Bridging the Primary Care Gap: Exposing Trainees to High-Performing Practices to Address the Workforce Shortage

Early in my life, I viewed primary care through the lens of a patient or family member. Through this lens, I saw primary care for what it was and what it was not. For my grandparents, in rural segregated Georgia, primary care did not exist. This meant my grandparents died too soon from preventable conditions. For my grandmother, limited healthcare access meant she died from widely metastatic breast cancer. She had never established a meaningful primary care relationship to facilitate mammogram screenings that might have detected her cancer earlier. Screening mammography was the standard recommended care for more than a decade before her death. Similarly, I imagine that my grandfather, with his elevated body mass index and lack of primary care, likely harbored undiagnosed conditions such as hypertension, diabetes, and hyperlipidemia. Silent killers were no longer silent when he collapsed on the job and ultimately died of a myocardial infarction. I can only imagine how a primary care relationship might have changed his outcome.

As an “army brat,” primary care was different for me. Born at Martin Army Hospital in Fort Benning, Georgia, and covered by Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), also known as TRICARE, I had great healthcare access and met all pediatric primary care milestones. As a healthy family, our care was straightforward, including routine checkups (albeit with different military clinicians), vaccines, and dental and orthodontic care. Our experience was characterized by accessibility and reliability, a stark contrast to the limited healthcare landscape my grandparents faced. Motivated by these personal experiences, I entered medicine to address inequities and provide primary care access for vulnerable populations like my grandparents.

As a physician and leader, I am even more convinced that comprehensive, accessible, and continuous patient-centered primary care is the cornerstone of an effective and efficient healthcare system. This view is reinforced by the 2021 National Academies of Sciences, Engineering and Medicine consensus report that found that “primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes.”¹

Despite the well-documented benefits of primary care access in improving health outcomes, the shortage of primary care physicians is worsening. Projections from the Health Resources and Services Administration (HRSA) National Center for Health Workforce Analysis project a shortage of 68,020 primary care physicians, including a shortage of 30,080 general internal medicine physicians, by 2036.² As academic general internists, advocating for and investing in highly functioning primary care teaching practices that train and recruit the next generation of primary care physicians is fundamental to addressing current and future healthcare challenges.

Primary Care Is Undervalued

Primary care is often not given the prominence it deserves in medical training. Trainees’ perceptions of primary care are significantly influenced by its presence, or lack thereof, in their clinical education. Many training programs focus on inpatient teaching and inadequately emphasize ambulatory care. Further, trainees often spend much of their ambulatory time in specialty clinics rather than primary care settings. This limited exposure leads to diminished comfort with primary care and ultimately fewer trainees opt for primary care careers.

Moreover, the career choices of trainees are strongly influenced by their mentors and role models. Unfortunately, primary care faculty may be perceived as overworked or even “burned out” due to challenges including demands of late-night documentation, inbox management, complex intervisit care, lower compensation, and a relative lack of prestige. This negative perception can further deter trainees from pursuing careers in primary care.

The Primary Care Training Environment Is Strained and Evolving

The work of primary care is evolving rapidly with increasing work that is not patient facing. Non-patient facing tasks—such as answering electronic messages, addressing insurance and formulary constraints, and adhering to regulatory and quality documentation requirements—threaten the joy in our profession and the pipeline of learners choosing this career. Clinicians have described a mismatch between work expectations and allocated time, leading to potential tradeoffs between high quality and their personal lives—ultimately fostering guilt and dissatisfaction.³ The shift towards value-based care and the rise of for-profit entities⁴ have also transformed the primary care landscape. Combined with the pressures of busy practices and increasing physician burnout, these changes highlight the urgent need to reassess and enhance the training and support systems for primary care physicians.

In sum, the primary care shortage is exacerbated by challenges such as limited training time in high-functioning primary care clinics, insufficient support for ambulatory education, and pressures from for-profit models that may prioritize quantity over quality.

The Way Forward

To address these challenges and ensure a robust future for primary care, the Society of General Internal Medicine (SGIM) is partnering with other organizations and agencies on several policy recommendations aimed at enhancing resident training and primary care practice environments. SGIM members have long been leaders and advocates for policies that better align compensation with primary care work. We have worked with the Primary Care Collaborative (a coalition of seventy organizational members) to inform and respond to the request for information (RFI) to accompany the introduction of the Senator Sheldon Whitehouse (D-RI) and Senator Bill Cassidy, M.D. (R-LA) bipartisan Pay PCPs Act. This legislation is intended to better support and improve pay for high-quality primary care.⁵

In addition to legislative advocacy, SGIM continues to support the work of the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) to operationalize work from the Hess Institute. Hess Institute work groups have been addressing the primary care workforce shortage by focusing on compensation, training, and team-based care. These work groups have made recommendations related to team composition and function, leveraging technology, aligning compensation with primary care work, and improving learner experience in primary care. This year, SGIM committed to additional financial resources to support efforts to benchmark team roles and best practice across academic general internal medicine practices.

Additionally, the ACLGIM education focused work group, led by Drs. Lauren Block and Anne Cioletti, focused on increasing learner exposure to and training time in high functioning primary care clinics, most relevant to expanding the primary care pipeline. This group was charged with proposing new training recommendations that prioritize high-functioning primary care experiences and continuity for internal medicine residents. Their preliminary recommendations consider the timing and amount of clinical time in primary care practices, trainee panel size, and curricular content to support trainee population management and intervisit care. The work group also considered the faculty, staff, and time needed to enable efficient practice management and ensure consistent and high-quality ambulatory trainee supervision.

Next Steps

It is important to acknowledge that recommendations to expand and improve primary care training are not new and not final. While similar recommendations for change were previously proposed to the Association of Professors in Medicine (APM) without success, this should not deter SGIM members from revisiting the issue now, especially considering the evolution in primary care and the urgent primary care physician shortage. These proposed recommendations are a crucial and necessary first step as we begin to engage stakeholders across SGIM, ACLGIM, American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), the Accreditation Council for Graduate Medical Education (ACGME), and other groups to advocate for policy implementation. When discussing these draft recommendations with colleagues at AAIM, we will need to consider the perspectives of program directors and department leaders from both community settings and major academic medical centers.

Not only the future of primary care but also the pipeline of well-trained primary care clinicians hinge on the ability to adapt and innovate amidst evolving healthcare paradigms. By prioritizing comprehensive training, supportive team-based practice environments, and policies that align payment with work, SGIM can ensure that future generations of primary care physicians are equipped to deliver high-value care and improve health outcomes for all.