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Primary care: at best, a multipronged challenge; at worst, a full-blown crisis

Globe staff; juliawhite/Adobe

Hospitals, insurers have combined to make a doctor’s job untenable

We are primary care pediatricians, and we read Jessica Bartlett’s article “Visits to primary doctors a struggle” (Page A1, Feb. 6) with great interest. Primary care is suffering from bureaucratic overregulation, ever-increasing mountains of unnecessary computer “paperwork,” and disproportionate and unbalanced reimbursements to doctors. The care of patients has necessarily taken a back seat, and for doctors committed to caring for patients it becomes cripplingly demoralizing.

On top of this, residency training programs are turning out fewer primary care doctors. Indeed, we were told years ago by one institution that “the mission of this hospital is not to train primary care physicians.” Given that medical school debt is substantial, low reimbursement rates and heavy workloads in primary care steer candidates toward more lucrative subspecialties.


Overburdened primary care doctors are more likely to refer patients to hospital specialists and emergency departments than to perform evaluations in their offices, driving up overall health care costs. The expansion of urgent care centers contributes to the fragmentation of care, further multiplying costs.

Hospitals and insurers have perversely conspired to drive us out of providing care to our patients. Insurers have little incentive to rein in costs because emergency and specialty care drive higher premiums (and revenues) for them.

The solution is economic. Primary care has always been key to controlling the cost of medical care. Preventing complications of untreated disease is more cost effective than treating illness. Hence, attracting doctors to primary care is urgent and critical. Returning doctors to caring for their patients (rather than preoccupied with their computers) is paramount.

The solutions are not easy, but if we fail to change the mounting trend, we all will suffer. It is no exaggeration to say that our health care system is imploding.

Dr. Roger Spingarn

Dr. Jonathan Benjamin

Newton Centre

Physicians, other providers must unite and push for single payer

As a primary care doctor at a federally qualified community health center in Boston, I would like to make a few comments regarding the unhappiness of primary care providers, including nurse practitioners and physician assistants. Among the many reasons are the fact that primary care providers feel undervalued, we are undercompensated compared with subspecialists, and the volume of patients is too high. Primary care medicine feels like an assembly line of brief visits. We often can’t deliver the high quality of care to our patients that we want to, and that causes a moral injury.


We lack control over our scheduling. Insurance companies hold great influence, with their formularies, prior authorizations, and paperwork. The bottom line is that America has a profit-driven health care system, and the electronic medical record is controlling our lives. Our “inbaskets” are often overflowing, as is described in Jessica Bartlett’s article. Despite the propoganda around these systems, the electronic medical record is primarily designed for billing, not for patient care.

Burnout and demoralization are common, and that leads to turnover, early retirements, depression, and suicide, all alongside subpar care. Meanwhile, clinic Employee Assistance Programs are inadequate.

The solution? It’s time for doctors to take to the streets for health care justice, wearing our white coats. We need an urgent call to action for a single-payer, national health program. Physicians and other health care workers must organize and unionize, before it is too late.

Dr. Philip Lederer

Jamaica Plain

The writer is a member of Physicians for a National Health Program.


Primary care is a team effort, and all members must be supported, respected

In her article on the growing shortage of primary care doctors in Massachusetts, Jessica Bartlett touches on the common themes of salary, work stress, and an aging workforce. As a primary care physician retiring this year after more than 47 years in practice, I have a different perspective.

Primary care medicine has become a team effort. Delivering safe, effective health care amid the complexities of present insurance models along with the catastrophic impact of the COVID-19 pandemic would be impossible without well-trained, motivated, and reasonably compensated medical assistants, administrators, licensed practical nurses, registered nurses, nurse practitioners, physician assistants, social workers, and dietitians, among others. The current shortage of applicants for these positions makes all of our jobs more difficult and adds to the stress and burnout. Yet we fail to provide a living wage, collegial support, and respect to many of these essential partners.

This shortage is compounded by the proliferation of private compensation, or concierge care, which restricts care to a relatively small number of patients per provider and deprives tens of thousands access to primary care services. As more providers choose this path, only the wealthy or those willing to pay the extra cost will be able to find a doctor, inflating health care costs and dramatically increasing the social disparity of our entire health care system.

Primary care today should be at the vanguard of comprehensive health care. We need to refocus resources on all members of the health care team and on the real needs of patients. Unless all in primary care can feel secure, respected, and valued, paying providers more will not make it easier for patients to see their doctor.


Dr. Martin Solomon

Brigham and Women’s Primary Care of Brookline

Internationally trained physicians could help fill gaps in access to care

As a primary care physician, I see patients struggle daily with the health care access issues highlighted in Jessica Bartlett’s article. It is increasingly difficult for Massachusetts residents to see primary care clinicians.

However, there is an existing resource that could help resolve this crisis: internationally trained physicians. Currently, Massachusetts requires these experienced physicians to repeat their postgraduate clinical training in order to practice here. This unnecessarily creates often insurmountable barriers for most, due to both expense and scarcity of options.

In 2021-22, I served as a member of the Massachusetts Special Commission on Foreign-Trained Medical Professionals, tasked with developing strategies to integrate experienced internationally trained health professionals into medically underserved areas of the state.

Based on the commission’s recommendations, state legislators filed legislation last month that would create a streamlined pathway to licensure for internationally trained physicians willing to practice in these areas.

Addressing the gaps in primary care access requires creative strategies. Licensing internationally trained physicians would be a key step.

Dr. Robert P. Marlin


The writer is a physician at the Lowell Community Health Center, where he serves as the chief of the Metta Health Center, which focuses on serving the needs of refugees and immigrants.


Nurse practitioners should not be left out of the discussion

The article “Visits to primary doctors a struggle” highlights an important issue within the state’s health care system. The article reports that this crisis is the result of an increase in primary care demand at the same time that many physicians are exiting the profession due to retirement or burnout from poor working conditions exacerbated by the COVID-19 pandemic. However, the primary care provider shortage is not new.

Nurse practitioners were established in the 1960s to fill a primary care need in the rural West, and the subsequent need for our work has not abated. NPs are an essential part of the primary care workforce. We care for patients across the life span and often do so for less than the cost of a comparable primary care physician.

Research has repeatedly shown that NPs can deliver high-quality, evidenced-based primary care, often in medically underserved areas. Unfortunately, the article fails to mention our contribution and our potential to mitigate the physician shortage.

Alison Marshall

Monica O’Reilly-Jacob

Patricia Underwood

Chestnut Hill

The writers are all family nurse practitioners with advanced graduate credentials and are on faculty at the Boston College Connell School of Nursing.