Why is it so hard to get medical care? And what should we do about it?

You may have noticed, should you or a family member or a friend have had a health problem recently, that it is difficult to get care. It is difficult to find a doctor (or a nurse practitioner, or any health care provider) who is available to add you to their panel. If you are lucky enough to have one, especially one who practices primary care (a family physician or general internist or geriatrician for adults), it is still difficult to get an appointment. If you think you just have a simple question, it can be difficult to get through to them to ask it. Sometimes you can get a nurse, or a medical assistant, or perhaps the desk clerk who may be familiar with some things enough to answer, but often they cannot. Many practices now have “patient portals” (e.g., MyChart ®) where you can post a question for your doctor (often in the form of “I have these symptoms but I can’t get an appointment; do you think I need to be seen?”) that, hopefully, they will answer before you are in extremis.

When all these methods fail, and you are still sick, you can visit an Urgent Care Center, sometimes run by local health systems and sometimes by private chains. They can care for many problems and do some tests, but a lot of things will lead to them sending you to the local Emergency Department. That is, of course, what you were trying to avoid, if for no other reason than the long wait (often hours, even if you have a severe problem that, once they diagnose it, can truly be an emergency; I wrote in the past about a close family member who waited 7 hours to be found to have appendicitis). Not all ED waiting rooms look like “The Pitt”, but it is not uncommon, especially in those centers who have the facilities to care for really dire problems needing urgent intervention (heart attacks, strokes, acute abdominal issues needing surgery, etc.) 

A big part of the problem is that there is a shortage of primary care physicians. This is worse in the US than in other countries but is becoming a problem elsewhere as well, as discussed by Dr. Kenny Lin in “Primary Care Supply and Access Challenges Around the World” on his substack CommonSenseMD. There are also shortages of other physicians (thus the line out the door of the cardiologist’s office), exacerbated by distribution problems (specialists tend to group in major cities and wealthier suburbs). But much of the delay in getting into subspecialists would be mitigated by having more family doctors and other primary care physicians. This works in 4 ways:

1.      The primary care doctor can take care of lots of the problems that people otherwise seek out subspecialty care for. Because you have a heart, it doesn’t mean you need a cardiologist.
2. If the primary care doctor identifies a problem that they think does require a subspecialist (say, a cardiologist) they can refer you to one who is less backed up because primary care doctors have done an assessment and identified that there is a problem requiring a subspecialist. This also makes the subspecialist more effective, because the people they see have already been assessed by a physician and they have a clearer issue on which to focus their attention.
3. Once the subspecialist does their assessment, makes their treatment plan, and initiates it, much of the follow-up can be done by the primary care doctor, freeing the subspecialist from needing to see so many follow-ups and having more appointments for new patient assessments.
4.  Many people (especially older people) have more than one health problem. Not only is going to a separate subspecialist for each potentially inefficient and possibly unnecessary, but can result in “communications problems” between them. This can be dangerous for the patient, in part because treatments for one condition sometimes worsen another. Having a primary care doctor who cares for the whole person, not just one organ system or disease, and is in possession of the assessments and plans from all the subspecialists, means the patient receives care that is coordinated and managed appropriately.

This model is understood and often utilized by subspecialty physicians who understand that their time and effort is best spent in the narrow area in which they are expert. The problem is that it requires a sufficient number of primary care doctors (about 40-50% of physicians), and, in the US, we don’t have them, and are not even moving in the right direction. As I have discussed before, a big reason that students do not choose to become primary care doctors is money…that their incomes are far less than subspecialists, and this needs to be addressed (see, for example, Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people, Sept 28, 2023).

Another part of the reason people do not access care is cost; the American Academy of Family Physicians (AAFP) newsletter Family Medicine Today reports on a survey by West Health-Gallup that 1 In 3 Americans Are Making Basic Living Sacrifices, Borrowing Money To Afford Health Care. Of course ‘…the “need to make these trade-offs was far more common among the uninsured, Gallup found, with 62% saying they made at least one sacrifice to afford their care. However, 29% of those with insurance also said they were forced to make a trade-off to cover their health care costs.” So…a big problem.

The cost issue may seem to be one that is more clearly related to my contention, in a recent blog (Feb 26, 2026), that The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., but in fact so is the shortage of primary care physicians and the difficulty getting appointments. On Feb 18, Health Care Un-covered addressed “The Economic Exploitation of Independent Physicians by Insurers”. It is also a result of practices being owned by profit-making private equity companies (or sometimes by insurance companies, such as UnitedHealth owning Optum) that determine the practice parameters and character, including the speed-up (seeing more patients more quickly) and other business approaches that are good for making money but not for people’s health. In addition, this includes the practice of replacing primary care physicians with less-trained non-physicians, such as nurse practitioners and physician’s assistants. I don’t mean to disparage these professionals, and indeed they can be very good and effective in the roles they are put in – seeing acute minor illnesses or checking on the status of chronic illness such as diabetes and hypertension. But being the coordinator, the “quarterback” – of care for the whole person that the primary care physician can fill, as I described above, requires more, not less, training. It makes care better; not the “most profit” or the “most efficient” but the “most likely to maintain and improve the patient’s health”. Even when for-profit companies don’t own the practices, “A wave of coordinated lawsuits is transforming the No Surprises Act’s arbitration system into a battlefield where insurers seek to intimidate physicians, rewrite the law and consolidate control” (How Insurers Are Using the Courts to Rewrite the No Surprises Act, Health Care Un-covered, Mar 11).

The health of the US population has long been worse, using generally accepted health parameters and measures, than in comparable countries. The situation is not improving, as insurers decrease access by increasing premiums and co-pays and deductibles, forcing a significant percentage of Americans to cut back on other necessities, as well as often denying coverage for important care. These practices control not only patients but physicians, along with the control exerted by hospital systems are for-profit ownership of physician practices. It also contributes to a downgraded role and lower pay for primary care physicians, who are key to maintaining health in the US and other countries. It is not a good situation, and it is getting worse, if Americans’ health is the measure.

It is past time for us to ensure that this is the measure, and not maximizing the profit of corporations!

Free tuition in medical school is only one step toward producing the doctors America needs

The NYU School of Medicine shook the world of medical education recently by announcing that tuition would be free. The NY Times article about it says that ‘Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.’ Certainly, it is easy to understand that a $55,000 per year tuition bill is going to be way beyond the ability of most medical students and their families to pay, and that a total indebtedness that is often over $250,000 may well affect the specialty choice of medical school graduates. While physicians in any specialty make far more than the average American, compound interest makes the payments a lot more than $25,000 a year for 10 years; often more, indeed, than that average American income (think about the payments on a $250,000 home loan, which usually has a lower interest rate). This may tip the balance between choosing betwee, say, family medicine or anesthesiology, when the latter choice can be expected to result in an additional $7 million in lifetime income.

The other, presumably obvious, impact of free tuition could be the ability of the school’s admissions committee to take more students from lower income families than they currently do. Note “lower income” is not necessarily the same as “low income”, as 80% of medical students now come from the top 20% of income. And, yet, they still have a lot of trouble paying for school, tuition plus the Times’ estimated $29,000 a year in living expenses (in NYC). It is not necessarily true that ability to pay is a significant criterion in the admissions decisions of medical schools, but rather that there are confounders. A big one is that being from a high-income family is associated with having the higher grades and test scores that are so valued by medical school admissions committees (probably especially those, like NYU, that are very interested in producing MD/PhDs and other laboratory researchers). Free tuition, however, might mean that those students from lower-income families who do gain admission will be under less financial pressure to take paying jobs while in school (a really bad idea when trying to succeed in medical school). In addition, those students who have started their own families or whose families of origin have counted on them helping to support them, would have one big less thing to worry about.

We definitely need more family physicians and other primary care doctors than we are producing now (and NYU has produced one of, if not the, lowest number family physicians of all US medical schools). We also need far more students from lower-income and underrepresented minority and rural backgrounds. The reason is not just for ethical or moral, or making up for past practices. It is directly about providing quality healthcare to all the American people, because physicians are most likely to practice in settings like those in which they grew up and feel most comfortable. Thus, students from upper-middle and upper income, primarily white (and Asian) suburbs are most likely to practice in those settings – which are precisely those least in need of more doctors. Students from rural or low-income or minority communities are much more likely to practice in such communities, and these are the places most in need of more doctors. Of course, the correlation is far from 100%, but the trend is overwhelming. Thus, to the extent that free tuition can increase either of these goals, it would be a great thing.

So what is the problem? Well, it is far from certain that free tuition will lead to these desirable outcomes. This point is made by family physician (and NYU medical school graduate) Kenny Lin, MD, in his Common Sense Family Doctor blog. Although Dr. Lin’s 2001 class had only four graduates entering family medicine, it was a larger number than any class since. He points to the fact that NYU has never had a Department of Family Medicine (one of the few such schools, almost all of which are “elite” private and on the East Coast). He also notes that in terms of producing other primary care doctors (general internists and general pediatricians), NYU has also done very poorly.

More important, Dr. Lin cites a study published in the JAMA Network by Grischkan, George, Chaiyachati, et al., that demonstrates that students entering family medicine (one of the lowest paying medical specialties) have a higher average debt load than those entering fields such as radiology, dermatology, and ophthalmology. He writes

These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

This is a very important point. Dr. Lin, focused on the critical issue of producing more family physicians and primary care doctors, believes that eliminating tuition and thus taking students from more diverse backgrounds “will likely have a small, but measurable, positive effect on primary care.” He urges that NYU and other schools increase their “pipeline” programs to help students from less advantaged background gain the skills that they need to be both admitted to and successful in medical school. I agree, but I would go beyond that.

Medical schools should train the doctors America needs. This means fewer subspecialists, and more primary care doctors. This means a smaller percentage of doctors practicing in the suburbs of big cities, and a larger percentage practicing in rural areas and underserved inner-city communities. This is not going to happen if we keep taking the same students we currently do, no matter how nice they are, no matter how high their grades are, and no matter how much they are like (or often are) the children of the faculty of the medical school. If you don’t think this is important, a recent paper from the National Bureau of Economic Research by Alsan, Garrick, and Graziani titled “Does Diversity Matter for Health? Experimental Evidence from Oakland” (reported in the Times article “The Secret to Keeping Black Men Healthy? Maybe Black Doctors”) demonstrates that it does: a significantly higher percentage of black men received important tests, took medicines, and made lifestyle changes when advised to by a black doctor rather than a white or Asian one. Importantly, this comes from more than a knee-jerk reaction to the race of the physician; it has a lot to do with how they were treated. While the ‘white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that referred to medical recommendations…black doctors often left more personal notes, like “needs food, shelter, clothing, job’. This goes beyond race, and suggests that both our overall medical curriculum focuses too much on the disease and not the person, and further that minority physicians may be more likely to realize that it is a person who needs to be treated, and identify the social determinants of health.

Indeed, Elisabeth Rosenthal, the editor of Kaiser Health News, argues in an Op-Ed in the Times that medical school should be free only for those who make a firm commitment to entering specialties and practicing in areas that have real need:

…if a student chooses to become an ear, nose and throat surgeon in suburban New York or a private cardiologist in Miami, fine. He or she can pay back what has been borrowed. But if that doctor chooses to deliver babies in rural Oklahoma or practice pediatrics on the South Side of Chicago, then he or she should get to keep every penny of salary.

I agree, and believe that to make this likely, medical schools, both private “elite” schools like NYU, and certainly state-supported schools, need to take a much higher percentage of students from the lower half of the family income scale, from rural areas and from groups that have been historically underrepresented in medicine. And not just a few more, not just a pilot program with 2% or 5% or 10% of the class. These programs must be far more extensive. The entire class should be composed either these groups of students or of students who, while perhaps from wealthier, whiter, more suburban backgrounds, have demonstrated an extended commitment to service to others. Extended, like the Peace Corps, or Teach for America, or VISTA, or working abroad for years in service programs, not a car wash fundraiser one Saturday.

Some, and sadly this may include many in the administration of medical schools, particularly “elite” ones, will say this can result in the exclusion of the “best” applicants. It may, in fact, lead to the exclusion of some of those with the highest grades, and may even require additional work on the part of the faculty to help students with less rigorous academic preparation. Or, perhaps, elimination of much of the nonsense memorize-detail coursework of the pre-clinical curriculum. But while “best” can mean many things, if the definition is not “most likely to make a positive difference in the health of all the American people” it needs to change, and soon.

Free tuition, at NYU, or other private schools, or state-sponsored schools, may be a terrific idea, and one that should be widely imitated. But it is only one part of an overall strategy, including changes in the selection of applicants, the curriculum of the schools, and the reimbursement of primary care, to significantly change the kinds of doctors that are produced so that they meet our nation’s needs.

How people die, and how should we?

On January 4, 2012, "How Doctors Die"; post on Zocalo Public Square by Ken Murray, I called attention to “How doctors die: it’s not like the rest of us, but it should be” a very articulate discussion by Dr. Murray about how the physicians he knows generally eschew “heroic” interventions at the end of life. This is because they know how futile, and often painful, such interventions can be and how disruptive they can be of the little time that they have left. Physicians know more than most other people about what is likely to work and what is not; they also know more about what is likely to just cause discomfort. I hope that Dr. Murray’s article will be widely read by both the physicians who make recommendations for patients at the end of life and the non-physician public who make decisions about what they want for themselves and their loved ones.

A version of Dr. Murray’s piece later appeared in the Wall St. Journal on February 25, 2012 with the headline “Why Doctors Die Differently”. It is discussed by Dr. Kenny Lin in his blog, Common Sense Family Doctor, “Addressing gaps in end-of-life planning”, March 15, 2012. Dr. Lin focuses on the important issue of “advance directives”, which includes Living Wills and Durable Powers of Attorney for Health Care (DPOAs), mechanisms through which people can help to ensure that their wishes for how they want to be treated – or not treated – at the end of their lives are honored, even when they themselves are not able to make specific decisions. A DPOA designates one person – one with whom, hopefully, you have had serious discussions about what you really want – to be your decision maker. This is very important; while under the law spouses have the right to make decisions, when there is no spouse and are multiple adult children there is no provision for who decides other than DPOA. There is no provision for a majority vote. While it is always best if everyone in the family agrees on a course of action, it doesn’t always happen. There may be several children in agreement, and one who wants something different. Sometimes this ends up in court, with a judge deciding. This is not the best scenario, which is why there should always be a DPOA. It does not solve every problem, but it definitely helps to have a specified decision maker. This issue is also addressed, from a patient and family perspective, in a recent NY Times Op-Ed by Sylvia Jacoby, Taking responsibility for death (March 31, 2012).

Such planning, however, requires thinking about hard issues. You have to decide if you want to have cardiac resuscitation if your heart stops, or be placed on a ventilator (breathing machine) when you can’t breathe on your own, or be “fed” through your vein when you can’t eat. These are all legitimate medical interventions that can have real value when there is an acute problem that is likely to be reversed (someone is temporarily unable to eat or swallow, or breathe on their own, but are likely to be able to in time). Cardiac resuscitation, which involves electric shocks and chest compressions, contrary to what you see on TV shows, hardly ever “works” when applied to people at the end of life whose body is in the process of dying, if by “work” one means a reasonable period of survival. It sometimes gets the heart re-started, but most of the time it happens again. A small percent of people who receive this treatment leave the hospital, and very few are back to “normal”. It is great to do for healthy younger people who have an episode of trauma (like on TV) but is unlikely to have benefit for folks at the end of life.

So why do we do it? Not only cardiac resuscitation, but so many other interventions that are of little or no benefit, especially when the body is suffering from the failure of multiple organ systems. And when, as indicated by Murray and Lin and many others, it is not what doctors want for themselves? As usual there are many reasons. Part of it is that doctors are, by and large, trained to do “whatever can be done” if there is “a chance”. However, a chance of what? This is a big question. To stay “alive” but unaware of one’s surroundings (from dementia, coma, or both), on a ventilator, and often in pain, for a few days, hours or minutes?  Even when doctors think about this issue, they often worry that if they don’t do something, they may be criticized, or even sued, by the patient’s family; they tend to go with the idea that doing something is always safer (from this point of view) than doing nothing.

The whole field of palliative care exists to help people and their families get through the inevitable process of dying with dignity, but there are far too few palliative physicians relative to the number of doctors trained to “do something”. Years ago, a co-worker’s elderly mother was dying in the intensive care unit (ICU). I went to visit. The woman was very far gone and unable to understand anything; the family, several adult children, was being asked to give permission for a fairly invasive procedure. They had been told it might “help”, and asked me what I thought. I was pretty sure it wouldn’t, but first checked with the doctor to see how he thought it would. I then spoke with the family and asked what “it might help” meant to them. They said that they hoped that it would make her “better”. I asked if this meant that she might become conscious, alert, maybe be able to talk with them, maybe be able to say goodbye one last time before she died? Yes, that is what they meant. I gently explained that this procedure might help correct some laboratory values, but that there was no way it was going to make her “better” in the way they hoped, although there was a good chance that she would still experience the pain associated with doing it. They opted not to have it.

Why didn’t the doctor make this clear to them? Perhaps it was because he was young, and wanted experience doing the procedure, and really thought that making lab tests better was “helping”. (There is an old joke that at Harvard students and residents were always pressured to make sure their patients had normal laboratory tests; the patient might die, but it was critical that they did so with their electrolytes in “perfect Harvard balance”.) Perhaps he had been trained to always “do something”. Perhaps he saw this large, hovering family and was concerned that they would be upset, might sue, if he didn’t.

Or perhaps he didn’t know how to talk to them. Is there a social justice issue here? After all, death comes to everyone, and as Dr. Lin points out, advance directives are important for all people to have, not just members of communities that have suffered health disparities. But often the social class or ethnic difference between doctors and patients makes communication more problematic, makes it harder for doctors to know how to best address what are already difficult issues, makes patients’ families suspicious of whether a treatment being offered is “research” being done on someone because they are poor or minority, or, alternatively, whether a treatment is not being offered for the same reasons.

I have cared for many people who were dying but whose families wanted more done. People who already had advanced dementia and whose physical bodies were falling apart. People whose heart and kidneys and lungs were failing, who couldn’t swallow and might choke on even a small amount of food, but whose families believed that if we didn’t do a surgical procedure to poke a hole directly into their stomach we would be starving them; who thought that if we didn’t plan to do cardiac resuscitation or given antibiotics for a possible pneumonia, that we would be killing them. Sometimes I am able to point out that death happens to everyone, and that having your heart just stop, or having pneumonia, or not being fed, are relatively easy painless and natural ways to die. Sometimes I am believed and sometimes not.

While there are, of course, times when a family member is truly “crazy”, paranoid or delusional, a more common issue is that they are just acting out their guilt. The stereotype (because it often happens) is the “son from California”, who flies in at the end of life, has usually not been involved in the care of his parent for years while a sibling (usually a sister) was doing all the work, and who now wants “everything done”. (A really good reason for one person to be designated DPOA.) But sometimes there is simply a trust issue, not being sure that the doctor, especially one from a different class, race or ethnic background, is really treating their parent with the respect that they deserve, with the respect they would give to one of their own family members.

Perhaps if more people understood what Dr. Murray is saying about what it is doctors really want for themselves and their families, or if their doctors took the time and energy and effort to explain it to them, folks would be more able to believe and accept it when the best course is not to do any more.

Common Sense Family Doctor: Coronary CT: nonindicated and costly screening test

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Another excellent post by Common Sense Family Doctor Kenny Lin, MD, on the incredible fact that Texas, bankrupt largely due to Medicaid costs and limiting elective Caesarean sections to decrease Neonatal Intensive Care Unit (NICU) costs, will pay for the non-indicated (but very profitable) coronary artery CT screening test. Dr. Lin also calls to task Texas Senator Kay Bailey Hutchinson for her inaccurate article criticizing the US Preventive Services Task Force (USPSTF) for "interfering" with decisions that should be made by a patient and doctor.

Some years ago, after the sudden death of St. Louis Cardinals' pitcher Darryl Kile of a heart attack at age 33, I met someone who asked me if he should get a coronary CT. I said I didn't recommend it, and wondered why he wanted it. He said if it was negative he wouldn't have to worry. I pointed out that he was very overweight and smoked, and that what would help him to live to see his children graduate from High School was not a coronary CT, but eating less and stopping smoking and beginning to exercise.

He was hoping that a negative CT had would mean he wouldn't have to do the hard work of changing his lifestyle.

Sorry, Charlie. It's not a good screening test for coronary artery disease and it is certainly not protective against developing it.
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Common Sense Family Doctor blog: Maybe PSA's time has finally come -- to an end!

I highly recommend reviewing Dr. Kenny Lin's blog post on "Common Sense Family Doctor" regarding PSA testing, http://commonsensemd.blogspot.com/2011/02/psa-testing-will-science-finally-trump.html
It reviews not only Dr. Lin's experience in helping write the guidelines but the political pressure to "trump" science.
Hopefully, now, the evidence on the non-utility of PSA testing is clear -- but read his piece for the details.