When we were kids, everybody had a family doctor. Sometimes we went “over city” to Essex Street in Lawrence to see him, other times he came to our house. His name was Leonard Bennett Ainsworth, and he was just one of a vast army of family doctors in town, people you could actually call if you were sick and get an appointment with the next day. It was a little scary going to see Doctor Ainsworth because sometimes there were needles involved or other disagreeable surprises, like when I was in the second grade and was told I had Rheumatic Fever. In those days, nobody ever got a second opinion, the diagnosis of the family doctor was always sacrosanct, so I missed all but two months of school and the greatest snowfall in twenty years. Despite the cold weather, my sympathetic mother sometimes let me open the living room window and talk to the frolicking kids outside. In retrospect, I don’t think I really had Rheumatic Fever, which I was advised would likely return around age thirteen, but didn’t. Due to my mother’s constant use of flash cards, I learned my multiplication tables and got promoted to third grade anyway. Go ahead---ask me how much is eight times seven.
I’m not sure I needed my tonsils out, either. I mean, how do you know? Who gets his tonsils out these days, and what’s different now? Nonetheless, one day I thought I saw Doctor Ainsworth’s car pull up in front of our house and I went to tell my mother, who pretended she didn’t know he was coming. The doctor was there with his crew of assassins to take out my tonsils on the kitchen table and everybody thought it best to keep me in the dark. I put up a pretty good fight and used excessive profanity my mother was shocked to hear, but I was sorely outnumbered and the inevitable ether rag came down and put me out of commission. My parents tried to buy my forgiveness with ice cream the next day but I was able to maintain a sulky front for about a week. I wasn’t too trusting of the knighted Dr. Ainsworth after that, or my mother either, for that matter.
My sister Alice (the Republican) loved her doctors, and no wonder. At the drop of a hat, her asthma would act up and three minutes later she looked like an original member of the Blue Man Group. Alice was in the hospital more than Marcus Welby, M.D. and kept her asthma doctor beside her in a golf cart at all times. “How about another shot of adrenaline, Alice?” “Don’t mind if I do, Doctor Who!”
Love ‘em or leery of ‘em, our doctors had the superpower of Availability. They were like members of the family, knew everyone’s name and history and where we all lived. When you went to their offices, you did not wait an hour to see them and when you did, you got a lollipop and a pat on the head. We thought our doctor-patient relationships would be like that for eternity. We could not have been more wrong.
“If This Is An Emergency, Please call 911.”
“If it isn’t, go soak your head. We’re busy with our telemarketing customers, our gym workouts, our golf games. Friday appointment? Not an option, that’s the day we sop up our halotherapy, suck in healing NACL and improve our immune function in the salt room. But Nurse Annie here will take care of you and answer all your questions if they’re not too difficult. Don’t forget to bring your co-pay card.”
All that is assuming you can find a viable doctor in the first place. Docs independent of family practice groups are rare as septuagenarians’ teeth and some of those family practice outfits are run by people who look suspiciously like Doctor Phil. I had an edgy doctor myself for several years, selected by virtue of his New Age credentials and willingness to push the envelope on occasion. Unfortunately, he morphed into a reactionary twit and would only prescribe Ivermectin horse wormer when I needed Paxlovid, so he’s somewhere under the bus. Finding a replacement was a chore, and when I did the office staff was Lucy-In-The-Chocolate-Factory nuts. One day, I waited 35 minutes past appointment time, then left. They called an hour later to tell me the doctor was ready to see me. “I can’t say the same for myself,” I told them. They told me if I didn’t come back, I would no longer be a client. “Now you get the idea,” I said.
Where Have You Gone, Doogie Houser-o, Our Nation Turns Its Weary Eyes To You?
The National Center for Health Workforce analysis reports that in 2022 there were 279,194 primary care physicians in the USA, which meant there were 270,660 Nurse Practitioners delivering primary care. According to the Association of American Medical Colleges, by 2034 there will be a shortage of 124,000 physicians, which will be particularly acute in nonmetro areas like, say, Williston, where on an average day you will find exactly no doctors. This is why colossal medical centers like UFHealth are spreading their wings and popping up everywhere. If they are slow to enroll new clients and offer only rotating doctors who mature out after one or two years for greener pastures, they’re still better than the alternative. What happened, anyway, to a medical field which once drew zillions of excited new faces eager to put up their own shingles?
First of all, aging happened, creating a growing demand for healthcare services. Next, fewer candidates started appearing at medical schools, and those who graduated were less interested in primary care. Third, the number of primary care providers who are entering retirement continues to grow. More than 2 out of every 5 physicians in the U.S. will be 65 or older in the next decade. Additionally, public health crises like the COVID-19 pandemic, which spike the demand for primary care, put an additional strain on primary care doctors and made the challenge of meeting patients’ needs all the more daunting. Altogether, a perfect storm leading to the current medical miasma.
U.S. health care staffing shortages aren’t unique to primary care physicians. While lower starting salaries have contributed to fewer primary care providers, the number of working registered nurses has also been declining for almost three decades. The shortage began in the early 1990s, when health insurance providers initiated cost-cutting policies. Licensed, experienced nurses were replaced with less skilled aides and the layoffs made the profession unattractive to those who had other career prospects. Oy vey, Marty, whadda we do? Let’s take a look:
The Empire Strikes Back
Many medical students start out expressing interest in primary medical care. Then they wind up at schools based in academic medical centers, where it’s common to become enthralled by complex cases in hospitals while witnessing little primary care. The driving force is money, says Andrew Bazemore, a physician and senior vice-president at the American Board of Family Medicine. “Subspecialties tend to generate a lot of wealth,” says he, “not only for the individual specialists but for the whole system in the hospital.”
A department’s cache of federal and pharmaceutical company grants often determines its size and degree of prestige. And at least 12 medical schools, including Harvard and Yale, don’t even have full-fledged family medicine departments. Students at these schools can study internal medicine, but many of those graduates end up choosing subspecialties like gastroenterology or cardiology, and there’s a glut of candidates seeking to be dermatologists.
One potential solution is to eliminate tuition in the hope that debt-free students will take the medical path less followed. In 2024, two elite medical schools---the Albert Einstein College of Medicine and the Johns Hopkins University School of Medicine---announced that charitable donations are enabling them to waive tuition, joining a handful of other tuition-free schools.
Some schools find ways to produce significant numbers of primary care doctors through recruitment and programs that provide positive experiences and mentors. U.S. News & World Report recently ranked 168 medical schools by the percentage of graduates who were practicing primary care six to eight years after graduation. The top ten schools are all osteopathic medical schools, with 41-47% of their students still practicing primary care. Unlike allopathic medical schools which award M.D. degrees, osteopathic schools award equivalent D.O. degrees and have a history of focusing on primary care; these schools are now graduating a growing share of the nation’s primary care physicians.
The University of Washington, number 18 in the rankings with 36.9% of graduates working in primary care, has a decades-old program placing students in remote parts of Washington, Wyoming, Alaska, Montana and Idaho. UW recruits students from those areas and many go back to practice there, with more than 20% of graduates settling in rural communities, according to Joshua Jauregui, assistant dean for clinical curriculum.
Likewise, the University of California-Davis, number 22 in the rankings with 36.3% of its graduates in primary care, increased the percentage of students choosing family medicine from 12% in 2009 to 18% in 2023, even as it ranks high in specialty training. Programs such as an accelerated three year primary care “pathway,” which enrolls primarily first-generation college students, helps sustain interest in non-specialty medical fields.
The American Medical Association says that other solutions are not that difficult to find. The process starts with removing the multitude of administrative headaches that fuel the burnout and early retirement of many physicians. A second critical solution is reforming a bumbling and antiquated Medicare payment system that has seen physician reimbursement drop by more than 33% since 2001, creating financial hardships especially for independent practices. A third solution lies with greatly expanding the number of Medicare-funded graduate medical education residency slots, with particular emphasis on primary care. The AMA enthusiastically supports the newly introduced Resident Physician Shortage Reduction Act of 2025, which would add 14,000 Medicare GME positions over seven years and codify the Rural Residency Planning and Development Program. This bipartisan measure would help insure that patients have access to well-trained physicians in their communities by expanding training opportunities in both urban and rural hospitals with the greatest workforce needs.
Until then, however, we’re in the medical shitter. Come back wherever your are, Leonard Bennet Ainsworth, all is forgiven. Well, almost all. We’re still having nightmares about medicos in SWAT uniforms carrying ether rags.
That’s all, folks….
