Match Day on March 21, 2025 unfolded similarly to the National Resident Matching Program in previous years. My program successfully recruited a full class of 13 future interns from medical schools across the country, but family medicine as a whole, despite the typically rosy American Academy of Family Physicians news story, didn't even come close, with 15% of slots unfilled and a quarter of programs needing to enter the Supplemental Offer and Acceptance Program (SOAP, previously known as the "Scramble"). The sub-headline from a Medscape news article said it all: "Anesthesiology Still Hot, Family Medicine Is Not."
Before becoming a core faculty member at the Lancaster General Hospital Family Medicine Residency Program, I spent more than 15 years teaching in Georgetown's family medicine department. Part of my job was to encourage students' interest in primary care careers and mentor those who chose to enter family medicine. Out of a typical graduating class of 200 students, our largest family-medicine bound group was 15 (7.5%) and the smallest was 6 (3%). Most years, two or three times as many students matched into Anesthesiology or Orthopedic Surgery.
While I'm grateful for subspecialists who alleviate pain, rescue patients who are unable to breathe on their own, manage complicated fractures, and replace worn-out hips and knees, the gap between the number of family doctors we need and the number we have keeps getting wider. The number of visits to primary care physicians fell by 43% from 2010 to 2021 despite 7.4% growth in the U.S. population, and a near-doubling in outpatient visits to advanced practice providers (the majority of whom work in medical subspecialties) wasn't enough to make up for this deficit. Challenges in accessing timely primary care affect not only private practices and health systems, but also the publicly funded Veterans Affairs system.
How can we train more family physicians? A recent study in Family Medicine found that contrary to conventional wisdom, more graduating students switch in to family medicine from another specialty than switch out of it after intending on family medicine upon matriculation. (I'm an example of this pattern, having intended to become a pediatrician when I started medical school.) Although this doesn't diminish the importance of nurturing students who (like my wife) declare their interest in family medicine starting on day one, it seems to make representation on admissions committees less critical. Other proposals include streamlining pathways for international medical graduates to enter residency programs in fields with physician shortages.
A report funded by the Milbank Memorial Fund highlighted five states - Virginia, Rhode Island, Connecticut, Oklahoma, and California - that are or will be setting spending targets for primary care as a percentage of their overall health care spend in order to increase their supply of clinicians and give practices more of the resources they need to improve health outcomes. This is, to put it mildly, easier said than done, starting with how to define primary care, estimate the health care dollars flowing into it, and determine the optimal percentage of those dollars. And if you build it, will they come?
We can hope and pray that some combination of interventions in premed programs, medical school, residency, and financial compensation will build the primary care infrastructure that America needs and prevent our health outcomes from getting much worse than they already are. But we need more research to design and implement these efforts. Dr. Rochelle Walensky, who directed the Centers for Disease Control and Prevention (CDC) from 2021 to 2023, calls the current state of affairs an "evidence emergency":
There is no more urgent research need than addressing the health of the workforce that is charged primarily with caring for the people of its nation. And yet, there is neither a funding stream nor a cohesive research community to do so. An investment in the evaluation of initiatives to strengthen the physician workforce is critical, and such research should not be conducted in silos. Data must be shared and evidence compiled and then directly interpreted and acted on for program and policy decision making.
Foundations such as Milbank, the Kaiser Family Foundation, and the Commonwealth Fund can't support this work by themselves. This is where the federal government must step up. But the Trump administration's radical shrinking and restructuring of the Department of Health and Human Services (HHS), which decimated the workforces and research grant-issuing functions of the better-known National Institutes of Health and the CDC, has also vanished the agency responsible for supporting health services research. According to HHS, the Agency for Healthcare Research and Quality will be merged into an "Office of Strategy," and the Health Services and Resources Administration (HRSA), which supports the backbone of federally qualified health centers that provide primary care to 1 in 11 Americans, will be consolidated into RFK Jr.'s "Administration for a Healthy America." To use a professional football analogy, it's as if the general manager of the team with the league's worst record used their premium draft picks to select a bunch of recreational players who wouldn't have been drafted by any other team in the first place. Instant analysis: a failing grade for HHS.