As medical students and residents, in as much as we were trained to be primary care physicians in the ambulatory setting, we were taught to provide high quality care to the patient we find ourselves sitting across from in the exam room. Unless we also picked up an MPH, we are not likely to think of this individual person as part of a larger population of patients who share something in common, e.g., age, gender, diagnosis, primary care provider. We have been taught to use the knowledge and skill we have acquired to treat those patients, who manage to come to our office, and we restrict our intervention(s), for the most part, to the 15 minutes we spend with the patient 3-4 times a year. This is what we were taught was expected of a primary care provider.

However, the new paradigm of what defines quality care in the outpatient setting requires a completely different mindset. To successfully respond to current expectations of primary care providers, we need to be willing to abandon the attitude embodied in such comments as, "How can I be responsible for patients who don't come to see me or aren't compliant?". Most all of the quality improvement programs associated with incentives that we are going to qualify to participate in will consider the "denominator" to be all our patients with a given parameter, such as medical condition, age, or gender. We need to consider ourselves responsible, in a sense, for engaging all our patients in what we consider to be the recommended treatment for a given condition, or as it applies to preventive health.