Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
============================================================================

* Kurt C. Stange

Key words:
*   physicians, family
*   primary health care
*   personal physician
*   counterculture
*   revolution
*   love

It is time for family medicine to stop enabling a dysfunctional health care system.

The patient needs that family physicians witness and strive to meet each day are immediate and personal.1 That immediacy, and directly knowing the individuals, families, and communities we serve over time, have impelled us to continue to do whatever it takes to be a force for integration in a disintegrating system.2

But in doing whatever it takes, we have enabled the larger system’s avarice and depersonalization to grow. We have unintentionally become part of the problem by holding together an unsustainable, unfair, and too often ineffective system.3 Every day we witness the needs of people we are no longer able to help, as we crank patients through and tick boxes to meet so-called productivity and quality metrics. This is a perfect recipe for the burnout, moral distress, and depersonalization that are rampant among clinicians, staff members, and patients.4-6

We can’t do it anymore.7-10 We are burned out, not as much by overwork as by under value—stuck in a system that asks us to meet business goals first and patient needs with what time and energy is left over. We are like the hobbled parent, a step too slow to rescue her child from running into the busy street. We are the line worker, dutifully tightening a couple bolts on a jalopy when we are trained and motivated to lead teams building Ferraris. We are the unreplenished main course of a buffet in which the dessert side of the table has been so oversupplied that most diners are left starving while a few grow corpulent.

Our hallowed role as the front door for people seeking health, healing, and connection11 has been relegated to the position of weathered doormats for a system bent on optimizing its ability to deliver and be paid for commodities.12,13 But as was pointed out by a recent National Academies report, primary care is a common good that benefits and is deserved by everyone.14 The health it seeks to foster fundamentally emerges from relationships.15-27 Our system has lost the thread of connected, personalized care because it has not invested in supporting family physicians who provide the majority of the care that people need.28 It has not invested in or prioritized the relationship bank of the personal physician that can be drawn upon with interest when the chips are down.29,30

The many well-intentioned patches designed to improve primary care have added untenable administrative burden,9,10 made care less available and less open to the patient’s agenda,31 and have diminished and demoralized the workforce.32 How ironic is it that we take the most complex task in medicine—integrating, personalizing, and prioritizing care for whole people—try to cram it into 10 minutes, and pay those doing this work less than those providing narrow technical care?

What if we stop asking an insufficiently sized and undersupported primary care workforce33,34 to assume the responsibility of holding together a fragmented and failing health system? What if, rather than just providing the easiest, simplest medical services for all Americans, we focus family medicine on delivering the highest quality personal doctoring for the number of people for whom that is feasible,35 and let the resulting growing demand drive the needed systemic changes?

What if, for the moment, we worry less about the number of people we are training and more about the situations in which they will be practicing? What if we offer care that is so personal and effective in advancing health, healing, and connection that students clamor and compete to enter our training programs—care for which patients create such demand that payments to generalist personal physicians began to exceed those to narrowly focused technical providers? What if we make urgent care unnecessary for our patients, and emergency and hospital services a rarely used but well-integrated part of care? What if we show that a recent call for a new specialty for patients with perplexing conditions36 is unnecessary if people have a personal family physician who knows and cares for them over time in their family and community context?

Now is the time to invest in developing primary care that is able to serve as the foundation of an effective, sustainable, and fair health care system.

Accessible personal doctoring by well-trained, well-supported family physicians with reasonable panel sizes would create demand among patients, health care systems, and medical students for the thing we actually most value—care in the context of ongoing relationships with a person who has earned our trust.37,38 The market, which currently is driving fragmentation and low-value expenditure, would then be disrupted toward supporting and expanding the short supply of family physicians offering personal doctoring.

Re-energizing the internal motivations and professionalism that have been co-opted by external command and control metrics21 would begin to unknot the tangled problems of burnout and low student interest.39 It would enable on-the-ground action to personalize care for the disadvantaged and provide time with patients to address the social and environmental drivers of health that also require complementary systemic solutions.

Some, by necessity or choice, will need to keep working in dysfunctional systems. As a transitional phase, some will need to continue in the current protocol-driven primary care system, even as a growing number of others show the benefits of more sophisticated primary care. But the more family physicians who insist on and create practice situations that support them in using their full skills to meet the needs of their patients and communities, the more people will see that having a personal physician is not a dream from the past but a reality for today and a feasible foundation for a functional health care system of tomorrow. The more of us that can work in practices and systems that allow our “family doctorness” to shine, the sooner we’ll reach a tipping point in which the high-level generalist personal doctor becomes the valued norm for nearly everyone.40

We already see glimmers of possibility for re-energizing the role of the personal family physician in the actions of direct primary care physicians who care for mixed panels of working poor and more-advantaged patients, charging an accessible monthly subscription fee to assure all primary care for panels of around 500 patients.41-44 We see the systemic possibilities in physician-led accountable care organizations that have improved quality and controlled costs by investing in on-the-ground knowing and relationships and use that capital to selectively contract for targeted use of more specialized services.45,46 We see hope in the eyes of a new generation that wants to model in their own lives the fairness, balance, and health they seek for their patients.

When *Annals of Family Medicine* was launched two decades ago47,48 as an unprecedented collaborative forum,49 the discipline believed that we should strive to prepare one-half the health care workforce that would provide a “basket of services” for a “New Model of practice.”50-52 Embedding that experiment in a system that knows how to take, but not to give, doomed it to failure. We now have the opportunity to move from a broken system, that supports us only in providing commodified services, toward a system that values and invests in healing and health-promoting relationships with our patients and communities. By refusing to enable our dying system, we can plant the seeds for the rebirth of health care that starts with the whole person and then focuses on the parts only in the context of knowing and connectedness.30,53,54 We can show that the personal doctoring that fosters health and healing is possible. This is not a pipe dream. We can be the change we wish to see.

## Acknowledgments

I am grateful to Olivia Dhaliwal, Rebecca Etz, Robin Gotler, Larry Green, and Will Miller who provided very helpful comments on an earlier version of this editorial. I appreciate the many valiant family physicians and other primary care clinicians who swim upstream every day against a system that makes it so challenging to use their skills to make a difference in peoples’ lives. I am grateful for the support of the University Suburban Health Foundation Wisdom of Practice Initiative and a Distinguished Scholar fellowship from the American Board of Family Medicine Foundation.

I appreciate the invitation from the *Annals of Family Medicine* editorial team to write an editorial as part of their celebration of the *Annals of Family Medicine’s* 20th anniversary. And I am grateful to the vision of the leaders who birthed *Annals*, and gave someone who originally had no desire to be an editor (me) a chance to serve in that role for 17 years. I am thankful for the continued support of the sponsoring organizations, editorial and publishing teams, and contributors who have made *Annals of Family Medicine* a forum for the knowledge we need49 to support the kind of personal doctoring espoused in this editorial.

## Footnotes

*   Conflicts of interest: author reports none.

*   [Read or post commentaries in response to this article](https://www.annfammed.org/content/21/3/202/tab-e-letters).

*   Received for publication March 4, 2023.
*   Revision received March 4, 2023.
*   Accepted for publication March 22, 2023.


*   © 2023 Annals of Family Medicine, Inc.

## REFERENCES

1.  1.Stange KC. The generalist approach. Ann Fam Med. 2009; 7(3): 198-203. doi:10.1370/afm.1003
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8zLzE5OCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2.Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009; 7(2): 100-103. doi:10.1370/afm.971
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8yLzEwMCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  3.Tikkanen R, Abrams MKUS. U.S. health care from a global perspective, 2019: higher spending, worse outcomes? Commonwealth Fund. Published Jan 30, 2020. Accessed Mar 4, 2023. [https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019](https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019)
    
    

4.  4.Edwards ST, Marino M, Balasubramanian BA, et al. Burnout among physicians, advanced practice clinicians and staff in smaller primary care practices. J Gen Intern Med. 2018; 33(12): 2138-2146. doi:10.1007/s11606-018-4679-0
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1007/s11606-018-4679-0&link_type=DOI) 

5.  5.Hartzband P, Groopman J. Physician burnout, interrupted. N Engl J Med. 2020; 382(26): 2485-2487. doi:10.1056/NEJMp2003149
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJMp2003149&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=32356624&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 

6.  6.The Larry A. Green Center. Quick COVID-19 primary care patient survey. Accessed Mar 1, 2023. [https://www.green-center.org/covid-survey/](https://www.green-center.org/covid-survey/)
    
    

7.  7.Miller WL. The impending collapse of primary care: when is someone going to notice? J Am Board Fam Med. 2022; 35(6): 1183-1186. doi:10.3122/jabfm.2022.220145R2
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.3122/jabfm.2022.220145R2&link_type=DOI) 

8.  8.Hoff TJ. Searching for the Family Doctor: Primary Care on the Brink. John Hopkins University Press; 2022.
    
    

9.  9.Bujold E. When practice transformation impedes practice improvement. Ann Fam Med. 2015; 13(3): 273-275. doi:10.1370/afm.1789
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMy8yNzMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. 10.Bujold E. The impending death of the patient-centered medical home. JAMA Intern Med. 2017; 177(11): 1559-1560. doi:10.1001/jamainternmed.2017.4651
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jamainternmed.2017.4651&link_type=DOI) 

11. 11.Etz R, Miller WL, Stange KC. Simple rules that guide generalist and specialist care. Fam Med. 2021; 53(8): 697-700. doi:10.22454/FamMed.2021.463594
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.22454/FamMed.2021.463594&link_type=DOI) 

12. 12.Stange KC, Gaglioti AH, Bindas JP. Integrated, personalized care for older people. Journal of Elder Policy. 2022; 2(2): 23-78. doi:10.18278/jep.2.2.2
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.18278/jep.2.2.2&link_type=DOI) 

13. 13.Heath I. Patients are not commodities. BMJ. 2006; 332(7545): 846-847. doi:10.1136/bmj.332.7545.846
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMzIvNzU0NS84NDYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. 14.National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. The National Academies Press; 2021.
    
    

15. 15.Stange KC. Holding on and letting go: a perspective from the Keystone IV conference. J Am Board Fam Med. 2016; 29(Suppl 1): S32-S39. doi:10.3122/jabfm.2016.S1.150406roches
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTk6IjI5L1N1cHBsZW1lbnRfMS9TMzIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

16. 16.Miller WL. Unfilled hunger: seeking relationships in primary care–a perspective from the Keystone IV Conference. J Am Board Fam Med. 2016; 29(Suppl 1): S19-S23. doi:10.3122/jabfm.2016.S1.150405
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTk6IjI5L1N1cHBsZW1lbnRfMS9TMTkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

17. 17.Green LA, Puffer JC. Reimagining our relationships with patients: a perspective from the Keystone IV Conference. J Am Board Fam Med. 2016; 29(Suppl 1): S1-S11. doi:10.3122/jabfm.2016.S1.160152
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTg6IjI5L1N1cHBsZW1lbnRfMS9TMSI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

18. 18.DeVoe JE, Barnes K, Morris C, et al. The personal doctoring manifesto: a perspective from the Keystone IV conference. J Am Board Fam Med. 2016; 29(Suppl 1): S64-S68. doi:10.3122/jabfm.2016.S1.160012
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTk6IjI5L1N1cHBsZW1lbnRfMS9TNjQiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

19. 19.Colwill JM, Frey JJ, Baird MA, Kirk JW, Rosser WW. Patient relationships and the personal physician in tomorrow’s health system: a perspective from the Keystone IV Conference. J Am Board Fam Med. 2016; 29(Suppl 1): S54-S59. doi:10.3122/jabfm.2016.S1.160017
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTk6IjI5L1N1cHBsZW1lbnRfMS9TNTQiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

20. 20.Bazemore A, Petterson S, Peterson LE, Phillips RL Jr. More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations. Ann Fam Med. 2015; 13(3): 206-213. doi:10.1370/afm.1787
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMy8yMDYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

21. 21.Stange KC, Etz RS, Gullett H, et al. Metrics for assessing improvements in primary health care. Annu Rev Public Health. 2014; 35: 423-442. doi:10.1146/annurev-publhealth-032013-182438
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1146/annurev-publhealth-032013-182438&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=24641561&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000336207500025&link_type=ISI) 

22. 22.Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005; 3(2): 159-166. doi:10.1370/afm.285
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy8yLzE1OSI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

23. 23.Mainous AG III., Goodwin MA, Stange KC. Patient-physician shared experiences and value patients place on continuity of care. Ann Fam Med. 2004; 2(5): 452-454. doi:10.1370/afm.84
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi81LzQ1MiI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

24. 24.Loxterkamp D. A vow of connectedness: views from the road to Beaver’s farm. Fam Med. 2001; 33(4): 244-247.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=11322515&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 

25. 25.Heath I. The Mystery of General Practice. Nuffield Provincial Hospitals Trust; 1995.
    
    

26. 26.Hsu C, Phillips WR, Sherman KJ, Hawkes R, Cherkin DC. Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff. Ann Fam Med. 2008; 6(4): 307-314. doi:10.1370/afm.838
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNi80LzMwNyI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

27. 27.Scott JG, Cohen D, Dicicco-Bloom B, Miller WL, Stange KC, Crabtree BF. Understanding healing relationships in primary care. Ann Fam Med. 2008; 6(4): 315-322. doi:10.1370/afm.860
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNi80LzMxNSI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

28. 28.Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001; 344(26): 2021-2025. doi:10.1056/NEJM200106283442611
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJM200106283442611&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=11430334&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000169508200011&link_type=ISI) 

29. 29.Stange KC, Etz RS, Miller WL. The role of primary care in improving population health. Milbank Quarterly. 2023; (in press for special issue on the future of population health).
    
    

30. 30.Stange KC. A science of connectedness. Ann Fam Med. 2009; 7(5): 387-395. doi:10.1370/afm.990
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy81LzM4NyI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

31. 31.Tarn DM, Wenger NS, Stange KC. Small solutions for primary care are part of a larger problem. Ann Intern Med. 2022; 175(8): 1179-1180. doi:10.7326/M21-4509
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.7326/M21-4509&link_type=DOI) 

32. 32.The Larry A. Green Center. Quick COVID-19 survey. Accessed Feb 28, 2023. [https://www.green-center.org/covid-survey](https://www.green-center.org/covid-survey)
    
    

33. 33.Bazemore A, Wilkinson E, Petterson S, Green LA. Proportional erosion of the primary care physician workforce has continued since 2010. Am Fam Physician. 2019; 100(4): 211-212.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=31414781&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 

34. 34.National Center for Health Workforce Analysis. National and Regional Projections of Supply and Demand for Primary Care Practicionters: 2013-2025. US Deparatment of Health and Human Services, Health Resources and Services Administration; 2016.
    
    

35. 35.Raffoul M, Moore M, Kamerow D, Bazemore A. A primary care panel size of 2500 is neither accurate nor reasonable. J Am Board Fam Med. 2016; 29(4): 496-499. doi:10.3122/jabfm.2016.04.150317
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjkvNC80OTYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

36. 36.Geng LN, Verghese A, Tilburt JC. Consultative medicine - an emerging specialty for patients with perplexing conditions. N Engl J Med. 2021; 385(26): 2478-2484. doi:10.1056/NEJMms2111017
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJMms2111017&link_type=DOI) 

37. 37.Etz RS, Zyzanski SJ, Gonzalez MM, Reves SR, O’Neal JP, Stange KC. A new comprehensive measure of high-value aspects of primary care. Ann Fam Med. 2019; 17(3): 221-230. doi:10.1370/afm.2393
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTcvMy8yMjEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

38. 38.Starfield III Summit. STARFIELD III: Meaningful Measures for Primary Care. Accessed Mar 1, 2023. [https://www.starfieldsummit.com/starfield3/](https://www.starfieldsummit.com/starfield3/)
    
    

39. 39.Phillips RL Jr. The built environment for professionalism. J Am Board Fam Med. 2020; 33(Suppl): S57-S61. doi:10.3122/jabfm.2020.S1.190441
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTc6IjMzL1N1cHBsZW1lbnQvUzU3IjtzOjQ6ImF0b20iO3M6MjM6Ii9hbm5hbHNmbS8yMS8zLzIwMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

40. 40.Stange KC, Ferrer RL, Miller WL. Making sense of health care transformation as adaptive-renewal cycles. Ann Fam Med. 2009; 7(6): 484-487. doi:10.1370/afm.1032
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy82LzQ4NCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

41. 41.Brekke G, Onge JS, Kimminau K, Ellis S. Direct primary care: family physician perceptions of a growing model. Popul Med. 2021; 3: 21. doi:10.18332/popmed/140087
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.18332/popmed/140087&link_type=DOI) 

42. 42.Brusch F, Grzeskowiak D, Huth E. Direct Primary Care: Evaluating a New Model of Delivery and Financing. Society of Actuaries; 2020. [https://www.soa.org/resources/research-reports/2020/direct-primary-care-eval-model/](https://www.soa.org/resources/research-reports/2020/direct-primary-care-eval-model/)
    
    

43. 43.Direct Primary Care Alliance - Home. [https://dpcalliance.org/](https://dpcalliance.org/)
    
    

44. 44.Direct Primary Care Coalition. Accessed Feb 9, 2023. [https://www.dpcare.org/](https://www.dpcare.org/)
    
    

45. 45.McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME. Medicare spending after 3 years of the Medicare Shared Savings Program. N Engl J Med. 2018; 379(12): 1139-1149. doi:10.1056/NEJMsa1803388
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJMsa1803388&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=30183495&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 

46. 46.McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early performance of accountable care organizations in Medicare. N Engl J Med. 2016; 374(24): 2357-2366. doi:10.1056/NEJMsa1600142
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1056/NEJMsa1600142&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=27075832&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 

47. 47.Stange KC, Phillips WR, Acheson LS, et al. Welcome to the *Annals of Family Medicine*. Ann Fam Med. 2003; 1(1): 2-4. doi:10.1370/afm.46
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NToiMS8xLzIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

48. 48.Stange KC. The first 20 days. Ann Fam Med. 2003; 1(2): 119-120.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMS8yLzExOSI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

49. 49.Stange KC. Forces for integration. Ann Fam Med. 2018; 16(3): 192-194. doi:10.1370/afm.2245
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTYvMy8xOTIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

50. 50.Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004; 2(Suppl 1): S3-S32. doi:10.1370/afm.130
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6MTI6IjIvc3VwcGxfMS9zMyI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

51. 51.Stange KC. The future of family medicine? Reflections from the front lines reveal frustration and opportunity. Ann Fam Med. 2004; 2(3): 274-277. doi:10.1370/afm.201
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi8zLzI3NCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjEvMy8yMDIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

52. 52.Task Force 1 Writing Group, Green LA, Graham R, Bagley B, Kilo C, Spann S, Bogdewic SP, Swanson J. Task Force 1. report of the task force on patient expectations, core values, reintegration, and the new model of family medicine. Ann Fam Med. 2004; 2(Suppl 1): S33-S50. doi:10.1370/afm.134
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6MTM6IjIvc3VwcGxfMS9zMzMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIxLzMvMjAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

53. 53.Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care. 2002; 14(4): 267-268. doi:10.1093/intqhc/14.4.267
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1093/intqhc/14.4.267&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12201184&link_type=MED&atom=%2Fannalsfm%2F21%2F3%2F202.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000177425200001&link_type=ISI) 

54. 54.Stange KC. What a pandemic reveals about the implementation of high quality primary care. Commissioned paper for the NASEM Consensus Report: implementing high-quality primary care rebuilding the Foundation of Health Care. Published 2021. Accessed Mar 4, 2023. [https://nap.nationalacademies.org/resource/25983/What%20a%20Pandemic%20Reveals%20About%20the%20Implementation%20of%20High%20Quality%20Primary%20Care.pdf](https://nap.nationalacademies.org/resource/25983/What%20a%20Pandemic%20Reveals%20About%20the%20Implementation%20of%20High%20Quality%20Primary%20Care.pdf)