Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad army of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.[2] Wagner and colleagues[3] believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.