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As usual, we are stuck here in the middle.

Upstream from us in primary care is the world our patients live in, their social situations, their mental health challenges, the wearing down on a body and soul that living a life leads to, the things they need to deal with every day, many of the so-called social determinants of health.

When our patients come to us every day, we see the harm that has been caused by these social ills, the ramifications and sequelae of all those hard things.

We've been told that we need to screen for social determinants of health for all of our patients, asking about housing stability, food insecurity, equitable employment and education, access to safe places to exercise. But we're not given nearly enough of the resources we would need to do anything about so many of them.

Downstream from us in primary care are the places we need to send our patients to: the specialists; the subspecialists; the surgeons; the proceduralists; the imaging center, and so much more of the healthcare system that is opened up once we do our best to take care of our patients and to help fix what ails them.

The current state of our healthcare system finds our patients waiting weeks if not many months to be seen by a specialist, to get a procedure done, to get their routine mammogram or colonoscopy done. And every time our patients are seen by these other providers, if they mentioned something that isn't exactly in the purview of the person they are seeing, the usual answer is to send them back to their primary care doctor -- they'll take care of it.

Blood pressure is elevated at your orthopedist's office? See your primary care doctor immediately. You need to get a visiting nurse and specialized home care after a hospitalization? Fax the forms to your primary care doctor; they'll fill them out. You need wound care supplies, specialized medical equipment, pre-authorization from insurance companies for durable medical equipment? See your primary care doctor; we don't fill out forms here.

So here we are; here we sit; here we'll stay: stuck in the middle, trying to take care of it all, with fewer resources than everybody else.

If folks out there really wanted us to address and improve the mental health crisis in this country, the inequities that have been built into the systems of health and wellness, the poor health outcomes that have arisen because of limited access to healthcare and low health literacy, then they would give us the resources we need to do this, and empower us to use our voices to call for change. They would listen when we use those voices to shout about what's wrong -- and then actually do something about it when we tell them what we think needs to be fixed and changed.

We need to create a system where patients can get in to see the providers they need in a timely way, where there shouldn't be a wait of months to get a routine test done, where our patients shouldn't have to sacrifice rent or food money to pay for medication (or, as likely happens more often, pay the rent, buy food, and skip their medications). It needs to be a system where everybody who's playing in the pool does their part, helps out, and fills out the forms that are relevant to the care that their patients are receiving.

We keep looking at all these systems that are set up -- things that pretend to provide care for our patients but really just get in the way of getting them the care they need. Of the countless hours that any of us have spent getting prior authorizations, or spent online or on hold with an insurance company, has it ever felt like that really helped the patient get better?

If you ask us to screen for homelessness, unstable housing, access to healthy and nutritious food, broadband access for telehealth, and depression and suicidality, then we absolutely must be given the wealth of resources needed to make a difference for each and every one of these, both for every single individual patient, every community, and for society as a whole.

The past few years have revealed many faults in the system and burned out many providers. Doctors have fled the profession and would-be students have shunned it. Changes will need to be made at the core of our healthcare system to fix what is failing. Build a better system to fulfill the vision we all have -- to make the lives of all doctors and all the members of the healthcare team, as well as the patients, as good as they can get.

Otherwise, we're all just going to be stuck.

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