THE GENERALIST ROLE OF SPECIALTY PHYSICIANS - IS THERE A HIDDEN SYSTEM OF PRIMARY-CARE

Context.-Despite increased emphasis on primary care in the United Stat es, most care continues to be provided by specialists. The extent to w hich specialists incorporate elements of primary care in their approac h to ambulatory patients is unknown. Objectives.-To examine the extent to which selected medical and surgical subspecialties provide general ist care to Medicare patients, and to compare patterns of care between specialists and generalists. Design.-A cross-sectional study of all a mbulatory care recorded in Part B of the Washington State Medicare Cla ims Database in 1994 and 1995. Setting.-Ambulatory practices in Washin gton State. Patients.-Medicare beneficiaries 65 years or older who mad e office visits to the study physicians. Main Outcome Measures.-The ex tent to which individual specialties accounted for the majority of vis its made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization. Results.-A to tal of 373 505 patients constituted the sample. Patients had an averag e of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and f amily physicians differ systematically from the practices of most spec ialists. Approximately half (49.8%) of all ambulatory visits to genera l internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medica l specialist and 11.7% of surgical specialist visits. The rate of infl uenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6 % from surgical specialists. Pulmonologists, general surgeons, and gyn ecologists were more likely than other specialists to provide services outside their specialty. Conclusions.-Most specialists do not assume the principal care responsibility for elderly patients, although a sub stantial proportion of patients see only specialists for their care. S elected specialties assume the generalist role more often, particularl y when they provide the majority of outpatient care for an individual patient.