AAFP constructs definitions related to primary care

American Family Physician,  Nov 1, 1994  by Norman B. Kahn, Jr.,  Daniel J. Ostergaard,  Bob Graham

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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.