The four community dimensions of primary care practice

Despite the growing belief that "the community" should play a larger role in the work of physicians, there is no clear understanding of exactly how physicians should participate in their communities. The primary goals of this study were to propose and test an organizing framework that identified four distinct categories of activities whereby physicians can interact with their communities: (1) identifying and intervening in the community's health problems; (2) responding to the particular health issues of local cultural groups when caring for patients; (3) coordinating local community health resources in the care of patients; and (4) assimilating into the community and its organizations. Other goals were to characterize physicians' level of involvement in each of these four types of community activities, and to identify the correlates of greater and lesser involvement.

A questionnaire was mailed to a random sample of 500 young primary care physicians in the United States. The response rate was 66.6%. Physicians reported how confident they were in performing each of 15 specific community-relevant activities. Confidence ratings were factor-analyzed to test the hypothesis that physician involvement in community activities can be organized into the four proposed categories. Physicians also self-rated their involvement in various community activities within each of these four categories, and predictors of involvement were identified through ordinary least-squares regression models.

Using factor analysis, the community activities sorted cleanly into the four postulated community dimensions of medical practice, providing a measure of validation for the distinctiveness of the four dimensions. Physicians reported active involvement in some activities (eg, speaking to community groups and gaining acceptance in their communities) and little involvement in other activities (eg, working with community groups to address local health problems, familiarity with local women's shelters). Contrary to expectations, physicians who worked with minority and poorer patient populations and counties generally reported less community involvement. Physicians caring for more patients covered by HMO or capitated health insurance plans also reported lower participation in their communities.

This study provides support for the hypothesis that the community plays a role in the work of physicians that can be categorized into four types of activities. This framework may help physicians and practices recognize the breadth of ways they can meet the growing demand that they approach their work with a community perspective.