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Over the past 5 or 10 years (and seemingly even more so since the pandemic) I've had a lot of new patients come to see me with the chief complaint of "My primary care doctor has gone concierge."

I think the concierge model can be a good one, but this trend within our healthcare system seems to reflect so many of the overarching problems with primary care, rather than the ultimate and best solution. If the answer to so many of the problems of our healthcare system today is a good solid foundation of primary care doctors to take care of everybody, then selecting out patients by their ability to pay doesn't seem like the best way out. Instead, making sure patients can get the right care where they need it and when they need it, helping them navigate a complicated healthcare system, finding the right subspecialists who can help with complex issues, and building a robust team to ensure that all of the patient's healthcare needs are met is what we really need.

At our academic medical center, trying to inspire trainees, whether in medical school or in the early stages of their training, to choose a career in primary care outpatient medicine has gotten more challenging, not less. Throughout their training they are exposed to cool technology and whiz-bang procedures, and are often encouraged to avoid the less sexy world of primary care. They are too often even advised by our colleagues that "You're too smart to go into primary care."

Medical students and residents see the burdens that fall squarely on the shoulders of the primary care doctors, the trauma and consequences of a fractured and discontinuous healthcare system that so often lead to overtesting, overtreating, and poor health. The burdens of the electronic health record, the endless documentation, the clicks to get through the chart, the endless cutting and pasting, and the forms and the paperwork that no one else wants to do -- duties that rob us of the will to actually practice sound medicine -- only discourage the next generation seeking inspiration.

Medical students and residents are burdened with significant debt that of necessity must inform their choices, and they know where the income disparities lie across the medical fields they can choose from. Maybe the orthopedists and neurosurgeons and radiologists should make a little less, and the pediatricians make a little more?

It's hard to plead poverty, but it's less about direct reimbursement to the physician than it is investment in the primary care infrastructure at the health system level that might better level the playing field. I firmly believe that if we were to restructure things with a system focused on primary care, as it is in most countries around the world, by ensuring that everyone gets in for routine care, that everyone has boundless access to manage their acute and chronic medical problems, and that everyone can get all of their vaccines and other preventative healthcare maintenance issues addressed, then we might avoid the disease burden that too often comes from missing these opportunities.

The message of investing in wellness and prevention, while it costs more up front, seems like a no-brainer when it comes to avoiding the trillions of dollars that we're spending on healthcare right now with less-than-optimal outcomes. Waiting until we see the sequelae of untreated illness, of missed screening opportunities, and of poor investment in healthy environments and other social determinants of health, leads to costly attempts to clean up and fix things once the horse has left the barn.

If we can convince the people who hold the purse strings to academic medicine to invest in creating a primary care setting that is a satisfying model for trainees to work in, that is satisfying for providers to work in, and that gives providers a real team to help handle all the tasks that need doing, then maybe these trainees will turn to primary care in the future in ways that they just aren't right now. We need to share the burden of the administrative things that need to be done, the boxes that need to be clicked, and the prior authorizations and endless forms that need to be filled out.

I don't think the solutions are going to be the stuff around the margins, like charging for video visits and tacking on fees for replying to patients' questions in the electronic health record. This can perhaps soothe some of the rough edges for now, but it's putting lipstick on a pig.

Right now, we're looking back on where our healthcare system was decades ago, and wishing we'd made these changes way back then. I can only hope that we won't be somewhere down the line 10, 20, or 30 years from now, kicking ourselves for not having made these changes today.

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