The Contemporary Ecology of U.S. Medical Care Confirms the Importance of Primary Care

One Pagers | Sep 15, 2001 Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

More women, men, and children receive medical care each month in the offices of primary care physicians than any other professional setting. There is an urgent need for health policies that encourage further innovation and implementation of first-rate primary care for everyone.

For beleaguered primary care physicians, wondering about their role and place in a chaotic non-system of health care that makes their work difficult if not impossible, the current ecology of medical care makes clear that they are very important. More than 12 times as many people are seen in primary care physicians’ offices as in hospitals. Thus, the design and implementation of first-rate primary care in the United States is a critical focus needing urgent attention by governments, professional societies, business executives, health payment systems, policy analysts, and voluntary organizations.

Figure. A Typical Month of Healthcare in the United States

Since its publication in 1961, “The Ecology of Medical Care” by White, Williams, and Greenberg1 has provided a framework for thinking about the organization of health care, medical education and research. This landmark analysis focused on two questions: Is new knowledge fostered by immense public investment in medical research being delivered effectively to the consumers? Is the available quantity, quality and distribution of contemporary medical care the best it can be from the consumer’s perspective? These questions remain strikingly relevant today.

Using contemporary data from the United States the ecology of medical care has been updated to show where the people of the United States are getting health care in a typical month (see accompanying figure).2

This figure includes children and reconfirms that most of the problems most people have most of the time would escape detection, analysis, and response by health care efforts restricted to hospitals and academic health centers.

An overemphasis on any one level of care will neglect issues of great importance to people. A balanced approach is necessary for adequate health policies. This need for balance applies, for example, to important current policy issues such as medical errors, government appropriations for research, the focus of education of physicians and nurses, the implementation of medical information systems, and to the relative allocation of resources to public health and personal health care.

Despite substantial changes in the organization and financing of health care in the United States, this updated medical ecology shows that the estimated monthly use of health care services in the United States has remained remarkably consistent over the past 40 years. The bulk of the health care enterprise remains in primary care, self-care and ambulatory care.


  1. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.
  2. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021–2025.

The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP. 

Published in American Family Physician, Sep 15, 2001. Am Fam Physician. 2001;64:928. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.