The generalist role of specialty physicians: is there a hidden system of primary care?

CONTEXT Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown. OBJECTIVES To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists. DESIGN A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995. SETTING Ambulatory practices in Washington State. PATIENTS Medicare beneficiaries 65 years or older who made office visits to the study physicians. MAIN OUTCOME MEASURES The extent to which individual specialties accounted for the majority of visits 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 total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza 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 gynecologists 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 substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient.