The Doctor Shortage We Designed

America’s two-tier system is here: concierge care for the few, crowded waiting rooms for everyone else

We all want the same thing: a doctor who knows our name and our health story.But across the country, that relationship is disappearing

In The Doctor Shortage We Designed, we unpack how a 1997 policy decision set off a slow-motion crisis. And what we’re not changing, we’re choosing.

—Sharon McMahon

Editor-in-Chief, The Preamble

Don’t forget: our next issue heads to the heart of America, where food, family, and policy meet. If your life’s been shaped by the land, we’d love to hear your story.

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American health care was built on the promise of a trusted family doctor who knows your history. For most of my adult life, I had one.

I loved my primary care doctor, whom I’d seen for more than 20 years since moving to Washington, DC. He was recommended by a close friend, and he became more than just my physician. He was a wonderful diagnostician who saw me through more than one health crisis, including an emergency surgery in 2007, and all the routine care that keeps you healthy. I never had a problem getting an appointment. Then, two years ago, a letter arrived.

My doctor was converting to “concierge” medicine, in which a limited number of patients would pay higher fees in exchange for enhanced services. For $2,500 a year, I would be entitled to a handful of in-person and virtual appointments (further visits could be submitted to insurance), same-day or next-day when needed. But the $2,500 was unaffordable. I was unhappy that I had to leave him but wasn’t worried about finding a new primary care physician, telling myself there are plenty of doctors in Washington.

Little did I know that for the next two years I would be on a merry-go-round looking for a new doctor. First, I tried numerous private practices, but their physicians weren’t taking on new patients. Then I contacted a physician group through one of the local hospitals. The attending physicians also weren’t accepting new patients, but I could wait three months to see a medical resident (someone who has graduated from medical school but is still completing their training while working as a doctor). After I saw the resident once, she finished her residency and moved out of Washington. The process began again.

My story isn’t unique. Many of my friends, and probably many of you readers, have had a similar experience waiting an ungodly long time for a doctor’s appointment. The average wait time for a primary care appointment in America is now 31 days, according to the 2025 Survey of Physician Appointment Wait Times.

Most medical practices and attending physicians at hospitals aren’t accepting new patients, leaving many people to see resident medical students if they can get an appointment at all. The American Medical Association estimates that more than 83 million people in the US live in areas without sufficient access to a primary-care doctor. By 2036, if current trends continue, the physician shortage could reach 140,000 doctors.

This puzzled me. If we know there’s a shortage, why haven’t we fixed it? Medical schools have increased enrollment by nearly 40% since 2002, according to the Association of American Medical Colleges. We’re graduating more doctors than ever before. So where are they?

And what would make my original doctor, a good physician who clearly cared about his patients, decide to abandon most of them in the first place?

The foundational problem: not enough training slots

At the heart of America’s physician shortage is a policy decision made in 1997. That year, Congress passed the Balanced Budget Act, which capped the number of Medicare-funded residency positions at hospitals at their 1996 levels. This had a huge effect, since 86% of medical residencies are funded by Medicare, Medicaid, or the Department of Veterans Affairs, with Medicare paying for the largest share. The policy change means that even though our population has grown by over 70 million people since 1997 and is rapidly aging, the number of doctors we can train has barely budged.

In March 2025, 47,208 applicants, including US medical school graduates and international physicians, competed for only 37,667 first-year residency positions, according to the National Resident Matching Program. That means 9,541 qualified medical graduates could not obtain residency slots, and therefore could not become licensed physicians. (Every state requires at least one year of medical residency for licensure, and most require three or more.) This figure doesn’t include the thousands more who stopped searching for a residency because they weren’t offered interviews.

Think about that: we have thousands of people who’ve completed medical school, passed their exams, and desperately want to become doctors, but our system won’t let them finish their training.

The Association of American Medical Colleges projects a shortage of up to 86,000 physicians by 2036, including as many as 48,000 primary care physicians.

“Given the new findings, it is clear that both sustained and increased investments in training new physicians are critical to mitigating projected shortfalls of doctors needed to meet the health care needs of our country,” said AAMC President and CEO David J. Skorton, MD.

Why doctors avoid primary care

Even when medical graduates do secure residency slots, many avoid primary care. And it’s not hard to understand why.

The average medical student graduates with crushing debt, sometimes $400,000 or more. When you’re facing that kind of debt, the financial pressure to specialize becomes overwhelming, since primary care physicians earn $100,000 to $160,000 less annually than specialists. “Last year, 30% of pediatric residency programs did not fill their positions,” said Dr. Alessandro Larrazabal, chief medical officer of Clarity Pediatrics. “And those who do enter pediatrics are less incentivized to pursue a subspeciality because of the lower compensation than offered by most adult subspecialties.”

Only 25% of US physicians practice primary care today, and that number is shrinking. Post-Covid, 32% of primary care physicians report high burnout levels. One-fifth of the clinical physician workforce is 65 or older. The demographics are stark: many doctors are retiring, few are entering the field, and those who do often leave within years.

The administrative nightmare

Money isn’t the only reason doctors avoid or leave primary care. The job itself has become nearly impossible.

In traditional practices, doctors have 2,000 or more patients, according to the American Academy of Family Physicians. They’re expected to see about 20 to 25 patients a day, while also handling an avalanche of administrative work.

According to a study published in the Annals of Internal Medicine, primary care doctors spend nearly two hours on computer work for every hour with patients. Ordering something as simple as Tylenol can require up to 62 clicks. In a single emergency room shift, doctors click nearly 4,000 times. Nearly 60% of doctors’ notes are identical to previous ones, since insurance companies and electronic medical record systems require redundant documentation. A 2016 study in the Journal of General Internal Medicine found that primary care doctors are expected to fit 26.7 hours of work into each day.

“We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company,” said Dr. Shayne Taylor, who recently opened a direct care practice in Massachusetts.

Dr. Bruce Scott, president of the American Medical Association, put it bluntly: “We all became physicians to take care of patients, and that is getting tougher every day... Right now, things are at almost crisis level and physicians are literally closing their practices.”

The specialist shortage

Patients are having a hard time meeting with specialists, too. A friend of mine is a good example. When her two-year-old son was experiencing hearing issues, she had to wait six months to see a pediatric specialist. That half-year wait wasn’t just inconvenient; it was potentially life-altering for a toddler learning to communicate.

In a recent social media thread, dozens of people, even those with serious medical conditions, shared unnaturally long wait times for specialist appointments. A friend of the original poster couldn’t get a neurology appointment for more than a year after having a stroke. Yes, you read that right: a stroke patient waited over a year to see a neurologist.

The stories piled up. One Philadelphia patient was quoted an 18-month wait to see a gynecologist at a local hospital for a routine annual exam. When she tried private practice instead, the best available was a telehealth visit in two months. Another woman with a concerning mammogram was told she’d need to wait a month before she could even call to schedule a biopsy, a stomach-churning delay for someone who might have cancer.

Another poster on the thread had a neighbor who waited over four months for a routine pediatric allergy appointment at Children’s Hospital of Philadelphia. Someone seeking an autism specialist at the same hospital was told that none were available. No waitlist. No cancellations. “Please don’t call back,” the scheduler said.

The shortage isn’t limited to any single specialty. It’s systemic.

“There’s been a marked increase in chronic conditions and complex health issues requiring specialist care, particularly post-Covid,” said Dr. C. Vivek Lal, who specializes in pediatrics and pulmonary medicine. “Patients who postponed regular checkups and preventive care are now presenting with more advanced conditions that require more intensive specialist intervention.”

Getting to a specialist also means jumping new bureaucratic hurdles. Insurance companies require primary care physicians to conduct extensive initial assessments and testing before specialists will review cases. While this approach aims to ensure that specialists focus on cases truly needing their expertise, it creates additional layers of approval that delay care.

And once you do get an appointment, the specialist may be overwhelmed. According to Dr. Ashish Nanda, a neurologist at Providence St. Jude Medical Center, administrative work and documentation requirements consume almost 50% of specialists’ time, limiting their interaction with patients and further lengthening wait times.

The concierge solution and its cost

This brings us back to that letter I received. My doctor, like thousands of others, chose concierge medicine as his escape route.

According to Concierge Medicine Today, there are about 12,000 concierge practices operating in the US now. Doctors charge annual membership fees ranging from $1,000 to $50,000, and in exchange they reduce their number of patient panels from 2,000 to 300–600. They can finally spend adequate time with patients, answer messages thoroughly, and practice medicine the way they were trained to.

For patients who can afford it, the care is excellent. But here’s the problem: When a doctor goes concierge, 1,400–1,700 patients are suddenly looking for a new physician in a system that’s already underwater.

“Each time any physician makes that switch, it exacerbates the shortage,” said Michael Dill of the Association of American Medical Colleges. “Even one or two make that switch, you’re going to feel it,” especially in rural areas.

Some patients, like Patty Healey, accepted the concierge model without hesitation. “I didn’t question it,” she said. As a retired nurse, she knew finding a new doctor would be nearly impossible. “And it might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns.”

Other patients, like Michele Andrews, were insulted: “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

Dr. Paul Carlan, who runs Valley Medical Group in Western Massachusetts, points to the fact that taxpayers fund doctors’ residency training through Medicare. “We all contribute through our tax dollars which fund these training programs,” he said. “And so we should be worried when folks are making decisions about how to practice that reduce their capacity to deliver that good back to the public.”

But Dr. Shayne Taylor, the Massachusetts physician who opened a direct care practice, offered a different perspective: he said it was either the concierge model or leaving medicine, and that serving 300 patients was better than serving zero.

While I didn’t move to the concierge practice with my long-time doctor, I made a different choice for my aging mother, who has an autoimmune disease. She recently moved to northern California, where she needed immediate and ongoing access to a primary care physician. We aren’t a wealthy family, so the $3,000 annual fee to join a concierge practice (plus insurance costs for the actual visits) was very steep. But being able to call and text, and to have virtual or in-person appointments on the same or the next day, was invaluable.

What this means for the future

We’re witnessing the creation of a two-tier medical system: one for those who can pay high prices for access, and another for everyone else where wait times stretch into months, where you see whoever’s available rather than a doctor who knows your history, and where preventive care becomes a luxury.

The consequences will ripple through the entire health care system. People who can’t get primary care appointments end up in emergency rooms for non-emergencies. Chronic conditions go unmanaged until they become acute crises.

Dr. Thomas Lee, chief medical officer at Press Ganey, points to a feeling among patients that the system can’t take care of them. “People are almost expecting it to be an ordeal every time they need to make a doctor’s appointment,” he says.

The solution isn’t opening more medical schools. We’ve already done that. The solution is lifting the 1997 cap on residency positions and fundamentally rethinking how we train, pay, and support primary care physicians.

The Resident Physician Shortage Reduction Act, a bipartisan legislative proposal, would add 14,000 Medicare-supported residency positions over seven years. It’s a start, but even the AAMC acknowledges it won’t eliminate the shortage.

“Until the cap is significantly raised, the shortage of physicians will never be truly resolved,” wrote Dr. James L. Madara, AMA Executive Vice President and CEO. “Therefore, it is essential that we invest in our country’s health care infrastructure by providing additional Medicare-funded residency slots so that more physicians can be trained and access to care can be improved.”

But increasing the number of training slots alone won’t fix the crisis if newly trained doctors continue to avoid primary care. We need parallel reforms to make primary care financially viable and professionally sustainable. That means narrowing the income gap between primary care and specialty medicine through adjusted Medicare reimbursement rates, and simplifying the electronic health record systems and prior authorization requirements that consume hours of administrative work. Without addressing both the supply of doctors and the conditions that drive them away from primary care, we’ll simply train more physicians who choose specialties.

Meanwhile, like countless others, I’m still looking for a primary care doctor. This isn’t just an inconvenience. It’s about what we value as a society. We train doctors with public money, but then abandon them to a system that makes primary care financially and emotionally unsustainable.

The result is entirely predictable: doctors leave, patients suffer, and the foundation of health care, the relationship between a patient and a doctor, crumbles. It’s a crisis that we designed through policy choices, and that we can fix with better ones.