Primary care at a crossroads.

The author explains why primary care is especially beleaguered today (e.g., growth in specialization and widening income gaps between specialists and generalists, growth of managed care, cutbacks in Medicare and Medicaid payments to academic medical centers, and pro-technology biases in fee-for-service payment). Medical students sense primary care's troubles; primary care residency matches continue to decline. Attempts to encourage generalist practice cannot compete with such forces as pro-specialist reimbursement policies, the way research is funded, the dominance of specialist role models, and the daunting knowledge demands of the generalist mandate. Can generalists find a niche in the current health care marketplace? How will the under-65 population influence the future of primary care practice? (The author predicts a scenario based on patients' degrees of affluence.) Will consumers be willing to pay for the services that primary care is uniquely well positioned to offer? The author explains why increasingly important issues of cost, quality, and convenience could help create a niche for primary care. He also maintains that academic medicine must rededicate itself to producing well-trained generalists, despite all the pressures not to, and discusses the challenges that family practice, internal medicine, and pediatrics must face if they are to flourish. He concludes that if generalism fails the market test, something very precious will be lost-and that generalist physicians would be so badly missed that they might have to be reinvented.