Roemer M I
Int J Health Serv. 1977;7(4):545-55. doi: 10.2190/PWAR-VJ44-AQ79-CKGC.
The worldwide growth of specialization in medicine has led to a perceived shortage of primary care. A major response in the United States has been the training of physician extenders (both physician assistants and nurse practitioners). Other industrialized countries have rejected this approach, in favor of strengthening general medical practice through continuing education, provision of ancillary personnel, use of health centers, and by other methods. Developing countries use doctor-substitutes as a reasonable adjustment to their lack of economic resources. All countries use ancillary personnel for selected procedures, such as midwifery, which involve only limited judgment and decision making. The American strategy on use of doctor-substitutes for primary care, however, follows from unwillingness to train greater numbers of primary care physicians and to require them to serve in places of need. This results in an inequitable concentration of doctor-substitutes on service to the poor in both urban and rural areas.
医学专业化在全球范围内的发展导致了人们感觉到初级保健的短缺。美国的一个主要应对措施是培训医师助理（医师助理和执业护士）。其他工业化国家则拒绝这种方法，而是倾向于通过继续教育、提供辅助人员、使用健康中心以及其他方法来加强全科医疗实践。发展中国家将替代医生作为对其经济资源匮乏的合理调整。所有国家都在某些特定程序中使用辅助人员，比如助产工作，这类工作只涉及有限的判断和决策。然而，美国在初级保健中使用替代医生的策略，是源于不愿意培训更多的初级保健医生并要求他们到需要的地方服务。这导致替代医生不公平地集中于为城乡贫困人群提供服务。
