Charles Jantzen, M.D., found himself swept up in the same current so many newly trained family physicians are in upon graduating from residency: employed by the health system where he previously trained. Jantzen quickly got very busy, bonded with staff and became masterful at getting the most out of coding and billing for every patient encounter. Yet over the next four years of health system employment, his autonomy eroded—and with it his morale.
According to Jantzen: “Days turn to weeks, weeks to months, months to years … it is hard to pick a specific time where I was mentally done with what I was doing, but as time passed it just got worse and worse. I was the epitome of physician burnout—a word I didn’t even really believe in until I was experiencing it. There were several days when I drove to work and cried in the parking lot.”
Just four years into practice, Jantzen had nothing left to give. He resigned, without a plan, not knowing whether he’d ever practice medicine again. He moved his family across the state in a fog of mixed emotions fueled by dread, remorse and the bliss that follows emancipation.
Eventually, he realized that much of his burnout had to do with how he had to earn payment. “I was always good at the coding game—in-person visit, chart, code, wRVU—and then I get paid. One day I started thinking about medical spending; am I part of the problem?”
Jantzen’s story is not an anomaly. His experience is shared by thousands, representing a worsening trend in the primary care workforce. Primary care burnout affects 13.5% to 60% of primary care physicians, and the most common predictor is the practice environment. And 1 in 3 primary care clinicians told the Primary Care Collaborative (PDF) they expect to leave primary care within five years. This mass exodus only adds to our country’s crisis-level shortage of primary care. As the population ages and healthcare needs increase, the crisis escalates—particularly in non-metropolitan areas. As described in the Primary Care Collaborative’s 2022 Evidence Report (PDF), the percentage of Americans without an ongoing primary care relationship has risen from 16% in 2000 to 25% in 2020
(Editor's note: Greiner is president and CEO of the PCC.)
But the primary care workforce crisis isn’t just about premature departures from practice. The number of new primary care physicians joining the workforce annually is not keeping pace with the public need, and the projected shortage is expected to reach 68,020 (PDF) full-time equivalent primary care physicians by 2036. Like many, we believe this is too conservative an estimate. According to the 2024 annual report on physician shortage projections published by the Association of American Medical Colleges, projections modeled in a health equity scenario “highlight the large disparities in use of physician services between people with and without insurance, among people residing in counties across different levels of rurality, and by race and ethnicity.” These models suggest the looming shortage crisis may be even worse than we thought.
There is no single solution to this primary care shortage. Its complex drivers both shrink the entry pipeline and increase the terminal exodus. Tackling the problem will require approaches that permeate the roots, addressing the origins of an inhospitable practice environment and barriers to entry.
Change the training model
Primary care training programs must shift into community settings, where primary care is needed most and where primary care physicians and other primary care clinicians are more likely to thrive. Janzten’s story reflects a very common trend: Training primary care within a hospital or health system setting increases the likelihood of practicing within a similar environment after completion of training. Yet these are the precise practice environments that are most likely to strip autonomy and result in symptoms of stress and burnout. Community-based training creates a natural path to community-based practice.
Increase debt relief programs tied to choosing primary care
The average cost of a medical degree
With such large-looming educational debt, it makes sense that graduating medical students who are initially drawn to primary care might end up choosing a more lucrative specialty area. While
Change how primary care is paid
While the above solutions will help get more medical professionals to choose primary care, it won’t keep them there. PCPs know they will be paid 30% less on average than their subspecialty colleagues and do not choose primary care for money or glamor.
However, Jantzen’s experience illustrates the powerful influence that the payment model can have on burnout and retention. Broken payment models rob physicians of the autonomy to partner meaningfully with patients and quite predictably divest them of the fundamental reason they chose primary care in the first place: their ability to have a powerful impact on patients and their families. As discussed recently by the Commonwealth Fund, upfront, predictable payments are the key to primary care sustainability.
After taking five months off work to recover and spending a year working in urgent care, Jantzen finally returned to practicing primary care by joining a community-based direct primary care practice, where the prospective payment model supports his ability to deliver the kind of care he always wanted to give. He has reclaimed his autonomy and strengthened his self-esteem and is the happiest he has ever been. Says Jantzen: “I feel like I do a much better job now being a physician.”
Sara Pastoor, M.D., is director of primary care advancement at Elation Health. Ann Greiner is president and CEO of the Primary Care Collaborative.