The “Policy Center One-Pager” published in this issue1 contains take-home lessons for family physicians and challenges for policy makers. The study cited in the report found that children and adults with a usual source of care were more likely to have received preventive services, compared with patients who do not have a usual source of care. In addition, adults seeing an internist were more likely to receive these services than adults seeing a family physician. There are a number of potential reasons for these differences, but two implications of the findings are particularly worth considering.
First, the data appear to validate the importance of developing a relationship with a generalist clinician to obtain preventive services. Specific aspects of the relationship affect the delivery of different types of services.2–4 If the context of a physician-patient relationship is vital for delivery of relatively routine preventive services, it is even more important for care of chronic illnesses, recognition of mental health problems and guiding access to appropriate subspecialty care.5,6 However, the relationship context for the commodities of health care is being disrupted in the current health care environment, with detrimental consequences to the quality of patients' care.7,8 In addition, for the more than 44 million Americans who do not have access to regular medical care because of a lack of insurance, ongoing health care relationships are scarce and preventive care remains a largely unmet need.9,10
The services listed in the “One-Pager,”1 with the exception of prostate cancer screening and perhaps the general medical examination, are well-supported by scientific evidence and are generally well-accepted by patients.11 Therefore, regardless of the difficulties in maintaining ongoing patient-physician relationships, these services should be routinely available to all people. Yet, because of the competing demands and opportunities to meet a broad array of patient needs in family practice,12 physicians often have little time left for prevention after other needs are met.13
Involving nurses and office staff in systems for identifying patients eligible for these routine services and delivering services is effective.14 Outreach to patients who do not visit the office routinely is another important strategy and is a potentially valuable role for managed care organizations.15 Developing systems and team approaches can free up physicians to selectively deliver more intensive preventive services to high-risk patients or to take advantage of teachable moments that are linked to risk factors and illness presentations.3,16 The higher rates of preventive service delivery by internists are a reminder of the need to ensure routine delivery of important services that don't make it onto the agenda of the broad and more time-limited family practice visit.
All Americans deserve a relationship with a primary care physician. We need to design a health care system that fosters this relationship. We also need to design our practices so that the aspects of care that particularly benefit from a relationship are facilitated by well-established routines.