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Voyage of care: Defining primary care
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I was a child born so free; It seems that time has put age on me. And when I grow old, will I once again find All of those sweet, innocent times? I was a child born without fear; It seems that time has placed me here. With no freedom to laugh, there’s more reason to cry. I really miss those innocent times. I used to feel joy in my soul, But now my sorrow has taken control. As I look around I pray, Lord be kind; Just one more taste of those innocent times.
— Eric Clapton and Marcy Levy, “Innocent Times,” 1976
At a time in the world of medicine where hospitals, accountable care organizations, and insurance companies are becoming one entity while our community appears disjointed to the point of incoherence, what is left to the meaning of “primary care”? What can we, as primary care pediatricians truly own in this endeavor we euphemistically call the ‘practice of medicine’ except our exam room and our commitment to the well-being of our patients? In order to own that future and again feel that soulful joy, I believe we need to carefully appreciate the past; one that is remembered as a time without fear, perhaps more innocent, but certainly one in which it was easier for me to laugh. It was a past with a model for future success.
What is primary care?
To conclude that pediatrician-led primary care is essential, we must first take a stab at a definition of primary care. You will be gratified to be reminded, I hope, that a superb generation of American pediatricians was integral to this debate over the past fifty years. With encouragement from Robert Haggerty, in 1973, Joel Alpert and Evan Charney established the framework for what we now acknowledge as primary care in The Education of Physicians for Primary Care, offering a cogent definition of primary care: first-contact medicine, longitudinal responsibility for the patient in an integrationalist role.
The late Barbara Starfield, a global voice in the field of primary care and public health and an American pediatrician, literally wrote the book on primary care, Primary Care: Concept, Evolution, and Policy in 1992, and forever stamped primary care as community-oriented, first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease or organ system.
Who are we?
The origins of American pediatric primary care, however, predates Alpert and Starfield by almost a century. How did we get children’s hospitals and pediatric primary care without pediatricians, and even earlier, a medical profession without physicians? They all derived from the community, meeting perceived needs and actual afflictions, deriving ongoing privileged status after achievement – surprisingly, all without overworked mission statements.
Primary care is obviously practiced in many settings in this country: community practices either privately owned or directed by a health care system, federally-qualified health centers, and hospital-based or school-based clinics. For the most part, primary care pediatricians are employees, and unlike most of the rest of the world, American pediatricians provide the majority of primary care for children, and since the new century, the majority of adolescent care.
At the turn of the 20th century there were only a handful of physicians that would now be recognized as pediatricians. Urban milk stations (and children’s hospitals), which began in the late 19th and early 20th centuries as a socially-driven response to a crisis in infant morbidity and mortality and a fear of social chaos fired by immigration, were run by public health nurses and focused on infant feeding and growth under the supervision of that original generation of pediatricians. These milk stations later evolved into well received infant welfare clinics and well-baby conferences.
The Sheppard-Towner Act of 1921, the first federal legislation to provide funding ($1,000,000/year) to states for maternal and child care, established 3,000 of these clinics, many in rural areas, with care provided free of charge. Woman had just been given the right to vote, thus creating the first example of male pediatricians joining arms with women to advocate for health justice for children and their families.
The AMA strongly opposed the act and it soon lapsed. The House of Delegates of the AMA publically rebuked the Pediatric Section of the AMA for endorsing the renewal of the act, and with this action led to the creation of the AAP, thus launching an opportunity for organized professional ongoing advocacy for children’s well-being without an overriding preeminent conflict of physician economic well-being.
What do we do?
By the following decade there were 4,000 pediatricians in the US, of whom half limited their practice to pediatrics. Somewhat less than half of pediatric practice then was well-care visits. Today there are nearly 60,000 general pediatricians (1 per 1,200-1,500 children aged <21 years), 4,000 medicine/pediatrics practitioners, and 20,000 pediatric subspecialists. In general pediatric practice, it is estimated 30% of our visits are well care, 55% acute care and 10% are chronic care.
While attention has appropriately focused on the changing nature of morbidity in pediatrics over the last few decades, do not forget that acute general pediatric care (and, of course, chronic care and mental health care) takes place in our offices in a longitudinal or continuous care context – something our current public health colleagues often fail to recognize.
The generation of pediatricians that defined modern pediatric primary care were 21st century public health practitioners with the hearts of 20th century general pediatricians, and perhaps, we need a return of those “innocent times” today.
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- William T. Gerson, MD, is clinical professor of pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.