Where Have all the Doctors Gone?

Why It's Hard to Find a Primary Care Doctor and What Can We Do About It

“Hey”, an acquaintance from my gym grabs me after spinning class. “Can you recommend a doctor for my husband? He’s terrible about going for care and he doesn’t have an internist.”

“You mean he needs primary care, right?”

“Yes. He needs a physical and I think he needs colon cancer screening. He definitely wants a male doctor. He won’t be comfortable with a woman. And he says not too young, but also not old. 40’s or 50’s, I guess.”

“Well,” I reply hesitantly, “that’s a really tall order. A lot of primary care doctors are women these days. But I’ll cast my net and see what I can find for you.”

At home, I rack my brain for options. I call a medical school classmate, but he says his practice is closed; he has way too many patients already. “Please don’t beg,” he tells me. I gave in to other people who begged and now I’m completely overloaded.”

I try a younger man at a practice where I used to see patients. He’s a great doctor, a little younger than requested, but competent and confident. “I’d love to help you, but I’m getting ready to move to Iowa City in two months. There’s a practice there that offered me a big signing bonus and full student loan repayment. And the cost of living is lower there than here in Philly.”

My last call is to a doctor in a large academic practice in the city. He was a resident when I was a young attending at the medical center he is affiliated with. He’s got a nice bedside manner and is well-trained. “Sure I can take a new patient. But there’s a catch. My practice is starting a concierge program. Half of us will be concierge doctors, the other half will continue to accept insurance without an additional fee. I’m going to be one of the concierge docs. My annual fee will be $5000 per patient.”

Wow, that’s a hefty fee. If my friend’s husband is reasonably healthy, he won’t want to pay an annual fee to get access to a doctor. I’m not surprised that such a practice is developing a concierge program. In concierge medicine, patients pay a yearly fee to see the doctor they have chosen, usually with upgraded ‘service’ guaranteed, including phone access 24/7, sick visits available during the week, and extra time at each appointment. Not every doctor can do this. It works best when a doctor has a loyal patient base that has the financial means to sign up for concierge service. It cuts down on the number of patients on the doctor’s panel, so there is more time and energy for the patients he does have. The office can bill insurance in addition to the concierge fee, so the income generated is much improved.

A hospital-affiliated practice cannot have all of its primary care doctors working in a concierge model, as healthcare institutions need to ensure access to patients with broad demographics, including those who cannot or don’t want to pay for a concierge physician. That makes two ‘tiers’ of primary care, depending on wealth. This is a concept doesn’t feel quite right to me, but I understand it. It allows the doctors in those practices to have a much better quality of life, with better work/life balance. They are not overwhelmed by large patient panels, and they can give patients the attention they deserve.

Fees for concierge care range from under $1000/year to tens of thousands of dollars per year. Some practices have different models, such as ‘membership’ practices, where a modest supplemental fee allows access to care but not necessarily much else in the way of amenities. This boosts revenues but only modestly reduces the number of patients on the doctors’ panel.

In any case, I returned to my gym acquaintance with the news that two out of my three recommendations are not going to work, and the third will only work if her husband is willing and able to pay a concierge fee.

“There’s nobody else you can recommend?” she asks.

“Nobody male and in the right age group. Would he consider a much younger person, someone in early career? Or a woman? I can tell him all about how women physicians have improved patient outcomes! Honestly, I’d have a whole lot more options for you if he’d be flexible.”

She told me she’d talk to her husband and get back to me.

In Philly, if you need a cardiologist or a pulmonologist, I can get you in within two weeks. An orthopedist or sports medicine? Probably this week. But try to get in to see a new Primary doctor, and you might be waiting months. Even if you have a doctor, if you get sick and need to be examined urgently, you may have to go to an urgent care center or an ER. General internists open to taking new patients these days are rarer than giant pandas and may be just as endangered.

Why? There are a number of reasons that I see. Internal Medicine was once a highly respected medical field, and viewed as an intellectual specialty. I loved being and internist, a doctor for adults, because I was the person my patients came to for comprehensive care. I was the person they called ‘my doctor’.

I could never imagine taking care of just one organ system or one type of problem. To me, health was about the integration of all the organ systems, and beyond that, the integration of the body and the mind, the psyche and the environment. As an internist, I had the opportunity to treat the whole person.

Back in those days, the days of the dinosaur (1980s and ‘90s), I saw outpatients, but I also took care of my patients when they were admitted to the hospital. I knew what subspecialists my patients were seeing and what each consultant had to say. I watched teens grow up and then took care of their children when they reached 16 or older. I knew multiple generations of families. I was a confidante and advisor to many of my patients. Occasionally, in special circumstances, I made a house call.

Obviously, things have changed a lot. With increased technology and decreased lengths of hospital stays, our inpatient care was replaced by the care of other internists called ‘hospitalists’, specializing in the care of inpatients. Present in the hospital 24/7, hospitalists move patients in and out as quickly and expediently as possible. While outpatient physicians can read about someone’s hospital course in the extensive notes in the electronic medical record (EMR), we often aren’t with our patients at the times when they are most vulnerable. The EMR lets us look at consultant notes and ER visits and procedure notes and X-rays- I should know more than ever about my patients, yet it feels to me like something was lost in translation.

The economic realities of doing outpatient-only internal medicine means having a larger patient panel and seeing patients in shorter visit times. Approximately the same number of internists are trained each year now as were 20 years ago, but now a big chunk of those internists will become hospitalists, so there are also less doctors to care for outpatients.

To boot, the heady, intellectual specialty of General Internal Medicine (GIM) became the poor stepsister of subspecialists and surgeons (this applies to Family Medicine and General Pediatrics, as well). We don’t see people in the hospital and we don’t do procedures. Our job is to keep patients healthy (think vaccines, cancer screenings, lifestyle recommendations and early treatment of chronic conditions like hypertension and high cholesterol). Rather than translate into appreciation of the good health we encourage and help maintain, this translates into less money and less respect than received by those who fix what’s already broken. As the generalists, we also get the bulk of the late-night and weekend phone calls when someone is sick or injured, and the medication refill requests for the medications prescribed initially by specialists.

The erosion of trust from patients over recent years, and especially during the pandemic has also, I think, disproportionately affects generalists. Vaccines, procedures that are meant for early detection, and medications to stave off asymptomatic problems like hypertension have become more suspect, because patients are asymptomatic. In contrast, some people are more likely to trust care of symptomatic illness, in which patients are aware of a problem and want it alleviated. Caring for patients who have little confidence in your recommendations is exhausting and demoralizing.

The pandemic also caused economic hardship to outpatient doctors. Some practices shut their doors entirely; others had to lay off physicians to stay afloat. A portion of those doctors never returned to practice. The ones who did were inundated with new patients and behind on the routine care of pre-existing patients. And that leads to the elephant in the room: BURNOUT.

All in all, a perfect storm to blow away the primary care doctors. Some find non-clinical careers, such as research or the pharmaceutical industry. Some are retiring early, or cutting back hours because of burnout. Still others are finding alternative models for practice, or looking for jobs at institutions that pay better, or are known to be more concerned with work-life balance. Internists who remain in high-volume practices are finding the need to close their practices to new patients so that they can concentrate on the ones they already have.

The healthcare system in the US needs an overhaul, and part of that needs to be prioritizing primary care through financial incentives including student loan repayment and better reimbursement rates, educational initiatives, and relief from administrative burdens.

Multiple studies show that patients with a primary care doctor have better health outcomes and that the cost of care is overall lowered by receiving primary care services. Everyone needs that person they refer to as ‘my doctor.’

Next week I’ll write about how you can best find a primary care doctor who’s right for you, and what to do if you haven’t found one yet.