More Patients Are Losing Their Doctors — And Trust in the Primary Care System

The loss of a trusted doctor is never easy, and it's an experience that is increasingly common.

This article was published on Tuesday, April 2, 2024 in KFF Health News.

First, her favorite doctor in Providence, Rhode Island, retired. Then her other doctor at a health center a few miles away left the practice. Now, Piedad Fred has developed a new chronic condition: distrust in the American medical system.

"I don't know," she said, her eyes filling with tears. "To go to a doctor that doesn't know who you are? That doesn't know what allergies you have, the medicines that make you feel bad? It's difficult."

At 71, Fred has never been vaccinated against covid-19. She no longer gets an annual flu shot. And she hasn't considered whether to be vaccinated against respiratory syncytial virus, or RSV, even though her age and an asthma condition put her at higher risk of severe infection.

"It's not that I don't believe in vaccines," Fred, a Colombian immigrant, said in Spanish at her home last fall. "It's just that I don't have faith in doctors."

The loss of a trusted doctor is never easy, and it's an experience that is increasingly common.

The stress of the pandemic drove a lot of health care workers to retire or quit. Now, a nationwide shortage of doctors and others who provide primary care is making it hard to find replacements. And as patients are shuffled from one provider to the next, it's eroding their trust in the health system.

The American Medical Association's president, Jesse Ehrenfeld, recently called the physician shortage a "public health crisis."

In Fred's home state of Rhode Island, the percentage of people without a regular source of routine health care increased from 2021 to 2022, though the state's residents still do better than most Americans.

Hispanic residents and those with less than a high school education are less likely to have a source of routine health care, according to the nonprofit organization Rhode Island Foundation.

The community health centers known as federally qualified health centers, or FQHCs, are the safety net of last resort, serving the uninsured, the underinsured, and other vulnerable people. There are more than 1,400 community health centers nationwide, and about two-thirds of them lost between 5% and a quarter of their workforce during a six-month period in 2022, according to a report by the National Association of Community Health Centers.

Another 15% of FQHCs reported losing between a quarter and half of their staff. And it's not just doctors: The most severe shortage, the survey found, was among nurses.

In a domino effect, the shortage of clinicians has placed additional burdens on support staff members such as medical assistants and other unlicensed workers.

Their extra tasks include "sterilizing equipment, keeping more logs, keeping more paperwork, working with larger patient loads," said Jesse Martin, executive vice president of District 1199 NE of the Service Employees International Union, which represents 29,000 health care workers in Connecticut and Rhode Island.

"When you add that work to the same eight hours' worth of a day's work you can't get everything done," Martin said.

Last October, scores of SEIU members who work at Providence Community Health Centers, Rhode Island's largest FQHC, held an informational picket outside the clinics, demanding improvements in staffing, work schedules, and wages.

The marketing and communications director for PCHC, Brett Davey, declined to comment.

Staff discontent has rippled through community health care centers across the country. In Chicago, workers at three health clinics held a two-day strike in November, demanding higher pay, better benefits, and a smaller workload.

Then just before Thanksgiving at Unity Health Care, the largest federally qualified health center in Washington, D.C., doctors and other medical providers voted to unionize. They said they were being pressed to prioritize patient volume over quality of care, leading to job burnout and more staff turnover.

The staffing shortages come as community health centers are caring for more patients. The number of people served by the centers between 2015 and 2022 increased by 24% nationally, and by 32.6% in Rhode Island, according to the Rhode Island Health Center Association, or RIHCA.

"As private practices close or get smaller, we are seeing patient demand go up at the health centers," said Elena Nicolella, RIHCA's president and CEO. "Now with the workforce challenges, it's very difficult to meet that patient demand."

In Rhode Island, community health centers in 2022 served about 1 in 5 residents, which is more than twice the national average of 1 in 11 people, according to RIHCA.

Job vacancy rates at Rhode Island's community health centers are 21% for physicians, 18% for physician assistants and nurse practitioners, and 10% for registered nurses, according to six of the state's eight health centers that responded to a survey conducted by RIHCA for The Public's Radio, NPR, and KFF Health News.

Pediatricians are also in short supply. Last year, 15 pediatricians left staff positions at the Rhode Island health centers, and seven of them have yet to be replaced.

Research shows that some of the biggest drivers of burnout are workload and job demands.

Community health centers tend to attract clinicians who are mission-driven, said Nelly Burdette, who spent years working in health centers before becoming a senior leader of the nonprofit Care Transformation Collaborative of Rhode Island.

These clinicians often want to give back to the community, she said, and are motivated to practice "a kind of medicine that is maybe less corporate," and through which they can they develop close relationships with patients and within multigenerational families.

So when workplace pressures make it harder for these clinicians to meet their patients' needs, they are more likely to burn out, Burdette said.

When a doctor quits or retires, Carla Martin, a pediatrician and an internist, often gets asked to help. The week before Thanksgiving, she was filling in at two urgent care clinics in Providence.

"We're seeing a lot of people coming in for things that are really primary care issues, not urgent care issues, just because it's really hard to get appointments," Martin said.

One patient recently visited urgent care asking for a refill of her asthma medication. "She said, ‘I ran out of my asthma medicine, I can't get a hold of my PCP for refill, I keep calling, I can't get through,'" Martin said.

Stories like that worry Christopher Koller, president of the Milbank Memorial Fund, a nonprofit philanthropy focused on health policy. "When people say, ‘I can't get an appointment with my doctor,' that means they don't have a usual source of care anymore," Koller said.

Koller points to research showing that having a consistent relationship with a doctor or other primary care clinician is associated with improvements in overall health and fewer emergency room visits.

When that relationship is broken, patients can lose trust in their health care providers.

That's how it felt to Piedad Fred, the Colombian immigrant who stopped getting vaccinated. Fred used to go to a community health center in Rhode Island, but then accessing care there began to frustrate her.

She described making repeated phone calls for a same-day appointment, only to be told that none were available and that she should try again tomorrow. After one visit, she said, one of her prescriptions never made it to the pharmacy.

And there was another time when she waited 40 minutes in the exam room to consult with a physician assistant — who then said she couldn't give her a cortisone shot for her knee, as her doctor used to do.

Fred said that she won't be going back.

So what will she do the next time she gets sick or injured and needs medical care?

"Well, I'll be going to a hospital," she said in Spanish.

But experts warn that more people crowding into hospital emergency rooms will only further strain the health system, and the people who work there.

This article is from a partnership that includes The Public's Radio, NPR, and KFF Health News.