Reading the book The Doctor Stories by William Carlos Williams seared into my mind the ways in which a primary care physician (PCP) can transform the lives of patients with a nuanced blend of careful listening, emotional connection, and medical skill. This book inspired me to become a PCP.
According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes. With our country's fraying healthcare system, it is essential to have a PCP who knows you, because it is almost impossible to access any type of coherent medical care without the coordination of a PCP.
The most common question I get asked as a doctor — by friends, acquaintances, relatives, families of patients, colleagues — is "Can you help me find a PCP?" I can't. None of us can. Why is it so difficult to find a PCP nowadays?
Unfavorable demographics and PCPs leaving the profession
While the COVID pandemic certainly pushed a large subset of already burned-out PCPs over the brink into semi- or full retirement, or into less stressful jobs, the current primary care crisis has been brewing for much longer. The US is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033.
Both patients and doctors are getting older. As patients age, they tend to need more care from their PCPs to address the proliferation of medical problems and medications that inevitably comes with aging. At the same time, the Association of American Medical Colleges reports more than 40% of active physicians in the United States will be 65 or older within the next decade. The American Medical Association notes that 29% of physicians retire between the ages of 60 and 65, and 12% retire before the age of 60.
These numbers have daunting implications for the future supply of seasoned doctors. Further, one-fifth of doctors say they will likely leave their current practice within the next two years, and one-third of doctors are intending to reduce their work hours within the next 12 months.
PCPs have higher burnout and lower pay than many specialties
Primary care is getting hit harder than most specialties, due to having lower salaries, higher ratings of burnout, and a growing feeling that their job is generally impossible and thankless on all fronts. According to a 2019 physician survey, the burnout scores among PCPs were up to 79%. Many hospitals are happy to replace PCPs with even lower-paid NPs and PAs, who do a good job with routine care but aren't trained in subtleties and complexities, which come into play if you develop a challenging or rare medical condition, or if you have multiple medical comorbidities.
Multiple causes of primary care dissatisfaction
Many PCPs are facing requirements by their hospitals to see a greater number of patients, who get sicker and whose care gets more complicated every year, in the face of significant salary and benefit cuts and with dwindling administrative and clinical support. PCPs have more to do at each visit, as new requirements and treatments come up, but none of the work aimed toward preventive health seems to disappear, such as managing blood pressure and cholesterol, as well as discussing and providing hospital scheduling requests for health screenings like mammograms and colonoscopies.
Further, when patients are finally able to get in to see us in person, they have many more unaddressed problems and concerns because they often haven't seen us for a year or two. This creates a vicious feedback cycle, with PCPs having ever-growing issues to address under a time pressure and patients having increasingly unmet medical symptoms and needs.
Time devoted to electronic medical records is further impacting burnout
It is estimated that for each hour a PCP spends with a patient, up to two hours of work are generated, which includes writing summary notes and treatment plans in a patient's electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs that I know go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated. Many also have second jobs or side gigs to pay off their medical school debts.
What we are managing in today's clinics is increasingly complicated and out of our control. As our entire health care system struggles, it is more difficult to get patients into the emergency department, into the hospital, and scheduled to see medical specialists. PCPs are left managing many things in the absence of the support that we are ordinarily used to.
We are also managing greater mental health needs and dealing with the brunt of our patients' problems, such as lack of housing and employment, unaffordable medications, and widespread financial problems. The fact that we are unable to care for our patients nearly as well as we previously could is considered to be a "moral injury" that many of us are suffering. And there is research that when your doctor is struggling like this, the quality of your health care can suffer.
What can patients do to find a PCP?
If your current PCP quits or retires, ask the practice to assign you to someone new. In theory, practices aren't supposed to leave patients stranded and abandoned, even if they, like many places, don't truly have enough experienced physicians to take adequate care of patients. If that doesn't work, or if you don't feel that your new doctor is a good match for you, you can call your health insurance and see which doctors are accepting new primary care patients.
If you happen to have a friend who is a doctor or a nurse, perhaps they can advocate for you by asking a colleague to accept you into their practice. Our system shouldn't work this way, but it often does. Most practices have waiting lists, so if you are without a PCP, put your name down, as late is better than never.
What might reverse the primary care crisis?
We need to train and financially support more PCPs by encouraging trainees to go into primary care, and to eliminate the pay gap between PCPs and specialists. We need to buttress those doctors who are currently trying to stick it out as primary care doctors, so they don't cut down hours or quit. These doctors urgently need emotional, financial, logistical, and psychological support.
Finally, we need to cultivate in new doctors the magic of primary care, so eloquently spelled out by William Carlos Williams, so that people can, in fact, access the care that will enable them to live and enjoy the long and healthy lives they deserve.