The pandemic has taught us about an economic and logistic concept that most people take for granted, if they’ve even thought about it at all: the global supply chain. Beginning early in the Covid-19 pandemic, stories in the media have featured reports of clogged ports, stranded goods, and gummed-up supply lines leading to empty shelves in stores and long waits for online goods.
The chaos will continue for months to come.
But a previous supply chain crisis that the pandemic has made worse — the diminishing supply of primary care doctors and nurses — has gotten relatively little attention even though it affects most Americans.
Primary care clinicians are trained in family medicine, internal medicine, or pediatrics. These professionals — doctors, nurse practitioners, and physician assistants — are supposed to be the main source of health care for people. They take of care of people when they are sick. They identify and manage chronic conditions, such as high blood pressure or depression. And they ensure that people are knowledgeable about and up-to-date on preventive care. Primary care clinicians take care of the whole person. They do this in the context of the relationships that they build and sustain with patients, families, and communities, as well as with specialists, as needed, to cover the entire range of an individual’s health and wellness needs.
The supply of primary care clinicians has been dwindling: the proportion of medical students and residents going into primary care is shrinking, and the same thing is happening with nurse practitioners and physician assistants working in primary care.
This loss can be seen in many ways. The U.S. is not only falling behind other developed countries for health outcomes, it continues to lose ground. Decades of improvement in life expectancy are being reversed, due in part to primary care supply chain problems.
More than one-third of U.S. counties have a primary care supply problem. The people living in these counties die sooner — by nearly a full year — than other Americans. And there are similar pockets throughout the other two-thirds of U.S. counties where the primary care supply chain is broken, which is also associated with early death.
It’s easy to think of this as a numbers problem. But it is a very human problem, as my dad’s story shows.
For years, my dad had a primary care doctor he trusted. But his doctor retired early, burnt-out and exhausted, in the early 1990s when my dad was in his late 40s. While my dad found another primary care doctor, he never really replaced this valued relationship, and he didn’t understand the full impact of that disruption or how it would affect him 30 years later, at the end of his life.
Instead, my dad relied on 28 specialists to provide care. In 2020, he was in his late 70s and living with a range of chronic conditions that had different degrees of seriousness. He had cancer and struggled with heart problems, along with a range of other issues like numbness, headache, and joint pain that affected his quality of life but weren’t likely to kill him. His new primary care doctor referred him to many of these specialists. This same doctor later declared himself as “superfluous” — no longer relevant to my father’s health care because his medical situation was too complicated and the specialist team had things covered. My dad agreed.
So did I, even though I knew he needed a clinician to make cohesive sense of his troubling symptoms, find ways to reduce them without creating new problems or, if necessary, help him accept and live with them. He needed someone with a whole-person view of him rather than someone who viewed him as a collection of organs and illnesses.
The upshot of this form of “care” was that my dad was alone medically and frightened at the end of his life. Cancer and chemotherapy had substantially weakened him. Sometimes when he got out of bed or stood up from a chair, he would fall due to a drop in blood pressure. He called his oncologist, who had no advice. He called his cardiologist, who modified his medication. I am sure he made other calls, but no one took ownership of this problem and stuck with him until it was resolved.
Early one evening, my mom called 911 because my dad was having chest pain. He was taken to the hospital, where he died several hours later under the care of a team of hospitalists who did not know him or his end-of-life wishes.
My dad believed, like many Americans believe, that having access to the full range of specialists means access to the best care possible. And though he was right about many things, he was wrong on this point.
The supply chain problem in my dad’s story was not one of absolute shortage. He did not live in a rural, medically underserved area. He lived in an urban, medically overserved area teeming with specialists but lacking in primary care clinicians, nurses, and teams that were supported in having relationships with their patients.
My dad’s experience is not unique. This is happening to families across the country. A 2021 report from the National Academies of Sciences, Engineering, and Medicine details the two supply chains, now broken, that are essential to a well-functioning primary care system.
The first supply chain problem is literal: the pipeline of primary care clinicians is drying up. Primary care positions offer comparatively low incomes relative to the high burden of educational debt and heavy patient care responsibilities, without the time or resources to fully engage with patients. The relatively small percentage of clinicians who choose primary care isn’t sufficient to address the current and future shortage and meet the need for care. Clinicians are, instead, choosing more lucrative professional paths. This has led to an estimated projected shortfall of approximately 140,000 primary care clinicians by 2033.
The second supply chain problem is figurative. There is a lack of support for primary care in the U.S. In today’s health care, primary care teams are not paid to care for people but to deliver services. Caring for people takes time and includes, for example, talking on the phone with a patient who is worried about a test result or working with a patient to transfer a medication refill to a more convenient pharmacy, neither of which are billable services. Policy and payment reforms are needed to change this.
Compounding the support problem, the understaffed primary care workforce is now organized into a triage service that minimizes the time doctors have with patients and measures their quality of care one disease at a time — not recognizing that they could be a force for bringing the fragmented parts of care together if they were given time and support.
Primary care teams also lack adequate information technology support. A clinician may care for more than 1,000 people and a practice could care for thousands of people. Most primary care practices currently lack the tools they need to support communication and information exchange among team members, with patients and families, and with specialists.
Everyday people — like my dad — experience both of these shortages but don’t connect it to their health care experiences. Primary care teams, where available and accessed, are the glue and the hub of health and wellness. These clinicians know and care for the whole person over years, decades, or in some cases, entire lives. The failure to provide primary care to everyone results in more sickness, more indignities, greater health inequities, and lowered life expectancy across the country.
The U.S. now has leadership at a high level that is beginning to pay more focused attention to the primary care supply chain and is working to find solutions that will enable primary care to fulfill its valuable function of creating and maintaining trusted, healing relationships.
These leaders need to pay attention to and address both primary care supply chain problems. This includes understanding where primary care is thriving and where it is struggling, and investing in what is needed to shore up this essential foundation. This includes not only training more people who are excellent personal doctors but putting them into practices where teams, technology, and time allow them to thrive and develop relationships with their patients.
The U.S. needs to make it easier for everyday people, like my dad, to appreciate the value of having a primary care doctor. If my dad had a primary care doctor who was there for him, and took pride in knowing and caring for him as a whole person, I believe his end of life experience would have been different.
Deborah Cohen, a professor of family medicine and the vice chair for research with the Department of Family Medicine at The Oregon Health & Science University, was recently elected to the National Academy of Medicine.