Primary care medicine: An empty promise in health care reform? There is an article of faith among proponents of health care reform that expanding the primary care workforce, particularly at the expense of medical and surgical specialists, is a critical component of “bending the cost curve” and enhancing access to care. This approach is favored in several models of health care delivery, particularly using the concept of a “gatekeeper” physician who follows guidelines of care to prevent over- utilization of expensive care by specialists. Increased training of and reliance on primary care physicians is a stated goal of various health care proposals and has been encouraged in the past through specific funding mechanisms by the government. It has been one of the major sources of frustration with the managed care paradigm of control of utilization of medical services.

One optimistic view of how this gatekeeper model would work has the general practitioner with an orderly and happy group of patients waiting at the “gate” to find out whether they need anything more from the health care system and then gaining appropriate and easy access to advanced care when that test or procedure is indicated. Another view, perhaps a little more clear-eyed, has the primary care physician having a default position of avoiding any expensive treatment or test provided by specialists unless there is overwhelming evidence that the procedure or test will be highly likely to be effective, not just possibly effective. Which one is accurate? Are there data on the effectiveness of primary care physicians compared to specialists in the treatment of a variety of diseases? Is there not an intuitive problem with assuming a “generalist” can be as knowledgeable and as efficient and effective as a well-trained specialist given the ongoing explosion in medical knowledge and technical capabilities?