AAFP constructs definitions related to primary care – American Academy of Family Physicians – includes definitions

AAFP constructs definitions related to primary care – American Academy of Family Physicians – includes definitions – Editorial

Norman B. Kahn, Jr.

The American Academy of Family Physicians first carved a definition of primary care in 1975, and that definition served the discipline well for a decade and a half. With the national focus on the issue of health care reform, the political ramifications of the definition of primary care have created much controversy over what constitutes primary care.

Without a generally accepted definition of primary care, many groups, physicians and nonphysicians alike, have attempted to capitalize on the potential political benefit of being identified as a primary care provider or perceived as a health care provider who incorporates primary care services into their scope of practice.

As Rodney described in a recent AFP “Medicine and Society” essay,[1] everyone seems to be scurrying to the front of the line to position themselves to get whatever is being doled out. If primary care becomes a qualification for receipt of federal training funds, for example, a rational definition of primary care that will stand the test of politics is needed.

Many have attempted to define primary care since White’s landmark article in 1961, “The Ecology of Medical Care,” and his later papers that called attention to the need for primary medical care.[2-4] Millis, in his 1966 report,[5] “The Graduate Education of Physicians,” suggested use of the term “primary physician,” whose role was to provide” comprehensive and continuing health care, including not only diagnosis and treatment of illness, but also its prevention and … supportive and rehabilitative care.” Such a physician would “serve as the primary medical resource” and also fill a coordination role. The concept of first contact was included in Mills’ definition.

Alpert followed with a definition drawing from the contributions of others,[6] Alpert’s definition focused on personal health rather than public health, distinguished “first contact” care from secondary and tertiary care based on referral, and included longitudinal responsibility in health as well as disease. Importantly, Alpert’s definition did not limit primary care to the ambulatory setting; he saw the primary care provider as the coordinator of health services.

In 1978 the Institute of Medicine published its definition of primary care.[7] Five essential attributes of primary care were identified: accessibility, comprehensiveness, coordination, continuity and accountability.

The 1992 report[8] of the federal Council of Graduate Medical Education on improving access to health care characterized primary care as first contact care for individuals with undifferentiated health concerns, comprehensive care that is not organ- or problem-specific, longitudinal care of the patient and coordinated care. The report further suggested that physicians providing primary medical care should possess the competencies of health promotion, disease prevention, assessment/evaluation of common symptoms and signs, management of common acute and chronic medical conditions, and identification and appropriate referral for other needed health care services.

Recently, Rivo and colleagues[9] defined the primary care physician on the basis of elements required in various training programs. Their definition includes the following characteristics: care for a broad spectrum of the population, care for patients in multiple settings, provision of comprehensive preventive care, treatment of common acute illnesses, and provision of continuous and coordinated care for common chronic conditions and behavioral problems.

Definitions of primary care, primary care practice, primary care physician and limited primary care provider, as given in the boxed text, were adopted by the 1994 AAFP Congress of Delegates, convened at the AAFP annual meeting in September 1994. By developing definitions for these four terms, the AAFP hopes to accomplish the following: (1) determine, outside the political arena, which attributes of health care are considered “primary”; (2) define how the delivery system delivers primary care to people; (3) delimit physicians who are trained, are experienced and receive continuing education in the practice of primary care from those physicians who hope to capitalize on identification under the political primary care umbrella by calling themselves primary care physicians and (4) acknowledge that physicians other than those who by specialty are primary care physicians may incorporate limited aspects of primary care into their scopes of practice. The AAFP also recognizes that many physician assistants and nurse practitioners provide some services in the domain of primary care, although their scope of practice is limited compared to that of a primary care physician.

AAFP Definitions Related to Primary Care

Preamble

In defining primary care, it is necessary to describe the nature of services provided to patients, as well as to identify who are the primary care providers. The domain of primary care includes the primary care physician, other physicians who include some primary care services in their practices, and some nonphysician providers. (In this document, the term physician,, refers only to doctors of medicine and osteopathy.) However, central to the concept of primary care is the patient. Therefore, such definitions are incomplete without including a description of the primary care practice.

The following four definitions relating to primary care should be taken together. They describe the care provided to the patient, the system of providing such care, the types of physicians whose role in the system is to provide primary care, and the role of other physicians, and nonphysicians, in providing such care. Taken together, they form a framework within which patients will have access to efficient and effective primary care services of the highest quality.

Definition of primary care

Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral or social), organ system, gender or diagnosis.

Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician, utilizing other health professionals, consultation and/or referral as appropriate.

Primary care provides patient advocacy in the health care system to accomplish cost effective care by coordination of health care services. Primary care promotes effective doctor-patient communication and encourages the role of the patient as a partner in health care.

Definition of primary care practice

A primary care practice serves as the patient,s first point of entry into the health care system and as the continuing focal point for all needed health care services. Primary care practices provide patients with ready access to their own personal physician, or to an established back-up physician when the primary physician is not available.

Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long@term care, home care, day care, etc.).

Primary care practices are organized to meet the needs of patients with undifferentiated problems, with the vast majority of patient concerns and needs being cared for in the primary care practice itself. Primary care practices are generally located in the community of the patients, thereby facilitating access to health care while maintaining a wide variety of specialty and institutional consultative and referral relationships for specific care needs. The structure of the primary care practice may include a team of physicians and nonphysician health professionals.

Definition of primary care physician

A primary care physician is a generalist physician who provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for providing the patients care. Such a physician must be specifically trained to provide primary care services.

Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient,s medical and health care needs – not limited by problem origin, organ system, gender or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.

Definition of limited primary care providers

Individuals who are not trained in the primary care specialties of family medicine, general internal medicine or general pediatrics will sometimes provide limited patient care services within the domain of primary care. These limited primary care providers may be physicians from nonprimary care specialties. Such providers may also include nurse practitioners, physician assistants or other health care providers. Limited primary care providers may focus on specific patient care needs related to prevention, health maintenance, acute care, chronic care or rehabilitation.

The contributions of limited primary care providers may be important to specific patient needs. However, the absence of a full scope of training in primary care requires that these individuals work in close consultation with fully trained primary care physicians. An effective system of primary care may use limited primary care providers as members of the health care team with a primary care physician maintaining responsibility for the function of the health care team and the comprehensive health care of each patient.

REFERENCES

[1.] Rodney WM. Health care reform; does primary care mean, “whoever gets there first”? Am Fam Physician 1994;50:297-300. [2.] White KL, William TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-92. [3.]White KL. General practice in the United States. J Med Educ 1964;39:333-45. [4.] White KL. Primary medical care for families – organization and evaluation. N Engl J Med 1967;277:847-52. [5.] Council on Medical Education and Hospitals. The graduate education of physicians, the report of the Citizens Commission on Graduate Medical Education. Chicago: American Medical Association, 1966. [6.] Alpert JL. New directions in medical education: primary care. In: Purcell EF, ed. Recent trends in medical education. New York: Josiah Macy, Jr. Foundation, 1976:166. [7.] A manpower policy for primary health care: report of a study. Washington, D.C.: National Academy of Sciences, 1978:16-26. [8.] Improving access to health care through physician workforce reform: directions for the 21st century: changing the physician supply, increasing minority representation in medicine, reforming medical education. Third report of the Council on Graduate Medical Education. Washington, D.C.: Dept. of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1992. [9.] Rivo ML, Saultz JW, Wartman SA, Dewitt TG. Defining the generalist physician’s training. JAMA 1994;271:1499-504.

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