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Community Oriented
Primary Care
New Directions for Health
Services Delivery
Conference Proceedings
Edited by Eileen Connor and Fitzhugh MulIan
Division of Health Care Services
Institute of Medicine
NATIONAL ACADEMY PRESS
Washington, D. C. 1983
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The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to
enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy's 1863 congressional charter responsibility to be an adviser tO the federal gov-
ernment and its own initiative in identifying issues of medical care, research, and education.
Supported by the United States Public Health Service Contract No. 282-80-0043, T.O.
10, The Commonwealth Fund, and The Henry J. Kaiser Family Foundation.
Library of Congress Cataloging in Publication Data
Conference on Community Oriented Primary Care (1982:
Washington, D.C.)
Community oriented primary care.
1. Community health services Congresses.
I. Connor, Eileen. II. Mullan, Fitzhugh. III. In-
stitute of Medicine (U.S.). Division of Health
Care Services. IV. Title. {DNLM: 1. Community
health services- Congresses. 2. Delivery of health
care Congresses 3. Primary health care- Congresses.
4. Community medicine Congresses.
RA422.C6397 1982 362.1'0425
ISBN 0-309-03339-X
Available from
NATIONAL ACADEMY PRESS
2101 Constitution Ave., NW
Washington, DC 20418
Printed in the United States of America
WA 546.1 C7245}
82-25977
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COMMI'l~l'~E ON COMMUNITY ORIENTED PRIMARY CARE
JOYCE C. LASHOF, Chairman: Dean, School of Public Health, University
of California (Berkeley)
H. JACK GEIGER, Professor of Community Medicine, Center for Biomed-
ical Education, City College of New York
CLARK HANSBARGER, State Director of Health, State of West Virginia
MARGARE~r C. HEAGARTY, Director of Pediatrics, Harlem Hospital Center
SIDNEY L. KARK, Professor and Chairman, Department of Social Medicine,
Hadassah-Hebrew University School of Medicine
DONALD MADISON, Associate Professor of Social Medicine, University of
North Carolina
HANS MAUKSCH, Behavior Sciences Section, Department of Family and
Community Medicine, University of Missouri
JACK H. MEDALIE, Professor and Chairman, Department of Family Med-
icine, Case Western Reserve University
S. SCOTT OBENSHAIN, Assistant Dean of Undergraduate Medical Educa-
tion, School of Medicine, University of New Mexico
LISBETH B. SCHORR, Adjunct Professor, School of Public Health, Uni-
versity of North Carolina
SIRES R. SHANNON, Associate Professor, Community Health Nursing, Rush-
Presbyterian-St. Luke's Medical School
AARON SHIRLEY, Project Director, Jackson-Hinds Comprehensive Health
Center
FREDRICK.~. WENZEL, Executive Director, Marshf~eld Clinic
Conference Convener
FITZHUGH MULLEN, M.D., Scholar-in-Residence
Conference Staff
EILEEN CONNOR
AZORA L. IRBY
RAYMOND JARRIS
Member of the Institute of Medicine
. . .
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Preface
The Conference on Community Oriented Primary Care, held in March of
1982 under the auspices of the Institute of Medicine, represented an im-
portant historical point in the development of primary care in the United
States. Set as it was against a backdrop of 20 years of vigorous efforts to
provide more equitable health services to the entire population of the
United States, it was nonetheless firmly rooted in the realities of the 1980s.
The antecedents of the conference were several. I~rge-scale federal com-
mirment to the provision of medical care was one. That began in the 1960s
with the OEO Neighborhood Health Centers, the Children and Youth and
Maternal and Infant Care Programs, and the Migrant Health Program. It
continued in the 1970s with the authorization and growth of the National
Health Service Corps and its scholarship program. A second factor was the
reemergence of general practice medicine in the form of family practice as
called for in the Millis and Willard Reports, both published in 1966.~ The
faintly medicine movement grew apace from the sentiments that these
documents articulated. By the late 1970s some 13 percent of American
medical graduates were pursuing careers in family medicine many prac-
ticing in rural and traditionally underserved areas.
Citizens' Commission on Graduare Medical Educarion, Report, The Graduare Educarion
of Physicians, John S. Millis, Chairman (Chicago: American Medical Associarion, 1966);
Ad Hoc Committee on Educarion for Family Practice of the Council on Medical Educarion
of the American Medical Associarion Report, Meeting the Challenge of Family Practice,
William R. Willard, Chairman (Chicago: American Medical Associarion, 1960).
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V1
Preface
Finally, during the 1970s, the concept of primary care gained prominence
and acceptance as an anchor against the subspecialty drift of the major
medical disciplines. Not only was family practice included in the concept
of primary care, but general internal medicine and general pediatrics and
some elements of psychiatry and obstetrics and gynecology were included
as well. The Institute of Medicine (IOM) helped to solidify the concept
with its 1978 publication, A Manpower Policy for Primary Health Care, which
clearly defined the field and made specific policy recommendations perti-
nent to it.
All these developments had taken place in an environment of greater
community participation. From the civil rights movement of earlier years
to the consumerism of the 1970s, the role of the community and the patient
had become more prominent in the delivery of health services. Departments
of community and social medicine had grown up in medical schools, and
increasing numbers of medical students and young health professionals
. . . . . . .
soug It career opportunities in communlty-responslve practice settings.
The conference occurred at a time when the difficult economic, social,
and political circumstances of the 1980s were being experienced for the
first time in all sectors. The nation's economy was hard-pressed. Serious
cutbacks in governmental support for health care were a reality. The en-
ergetic efforts of medical schools in previous years had succeeded in pro-
ducing a vastly expanded pool of physician graduates whose availability was
unquestionable but whose ultimate place and type of practice was uncertain.
The historical trends in health service delivery, set against the political
and economic realities of 1982, provided the backdrop for the meeting.
The National Academy of Sciences supplied a small program initiation
fund that enabled the Institute of Medicine to assemble a planning com-
mittee to examine issues emerging out of these events. This group met for
2 days in June 1981 and then continued to deliberate by phone, letter, and
subcommittee meeting for the balance of the year. The planning committee
played an important role in formulating the questions for the conference
and supplying a format for the answers. They selected the term "community
oriented primary care" (COPC) over a number of other possibilities because
they felt it represented an amalgam of the main themes of their delibera-
tions. The term itself had been coined by Dr. Sidney Kark of Hadassah-
Hebrew University in Jerusalem to describe his well-established program
of training and research in the area of population medicine and primary
care. Dr. Kark, who was visiting in the United States, served as a member
of the planning committee and played an important part in framing the
concept.
The committee further agreed on two important points that shaped the
substance of the conference. The first was that, while COPC had major
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Preface
. .
V11
implications for health services delivery, its implementation would be im-
possible without education and training programs that would prepare phy-
sicians and other health providers for the demands of community practice.
Therefore, any deliberations on the subject should recognize the issues of
education as well as service. Second, there was a strong sense that the
COPC discussion should not be limited to the United States because much
could be gained from and exchanged with other nations who had undertaken
similar approaches tO the delivery of health services. Many committee mem-
bers felt that the rapid developments of the previous years in the United
States had taken place without the benefit of the experience of similar
efforts around the world. Therefore, it was decided that the conference
should attempt to incorporate representatives of community oriented pro-
grams in progress in other countries. The committee stated four goals for
the conference:
. to refine the concepts and techniques of COPC and to trace its de-
velopment in the United States in comparison with that of other nations;
. to examine the theories and practices that have been applied in COPC;
. to consider the means of incorporating the theory and practice of
COPC into the education and training of health care providers; and
. to publish and disseminate the results of this conference in order to
facilitate further developments in COPC.
In summary, the conference was intended as a forum in which the practice
of community medicine in the United States could be reassessed, codified,
and, as appropriate, redirected. This volume represents the record of that
undertaking. It is our hope that it will be of assistance to health care
practitioners, planners, and teachers in the decade to come.
And, finally, a word of thanks. Conference participants were drawn from
many walks of professional and community life in an effort tO provide broad
and varied contributions to the deliberations. Although many participants
raised their own funds to enable them to attend the conference, crucial
financial assistance for others, as well as for the undertaking as a whole,
was provided by the U.S. Public Health Service, the Commonwealth Fund,
and the Henry J. Kaiser Family Foundation. The COPC committee wishes
to thank them for their trust and their support.
FITZHUGH MULLAN
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Contents
Overview and Summary
Eileen Connor
Community Oriented Primary Care: Lessons Learned in Three
Decades
Kart W. De~schle
PART I THEORETICAL ISSUES
Community Oriented Primary Care: Meaning and Scope
Joseph H. Ahrarmson and Sidney L. Kark
The Meaning of Community Oriented Primary Care in the
American Context
H. Jack Geiger
DISCUSSANTS/9 1
David! A. Kindig
Fred Ritz
Nora Piore
Community Oriented Primary Care: An International Perspective
Rodrigo G~ewero
DISCUSSANTS/1 12
Stephen C. Joseph
Keith Bolden
1X
1
6
19
21
60
104
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x
Opportunities and Constraints for Community Oriented Primary
Care
Donald L. Madison
DISCUSSANTS/1 3 1
Litany Reyes
Karen Davis
Health Worker Roles in Community Oriented Primary Care
form Hatch and E~ger~ia Eng
DISCUSSANTS/ 1 5 8
Richard Smith
Fay W. Whitney
Medical Education and Training for Community Oriented Primary
Care
lo Ivey Boafford
DISCUSSANTS/1 90
Robert Tranq~ada
Richard Kozoll
Thoughts on Community Oriented Primary Care
David E. Rogers
PART II PRACTICAL APPLICATIONS
Promoting COPC Through a Rural Health Care Network:
Marshfield Clinic
David L. D raves
COPC in the Texas Valley
Stanley 1. Fisch
Elements of COPC in the UMWA Health and Retirement Funds
Program
George S. Goldstein
COPC and a State Health Department: West Virginia's Experience
L. Clark Hansharger
Columbia University-Harlem Hospital Primary Care Network
Margaret C. Heagarty
COPC in a Hospital-Aff~liated Health Center
Harvey A. Holzberg
Denver Health and Hospitals Experience
J. L. Karowski
Contents
119
138
167
198
207
209
214
217
222
225
227
230
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Contents
Partnership for Health: The Family Nurse Practitioner/Family
Physician Tearn
Mary O'Hara Devereaz~x
The Patient Advisory Council Concept
Milton H. Seifert, Jr.
The Application of COPC Principles in a Welsh Mining Village
Graham Watt
Training for COPC in the Netherlands and Around the World
Jacoloas M. Greep
Can Area Health Education Centers Promote COPC?
The Colorado Experience
Karen F. Hansen
Departments of Family Practice as Vehicles for Promoting COPC
Thomas M. Mettee and Jack H. Medalie
New Mexico's Primary Care Curriculum
S. Scott Oloenshain
The Beersheva Experience in COPC
Archer Segall, Carmi Margolis, and Moshe Prywes
The Upper Peninsula Medical Education Program
Daniel S. Mazz~chi and W. Donald Weston
PART III WORKSHOP DISCUSSION SUMMARIES
X1
234
239
243
250
258
264
269
272
276
281
Workshop A DeWitt C. Baldwin, Jr. 283
Workshop B Janice Robinson 285
Workshop C Patrick Mattingly 287
Workshop D Lisbeth Schow 289
Workshop E Robert S. Lawrence 291
Participants 293
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Community Oriented
Primary Care
New Directions for Health
Services Delivery
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