Doctors fleeing primary care is a crisis for Boston’s low-income neighborhoods
I am one of those physicians. It takes time and resources to treat our most vulnerable patients — and we don’t have enough of either.
By Tasnim Ahmed
Updated August 13, 2024, 10:41 a.m.
My patient tells me that her last visit to the clinic was nearly a decade ago. According to my schedule, I have less than 20 minutes to catch up on the last 10 years. She says she hasn’t come in for her annual physical in so long because she’s tired of seeing a new doctor each time.
It’s not just her. Many patients at the Dimock Community Health Center, where I practice, see a new face when they come in — that’s not uncommon. As at many community health clinics, the physicians at Dimock often don’t stay for very long. By the end of the year, three out of four of Dimock’s current attending physicians will be gone. As a resident physician training at Dimock, I am also likely to move on soon.
What’s happening at Dimock is representative of a larger problem facing community health care: the dwindling popularity of primary care. Physicians and other health care providers are leaving primary care in droves, and community health centers located in low-income neighborhoods are the worst affected.
A survey done by the National Association of Community Health Centers found that 71 percent of urban
community health centers lost between 5 and and 25 percent of their workforce over just a six-month period in 2022, and 19 percent of such centers lost between 25 and 50 percent of their workforce.
Burnout, poor compensation, and the promise of a better lifestyle in specialty practice are among the many reasons primary care has struggled in recent years. Those who do choose to stay in primary care favor higher-income communities, creating primary care deserts in low-income ones.
Dorchester, for example, has a population of roughly 140,000 residents but just two primary care practices and eight community health centers. Roxbury has five health centers for its population of nearly 47,000. Yet Back Bay has 15 primary care practices and two community health centers for its population of less than 58,000.
What separates these Boston neighborhoods? Race and money.
But the communities that have scant primary care services are the ones that need them the most. In 2023, the average life expectancy of people living in one Roxbury census tract was 68.8 years. Just two miles north in a Back Bay census tract, life expectancy was 91.6 years. The Roxbury neighborhood is predominantly Black and Hispanic with a median household income of $41,000. Households in the Back Bay neighborhood are mostly white and have a median income of $141,000.
On a busy afternoon, I’m often running behind schedule. In a 15-minute visit I might try to show a patient how to properly use his insulin and explain why it’s important to start colon cancer screening. I typically don’t have enough time to talk about everything. In one recent visit, I had to defer talking about a patient’s depression to a later appointment after addressing other issues because my next patient had arrived. It weighs on me that I can provide only a fraction of the care I know is needed.
This sentiment is a big reason why doctors leave clinics like Dimock. Marcelo Campos, a physician with Atrius Health, a private primary care practice group in Boston, says he left the community health center where he worked in Lawrence after seven years. It wasn’t an easy choice for him, but he felt he would be compromising his mental health by continuing to practice in that setting.
“There’s a decreased incentive for medical students to go into primary care in marginalized communities,” says Katherine Gergen Barnett, a physician and associate professor at Boston University’s medical school. “The burden of responsibility on primary care providers is higher in these community settings, leading to higher levels of burnout as well as turnover.”
There’s no easy solution. I chose to work at Dimock because I believe in its mission: to care for everyone’s health, regardless of their ability to pay. But like so many others, I’m unlikely to continue my career as a primary care doctor. I love the people I take care of, but the broad scope of primary care can be intimidating.
Ultimately, physicians will stop leaving primary care if it pays better and they get more time and resources for their patients.
One way to make that happen is to bring Medicaid reimbursements on par with private insurance. Most patients at community health centers are insured by Medicaid, which has notoriously low reimbursement rates. In Massachusetts, for every dollar Medicare spent on primary care in 2019, the state Medicaid program, MassHealth, spent 71 cents.
Economists have argued that if Medicaid were to increase its reimbursement rates, it could help decrease
disparities in accessing health care. MassHealth recently increased its rates for some independent practices, which are critical to providing primary care in the state, in a move physicians welcomed as a start toward making the community health centers financially sustainable. That being said, much more is needed.
Another incentive is to provide substantial loan forgiveness to physicians who decide to practice primary care. Again, Massachusetts has taken initiative — the state will help pay off school loans for health professionals who work in an underserved community. But the award of $50,000 for a two-year contract only covers a fraction of the average medical student’s debt, typically over $200,000.
I know from personal experience that it’s not just about the money. Treating patients in low-income
communities is complicated and resource-intensive. I cannot take for granted that my patients have their basic needs taken care of — like housing and food. Research shows that poverty is one of the biggest predictors of poor health. “I see so many diseases [like diabetes, cardiovascular disease, and obesity] that could be preventable but are present at a much higher magnitude and severity than in resource-rich communities,” says my colleague Bela Bashar, a primary care physician and the clinical director of HIV Services at Dimock.
Treating these patients requires more people and time. There aren’t enough of either at places like Dimock.
“When our day is done, after having seen an onslaught of patients with complex medical needs, we’re then being asked to put in multiple referrals, place prior authorizations, respond to multiple calls from patients and pharmacies — and while all of those things are important to patients, they should not all fall on the shoulders of already overburdened primary care physicians,” says Gergen Barnett. This support would best come from pharmacists, nurses, and medical assistants, who are just as essential to patient care.
In fact, nurse practitioners and physicians’ associates are taking on bigger roles in primary care. In 2021,
Governor Charlie Baker signed into law a bill that allows nurse practitioners to practice independently without physician oversight after two years of supervised practice.
However, even that solution may be a fleeting one: Studies show that such “advanced practice” providers are following the flight patterns of physicians and leaving primary care altogether. “We already see the migration to specialty care,” Campos says, adding that advanced practice practitioners are making the switch because primary care “a harder job to do.”
Ultimately, the victims of high physician turnover are our patients.
“With the challenging lives that some of these patients lead, I think it’s hard for them to tell their story over and over again,” says Bashar at Dimock. “There’s been historical issues with people of color trusting the medical field, so when someone does open up to you and you gain that trust, it’s enormous — you can effect a lot of change when that happens. But then if the patient finds the provider is leaving, it’s a broken trust.”