Where Have All the Experienced Primary Care Doctors Gone?

by wayne persky

The role of family doctors, once the cornerstone of American healthcare, is rapidly diminishing. Dylan Scott’s article “What happened to the family doctor?” published by Vox, highlights the profound transformation and ongoing challenges within the primary care system (Scott, 2023, September 14).1

Dr. Gerard Weigel’s career in Somerset, Kentucky, exemplifies the bygone era of family doctors who managed all aspects of patient care. From the 1960s through the 1980s, doctors like Weigel were integral to their communities, building deep, personal relationships with patients. This model fostered continuity and trust, essential elements of effective healthcare.​

By contrast,

today's healthcare system is characterized by fragmented care. Dr. Joseph Weigel, Gerard's son, reflects on the transition from comprehensive, personal care to a more compartmentalized system. His son, Sam, now works in a hospital where patient interactions are brief and often impersonal. This shift underscores the broader systemic changes affecting primary care.

The number of Americans with a personal physician is steadily declining. Younger generations, in particular, prefer the convenience of urgent care clinics and retail clinics over maintaining a relationship with a single doctor. As of 2018, nearly half of adults under 30 did not have a primary care doctor【29†source】.

Today's clinics apparently can't afford experienced physicians.

The traditional model of independent primary care practices and clinics with experienced primary care physicians began to disappear years ago as it became economically unfeasible. High overhead costs and administrative burdens make it difficult for these practices to survive.

Consequently, hospital systems and corporate entities have absorbed many primary care providers and then gone on to replace them with physicians assistants and other recent medical school graduates who can be hired at a much lower cost than experienced physicians. This consolidation often leads to a more transactional approach to healthcare, prioritizing efficiency over personal relationships (and from the patient;s perspective, reduced quality of healthcare).

This trend flies in the face of quality healthcare.

Research consistently shows that long-term relationships with primary care doctors lead to better health outcomes. Patients with steady primary care relationships are generally healthier and live longer. By contrast, the current trend has led to increased emergency room visits, hospital admissions, and mortality rates.​

Approximately 100 million Americans face barriers to accessing primary care. One in four Americans does not have a regular source of healthcare, a trend that has been growing since 2000. This lack of access is particularly pronounced in underserved areas, intensifying health disparities.

Some primary care practices are experimenting with new models

to re-engage patients and provide more personalized care. These include direct primary care and concierge medicine, where patients pay a flat fee for more accessible and personalized services. While these models offer a potential solution, they often cater to more affluent patients, leaving lower income patients underserved, because obviously such services increase the cost of healthcare for those patients who choose this option, adding insult to injury in view of the fact that healthcare is already way too expensive in the U.S.

But why have so many experienced physicians disappeared?

1. The pandemic dramatically increased the workload for primary care physicians, leading to higher levels of burnout. Many physicians faced extended hours, increased patient loads, and the emotional toll of dealing with COVID-19 patients, which prompted some to retire early or leave the profession altogether.
2. During the pandemic, many primary care practices faced severe financial challenges. With a significant drop in in-person visits and the rapid shift to telehealth, practices struggled to maintain revenue. Small and independent practices were particularly hard hit, leading some to close or merge with larger health systems.
3. Even before the pandemic, the U.S. was facing a projected shortage of primary care physicians due to an aging workforce. Approximately 2 out of every 5 physicians are expected to retire within the next decade. The pressures of the pandemic have accelerated this trend, pushing more experienced physicians to retire earlier than planned.
4. Women physicians and physicians of color were disproportionately affected by the pandemic. Many faced additional challenges such as balancing child care and professional responsibilities or addressing healthcare disparities in their communities. This added stress contributed to higher rates of burnout and workforce attrition among these groups.
5. While telehealth emerged as a critical tool during the pandemic, it also introduced new challenges. Providers had to quickly adapt to new technologies, often with little support or reimbursement certainty. Although telehealth helped maintain some level of patient care, it did not fully compensate for the loss of in-person visits, particularly for older or less tech-savvy patients.

​The combined effects of these factors have led to a noticeable reduction in the availability of experienced primary care physicians across most medical institutions. Addressing this shortage will require systemic changes, including increased investment in primary care, better support for telehealth, and initiatives to reduce burnout and support the well-being of healthcare providers. Whether that can actually be done remains to be seen.

Patients are being forced to face a new era in U.S. healthcare.

Most patients (most older patients, at least) have always considered their primary care physician to be the cornerstone of their healthcare. In most cases, that cornerstone is either gone, or soon will be, as healthcare institutions phase those experienced clinicians out of their system, and replace them.

The face of U.S. healthcare is drastically changing.

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As discussed in detail in a 2023 Politico article titled "No one’s promising you can keep your doctor anymore." Him him him him, the landscape of primary care in the United States is undergoing a significant transformation, driven by workforce shortages, the impacts of the COVID-19 pandemic, and evolving healthcare policies (Payne, and Schumaker, 2023, November 26).2 The traditional model of a lifelong relationship with a primary care physician is becoming less common, and both Democrats and Republicans in our government are seeking to reimagine primary care to better serve the needs of the population.

The main cause of this shift is the shortage of primary care physicians.

Medical schools are not producing enough doctors to keep pace with the growing and aging population. This shortage is compounded by the retirement of older physicians and the burnout experienced by many during the pandemic. The American Association of Medical Colleges (AAMC) projects a shortage of between 17,800 and 48,000 primary care physicians by 2034.

Our government appears to be playing a leading role.

To address this gap, policymakers are promoting alternative models of care. Legislation proposed by Senators Bernie Sanders and Roger Marshall aims to reorganize primary care by emphasizing community health centers and expanding the roles of nurses and physician assistants. This approach reflects a pragmatic response to the reality that the traditional model of independent physician practices is no longer feasible on a large scale.

Healthcare will be dished out by NPs and PAs.

The reliance on nurse practitioners (NPs) and physician assistants (PAs) has been increasing. A study published in The BMJ found that the percentage of healthcare visits handled by non-physicians nearly doubled from 2013 to 2019. This trend is expected to continue, with NPs and PAs taking on more responsibilities to alleviate the burden on doctors.

Telehealth utilization will be expanded.

The COVID-19 pandemic accelerated the adoption of telehealth, making virtual visits a common part of healthcare delivery. Both the Trump and Biden administrations have supported the expansion of telehealth by lifting restrictions on Medicare reimbursements for virtual care. This shift has made healthcare more accessible, especially for routine check-ups and managing chronic conditions, though it also means less face-to-face interaction with doctors.

Looking ahead,

​the primary care system is likely to continue evolving. Policymakers are pushing for more preventive care and better utilization of healthcare workers. The Biden administration has allocated over $100 million in grants to train more nurses and support their ability to open primary care practices independently. Additionally, there is a focus on increasing the compensation for preventive care services to attract more providers to primary care field.

Concierge medicine will be promoted for wealthy patients.

For those who can afford it, concierge medicine offers an alternative. This model provides personalized care with more immediate access to physicians, but it comes at a high cost, making it accessible primarily to affluent patients. Concierge medicine is growing, with a projected annual growth rate of over 10% through 2030.

The net effect of this transition is generally demoralizing.

These changes reflect a general trend that mirrors the way commercial feedlot operators process cattle and other animals destined for slaughter when admitting them into their facility. In other words, our future in the healthcare system appears to be reminiscent of the old saying that we'll be just a number in a vast system. We'll be pawns in an impersonal, faceless, one-size-fits-all system that focuses on speed and economy. This doesn't bode well for individuals who happen to be part of a subset of patients who don't fit into the overall pattern of the general population (such as MC patients).

And there are other problems weighing on primary healthcare providers.

A recent article in U.S. news discusses some additional reasons why doctors are leaving primary care and medical schools are not replacing them quickly enough (Shahidullah, 2023, January 4).3 The United States is facing a hidden crisis in its primary care system, characterized by an insufficient number of primary care physicians (PCPs) to meet the growing demand. This issue is compounded by the fact that fewer medical students are choosing to enter primary care fields, exacerbating the workforce shortage. This crisis demands immediate and comprehensive reforms to ensure that the healthcare system can effectively serve the population's needs.

PCPs are victims of "moral injury".

Unlike the commonly discussed "burnout," the concept of "moral injury" better captures the systemic issues within primary care. Moral injury refers to the stress caused by working in environments that prevent physicians from providing the best possible care. Primary care physicians are burdened with extensive clerical tasks and electronic medical record management, which detracts from patient care and diminishes job satisfaction. And all this extra clerical work is a primary reason why no one wants to be a PCP anymore.

PCPs are underpaid.

Primary care doesn't pay as well when compared with other medical specialties. Medical students, often burdened with substantial student debt, are more likely to choose higher-paying fields such as surgery or dermatology. Public health and preventive medicine, sectors that are crucial for serving vulnerable populations, offer the lowest compensation for physicians.​

Primary care physicians often work long hours and manage large patient loads, averaging 20 patients a day with approximately 18 minutes per visit. This schedule does not allow sufficient time to address complex health needs, leading to suboptimal care and contributing to physician dissatisfaction and attrition.

Government regulatory policies are a major problem.

A recent article in JAMA Health Forum points out why new U.S. healthcare facilities are not being built (Chen, 2024, June 27).4 The issue of new construction and expansion of hospital facilities in the U.S. has been significantly hampered by various federal and state regulations intended to control healthcare costs but have inadvertently stifled growth and competition. These regulations, while well-intentioned, have led to a decrease in the number of hospitals, particularly in rural areas, and have made it challenging for new facilities to emerge. This has resulted in higher healthcare costs and reduced access to care for many Americans.

The CON laws.

One of the primary regulatory barriers to hospital expansion is the Certificate-of-Need (CON) laws. Initially introduced in the 1970s, CON laws require healthcare providers to obtain state approval before constructing new facilities, expanding existing ones, or offering new services. These laws were designed to prevent the duplication of services and to ensure that new facilities were financially viable and necessary for the community. However, these regulations have had several unintended consequences:

1. By requiring approval for new projects, CON laws have restricted the supply of healthcare facilities, leading to fewer hospitals and higher prices due to reduced competition. The intended control of healthcare costs has paradoxically resulted in increased costs and decreased accessibility.
2. The stringent approval process and the need to demonstrate community need have slowed down the construction of new hospitals and the expansion of existing ones. This is particularly evident in states with strict regulations, such as California, where seismic retrofitting requirements further complicate hospital renovations and expansions.
3. Rural areas have been disproportionately affected by these laws, with many communities facing a significant shortage of healthcare facilities. A 2017 study highlighted that nearly 30 million individuals lived more than an hour away from trauma care facilities. The limited number of hospitals in these areas exacerbates the healthcare accessibility crisis.

The COPA laws.

In addition to CON laws, Certificates of Public Advantage (COPA) laws have also contributed to the stagnation of hospital development. COPA laws allow hospital mergers that might otherwise be prohibited under federal antitrust laws, in exchange for increased regulatory oversight. While intended to streamline and coordinate healthcare services, COPA laws have often led to negative outcomes:​

The Federal Trade Commission reported that hospital mergers conducted under COPA laws resulted in higher healthcare prices and diminished quality of care. The consolidation of healthcare facilities reduces competition, leading to higher costs for patients and less incentive for hospitals to maintain high standards of care.

The ACA also imposes disincentives.

The Affordable Care Act (ACA) introduced restrictions on physician-owned hospitals (POHs), further complicating the landscape of hospital development. These restrictions aimed to prevent conflicts of interest and the potential for unnecessary procedures driven by profit motives. However, the consequences have been largely counterproductive:

1. The ACA's restrictions on POHs, including limitations on expansion and new construction, have dampened market competition. This has resulted in fewer new facilities and hindered the growth of existing ones, limiting patient options and keeping healthcare costs high.
2. The anticipation of these restrictions led to the cancellation of numerous hospital projects, resulting in billions of dollars in lost economic activity. The lack of new facilities also meant less competitive pressure to lower costs and improve services.

So what can we conclude from all this?

Under currently emerging changes, as is usually the case, patients, and their needs, appear to be basically ignored, and are regarded no better than “commodities “by the healthcare system. The focus is on economies of scale, and policies are based on efficiency and economy. Patients have no input

The decline of experienced primary care doctors reflects a broader transformation and crisis within the U.S. healthcare system. Various factors, including regulatory barriers like CON and COPA laws, economic pressures, and the impacts of the COVID-19 pandemic, have contributed to the shrinking number of primary care physicians and the consolidation of healthcare facilities. These changes have led to higher costs, reduced competition, and limited access to care, particularly in rural areas.

The shift away from independent primary care practices toward a model that relies more on nurse practitioners, physician assistants, and telehealth represents an effort to adapt to these challenges. However, this transition has also resulted in a more impersonal and fragmented healthcare system, distancing patients from the long-term, personal relationships that have been shown to improve health outcomes.

To address these issues, comprehensive reforms are needed, including increased investment in primary care, better support for telehealth, and initiatives to reduce burnout and support the well-being of healthcare providers. Policymakers must reconsider the unintended consequences of existing regulations and explore new models of care that balance efficiency with the need for quality, continuity, and personalized patient care.​

And it's worth noting that nowhere (neither in the recommendations of government regulatory agencies, nor in healthcare facility policies) is the concept of improved healthcare that actually caters to the needs of patients being considered. The needs of patients, as usual, is an afterthought, at best.

References

1. Scott, D. (2023, September 14). What happened to the family doctor? Vox, Retrieved from https://www.vox.com/23817170/family-doctor-primary-care-physician-general-practitioner-shortage

2. Payne, D. and Schumaker, E. (2023, November 26). No one’s promising you can keep your doctor anymore. Politico, Retrieved from https://www.politico.com/news/2023/11/26/future-of-primary-care-family-medicine-00128547

3. Shahidullah, J. D. (2023, January 4). The Hidden Crisis in Primary Care. U.S.News, Retrieved from https://www.usnews.com/news/health-news/articles/2023-01-04/the-hidden-crisis-in-primary-care-medicine

4. Chen, L. J. (2024, June 27). The Unintended and Anticompetitive Consequences of Laws to Control Health Care Costs. JAMA Health Forum, Retrieved from https://jamanetwork.com/journals/jama-health-forum/fullarticle/2820716