OBJECTIVE:To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN:1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. SETTING:Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes. MAIN MEASUREMENT:Number of people per 1,000 per month who had at least one contact in a health care setting. RESULTS: According to a recent report by the Centers for Disease Control (CDC), racial and ethnic minorities fare worse than nonminorities in several major health status categories, with little progress in reduction of disparities in most areas since 1990.1 For blacks and Hispanics, the incidence of infant and maternal mortality is higher, life expectancy is lower, and rates of some chronic diseases are greater than for whites. The overwhelming evidence of disparities in health and health care has sparked research comparing populations in terms of their characteristics or receipt of specific services. However, this perspective does not address the broader interactions of populations with the various settings of health care. Looking at populations and where they go when they decide to seek health care provides an "outside-in" view that helps explain where there is the greatest contribution to disparities.The Ecology of Medical Care by White et al. in 1961 19 and reprised by Green et al. in 2001 20 is an example of such a perspective. The ecology model depicts the number of people per 1,000 who access the health care system in an average month. The model does not report the quantity of services provided, focusing instead on individuals and whether they received any care in a health care setting. The methods of the ecology model do not permit conclusions about cause and effect, but they do elucidate who is getting care in those settings.

In this direct care practice, in lieu of insurance, patients pay an age-adjusted monthly fee for unrestricted, comprehensive primary care. Patients have no copayments for visits. Low overhead allows providers to have small patient panels, giving patients better access and allowing more time per visit. The objective is to shift care away from expensive specialists and hospitals. K EY RE SU LT S Qliance has established a viable, sustainable business model with low overhead and patient panels about a third the size of those of the average insurance-based family physician. This has allowed patients to enjoy much greater access and clinicians to delve much more deeply into patients' health issues, do more research on health problems, work more closely with consultants when necessary, and work more intensively with patients on health change, leading to greater engagement of and satisfaction among clinicians. C HAL LEN G E S Patients still need to have health insurance to cover specialty services, high-cost procedures, emergency treatments, and hospitalization. Current patient expenses are less than prevailing insurance rates, but there are no quantified data yet on how this model affects overall health care costs. A proliferation of similar small-panel practices might exacerbate the shortage of primary care providers in the near term, although it might eventually attract more physicians to primary care.M edical home models providing direct primary care can enable comprehensive primary care and improved access at affordable prices by operating outside the insurance system. Such models have the potential to attract physicians and others into primary care by providing an income comparable to that generated by a traditional practice, while allowing more time to interact with patients.Such practices began to appear in the late 1990s, often directed at middle-and upperincome groups. They are now spreading geographically and are caring for patients from diverse socioeconomic groups, including the uninsured and underinsured.

BACKGROUND For family physicians to be prepared to deliver the core attributes and system services of family medicine in the future, especially within the New Model of family medicine that has been proposed, changes will need to be made in how family physicians are trained. This Future of Family Medicine task force report presents a plan for implementing appropriate changes in medical school and residency programs.METHODS As a foundation for the development of specifi c recommendations on medical education, this task force reviewed relevant fi ndings from research conducted for the Future of Family Medicine project and presents an historical perspective of the specialty. We addressed accreditation criteria for family medicine residency programs and examined various relevant projects and programs, including the Academic Family Medicine Organizations/Association of Family Practice Residency Directors Action Plan, the Residency Assistance Program Criteria for Excellence, the Accreditation Council for Graduate Medical Education Outcome Project, the Family Medicine Curriculum Resource Project, and the Arizona Study of Career Selection Factors. The task force relied on the Institute of Medicine report, Health Professions Education: A Bridge to Quality, as a foundation for proposing a new vision and mission for family medicine residency education. MAJOR FINDINGSThe training of future family physicians must be grounded in evidence-based medicine that is relevant to the care of the whole person in a relationship and community context. It also must be technologically up to date, built on a solid foundation of clinical science, and strong in the components of interpersonal and behavioral skills. Family physicians must continue to be broadly trained and have the competencies required to practice in a variety of settings. It is important that training in maternity care and training in the care of hospitalized patients continue to be included in the family medicine residency curriculum, but programs must be allowed to tailor that curriculum to be compatible with educational resources and individual trainee needs.CONCLUSION Given the changes taking place in the specialty and within the broader health care system, it is clear that the traditional family medicine curriculum, although successful in the past, cannot meet the needs of the future. The educational process must train competent family physicians who will provide a personal medical home for their patients, a key concept that must be an integral part of whatever new systems are designed. Such competency will require family physicians who understand and practice process-oriented care, who utilize the biopsychosocial model to create superb physician-patient relationships, who actively measure outcomes, and whose practices are driven by information system access to evidence-based principles of care. TASK FORCE CHARGE: Determine the training needed for family physicians to deliver the core attributes and system services. INTRODUCTIONU nlike many other specialties, fa...