Primacy and recency effects at immediate recall are thought to reflect the independent functioning of a long-term memory store (primacy) and a short-term memory store (recency). Key evidence for this theory comes from amnesic patients who show severe long-term memory storage deficits, coupled with profoundly attenuated primacy. Here we challenge this dominant dual-store theory of immediate recall by demonstrating that attenuated primacy in amnesic patients can reflect abnormal working memory rehearsal processes. D.A., a patient with severe amnesia, presented with profoundly attenuated primacy when using her preferred atypical noncumulative rehearsal strategy. In contrast, despite her severe amnesia, she showed normal primacy when her rehearsal was matched with that of controls via an externalized cumulative rehearsal schedule. Our data are in keeping with the "recency theory of primacy" and suggest that primacy at immediate recall is dependent upon medial temporal lobe involvement in cumulative rehearsal rather than long-term memory storage.