Although as an American family physician, I tend to focus on the primary care crisis in the United States, a recent New York Times story highlighted the familiar challenges of recruiting family doctors to rural communities in Canada. In a "Hunger Games"-style competition, cash-strapped communities with doctor shortages outbid each other with signing bonuses of up to $51,000 ($70,000 Canadian) each to foreign-trained primary care physicians who agree to move to town and start new practices. Stettler, an Alberta town that couldn't keep its emergency room open 24/7 due to a dearth of doctors, shelled out $300,000 to lure seven young physicians from Nigeria and Ghana. A Milbank Quarterly perspective by my family physician colleague Bob Phillips (the namesake of Georgetown's Robert L. Phillips, Jr. Health Policy Fellowship) and primary care leaders in the United Kingdom, Australia, Canada, the Netherlands, and New Zealand outlined how policies that deprive primary care of funding and other necessary resources have compromised care and access around the world, even in otherwise high-performing health systems.
Producing enough primary care clinicians to meet population demand is a problem worldwide, but North Americans are at a disadvantage compared to peer countries, according to the results of a Commonwealth Fund survey in this month's issue of Health Affairs. In 2022, 44 and 47 percent of U.S. and Canadian primary care physicians reported burnout, respectively, trailing only New Zealand. U.S. physicians also reported high rates of dissatisfaction and stress from 2012-2022, with a higher burden in females than males. These factors cause physicians to cut back on patient care hours or retire early, further depleting the primary care pool.
How many more primary care clinicians do we need? Traditional calculations which divide the eligible patient population by a standard panel size of 2,000 for a full-time physician fail to account for the aging population with multiple chronic conditions and the increasing complexity of medicine in general. Two recent studies used novel methods to approach this question at a national and state level. In JAMA Internal Medicine, Dr. Katherine Morgan and colleagues examined trends in the numbers of primary care clinicians accepting new patients from 2013 to 2021, with availability defined as billing >11 new visit evaluation & management codes for fee-for-service Medicare beneficiaries annually. They found a steady decline in primary care physician availability that was incompletely offset by a rise in advanced practice clinician availability. It's not only harder to find a new doctor than it was a decade ago, it's harder to find a new primary care clinician of any kind.
Dr. Jacqueline Britz and colleagues measured primary care workforce capacity in Virginia from 2016 to 2021, and their data told a similar story. Of the 4,508 primary care physicians (PCPs) practicing in the state, more than one-third are older than age 60, while only 24 percent are younger than age 50. The median number of unique patients each PCP saw in 2021 was 1,290, with each patient being seen twice per year. In order for every Virginia resident to have a PCP, researchers calculated that 1,305 additional PCPs would be needed, a 29 percent shortfall compared to an 18 percent shortfall in 2016.
One policy solution for Virginia and other states facing widening gaps in primary care supply is to open more training programs. After all, the majority of family physicians still choose to practice in the state where they were trained. (I rejoined that group when I moved back to Pennsylvania 4 years ago.) But Dr. Morgan Stickler and colleagues pointed out in a commentary that the family medicine residency Match isn't exactly a "Field of Dreams": if you build it, they don't come. Since 2012, the number of family medicine positions offered in the Match has almost doubled to 5,357, but the number of unfilled slots has quintupled from 142 to 805, involving 288 unfilled programs. The absolute number of students attempting to match in Family Medicine decreased by 16.6 percent from 2019 to 2024.
As Dr. Arch Mainous reminded us in a 2025 Family Medicine editorial, the increasing production of nonphysician clinicians and capabilities of artificial intelligence means that the family physician-dominated model of primary care could rapidly become as archaic as the "Great Horse Manure Crisis of 1894" (which ended with the onset of cars and other motorized vehicles). That doesn't mean that doctors will all be replaced by chatbots or that we don't need to find ways to remove ever-multiplying tasks from overwhelmed physicians' plates (the "everything bagel" problem). It does mean that we will need to question old assumptions about primary care scarcity and come up with creative solutions to meet the primary care needs of the future, without resorting to zero-sum competitions.
