Where have all my doctors gone?

I've lost two brilliant MDs. I'm not alone.

We're losing too many primary care physicians. It's all too much for both sides of the stethoscope.

When I moved back to New York City ten years ago, I spent a lot of time looking for a great diagnostician to be my primary care doctor (PCP). I did my homework. I spoke with my revered specialists to see who they used. I called and emailed NYC-based family and friends, both medical professionals and civilians, to see if they loved their internist. So few were happy with the level of care they received; it was dispiriting, to say the least.

I thoroughly researched the few names I received to see if they took my insurance, what medical school they attended, where their residency was, have they published, what were the reviews of their one-on-one in the exam room diagnostic quality and results. I ignored the reviews of rude receptionists and billing departments. I wanted a brilliant mind. I truly didn’t care about the decor or how easily the paper gowns ripped.

It was not a successful quest.

The first highly recommended primary doctor met to review my prescriptions and ask me about my general health. I had three medical concerns: some numbness in one leg, right arm pain from what I surmised was a torn ligament when I stupidly moved a heavy box with extended arms (I had heard it snap), and a great deal of gastrointestinal pain. After decades of IBS, I knew what I was experiencing was not that. She never touched me, dismissed all my symptoms, told me my knee was numb because I was wearing leggings, and prescribed two Aleve twice a day for the arm pain. All three were diagnostic errors. The hepped up Aleve took a mild gastric issue and turned it into a major ulcer, the numbness in my knee was due to a spinal issue, and the right arm did have a torn ligament and needed rest followed by PT.

The next one, also well recommended and researched, spent our precious exam and office time sharing New Year’s Eve fireworks videos from all over the world while dismissing some bizarre and mysterious symptoms I had been experiencing.

Finally, thanks to inspiring physician, speaker, author Danielle Ofri, I found a wonderful diagnostician. He was an excellent listener, provided thorough exams, gave me good guidance for my medical mystery. [It took a total of four years to solve. Fodder for another article one day.] He was neither dismissive nor an alarmist.

Then, at my November 2022 annual checkup, my wonderful internist said goodbye. This was his last day. The prior two years of Covid were overwhelming and debilitating. He said he had no plans but expected he would take at least a full year off from practicing medicine and patient care. I asked if he had a noncompete with his current practice and he silently nodded. Behind the mask, and the clear plastic shield, I could see that he looked tired, thinner in his oversized white medical coat. I felt great empathy for him at the same time I experienced panic for myself. How was I going to find another great diagnostician like him?

A month later, we moved from New York City to Stamford, Connecticut, a small city less than one hour from Midtown Manhattan. So, I started my search again.

This time it was harder to find a great diagnostician. I still live very close to a world-class hospital system so I started there. Again, phone calls to family and friends in the area, researching backgrounds and reviews, checking insurance accepted. I discovered that most of the physicians who had been highly recommended and fit my criteria had closed their panels to new patients.

I found one who had all of the qualifications I was seeking — the reviews talked about her kindness, her expert listening skills and her excellent diagnostic skills. According to the website, she was open to new patients. However, when I called the practice, they told me that as of the week prior, she had closed her panel to new patients.

I begged and pleaded. I advocated for myself. I explained that my doctor had just retired, and I had my annual check up only a month prior. I assured them that I would not be a drain on the practice. I already had all of my specialists in New York City. All I would need was an annual check up in 11 months, and refills of my prescriptions when they ran out.

The staff checked, and the doctor agreed that I could join her panel of patients. We met briefly a few months later to review my prescriptions and medical records and to discuss my questions or concerns. I enjoyed our wide-ranging conversation. We spoke about the state of healthcare and about my focus on patient safety, and diagnostic error. She asked me a lot of questions. And I looked forward to working with her for years to come.

Then, one year after my prior physician quit medicine, I visited my new MD crush for my 2023 annual checkup. The atmosphere was festive; like the way an office feels during an employee birthday party. Half-eaten plates of cake sat on a couple of desks, the doctors dog was making exam room calls, and I thought, I love this practice.

And that's when I learned that it was her last day. She wasn't burned out from Covid. Instead, she was done dealing with the corporate overlords of her medical practice interfering in her ability to care for her patients. That's my phrase, not hers. But what she described was all too familiar. Physicians had banded together in corporate structures so they could share the difficulties of dealing with insurance companies’ ever growing requirements for documentation. They wanted to take advantage of being part of a large group so all the back room needs, the billing and insurance functions, the scheduling and testing, could be streamlined leaving the physicians to focus on patient care.

Sadly, over the decades, the back room functionaries have become the gatekeepers of the practice’s profitability. Instead of just easing the physician’s workload, they started to meddle with which tests could be ordered or how much time the physician could spend with a patient and which computer systems they had to learn and use.

And I lost another brilliant mind.

I'm not alone. And it's not just Covid.

We are losing primary care physicians and specialists, and have been for years. In October 2023, American Medical Association’s president Jesse M. Ehrenfeld, M.D., MPH stated, “It’s estimated that more than 83 million people in the U.S. currently live in areas without sufficient access to a primary care physician.”

Recent forecasts of supply and demand for internal medicine and family medicine practitioners indicate the shortage will worsen. By 2036, there will be 22 percent fewer family medicine practitioners and 24 percent fewer general internal medicine practitioners than we will need. In 2018, we had just 7.5 percent fewer family medicine doctors and 9.3 percent fewer internists than were needed. And the numbers are much worse in rural areas.

An international survey in 2018 compared the United States’ share of practicing physicians that are specialists and generalists against similarly economically successful countries and we were woefully inadequate. Just 12 percent of our doctors were generalists in 2018 compared to 48 percent in Canada and 26 percent in the United Kingdom.

It’s not just money, either, although general physicians are in the lowest 20 percent of doctor’s salaries. Plastic surgeons earn over $600 thousand a year compared with less than $275 thousand for primary care doctors like pediatricians, family medicine and internal medicine doctors.

According to Dr. Ehrenfeld the physician shortage is due to “enormous administrative burdens, burnout, attacks on science, increased consolidation across health care, a broken Medicare payment system, and health crises that worsen each day.”

In a recent speech he said, “Physicians everywhere [are] frustrated, burned out, abandoning hope … and in increasingly worrying numbers, turning our backs on the profession we’ve dedicated our lives to.”

As patients, we are not in a position to solve this.

We are left to find the best diagnosticians we can. If you have a primary care doctor who listens to you and is willing to stick with you to figure out what is happening, count yourself among the luckiest.

If you live in a medical desert — a rural area or an urban neighborhood where there aren’t enough physicians — you will have to get creative or being willing to travel. Do your research before you become ill. Find a local clinic or practice to do all your screenings and catch any problems while they are still small. Keep up with your vaccinations.

And be open-minded. Your best diagnostician may not be an MD. They may be a nurse practitioner (NP) or physician assistant (PA). If you have a specialist already, ask them for a recommendation of a primary care doctor. Ask your children's teachers who they go to. Speak with your local librarian. Chat with your dentist, your gynecologist, your friend’s sister, who is a nurse.

When you get a recommendation, check the doctor’s credentials and confirm that they have an up-to-date board-certified medical license to practice. Finally, if you have medical insurance, visit the website and look at the list of primary care, doctors, family, medicine, doctors, geriatricians, and pediatricians they have on their list.

Good luck. And may the odds ever be in your favor.

© Helene M. Epstein 2024