Primary care supply and access challenges around the world

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.

Smartwatch screening for hypertension

An analysis of 2021-2023 National Health and Nutrition Examination Survey (NHANES) data found that among nonpregnant adults with hypertension (defined as systolic blood pressure 130 mm Hg or higher, diastolic blood pressure 80 mm Hg or higher, or use of antihypertensive medication), nearly 80% had a mean of three blood pressure (BP) measurements higher than 130/80 mm Hg. Of this group with uncontrolled BP, based on some practice guidelines, fewer than 40% were taking antihypertensive medications. Although undertreatment of high BP may result from therapeutic inertia, many adults do not have a regular source of care and simply do not know that they have hypertension.

Identifying undiagnosed hypertension is the goal of the Apple Watch’s hypertension notification feature, which was cleared in September 2025 by the US Food and Drug Administration for use in nonpregnant people 22 years or older. The watch is not a substitute for a home BP monitor, and it does not provide individual BP measurements. Instead, it uses an optimal sensor that collects photoplethysmography (PPG) data during waking hours over 30-day intervals, analyzes that data with a machine-learning algorithm, and alerts the wearer if hypertension is suspected. The alert encourages patients to monitor their BP at home for 7 days and consult their doctor about next steps.

A clinical validation study involving more than 2,000 participants found that the Apple Watch correctly identified 214 of 585 people with BP of 130/80 mm Hg or higher (sensitivity = 41.2%) with a specificity of 92.3%. The alert’s positive and negative likelihood ratios were 5.35 and 0.64, respectively. In a research letter in JAMA, Dr. Jordana Cohen and colleagues applied the Apple Watch’s screening performance characteristics to the nationally representative NHANES population. The researchers calculated the posttest probabilities of hypertension after a positive or negative alert based on the prevalence of hypertension in different subgroups:

Among eligible individuals aged younger than 30 years, an alert increases the probability of hypertension from 0.14 (95% CI 0.11-0.17) to 0.47 (95% CI 0.39-0.56), wherein the absence of an alert lowers it to 0.10 (95% CI 0.07-0.12). Among individuals aged 60 years or older, an alert increases the probability of hypertension from 0.45 (95% CI 0.39-0.50) to 0.81 (95% CI 0.76-0.86) and the absence of an alert lowers it to 0.34 (95% CI 0.29-0.39).

Similar to the heart-rhythm monitoring and obstructive sleep apnea detection features of various wearable consumer devices, the Apple Watch’s hypertension screening feature may nudge some patients to seek appropriate care for an undiagnosed chronic condition. For others, it may cause unnecessary anxiety or provide false reassurance. Given the popularity of these devices, though, smartwatch screening for hypertension will become increasingly common.

**

This post first appeared on the AFP Community Blog.

Continuity of care: health benefits and compensation

Continuity of care—a trusting relationship with a personal physician based on recurring interactions over time—is an essential ingredient of the secret sauce of family medicine. Numerous studies have demonstrated that higher care continuity is associated with more appropriate care and lower costs. Data also support positive effects on health outcomes. A retrospective analysis from Alberta, Canada, reported that physician and clinic continuity (seeing a clinical partner when one’s primary physician was unavailable) correlated with fewer emergency department visits across all levels of patient complexity and fewer hospitalizations for highly complex patients. A similar US cohort study of Medicare fee-for-service claims from a nationally representative sample of 4,940 medical practices found that patients with higher primary care physician continuity were 5.5% to 6.8% less likely to be hospitalized and 4.9% to 6.3% less likely to visit the emergency department.

In 2023, the Accreditation Council for Graduate Medical Education changed the emphasis of family medicine resident training requirements from volume of encounters to continuity of care. In a special article published in Family Medicine, Dr. Gregory Garrison and colleagues described five domains of care continuity. In addition to traditional clinician-patient or “relational” continuity, they discussed benefits of informational (medical record), managerial (interdisciplinary care), family (caring for multiple family members), and geographical (care in multiple locations or environments, such as home, office, and hospital) continuity.

Unfortunately, the percentage of the US population who experience continuity of care has been decreasing since the turn of the century. A 2015 Graham Center Policy One-Pager found that fewer adults reported a personal physician (as opposed to a practice or facility) as their usual source of health care. From 2000 to 2019, the percentage of US patients who reported having a usual source of care declined from 84% to 74%.

To support continuity and compensate primary care clinicians for the additional complexity and cognitive load involved in these longitudinal relationships, the Centers for Medicare and Medicaid Services (CMS) introduced the add-on G2211 code in January 2024 and refined its use in 2025. Some private health insurers also recognize and pay for this code. A 2024 Graham Center analysis projected that applying the G2211 code to all eligible Medicare evaluation and management (E/M) visits would increase annual reimbursement by an average of $2,667 per physician. Attaching the G2211 code to E/M visits with 25 modifiers (approved by CMS in 2025) resulted in another $990 per physician. This year, G2211 codes also can be applied to home-based primary care visits. Relative to the established benefits of care continuity, the added compensation seems modest at best. In addition, a research letter published this week in JAMA found that in 2024, the largest share of G2211 codes (43%) was billed by specialist physicians, not primary care physicians (40%), many for diagnoses "that may not qualify as serious or complex" as CMS originally intended.

**

This post first appeared on the AFP Community Blog.

RFK Jr. is making measles great again: why it matters to everyone

2025 was a banner year for the measles. 2026 is already looking like it will be much worse.

Last year, there were more than 2,200 confirmed measles cases in the U.S., the highest number since 1991. More than 1 in 10 infected persons became sick enough to be hospitalized, and 3 people died.

This year, an ongoing measles outbreak in northwest South Carolina is up to 876 cases, more than 500 of which occurred after January 1. The first 5 cases of measles in Pennsylvania were just diagnosed here in Lancaster County. Measles spreads like wildfire. Vaccination denies it fuel. But county-level measles, mumps, and rubella (MMR) vaccination coverage has been falling for the past 5 years, creating pockets of vulnerability due to low immunity - perfect tinder for a highly contagious virus.

Now, you may wonder why this worsening epidemic should matter to you personally. If some people, for whatever reason, fear the MMR vaccine more than the measles (and mumps, and rubella), or want their "health freedom" so badly that they are willing to risk their well-being or that of their children, to each his own. You got your MMR vaccine as a child and made sure that your children did, too. You may sympathize with doctors and public health workers who have to clean up the mess that antivaxxers like Andrew Wakefield and Robert F. Kennedy, Jr. have made, but your good choices mean than you are protected, right?

Yes and no. Setting aside the issue that infants can't be vaccinated against the measles until they are 6 months old (and don't routinely receive their first dose of MMR vaccine until they turn one), those who have received two doses of measles vaccine are 97% protected against developing the measles from an exposure. On the individual level, 97% is about as good as it gets. That's much better protection than vaccines against Covid-19 or influenza or practically every other vaccine. But on a population level, because measles is so incredibly contagious, a kid with measles could attend school where every one of other the 500 students had received 2 doses of MMR, and 15 kids could still catch the virus. Someone with the measles could go to Disneyland, expose thousands of fully vaccinated people, and spread it to dozens.

An article in last week's Morbidity and Mortality Weekly Report described a measles outbreak investigation associated with an unvaccinated traveler who caught the measles in Colorado, then went to the airport in Denver and boarded an international flight. Epidemiologists painstakingly identified at least 17 measles cases that could be traced back to this traveler. Of the 9 cases in Colorado residents, 5 caught it at the airport and 4 on the flight. What I found striking was that 4 of the 9 had received two doses of MMR vaccine. Someone who doesn't understand statistics might look at that figure and say, well, the vaccine must not be very effective. Wrong: it's 97% effective. What almost certainly happened is that the index patient exposed at least 100 people at the airport and on the plane, most of whom were vaccinated. The unvaccinated people all caught the measles, while a few of the vaccinated did too.

Measles was once a common childhood illness. Thankfully, most of the time it resolves without any need for medical intervention. (That doesn't mean that patients don't experience significant suffering - take it from someone who caught chickenpox at age 16 and missed two full weeks of school, a few years before the varicella vaccine was approved.) But most of the time isn't all of the time. Per the MMWR article: "Complications occur in approximately 10% of patients with measles, including ear infections and diarrhea; serious complications including pneumonia (5%), encephalitis (0.1%), and death (0.1%–0.3%) also occur." Though rare, being unable to breathe, becoming comatose due to brain swelling, or dying are all real consequences of the measles. As a family physician who provides hospital care, I've seen plenty of patients with these complications as a result of other conditions that I can't prevent with two shots. I don't want to see them from an infection that is almost completely preventable. But as the measles wildfire burns on, and more communities become tinder, it's only a matter of time until I do.

Preventing RSV bronchiolitis in infants

In young infants, bronchiolitis caused by respiratory syncytial virus (RSV) is a common cause of hospitalization, with an annual incidence of 17.9 hospitalizations per 1,000 infants two months or younger in the United States. Although 4 in 5 children hospitalized for RSV have no risk factors, until 2023, prevention strategies for healthy term newborns were limited. That year, the US Food and Drug Administration approved two new options: the monoclonal antibody nirsevimab and maternal vaccination with a bivalent RSV vaccine, both of which are discussed in a STEPS new drug review in American Family Physician. (In June 2025, a second monoclonal antibody, clesrovimab, became available in the United States.)

In a multicenter randomized trial involving more than 8,000 infants, RSV hospitalization occurred in 0.3% of the group that received nirsevimab during the first winter of life compared with 1.5% of the usual care group (NNT = 83). A study of pediatric emergency departments in Spain found that universal RSV prophylaxis with nirsevimab beginning in the 2023-2024 season was associated with decreases in acute bronchiolitis, related hospital admissions, and pediatric intensive care unit admissions of 59%, 63%, and 63%, respectively. Similarly, infants up to 6 months of age whose mothers received RSV vaccine had a lower likelihood of medically attended severe RSV (0.5% vs 1.8% in the control group; NNT = 81). A Cochrane review of six randomized, placebo-controlled trials confirmed the benefits of RSV vaccination during pregnancy, and a retrospective cohort study of more than 54,000 pregnancies found no increases in preterm birth, premature rupture of membranes, or hypertensive disorders of pregnancy.

The American Academy of Pediatrics, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists recommend routine maternal vaccination or monoclonal antibody administration to prevent RSV infections in infants. Two studies at different institutions found that total uptake (vaccine or nirsevimab) was more than 80%, with acceptance of nirsevimab even in individuals who declined other maternal or infant vaccines. In one of the studies, 43% of parents who refused RSV, influenza, and Tdap vaccines during pregnancy consented to nirsevimab for their newborns. As a result, RSV hospitalization rates during the 2024-25 season were 41% to 51% lower than expected rates and rates in prior years, with the largest benefits observed in infants younger than 2 months.

Presented with two equally recommended prevention options, parents may ask whether one is more effective than the other. Although no head-to-head trials have occurred, a population-based cohort study in France found that compared with infants who were protected by maternal vaccination, those who received nirsevimab had lower risks of RSV hospitalization (adjusted hazard ratio = 0.74) and severe respiratory outcomes, including pediatric intensive care unit admission and the need for oxygen therapy and mechanical ventilation. It is unclear how to apply this finding to the United States, where neither prenatal nor well-child care are universally guaranteed. In a pregnant patient between 32 and 36 6/7 weeks gestation from September 1 through January 31 who is willing to receive RSV vaccine, it makes more sense to vaccinate than to wait to give a monoclonal antibody to the newborn.

**

This post first appeared on the AFP Community Blog.

Safely stopping screening for cervical cancer

All cancer screening tests have diminishing benefits and increasing harms as people age. An article in the December 2025 issue of American Family Physician reviewed considerations for discontinuing cancer screenings in older adults. For cervical cancer, the authors observed that 21% of new cases and 38% of deaths occur after 65 years, the usual age to stop screening. Notably, this stopping age applies only to patients without conditions that put them at high risk of cervical cancer (eg, HIV infection) who have had adequate prior screening, defined as “three consecutive negative cytology results or two consecutive negative cotesting results within 10 years.”

In a recently published guideline, the American Cancer Society (ACS) clarified that the last negative test before exiting cervical cancer screening should occur “at an age no younger than 65 years,” with primary human papillomavirus (HPV) testing at 60 and 65 years of age being preferred. The ACS reiterated its previous recommendation that clinicians continue screening beyond 65 years in those with a history of grade 2 or greater cervical intraepithelial neoplasia within the past 25 years.

An analysis of data from the 2013 and 2015 National Health Interview Surveys found that nearly 1 in 5 women 61 to 65 years of age had not been screened for cervical cancer with a Papanicolaou test in the preceding 5 years. Even in those with a more recent test, determining eligibility to stop screening after 65 years can be challenging. A retrospective study of electronic health records of 42,000 patients older than 65 years in two health systems in Dallas and Boston determined that 69% were not eligible to stop screening because “too few screening tests were documented”; nonetheless, 84% of these patients received no further screening. Of the 16% who continued screening, 2% had high-grade precancerous lesions detected, and 0.7% were diagnosed with cervical cancer.

Clinical studies of cervical cancer screening did not enroll women older than 65 years, so the evidence for the stopping age is derived from a modeling study commissioned by the US Preventive Services Task Force (USPSTF) to support its 2018 recommendations. (The USPSTF released a draft recommendation update in December 2024 that continues to support stopping screening at 65 years in women with adequate prior screening who are not otherwise at high risk of cervical cancer.) A large cohort study sponsored by the National Institutes of Health aims to add to this evidence base by estimating the effects of stopping vs continuing screening after 65 years on cancer outcomes and medical complications resulting from diagnostic procedures and surgical interventions.

**

This post originally appeared on the AFP Community Blog.