specialized, high-technology, disease-oriented care that is promoted by industry, the media, and for-profit organizations offers a rich spectrum to the wealthy, whereas the poorest lack access to the most basic health care and often depend on inadequate treatment in the emergency room. Furthermore, in managed care, the primary care physician acts as a gatekeeper to specialized care, which has had a deleterious effect on its image. Therefore, as shown convincingly in the chapters by Eric B. Larson and Harold A. Pincus, primary care seems to be more precarious than ever in spite of the fact that its components — continuous, comprehensive, and coordinated care — are ideal for handling chronic physical and mental disease in an aging population.
A group of authors conclude by establishing seven core principles to guide the reconstruction of primary care. Most people would agree with their proposition that health care must be organized to serve the needs of patients with the highest possible quality and that it should be documented by measurable outcomes, but how can these goals be achieved if there is no political will? Readers will also agree that education and research in primary care should be promoted, but how can this be accomplished when academic centers continue to depend on and are judged by the income they generate through the treatment of patients in specialty clinics, rather than by the value of their educational achievements?
It is regrettable that the book contains no contributions from international authors. There are examples of other countries where primary care has been successfully integrated into the health care system and where better patient outcomes and better quality of care have been achieved with lower financing costs. How did these countries succeed in these areas? When viewed from the outside, it seems clear that only a kind of social and cultural revolution in the United States can return primary care to the central place where it belongs.
Hans Stalder, M.D.
University Hospitals of Geneva
Geneva 1211, Switzerland
hans.stalder@hcuge.ch(Edited by Jonathan Showst)
The question, therefore, is: Was it worthwhile to publish a book about discussions that took place two and a half years earlier and have already partly been published? The answer, clearly, is yes. Primary care is in crisis, and this book contains a lot of information that contributes to the discussion of how it got there and how it can move forward. The book is well organized, nicely presented, and complemented by useful subject and name indexes.
The chapters by Larry A. Green and Barbara Starfield show convincingly that the poor performance of the U.S. health care system (which was ranked 37th worldwide by the World Health Organization in 2000) is due, at least in part, to the weakness in primary care. Why is this specialty doing so badly? Despite the fact that primary care was promoted by the managed-care movement from the 1970s to the 1990s, the U.S. health care system continues to be characterized by consumerism: specialized, high-technology, disease-oriented care that is promoted by industry, the media, and for-profit organizations offers a rich spectrum to the wealthy, whereas the poorest lack access to the most basic health care and often depend on inadequate treatment in the emergency room. Furthermore, in managed care, the primary care physician acts as a gatekeeper to specialized care, which has had a deleterious effect on its image. Therefore, as shown convincingly in the chapters by Eric B. Larson and Harold A. Pincus, primary care seems to be more precarious than ever in spite of the fact that its components — continuous, comprehensive, and coordinated care — are ideal for handling chronic physical and mental disease in an aging population.
A group of authors conclude by establishing seven core principles to guide the reconstruction of primary care. Most people would agree with their proposition that health care must be organized to serve the needs of patients with the highest possible quality and that it should be documented by measurable outcomes, but how can these goals be achieved if there is no political will? Readers will also agree that education and research in primary care should be promoted, but how can this be accomplished when academic centers continue to depend on and are judged by the income they generate through the treatment of patients in specialty clinics, rather than by the value of their educational achievements?
It is regrettable that the book contains no contributions from international authors. There are examples of other countries where primary care has been successfully integrated into the health care system and where better patient outcomes and better quality of care have been achieved with lower financing costs. How did these countries succeed in these areas? When viewed from the outside, it seems clear that only a kind of social and cultural revolution in the United States can return primary care to the central place where it belongs.
Hans Stalder, M.D.
University Hospitals of Geneva
Geneva 1211, Switzerland
hans.stalder@hcuge.ch(Edited by Jonathan Showst)