Primary care doctors are a practice of the past. They are referral specialists. Many times their knowledge is out of date, they make too many mistakes and are not into preventative care. PAs and NP practitioners are just as capable to do what Primary care physicians do. They are more economical to train
While certainly a feasible policy, this strikes me as just damage mitigation; perhaps that is all we have right now? The dominant stakeholders and policymakers in the US have complete contempt for the premises of public health.
Pay aside I see very similar issues in Canada, a shortage of doctors, excessively lengthy training to produce new ones and underutilization of Registered Practical Nurses. I'd also add that there is more potential in both systems to automate cancer, diabetes and heart disease screening.
Doctors are on the boards that set rules and there are actually a great number of them that could use their various associations to lobby for change that makes it easier to become a doctor or allows others to take bigger roles in medicine. This could hurt the long term pay for doctors but it gets more people cared for.
Licensing boards in effect act as a union that drives up wages by limiting who can participate. This is also important for public safety. Everyone from electricians to doctors benefit from this. I'm an engineer myself and because I can put my stamp on specific documents I'm more valuable and harder to replace than someone that could otherwise do most of my job without that one qualification. If engineers were overworked and a shortage of us was a public health emergency that keeps coming up in the news I'd make efforts to share the parts of my work that I can with people that have lower qualifications but can still complete those portions of my work.
“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.”
Interesting article & interesting passage. I know those statements to be true, but had not thought of the point you made quite that way before. I’m a Family physician & have been practicing for 20 years. I agree with you & others that residency trained physicians are crucial for our health care system. Why not allow experienced physicians (with some extra “bridging” training) to extend their careers & help in high need areas at the same time? I remember when I was in training (2001-2004)there were surgeons and primary care physicians who had a training track that allowed them to get credentialed to work in smaller ER settings—it was a similar idea—unfortunately, the program ended.
I don’t see why there couldn’t be a fellowship for AMBULATORY primary care for other specialists (many rural primary care physicians from my era still deliver babies, see patients in the hospital and do some surgery & colonoscopies, so it would definitely have to be a more narrow scope if there were to be a fellowship).
I have worked with PAs, NPs & Nurse Midwives in my career, all with varying levels of experience & training. My Mom was an RN, so I have great respect for the profession, and I can appreciate how the NP & PA professions came to be. I agree with other comments indicating the best NPs are those with 5-10 years of experience as RNs before getting their advanced degrees (unfortunately some programs only require 1-2 years) and the best practice approach is one in which there is collaboration between APPs & physicians. Some of the experienced, cross-trained physicians you suggest could be valuable mentors to them.
Lastly, I will get on my soapbox about the need to expand loan forgiveness programs for medical students/residents who choose primary care. For example, Community Health Centers, in conjunction with National Health Service Corps, do a good job with this AND they provide care for under- and uninsured patients. I also like the idea I’ve heard the Sensible Medicine doctors mention —it would be helpful if medical schools could identify kids who would make good primary care doctors and have a separate fast-track/ admissions process for them.
I am retired from general surgery. NO interest in resuming practice in primary care. Totally different mindset and skill set. As for a primary care physician who did a surgical rotation once becoming a surgeon, that is frightening. Surgery is both technical and intellectual skills. Not just a side hustle.
Medical specialty boards have become rent seekers. No difference in outcomes between board certified and non board certified practitioners, ask for the evidence. Malpractice rates are similar. NO data to suggest any superiority.
The future of primary care for physicians is concierge or direct patient care practice. This offers the only viable work/ life balance in the current environment.
Interesting that the author is an ER physician, the current trend is for FPs to go to ED “ boot camp” and become higher paid, shift limited ER providers than those going the other direction.
The additional consideration is the NC approach; as of 1/2/2026 physicians from foreign countries without U S training or ECFMG exam ( only need to be eligible) can be licensed to practice if they have practiced in any country. All they need is a “ sponsoring location.”
I am one of the many family doctors who retired after COVID, stepping away after 41 years in practice—14 years in a two-physician office and 27 years in a hospital-based setting. Caring for thousands of individuals and families over those years was a true privilege, and I feel deeply blessed to have experienced it. I genuinely loved primary care and the practice of medicine. In my last five years, I served as the senior physician in an office of six providers and felt I was at the top of my game when I retired. My quality of care, patient satisfaction, Press Ganey scores, patient flow, outcomes, and productivity were consistently among the highest in our organization. I left feeling very satisfied with what I had accomplished.
In the three years since retiring, I’ve been approached several times to return to practice. I was tempted, but it became clear how much things had deteriorated. The patient team-care model—which had worked so well—was abandoned because it required two MAs per physician, a cost administration deemed too high. That workload was then shifted directly onto providers. Paperwork had been nearly stifling even with MA support; without it, the burden would be overwhelming. The thought of reentering that increasingly chaotic environment made me grateful I had already stepped away.
If we are to address the primary-care provider shortage, simply increasing financial incentives will not be enough. High-quality primary care grows out of long-term relationships with patients and families—relationships that allow physicians and patients to build trust. That trust greatly influences treatment success. But excessive administrative burdens lead to early burnout regardless of compensation, and they undermine the continuity and stability required to form those long-term bonds.
The notion that primary care must be directly financially profitable to be “successful” is a fallacy, especially within large health systems. Primary care feeds the system. It is the doorway through which patients flow to all other services. A strong primary-care base creates a strong healthcare system. While my own practice was financially stable, we generated many times more revenue for the system through referrals, procedures, testing, and other downstream services. Primary-care physicians shape patient flow—and therefore revenue.
Providing high-quality healthcare requires a robust primary-care foundation, regardless of the profit margin of that department. Finding efficient care models that relieve physicians of tasks that non-physicians can perform is critical to system success. This allows physicians to focus on the highest-level work that only they can do—work that also generates the greatest value. In turn, it reduces stress, improves job satisfaction, decreases burnout and turnover, and makes this essential field more attractive to new physicians. That seems to be the most realistic formula for addressing the family-doctor shortage.
Sounds like a great idea to me. As an emergency physician with 60 years of experience under my belt I feel more than qualified to treat primary care patients. I do that in a free clinic, so I dont have to be concerned about insurance companies. BTW, insurance companies are a big part of the problem with American medicine. Rewarding doctors for treatment, rather than for prevention.
I know this sounds naive, but I still refer to my PCP as "my internist," as that describes his niche - it was the only term used for many years. (He is also board-certified in rheumatology.) Other docs effectively serve as a PCP, but they're still called gynecologists, pediatricians, etc.
Some physicians “retire” into urgent care in a building with other specialists. They refer patients to the specialists and surgeons in the building— the internal medicine doctors follow their sickest patients in the hospital. This allows the 9 to 5 older doctor to no longer have call and to not deal with complicated patients, but still direct them to a person that can actually help them quickly.
Forty-two year PA here, with multiple degrees and service as former PA program chair. Though I had broad autonomy in my career, I am opposed to totally independent practice for PAs and NPs. We need to have oversight and consultation; we need to discuss referrals to specialty care. In short, we need that physician relationship to be able to provide the best care.
So, why not recruit and "refurbish" (ie., reorient and provide some primary care retraining) to non-primary care physicians who may not want the daily primary care "grind" of patients every 7 minutes to work with PAs and NPs in general medicine clinics. I know from experience that these physicians have very valuable perspectives that would enhance the quality of primary care. And don't tell me that it's not viable financially - physicians and PAs have demonstrated for decades that the team approach is both good medicine and good business.
Whatever we do we absolutely can NOT lower standards or requirements. We're already seeing a lowering of standards and requirements in various professional fields in the name of Diversity , Equity & Inclusion and if we allow the same in medicine people will die.
It would be great if there was someway to see a doctor and by-pass the governments bureaucracy nonsense. My former PC doc f 18 years left to start his own practice that doe snot work with the government but is instead a membership like service. Yo pay an annual fee and for that yo get the see the doc anytime you need to for a very low cost (I want to say $20) plus you get 2 free checkup visits as well as some kind of plan on how you should proactively take care of yourself, things like what foods to focus on, exercise recommendations. The goal is to create a proactive approach to medicine versus reactive and to avoid as many pharmaceuticals as you can.
Assuming that the primary care shortage requires a multi-faceted solution, this seems like a viable option.
An outpatient/no after-hours gig for late-career docs could be appealing to those who aren’t quite ready to hang them up. But the devil is in the details of what that retraining and recertification would look like.
The reasons for the sorry state of current medical practice are ultimately traceable to government intervention. Bureaucratization and corporatization will inevitably follow as has been shown in many other industries. Rather than create paths or incentives to increase the number of doctors in primary care, it might be better to remove the barriers. Free market reforms will always eliminate shortages or surpluses in any goods or services. Any medical practitioner could offer their services, list their qualifications, and let those seeking medical care or advice make their own choices. Practitioners could set up their own time and fee schedules. What a wacky idea.
I recommend you review the Flexner report from 1910 to understand the era of unregulated medical practice in the United States. In some instances, barriers are appropriate. Would you get on a commercial flight with a pilot of unknown background or standards? I suspect not.
Thank you for the additional information about workloads. I've been guessing that the reason so many hospital systems (Washington University/BJC in St. Louis, specifically) have gone to NPs, supervised by physicians, is because of the cost.
However, it seems stupid to me to waste physicians' training on supervisory duties. My opinion is that doctors should perform their jobs using the various specialty skills they have spent years gaining.
Even more, the big corporate model of business needs to go. It seems to sicken and even kill people, no matter the specific business field.
250K primary care doctors in the US and 350K NPs and PAs. The math doesn't show a shortage. But no doubt that we have a distribution problem.
Primary care doctors are a practice of the past. They are referral specialists. Many times their knowledge is out of date, they make too many mistakes and are not into preventative care. PAs and NP practitioners are just as capable to do what Primary care physicians do. They are more economical to train
While certainly a feasible policy, this strikes me as just damage mitigation; perhaps that is all we have right now? The dominant stakeholders and policymakers in the US have complete contempt for the premises of public health.
Pay aside I see very similar issues in Canada, a shortage of doctors, excessively lengthy training to produce new ones and underutilization of Registered Practical Nurses. I'd also add that there is more potential in both systems to automate cancer, diabetes and heart disease screening.
Doctors are on the boards that set rules and there are actually a great number of them that could use their various associations to lobby for change that makes it easier to become a doctor or allows others to take bigger roles in medicine. This could hurt the long term pay for doctors but it gets more people cared for.
Licensing boards in effect act as a union that drives up wages by limiting who can participate. This is also important for public safety. Everyone from electricians to doctors benefit from this. I'm an engineer myself and because I can put my stamp on specific documents I'm more valuable and harder to replace than someone that could otherwise do most of my job without that one qualification. If engineers were overworked and a shortage of us was a public health emergency that keeps coming up in the news I'd make efforts to share the parts of my work that I can with people that have lower qualifications but can still complete those portions of my work.
“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.”
Interesting article & interesting passage. I know those statements to be true, but had not thought of the point you made quite that way before. I’m a Family physician & have been practicing for 20 years. I agree with you & others that residency trained physicians are crucial for our health care system. Why not allow experienced physicians (with some extra “bridging” training) to extend their careers & help in high need areas at the same time? I remember when I was in training (2001-2004)there were surgeons and primary care physicians who had a training track that allowed them to get credentialed to work in smaller ER settings—it was a similar idea—unfortunately, the program ended.
I don’t see why there couldn’t be a fellowship for AMBULATORY primary care for other specialists (many rural primary care physicians from my era still deliver babies, see patients in the hospital and do some surgery & colonoscopies, so it would definitely have to be a more narrow scope if there were to be a fellowship).
I have worked with PAs, NPs & Nurse Midwives in my career, all with varying levels of experience & training. My Mom was an RN, so I have great respect for the profession, and I can appreciate how the NP & PA professions came to be. I agree with other comments indicating the best NPs are those with 5-10 years of experience as RNs before getting their advanced degrees (unfortunately some programs only require 1-2 years) and the best practice approach is one in which there is collaboration between APPs & physicians. Some of the experienced, cross-trained physicians you suggest could be valuable mentors to them.
Lastly, I will get on my soapbox about the need to expand loan forgiveness programs for medical students/residents who choose primary care. For example, Community Health Centers, in conjunction with National Health Service Corps, do a good job with this AND they provide care for under- and uninsured patients. I also like the idea I’ve heard the Sensible Medicine doctors mention —it would be helpful if medical schools could identify kids who would make good primary care doctors and have a separate fast-track/ admissions process for them.
I am retired from general surgery. NO interest in resuming practice in primary care. Totally different mindset and skill set. As for a primary care physician who did a surgical rotation once becoming a surgeon, that is frightening. Surgery is both technical and intellectual skills. Not just a side hustle.
Medical specialty boards have become rent seekers. No difference in outcomes between board certified and non board certified practitioners, ask for the evidence. Malpractice rates are similar. NO data to suggest any superiority.
The future of primary care for physicians is concierge or direct patient care practice. This offers the only viable work/ life balance in the current environment.
Interesting that the author is an ER physician, the current trend is for FPs to go to ED “ boot camp” and become higher paid, shift limited ER providers than those going the other direction.
The additional consideration is the NC approach; as of 1/2/2026 physicians from foreign countries without U S training or ECFMG exam ( only need to be eligible) can be licensed to practice if they have practiced in any country. All they need is a “ sponsoring location.”
I am one of the many family doctors who retired after COVID, stepping away after 41 years in practice—14 years in a two-physician office and 27 years in a hospital-based setting. Caring for thousands of individuals and families over those years was a true privilege, and I feel deeply blessed to have experienced it. I genuinely loved primary care and the practice of medicine. In my last five years, I served as the senior physician in an office of six providers and felt I was at the top of my game when I retired. My quality of care, patient satisfaction, Press Ganey scores, patient flow, outcomes, and productivity were consistently among the highest in our organization. I left feeling very satisfied with what I had accomplished.
In the three years since retiring, I’ve been approached several times to return to practice. I was tempted, but it became clear how much things had deteriorated. The patient team-care model—which had worked so well—was abandoned because it required two MAs per physician, a cost administration deemed too high. That workload was then shifted directly onto providers. Paperwork had been nearly stifling even with MA support; without it, the burden would be overwhelming. The thought of reentering that increasingly chaotic environment made me grateful I had already stepped away.
If we are to address the primary-care provider shortage, simply increasing financial incentives will not be enough. High-quality primary care grows out of long-term relationships with patients and families—relationships that allow physicians and patients to build trust. That trust greatly influences treatment success. But excessive administrative burdens lead to early burnout regardless of compensation, and they undermine the continuity and stability required to form those long-term bonds.
The notion that primary care must be directly financially profitable to be “successful” is a fallacy, especially within large health systems. Primary care feeds the system. It is the doorway through which patients flow to all other services. A strong primary-care base creates a strong healthcare system. While my own practice was financially stable, we generated many times more revenue for the system through referrals, procedures, testing, and other downstream services. Primary-care physicians shape patient flow—and therefore revenue.
Providing high-quality healthcare requires a robust primary-care foundation, regardless of the profit margin of that department. Finding efficient care models that relieve physicians of tasks that non-physicians can perform is critical to system success. This allows physicians to focus on the highest-level work that only they can do—work that also generates the greatest value. In turn, it reduces stress, improves job satisfaction, decreases burnout and turnover, and makes this essential field more attractive to new physicians. That seems to be the most realistic formula for addressing the family-doctor shortage.
Sounds like a great idea to me. As an emergency physician with 60 years of experience under my belt I feel more than qualified to treat primary care patients. I do that in a free clinic, so I dont have to be concerned about insurance companies. BTW, insurance companies are a big part of the problem with American medicine. Rewarding doctors for treatment, rather than for prevention.
I know this sounds naive, but I still refer to my PCP as "my internist," as that describes his niche - it was the only term used for many years. (He is also board-certified in rheumatology.) Other docs effectively serve as a PCP, but they're still called gynecologists, pediatricians, etc.
Some physicians “retire” into urgent care in a building with other specialists. They refer patients to the specialists and surgeons in the building— the internal medicine doctors follow their sickest patients in the hospital. This allows the 9 to 5 older doctor to no longer have call and to not deal with complicated patients, but still direct them to a person that can actually help them quickly.
Forty-two year PA here, with multiple degrees and service as former PA program chair. Though I had broad autonomy in my career, I am opposed to totally independent practice for PAs and NPs. We need to have oversight and consultation; we need to discuss referrals to specialty care. In short, we need that physician relationship to be able to provide the best care.
So, why not recruit and "refurbish" (ie., reorient and provide some primary care retraining) to non-primary care physicians who may not want the daily primary care "grind" of patients every 7 minutes to work with PAs and NPs in general medicine clinics. I know from experience that these physicians have very valuable perspectives that would enhance the quality of primary care. And don't tell me that it's not viable financially - physicians and PAs have demonstrated for decades that the team approach is both good medicine and good business.
Whatever we do we absolutely can NOT lower standards or requirements. We're already seeing a lowering of standards and requirements in various professional fields in the name of Diversity , Equity & Inclusion and if we allow the same in medicine people will die.
It would be great if there was someway to see a doctor and by-pass the governments bureaucracy nonsense. My former PC doc f 18 years left to start his own practice that doe snot work with the government but is instead a membership like service. Yo pay an annual fee and for that yo get the see the doc anytime you need to for a very low cost (I want to say $20) plus you get 2 free checkup visits as well as some kind of plan on how you should proactively take care of yourself, things like what foods to focus on, exercise recommendations. The goal is to create a proactive approach to medicine versus reactive and to avoid as many pharmaceuticals as you can.
Interesting article.
Assuming that the primary care shortage requires a multi-faceted solution, this seems like a viable option.
An outpatient/no after-hours gig for late-career docs could be appealing to those who aren’t quite ready to hang them up. But the devil is in the details of what that retraining and recertification would look like.
The reasons for the sorry state of current medical practice are ultimately traceable to government intervention. Bureaucratization and corporatization will inevitably follow as has been shown in many other industries. Rather than create paths or incentives to increase the number of doctors in primary care, it might be better to remove the barriers. Free market reforms will always eliminate shortages or surpluses in any goods or services. Any medical practitioner could offer their services, list their qualifications, and let those seeking medical care or advice make their own choices. Practitioners could set up their own time and fee schedules. What a wacky idea.
So there really isn't a shortage - just a tremendous barrier to entry
I recommend you review the Flexner report from 1910 to understand the era of unregulated medical practice in the United States. In some instances, barriers are appropriate. Would you get on a commercial flight with a pilot of unknown background or standards? I suspect not.
The governments specialty, creating barriers to entry.
Thank you for the additional information about workloads. I've been guessing that the reason so many hospital systems (Washington University/BJC in St. Louis, specifically) have gone to NPs, supervised by physicians, is because of the cost.
However, it seems stupid to me to waste physicians' training on supervisory duties. My opinion is that doctors should perform their jobs using the various specialty skills they have spent years gaining.
Even more, the big corporate model of business needs to go. It seems to sicken and even kill people, no matter the specific business field.