Primary care: questions raised by a definition

In Defining Primary Care: An Interim Report, the Institute of Medicine offers a set of attributes for primary care that raise many unresolved empirical and philosophical questions. For instance, the "integrated nature" of primary care immediately challenges the validity of the content of research in primary care using data such as ICD-9 codes, which, by nature, reduce patients to disaggregated sets of problems rather than coherent wholes. Likewise, considering accessibility as a hallmark of primary care focuses attention on how health care is organized, and whether depending on primary care-trained professionals as the necessary or ideal first point of access might be a deterrent to the delivery of optimal care among some populations. Primary care clinicians should and will be held accountable for achieving the attributes of practice that make primary care unique. This paper provides a detailed examination of the Institute's definition, and identifies many aspects that require additional thought and research before these attributes can be applied as criteria for the evaluation of primary care practice.