This is such a necessary question, because concierge medicine sits at the collision point of two truths clinicians live with every day: time matters for quality, and access matters for justice. From a physician perspective, concierge care can be ethically defensible when it’s framed as paying for time and coordination( long visits, proactive prevention, careful follow-up, same-day access), especially in a system that chronically under-reimburses cognitive care. It can reduce fragmentation, improve adherence, and help patients navigate complex risk management. But the ethical tension is real: if concierge models pull clinician capacity away from everyone else, they can widen inequity and normalize a two-tier standard of care. The key questions become: What obligations remain to the broader community? Does the practice include sliding-scale or pro bono slots, partnerships with community clinics, or a hybrid model that preserves access? And are we transparent that what’s being sold is time and service, not “better medicine” or guaranteed outcomes? I appreciate posts like this because they move the conversation beyond virtue-signaling into design: if we can’t fix the payment model overnight, how do we build care structures that restore time for good medicine without leaving the most vulnerable further behind?
There is a much older doc in my practice who let his boards expire about 7 years ago.
I have mixed feelings about that, because working half time and being 75 years old it would seem that it would be important to maintain academic integrity.
I have not heard, though, that he is having trouble retaining insurance contracts.
It feels like a classic case of institutional drift. The rules meant to ensure quality have become barriers that prevent experienced doctors from doing the most needed work.
Yes - with some degree of training that commensurate with your current specialty, historical practice, etc. For something like cardiology that might still be the 1 year fellowship. But for EM from FM that might be fulfilling some number of precepted hours and passing a test. I think if you’ve been practicing FM for 15 years in clinic it’s more about filling the critical care knowledge gap and learning the cadence of an ED. That probably doesn’t take a 4 year residency.
Several countries are already utilizing telemedicine as a primary care solution, reducing the burden on doctors by offering virtual consultations, which may help alleviate the primary care shortage in underserved regions.
Sorry to say that, but 80%primary care doctors will be eliminated within 10 years by “AI doctors” and midlevel providers. If you are medical student you will be wise not to even think about this field.
And many of those seeking primary care who will be unable to find it over the next decade are older. The Baby Boom celebrates its 80th birthday in two weeks while interest in geriatrics by both the American Health System and American medical graduates is cratering. I’ve been fighting institutional neglect in primary care and community based geriatrics for thirty-five years. I’m worn out by all the things you mention as I don’t see much changing as changes won’t improve next quarter’s balance sheets.
This is this is a superb article. It is an idea that was new to me. In fact I didn’t know that insurance companies exerted the control that they do on reimbursement. You offer truly practical ideas
I think that in addition to career pathways to primary care, we have to ask how our medical training culture conveyed such low regard for primary care. This is partly a chicken and egg problem. Residents see that the conditions of work and the pay are lower. They are also taught by clinicians to see the work as “less than” excellence in an academic specialty
We could blame the insurers but it is crucial to recognize that both public payors and private are heavily influenced by doctors: either those who represent their specialties in the advisory group to CMS called “the RUC” or the many doctors who go into health care administration and insurance. They reflect “us”. They exemplify and appropriate all the values they were taught in medical school and residency, one of which was the devaluation of primary care
The whole premise of this article is false- that primary care (Peds, IM, FM) aren’t really that hard and that any other specialty can do it. They can’t. And NPs and PAs shouldn’t be doing it independently either. But it’s also fair to say that another full three years isn’t needed. I think many adjacent specialties could do it with one year of residency if they can pass the board exam and another year added on if they can’t. True primary care isn’t “just” sinusitis and cold. For me in FM, it’s pregnancy, Peds, elders with 6-8 chronic medical problems where treating one can throw off the other. It’s making sure that “I have a sinus infection” isn’t a cold or a brain tumor or nasal polyp. I don’t know what everyone thinks we do all day, but it isn’t colds. When I was doing true full scope family medicine, I was delivering babies, doing colonoscopy/colposcopy/vasectomy/skin surgery, inpatient medicine, and complex clinic patients from newborn to geriatric. I defy any other specialty to be an expert at that with no further training.
But your point is my point. Currently docs with PC adjacent training just go to DPC with no added training. I think that’s maybe okay as long as they don’t misrepresent themselves. But *I* think PC is complex and wouldn’t want to do that. What training is available is minimal, has no official sanction and doesn’t confer any ability to participate in the insurance/CMS marketplace. Instead we could have actual training, that doesn’t require a repeat residency, but is sanctioned.
As a former residency director, I would like to weight in. To be a family physician means being an expert at everything that is common, regardless of organ system. It also means balancing competing concerns across organ systems. Knowing the top frequency conditions as well as an -ologist for the entire body does require more than a freshen up training; I would recommend 2 yrs w entry as a PGY2.
Primary care physicians are not technicians or cogs. Corporations treat them as such. DPC has provided a path to reclaim physician autonomy and long term relationships with patients. Both of these core principles increase a physicians longevity of practice. We become professionals again.
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.
This is such a necessary question, because concierge medicine sits at the collision point of two truths clinicians live with every day: time matters for quality, and access matters for justice. From a physician perspective, concierge care can be ethically defensible when it’s framed as paying for time and coordination( long visits, proactive prevention, careful follow-up, same-day access), especially in a system that chronically under-reimburses cognitive care. It can reduce fragmentation, improve adherence, and help patients navigate complex risk management. But the ethical tension is real: if concierge models pull clinician capacity away from everyone else, they can widen inequity and normalize a two-tier standard of care. The key questions become: What obligations remain to the broader community? Does the practice include sliding-scale or pro bono slots, partnerships with community clinics, or a hybrid model that preserves access? And are we transparent that what’s being sold is time and service, not “better medicine” or guaranteed outcomes? I appreciate posts like this because they move the conversation beyond virtue-signaling into design: if we can’t fix the payment model overnight, how do we build care structures that restore time for good medicine without leaving the most vulnerable further behind?
Lots of old ways need to be reimagined.
Very insightful article.
There is a much older doc in my practice who let his boards expire about 7 years ago.
I have mixed feelings about that, because working half time and being 75 years old it would seem that it would be important to maintain academic integrity.
I have not heard, though, that he is having trouble retaining insurance contracts.
I was trained in primary care and I won’t do it. It’s the working conditions. Fix the working conditions and docs will come back.
It feels like a classic case of institutional drift. The rules meant to ensure quality have become barriers that prevent experienced doctors from doing the most needed work.
But are you ok with it going the other direction. If I want to go from FM to EM or Cardiology should that be allowed??
Yes - with some degree of training that commensurate with your current specialty, historical practice, etc. For something like cardiology that might still be the 1 year fellowship. But for EM from FM that might be fulfilling some number of precepted hours and passing a test. I think if you’ve been practicing FM for 15 years in clinic it’s more about filling the critical care knowledge gap and learning the cadence of an ED. That probably doesn’t take a 4 year residency.
Several countries are already utilizing telemedicine as a primary care solution, reducing the burden on doctors by offering virtual consultations, which may help alleviate the primary care shortage in underserved regions.
Sorry to say that, but 80%primary care doctors will be eliminated within 10 years by “AI doctors” and midlevel providers. If you are medical student you will be wise not to even think about this field.
And many of those seeking primary care who will be unable to find it over the next decade are older. The Baby Boom celebrates its 80th birthday in two weeks while interest in geriatrics by both the American Health System and American medical graduates is cratering. I’ve been fighting institutional neglect in primary care and community based geriatrics for thirty-five years. I’m worn out by all the things you mention as I don’t see much changing as changes won’t improve next quarter’s balance sheets.
This is this is a superb article. It is an idea that was new to me. In fact I didn’t know that insurance companies exerted the control that they do on reimbursement. You offer truly practical ideas
I think that in addition to career pathways to primary care, we have to ask how our medical training culture conveyed such low regard for primary care. This is partly a chicken and egg problem. Residents see that the conditions of work and the pay are lower. They are also taught by clinicians to see the work as “less than” excellence in an academic specialty
We could blame the insurers but it is crucial to recognize that both public payors and private are heavily influenced by doctors: either those who represent their specialties in the advisory group to CMS called “the RUC” or the many doctors who go into health care administration and insurance. They reflect “us”. They exemplify and appropriate all the values they were taught in medical school and residency, one of which was the devaluation of primary care
The whole premise of this article is false- that primary care (Peds, IM, FM) aren’t really that hard and that any other specialty can do it. They can’t. And NPs and PAs shouldn’t be doing it independently either. But it’s also fair to say that another full three years isn’t needed. I think many adjacent specialties could do it with one year of residency if they can pass the board exam and another year added on if they can’t. True primary care isn’t “just” sinusitis and cold. For me in FM, it’s pregnancy, Peds, elders with 6-8 chronic medical problems where treating one can throw off the other. It’s making sure that “I have a sinus infection” isn’t a cold or a brain tumor or nasal polyp. I don’t know what everyone thinks we do all day, but it isn’t colds. When I was doing true full scope family medicine, I was delivering babies, doing colonoscopy/colposcopy/vasectomy/skin surgery, inpatient medicine, and complex clinic patients from newborn to geriatric. I defy any other specialty to be an expert at that with no further training.
But your point is my point. Currently docs with PC adjacent training just go to DPC with no added training. I think that’s maybe okay as long as they don’t misrepresent themselves. But *I* think PC is complex and wouldn’t want to do that. What training is available is minimal, has no official sanction and doesn’t confer any ability to participate in the insurance/CMS marketplace. Instead we could have actual training, that doesn’t require a repeat residency, but is sanctioned.
As a former residency director, I would like to weight in. To be a family physician means being an expert at everything that is common, regardless of organ system. It also means balancing competing concerns across organ systems. Knowing the top frequency conditions as well as an -ologist for the entire body does require more than a freshen up training; I would recommend 2 yrs w entry as a PGY2.
Is this true or all countries or just the United States?
Well said! This same argument would apply in the UK too.
Primary care physicians are not technicians or cogs. Corporations treat them as such. DPC has provided a path to reclaim physician autonomy and long term relationships with patients. Both of these core principles increase a physicians longevity of practice. We become professionals again.
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.