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Primary Care In Crisis: A Physician's Take On Reform

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This blog reviews how the role of primary care practice has diminished greatly over the past 40 years.

When I became a physician in the 1980's primary care medicine entailed a physician specializing in pediatrics, family medicine, or internal medicine who served as the main point of contact for a panel of patients.

The primary care physician evaluated patients for their annual check-ups, monitored patients with chronic conditions, and was also available for same-day or same-week visits when someone was sick.

The primary care physician was able to address more than 90% of the care of sick patients in their clinic, and occasionally would refer patients for evaluation by a specialist.

In rare cases, when the required level of care could not be handled in the clinic, such as when a patient required intravenous therapy, patients would be sent to an Emergency Department (ED) for evaluation and treatment or sometimes even directly hospitalized, when indicated.

As a resident in pediatrics, I lamented when patients chose to come to the ED for primary care issues, because this used up precious resources at the ED, and also we could not provide continuity of care there.

For instance, if I saw a child with an ear infection for which I prescribed an antibiotic in the ED, I was unable to see them again 3 days later to ensure that the infection was improving.

The main issue with primary care in those days was what to do when in the evenings and nights when the primary care office was closed. Most practices had an on-call physician who would take phone calls at night and determine whether patients could wait until they were seen in the clinic on the following day. The few practices who did not provide overnight on-call coverage were thought of as poor practices in the medical community.

The role of the primary care physician was thought of as so important, that Health Maintenance Organizations (HMOs) insisted that patients first be seen by their primary care physician to determine whether the patient required evaluation by a specialist.

Unfortunately, over the past 40 years medicine has devolved into such a state that instead of providing timely care, the primary care provider provides rudimentary care and triages complicated patients to specialists, Urgent Care, or EDs.

Some of the reasons for this devolution include:

An insufficient number of primary care physicians that partially is related to the fact that primary care physicians are paid much less than specialists

Healthcare organizations that have insisted that physicians see many more patients per day for the purpose of generating more revenue

Many physicians have burned-out and left the medical profession as a result of the increased work burden imposed by healthcare organizations

Physician extenders such as Physician Assistants and Nurse Practitioners have become essential for primary care delivery, and yet these professionals do not have as much training as physicians and thus cannot provide the breadth of care that a physician could deliver

Young medical professionals have become much more focused on their own quality of life and healthy work/life balance thus limiting their work hours, as opposed to older physicians who placed patient care as their top priority

Many physicians have left traditional medical practices and instead have turned to delivery of concierge medicine, for which patients pay annual fees beyond the cost of their medical insurance. Thus, there are fewer physicians available to provide care to patients who are covered by private or government medical insurance.

How does primary care function today in many practices?

Recently, my wife developed a viral illness like that which affected thousands of Americans this winter. She felt very weak and was unable to eat or drink much. I suggested that she visit her primary care physician, who saw her three days after she called for an appointment, when a cancellation opened a timeslot.

The physician, who was part of a well-reputed large health care organization, performed a brief physical exam and ordered a blood test, which she said was normal.

My wife was instructed to go to Urgent Care if her condition worsened. Over the next two weeks my wife was seen in Urgent Care or an ED on three occasions, and finally was hospitalized with severe dehydration and malnutrition. It turned out that the primary care physician did not even note signs of dehydration in the blood test she performed during her only encounter with my wife during her illness.

Last week, I called my own primary care provider, who works for a large medical organization different than my wife's, for evaluation of a sudden new health issue. I was told that the first time I could be seen for this condition would be in a month.

The receptionist with whom I spoke also volunteered that if I was uncomfortable with waiting that long, I could go to Urgent Care. Fortunately for me, I am a physician, so I am in a better position of evaluating whether my symptom warrants an immediate evaluation than most other people.

Not surprisingly, in this new way of medical practice Urgent Care centers and EDs are overflowing with patients who do not require that level of care. This can be best demonstrated during holiday periods or while the Super Bowl is being played, when emergency facilities are almost empty.

Further complicating the situation is that healthcare delivered in an urgent or emergency care settings is much more expensive. Not surprisingly, healthcare facilities are not incentivized to change this system because they make much more money from delivering emergency as opposed to primary care.

I should note that there remain a minority of private primary care practices that still see patients in a timely and comprehensive fashion. Such practices do not generate as large of an income for the practice or participating physicians, which limit their scope.

When practices are owned by health organizations such as hospitals, they tend to be profit driven rather than patient centered.

What can be done to change the system?

The problems of today's primary care delivery system include an insufficient number of physicians, and an emphasis on financial gain rather than optimal patient care. For instance, a primary care practice can be more financially viable when it does not need to be staffed with enough health care providers to offer good coverage on nights, weekends, and to deal with ill patients in a timely manner. Instead, such a practice sends its patients to Urgent Care or the ED.

To solve this issue, as I discussed in a previous blog, I believe the primary care system could be transformed over the next 10-20 years to be administered by Medical Technicians (MTs), who would be guided by AI. Only in cases when their evaluation and management is insufficient to address patients' needs, would a physician need to be consulted.

The advantages of such a system would include a significant decrease in cost of training of the MTs, as compared to training physicians, advanced nurse practitioners, or physician's assistants, and a concomitant increase in availability of primary care access because a single primary care physician could be replaced at the same cost by several MTs who could staff primary care facilities efficiently.

I should note that most primary care, including evaluating vital signs, doing basic physical examinations, interpreting basic lab results, making basic diagnostic decisions, making basic behavioral health recommendations, and reassuring patients, does not require advanced degrees, especially in a world in which AI could help to alert MTs to abnormal findings.

Takeaway

Our current healthcare delivery system is broken. We need to think outside of the box to find solutions to this crisis.

Tallahassee Primary Care Associates Announces Closure Of Office After Nearly 30 Years Of Practice

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In a statement, TPCA says their office will close April 25th.

Alberto Camargo

I'm your neighborhood reporter dedicated to covering College Town.

BROADCAST TRANSCRIPT:

Despite Tallahassee Primary Care Associates announcing its closure this month, most patients can be assured that it will not affect their primary care too much.

I'm Alberto Camargo in Northeast Tallahassee.

Breaking down how TPCA got to this point and who stands to be most affected by it.

Tallahassee Primary Care Associates first opened in 1996, but had fallen on tough times recently.

In February, TPCA's lab and diagnostic services were closed.

The office announced it will be closing for good on April 25 after nearly 30 years of service.

The medical office announced the closure with an online statement saying, "We sincerely appreciate your loyalty and trust in us. Recently, we have made the very difficult decision to close our practice. This decision does not affect the exceptional care patients will continue to receive from their provider(s)."

I was able to speak with one TPCA patient as she was leaving the office Wednesday afternoon.

Peggy Reaves says she's thankful this transition won't affect her care under Dr. William Fleming.

"Trying to find another doctor, if you're up in age, which I am, it's kind of hard. It's hard to find another doctor. It would be difficult, because I have to take a lot of pain medication.'

Most TPCA doctors, including Fleming, include a transition letter on the TPCA website's "Where's My Doctor?" page which includes their commitment to their patients.

Some include the new locations the doctors will operate from.

Only one doctor's name, William Morse, has a note that patients will need to find a new primary care physician.

In his transition letter, Morse says he is moving into hospice care with Big Bend Hospice — and provides contact info for other TPCA physicians for his patients to continue their care.

His statement says, "I have complete confidence in my colleagues, who have availability in their practice to assume your primary medical care."

TPCA says all patients have been notified by their physicians about next steps to continue getting their care past April 25.

In Northeast Tallahassee, Alberto Camargo, ABC27.

Tallahassee Primary Care Associates is closing its doors after nearly 30 years of practice within the community. In a statement, TPCA says they've made the difficult decision to close their office at 1803 Miccosukee Commons Drive, beginning April 25th.

TPCA says this decision doesn't affect the care patients will continue to receive from their provider(s). They say all patients have been notified regarding the next steps.

Early this year, TPCA announced organizational changes and was undergoing some restructuring. In February, it discontinued services for its on-site laboratory.

To read the full recent announcement, click here.

Want to see more local news? Visit the WTXL ABC 27 Website.

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Most PCPs Strive To Offer LGBTQ+-affirming Care, But 'there Is Still A Lot Of Work' To Do

March 31, 2025

3 min read

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Key takeaways:

Under 40% of practices provided LGBTQ+ competency training to their clinicians and staff.

Such stigma and inequities can have significant impacts on the health of LGBTQ+ populations.

Most primary care practices collected data on sexual orientation and gender identity, or SOGI, a cross-sectional study indicated.

However, few practices provided their clinicians and staff with training on LGBTQ+ care, revealing that "gaps exist," Ellesse-Roselee L. Akré, PhD, MA, an assistant professor at Johns Hopkins Bloomberg School of Public Health, told Healio.

Data derived from: Akré E, et al. JAMA Netw Open. 2025;doi:10.1001/jamanetworkopen.2025.0392.

Akré said the data "were encouraging in many ways because they demonstrated that we have made improvements in collecting SOGI data in clinical settings."

"Knowing more about patients — any and all patients — helps ensure that clinicians provide informed, quality care," she added. "On the other hand, the results demonstrate that there is still a lot of work that needs to be done to create inclusive and affirming spaces for LGBTQ+ patients and meet their unique health care needs."

According to Akré and colleagues, LGBTQ+-affirming care — which can include collection of data on SOGI and pronouns, LGTBQ+-friendly policies and training, and appropriate language and services — "is an approach to health care that validates and supports the identities, experiences and needs of LGBTQ+ individuals."

But "to our knowledge, no national data exist on primary care practices' efforts to ensure high-quality care for LGBTQ+ patients," they wrote in JAMA Network Open.

The researchers examined the percentages of practices that engage in several LGBTQ+-affirming activities, as well as characteristics tied to a higher likelihood of performing such care.

Practice data utilized by Akré and colleagues in their analysis were taken from the National Survey of Healthcare Organizations and Systems II, administered from June 2022 through February 2023.

Of 1,245 practices included in the study sample:

77.4% collected data on gender identity;

75.62% collected data on sexual orientation; and

65.83% collected data on patients' pronouns.

However, only 34.42% and 39.2% of practices provided LGBTQ+ competency training for clinicians and staff, respectively, while fewer reviewed performance measures by patient sexual orientation (19.89%) and reviewed measures at the system level (28.99%).

Over half of practices (55.77%) gave referrals to providers specialized in treating LGBTQ+ patients.

"It seems like a missed opportunity to identify and address areas to improve care quality for LGBTQ+ populations," Akré told Healio.

The researchers also reported that practices designated as federally qualified health centers, or FQHCs, were 3.16 (95% CI, 4.6-19.73) percentage points likelier to engage in all SOGI-affirming activities vs. Non-FQHCs.

Practices with a Medicaid payer mix of at least 50% were 3.28 (95% CI, 1.19-5.36) percentage points likelier to engage in such activities compared with practices with less than 50% Medicaid payer mix.

Akré and colleagues noted that each 1-unit increase in the state-level LGBTQ+ Equality Score was tied to a 1.07 (95% CI, 0.28-1.85) percentage point higher likelihood of engaging in all SOGI-affirming activities.

Akré said clinicians can use the study findings "to gauge where they stand compared with their counterparts in primary care."

"They can also see how pervasive many of these gaps are, and they can be encouraged to adopt practices, even if they still need improvements," she added.

Akré also pointed out that the results have major health implications, as LGTBQ+ populations "have elevated risk for certain health conditions and reduced life expectancy of up to 12 years when they are exposed to social stigma, structural discrimination and subsequent inequities.

"It is the responsibility of the governing bodies of the primary care and medical education communities to use this information as evidence that requirements and incentives are necessary to ensure clinicians and staff are engaging in training," she added. "It's also important that this data continue to be collected to hold practices accountable when patients are receiving low-quality care and have poor patient experiences."

For more information:

Ellesse-Roselee L. Akré, PhD, MA, can be reached at eakre1@jh.Edu.

Sources/DisclosuresCollapse Disclosures: Akré reports no relevant financial disclosures. Please see the study for all other authors' relevant financial disclosures.

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