Fix the Primary Care Doctor Shortage by Allowing Doctors to Practice Primary Care

We are facing a shortage of primary care doctors.

If you have tried to find a primary doctor, you probably already know this. But it really is true.

The Millbank Memorial Fund’s Primary Care Report Card for 2025 states that, “[m]ore than 30% of U.S. adults lacked a usual source of care…in 2022 — the highest level in a decade, despite historically high rates of insurance coverage during this period.” Since COVID, the rate of primary care physician retirements has increased. This is exacerbated by the higher-than-average age of primary care physicians compared to other specialties. Furthermore, while there have been attempts to increase the number of primary care residency slots, the number of residents planning to stay in primary care has not increased.

There are numerous reasons why primary care is a shrinking specialty. For starters, primary care physicians are poorly reimbursed. Medicare and Medicaid rates are particularly low, especially compared with more procedure-intensive specialties. To increase their potential income, many doctors who complete a primary care residency pursue additional training through a subspecialty fellowship. This allows them to earn a higher salary, but it excludes them from the pool of doctors whom patients can see without a referral.

Overwhelming workloads are also driving doctors out of primary care. Large healthcare entities that have consolidated primary care push their doctors to see more patients with complex health problems to offset low reimbursement rates. The average primary care physician sees 2,000 patients per year, spending an average of 7 minutes per visit. And because they see so many more patients than subspecialists do, primary care physicians have to complete more paperwork. This administrative workload must either cut into patient care time or doctors’ personal time.

Combine these working conditions with the low pay, and it’s clear why burnout is rampant. Compared to other specialties, primary care doctors retire earlier, switch to part-time more often, or leave traditional medicine for smaller practices that don’t accept insurance. In the face of these poor working conditions, incentives for new medical graduates to pursue primary care are few and far between.

What are we doing to fix this primary care physician shortage?

We’ve added medical student slots and resident training slots since the early 2000s. There are a variety of student loan repayment programs for health professionals who practice in under-resourced areas. But the majority of these interventions aren’t specific to primary care.

Only this year, in 2025, the Center for Medicare and Medicaid Services (CMS) announced a restructuring of primary care reimbursements to increase payments for more complex primary care visits. While this rebalancing will help address the primary care shortage, it garners pushback from specialists because CMS must remain budget-neutral; therefore, adding to primary care takes resources away from them.

But currently — and bafflingly — there is no nationally approved path for doctors who have completed a U.S. residency to transition to primary care without repeating a three-year primary care residency.

While it is true that anyone who has earned a medical degree and passed a licensing exam can obtain a “license to practice medicine and surgery” from their state, it is also the case that these licensed doctors will struggle to contract with insurance companies or find employment with hospitals without board certification. And it is residency training that prepares doctors to become board-certified in a specialty that is recognized by the American Medical Association (AMA) and the American Board of Medical Specialties (ABMS).

We want residency-trained doctors. Residency teaches knowledge and skills specific to a field. But more importantly, residency and the ongoing practice of medicine teach skills that are integral to the art of medicine: leadership, followership, decision-making, communication, critical thinking, empathy, time management, pattern recognition, and resilience, among others. A doctor who has completed one residency and practiced for years may need to augment their knowledge and skills to switch fields. Still, an entire residency in a non-surgical field may not always be necessary.

Yet, once a doctor completes their residency training, they are limited to that one field for the rest of their career, unless they complete an entirely new residency. Even specialists with significant primary care overlap (emergency medicine, anesthesiology, general surgery, and obstetrics and gynecology) would need to complete a residency again to be officially recognized to practice in primary care.

For example, an older doctor, a doctor who would prefer a 9-to-5 job, or a disabled doctor — say, a surgeon who has lost complex motor function in their hands — could transition to primary care with some crossover training, but that is not an option. For many of these doctors, who are years into practice, going back to a residency with 24-hour shifts, 80-hour workweeks, and a 75% pay cut is nearly impossible. Doctors trained in the U.S. are trapped in their specialty.

Many other countries with high standards of medical training offer pathways for established doctors to practice outpatient, clinic-based, primary care without requiring repeat residency training. While the particulars may differ, these countries consider experience, allow doctors to sit for qualifying exams, and offer short periods of supplemental education and supervision. Singapore even allows doctors to practice as general practitioners immediately after medical school, while providing a 22-month evening program to earn a specialization in family medicine.

In some U.S. states, beginning in 2024, foreign-trained doctors can work in primary care after a brief period of supervision. Nurse practitioners (NP) can practice independently in 27 states, and physician assistants (PA) in six states. Both NPs and PAs can change specialties at will, but U.S. residency-trained doctors have to go back to residency for three years to transition into primary care from another specialty.

Instead of being preoccupied with fears of PA and NP scope creep and criticizing primary care doctors who transition from traditional practices to direct primary care models, we could develop a process for U.S.-trained doctors to transition into primary care from other fields.

Rather than doubling down on our guild mentality, why not create a clear, acceptable pathway for mid- and late-career doctors to transition to outpatient-only primary care? It need not be one-size-fits-all, but could take prior training and practice into account and include periods of supervision as needed. Why not develop a relevant board exam and certification for “general practice” outpatient medical care?

The University of San Diego School of Medicine is attempting to facilitate this through its physician re-entry and re-training certificate program in association with the American Academy of General Physicians, which the AMA and ABMS do not recognize. While there are a few other re-entry programs, this is the only one that offers retraining for general practice. (I have no affiliation with them whatsoever.) This program, as well as the re-entry programs, could serve as starting points for expansion.

If this program were officially sanctioned, our system would benefit by gaining experienced outpatient primary care doctors. Even better, doctors would pay for this themselves (no cost to the government or taxpayers), as in many cases, it would allow them to extend their years of practice. More importantly, it would ensure that doctors switching into outpatient primary care could do so safely and competently, with full participation in our health system.

If we genuinely care about the American Association of Medical Colleges’ projected shortage of 86,000 primary care doctors by 2036, we should deliberately support pathways to expand entrance into primary care. While creating a new path to retrain in primary care doesn’t address all the underlying factors contributing to our primary care shortage, it would allow us to address the problem with our own U.S.-trained doctors. Perhaps more compelling, it wouldn’t cost the government or taxpayers anything.

Dr. Colleen Smith is an Emergency Medicine physician and educator who practices in New York City. She is a Roots of Progress Institute Fellow and writes a Substack about medicine, health, and related topics.