Annals of Family Medicine -- Comments for Grumbach et al., 1 (2) 97-104

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Original Research:
Kevin Grumbach, L. Gary Hart, Elizabeth Mertz, Janet Coffman, and Lorella Palazzo
Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
Ann Fam Med 2003; 1: 97-104 [Abstract] [Full text] [PDF]

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Electronic letters published:

The underserved need all the help they can get!: Howard K. Rabinowitz (30 July 2003)

Caring for the under-served: who, when and where?: Roger A Rosenblatt (29 July 2003)

The underserved need all the help they can get! 30 July 2003

Howard K. Rabinowitz,
family physician
Jefferson Medical College
Send response to journal:
Re: The underserved need all the help they can get!

This is an excellent study. It clearly shows that irrespective of the definition of underserved which is used, family physicians and nonphysician primary care providers take care of a disproportionate share of these populations. Prior research has also shown that these outcomes can be increased even further through programs that provide preferential admissions (for special characteristics such as rural background), clinical experiences, and financial and practice support. Taken together, I agree with Roger Rosenblatt that there is more than enough ‘evidence’ about what to do in order to better address this problem.
This study also makes it clear that no single discipline is going to be able to solve this problem by itself. Those who are underserved need all the help they can get – from all types of primary care providers! And primary care providers will have more clout if they address these issues cooperatively.
Competing interests: None declared

Caring for the under-served: who, when and where? 29 July 2003

Roger A Rosenblatt,
family physician
University of Washington
Send response to journal:
Re: Caring for the under-served: who, when and where?

One reason that the under-served are under-served is that most clinicians practice in urban areas near insured patients. As Grumbach and his collaborators show, about 13% of Californians and 24% of Washingtonians live in rural areas of their states, but pediatricians, internists and obstetricians work in cities, for the most part. Only family physicians and especially physician assistants are consistently more likely to settle in rural areas than general members of the population at large.
The most fascinating part of this article in my opinion is the extent to which physician assistants have distributed themselves in under-served locations. This is a case where an entire profession was created largely around the need to augment the supply of health professionals to under-served populations – and it worked! Family physicians and nurse practitioners have also followed this pattern, fulfilling the expectation of those who sparked these programs. We can affect the distribution of health professionals, and we can do it with the programs that we have built and sustained over the last 30 years.
So the question is why don't we do more of it? Given the failure of attempts to craft universal health insurance, health professional interventions are relatively inexpensive ways to affect access to health care. Although Grumbach's evidence is indirect, it certainly suggests that we do know how to make a difference. So let's do more of it!
Competing interests: None declared