**2. Historical perspective**

#### **2.1 How primary care developed**

Family practice, which became its own board-certified specialty in 1969, evolved from general practice, which just 20 years earlier represented 50 percent of all U. S.

#### *Primary Health Care*

physicians [1]. But specialization in the aftermath of World War II changed the ratio of generalist physicians to specialists from 80 percent of all physicians in 1930 to just 20 percent in 1969 when family practice was recognized as a specialty.

Medical care was fragmented by the 1960s among many non-generalist specialties to the point that three national groups issued three major reports—the Millis Report, the Willard Report and the Folsom Report. All strongly stated the urgent need for the primary or family physician as the backbone of personalized comprehensive medical care.

Those reports, together with a shift of federal and state funding priorities, led to new family medicine teaching programs in U. S. medical schools and hospitals. By 1990, impressive progress had been made, as shown by these markers:


Fast forward, however, to 30 years later in 2020, and we still have an acute shortage of primary care physicians in an upside-down pyramid dominated by other specialties, with fragmented care the rule. A 2010 conference sponsored by the Josiah Macy, Jr. Foundation that brought together leading experts in health policy came to this conclusion:

*The lack of a strong primary care infrastructure across the nation has had significant consequences for access, quality, continuity, and cost of care in this country. It also has had consequences for our health profession educational enterprise and the healthcare workforce, resulting in numbers and geographic distributions of primary care providers that are insufficient to meet current and projected needs … We are facing an economic situation in which the current rate of rise of medical cost is unsustainable, and this situation is exacerbated by an aging population with higher care needs and expectations. These events have created a climate in which it is necessary and appropriate to question the models of care and health professions education on which we have relied [3].*

As the shortage of primary care persists with stagnation of the primary care physician workforce, part of this growing need has been filled by the rapid growth of nurse practitioners and physician assistants, typically working in teams with primary care physicians but sometimes more independently [4].
