In response to Bohler F, Blumenthal D. “A Eulogy for the Primary Care Physician.” J Grad Med Educ. 2025;17(3):371-372.
A recent piece in the Journal of Graduate Medical Education eulogizes the primary care physician. It’s a thoughtful piece. It names the usual suspects—private equity, administrative burden, economic disincentives. And it’s not wrong. But it’s incomplete. I’ve written before about how physicians aren’t simply burning out—they’re being burned down.
The demise of the PCP wasn’t just murder by external forces. It was also death by a thousand cuts from within, inflicted by the very people who claim to value primary care: patients, specialists, healthcare organizations, non-physician clinicians, and state legislatures. And underneath all of it, a reimbursement structure that has been quietly telling medical students for decades that cognitive work isn’t worth as much as procedural work.
Nearly everyone has contributed to writing this eulogy, whether they admit it or not.
PATIENTS: THE PARADOX OF TRUST
Patients want more from their PCPs while simultaneously valuing them less. Despite all the evidence that continuity with a primary care physician improves outcomes and reduces costs, patients increasingly skip their PCP for conditions squarely within primary care’s wheelhouse. Hypertension, musculoskeletal complaints, chronic lung disease, diabetes—bread and butter primary care—now get funneled to “specialists” by patients who’ve decided subspecialists must be better.
To be fair, most patients aren’t doing this intentionally. They’re just responding to what everyone else in the system is telling them. Healthcare organizations market NPs and PAs as interchangeable with physicians. Specialists tell them “your PCP should handle this.” Legislators grant independent practice to clinicians with minimal training. Patients naturally conclude that the differences don’t matter because no one is telling them otherwise. Every other stakeholder in healthcare has already decided primary care physicians are replaceable, so why wouldn’t patients think the same?
A patient with uncomplicated hypertension doesn’t need a cardiologist any more than someone with a simple laceration needs a plastic surgeon. But the cultural narrative has shifted: the specialist is the “real doctor” while the PCP is just a gatekeeper or triage nurse. And let’s use the correct term while we’re at it: in the actual taxonomy of medicine, the specialist provides secondary care. Primary comes first—the name was never an accident.
Here’s the irony. What does a specialist say to a patient when they can’t figure out what’s wrong? “Go back to your PCP.” The primary care physician has to be the most adept and resourceful physician in the entire system. When the cardiologist can’t explain the chest pain, when the neurologist can’t find the source of the headaches, when the gastroenterologist has run out of ideas—the patient comes back to primary care. The PCP is expected to solve the unsolvable, piece together fragments from multiple specialists, consider diagnoses spanning every organ system, and manage the uncertainty that specialists are trained to avoid. Yet this remarkable breadth gets dismissed as “general” medicine, as if comprehensive expertise is somehow less valuable than narrow specialization.
Then there’s the trend of patients valuing non-physicians over their PCPs. Chiropractors, online forums, social media influencers, nurse practitioners calling themselves “specialists”—they’ve replaced the trusted PCP in many patients’ decision-making. “My sister is a nurse and she said…” has become the go-to rebuttal to years of medical training. When did a Reddit thread become more authoritative than a physician who spent four years in medical school, three years in residency, and decades in practice?
The credential confusion makes it worse. Everyone wants to be a doctor, but only a few actually go to medical school. Now patients encounter all kinds of people calling themselves “doctor”—doctors of nursing practice, doctors of physical therapy, doctors of pharmacy, doctors of chiropractic. These are legitimate doctoral degrees in their respective fields, but they are categorically different from being a physician. This is wordsmithing, and it’s deliberate. When a patient sees “Dr. Smith, DNP” in the clinic, they assume physician-level training. The title “doctor” has been weaponized to blur critical distinctions, leaving patients unable to tell the difference between a physician with 11+ years of postgraduate medical training and a nurse practitioner with 600 clinical hours who happens to have a doctoral degree in nursing.
The go-to defense is etymology. “Doctor comes from the Latin docere — it means teacher. Anyone with a doctoral degree is a doctor.” And technically, yes, that’s accurate. The word traces back to the Latin docēre, meaning “to teach,” and was first applied in 14th century English to theologians certified to teach Church doctrine. A doctorate was originally a license to teach — not to diagnose, treat, or prescribe.
Here’s the problem with that argument: it proves too much. A PhD in Medieval Literature has a doctorate. So does a Doctor of Musical Arts. So does someone with an EdD in curriculum design. Nobody walks into a clinic expecting a musicologist to read their EKG. The “it just means teacher” defense — deployed in a clinical setting in front of a patient who is sick, scared, and looking for someone who went to medical school — isn’t etymological precision. It’s misdirection. Words mean what they mean in context. And in a clinical context, “doctor” means physician. Always has. Using a 700-year-old Latin root to blur that line isn’t a linguistic argument. It’s a marketing strategy.
SPECIALISTS: DELEGATING DOWNWARD
If patients undervalue PCPs from one direction, specialists hit them from another. We’ve all heard it: “Your PCP needs to do X, Y, and Z.” “Have your PCP order these tests.” “Your PCP can handle refilling your medication.” “Your PCP needs to do the referral.”
Here’s what these statements really mean: specialists increasingly see PCPs not as colleagues with their own expertise, but as administrative assistants for the bureaucratic grunt work specialists don’t want to touch. The irony is thick—PCPs are expected to manage every chronic condition, coordinate all care, handle every med refill, and navigate the Kafkaesque insurance authorization process, all while getting paid a fraction of what specialists earn for procedures that take the same amount of time.
The specialist who says “your PCP can handle this” is often the same one who keeps the lucrative procedures and refers everything else back. Primary care has become a dumping ground for everything specialists don’t want to deal with—not because these tasks require primary care expertise, but because they take time and generate no revenue.
What’s worse is what happens when PCPs push back. Any resistance—any attempt to redirect a task back where it belongs—gets met with sabotage. The specialist tells the patient, “Well, your PCP won’t do this for you,” making the PCP look obstinate or unhelpful when the specialist’s office is perfectly capable of doing it themselves. The cardiologist does a stent placement then expects the PCP to manage anticoagulation. The orthopedist does a joint replacement and dumps all the post-op chemistry surveillance, PT coordination, and home service arrangements onto primary care. The oncologist prescribes chemo but sends the patient back to their PCP for the anemia, nausea meds, and lab monitoring. These specialists do the billable procedure, then offload the complex, time-consuming, unreimbursed follow-up—while telling the patient their PCP “won’t help” if the PCP dares push back. Weaponizing the patient-physician relationship to avoid non-procedural work might be the most toxic thing specialists do to primary care.
HEALTHCARE ORGANIZATIONS: THE PRIMARY CARE PHYSICIAN DEVALUED INTO A “PROVIDER”
Healthcare organizations might be the most complicit of all. They’ve systematically blurred the lines between physicians and non-physician clinicians, sending an unmistakable message: your years of medical training don’t matter. The term “provider” is everywhere now, flattening decades of training differences into one bland category. When organizations lump PCPs together with physician assistants and nurse practitioners in staffing models, pay structures, and marketing materials, they’re saying that four years of medical school, three or more years of residency, and board certification mean nothing.
Try to object and watch what happens. Push back on being called a “provider” instead of a physician? You “don’t appreciate our physician assistants and nurse practitioners.” Object to being marketed interchangeably with clinicians who have a fraction of your education? You’re “elitist” and not a “team player.” This rhetorical trick turns a legitimate concern about accuracy into a character flaw, effectively silencing physicians who point out that training differences exist and matter.
The double standard is glaring in how organizations celebrate their workforce. During “Doctor’s Day,” healthcare systems happily include and celebrate nurse practitioners and physician assistants—diluting any recognition of physician-specific training. But there’s still a separate “Physician Assistant Week” and “Nurse Practitioner Week” where these professions get their own dedicated recognition. Physicians have to share their day with everyone, but other professions get to keep theirs. The message is clear: physician identity can be collapsed into the generic “provider” whenever convenient, but non-physician identity deserves protection and distinct celebration.
Adding insult to injury, these same organizations make PCPs keep “logs” of clinical skills they’ve been performing for years or even decades. Do cardiologists log every echo they read? Do surgeons prove annually they can still suture? This performative competency verification is insulting. PCPs with extensive training and years of practice have to repeatedly demonstrate the basic skills that define their specialty—bureaucratic theater that serves no educational purpose and exists solely to generate paperwork for accreditation bodies while signaling that PCPs can’t be trusted to maintain their own competence.
NON-PHYSICIAN CLINICIANS: THE COMPETENCY ILLUSION
The expansion of non-physician practice rests on a dangerous myth: that minimal education produces equivalent outcomes. Nurse practitioners and physician assistants, with a fraction of physician training, increasingly market themselves as equivalent or superior to PCPs. “I’m just as good if not better than you.” “I can do the same thing as you.”
Let’s look at the reality. A nurse practitioner might complete as few as 600 clinical hours—the same as a third-year medical student. We don’t let third-year medical students practice independently. Yet scope of practice laws let NPs with comparable clinical experience function independently in many states. Physician assistants complete significantly less training than physicians too, yet are granted independent practice in multiple states despite the massive educational gap.
The issue isn’t whether NPs and PAs can provide valuable care under appropriate supervision—they absolutely can. The issue is the false equivalency that devalues the training physicians complete and misleads patients about their clinicians’ qualifications. When healthcare systems hire less-trained clinicians because they’re cheaper and market them as interchangeable with physicians, they’re directly contributing to the death of primary care medicine.
STATE LEGISLATORS: RUBBER-STAMPING INDEPENDENT PRACTICE
State legislatures have been just as complicit, systematically expanding scope of practice for non-physician clinicians without any serious scrutiny of training gaps or patient safety concerns. State after state grants independent practice authority to nurse practitioners and physician assistants with minimal debate about the massive differences in educational preparation.
These legislative decisions rarely come from evidence of equivalent competency or outcomes. They come from effective lobbying, claims about improving access to care, and the appeal of a cheaper healthcare workforce. When physician organizations raise safety concerns or question whether 600 clinical hours really prepares someone for independent practice, they get hit with the same accusation: “You just don’t appreciate nurse practitioners and physician assistants.”
This rhetorical shield shuts down any real policy debate. Legislators can vote for scope expansion while claiming they’re improving healthcare access, and any physician who objects gets painted as self-interested and obstructionist. The conversation shifts from educational standards to physician attitudes, from patient safety to turf protection. The fundamental question—does the training justify the independence?—never gets seriously asked.
What’s lost in these legislative debates is any acknowledgment of what primary care physicians actually complete: four years of medical school, three or more years of residency with thousands of supervised clinical hours, board certification exams, and ongoing CME requirements. State legislators grant independent practice to clinicians with a fraction of this training, then act surprised when medical students choose specialties over primary care. Why would anyone pick the longer, more expensive, more rigorous path when the legislature has declared it unnecessary?
THE MONEY: WHAT THE RVU SAYS ABOUT WHO WE VALUE
Underlying all of this is a reimbursement structure that has been making the same argument for decades, just in the language of dollars instead of words.
The Relative Value Unit system—the formula that determines what Medicare pays, and by extension what most of healthcare pays—systematically undervalues cognitive work relative to procedural work. A primary care physician who spends 20 minutes carefully reviewing a patient’s medications, reconciling four specialists’ conflicting recommendations, counseling a patient through a new diagnosis, and coordinating follow-up care gets reimbursed at a rate that reflects none of that complexity. The cardiologist who performs a procedure in the same 20 minutes gets paid multiples more.
This isn’t an accident. The RVU formula is heavily influenced by the AMA’s Relative Value Scale Update Committee—a body historically dominated by specialists. The system was designed by the people who benefit from it.
The downstream effect is predictable and documented. Match data shows primary care residency positions going unfilled or filled disproportionately by international medical graduates while American graduates increasingly self-select into specialties. This isn’t a reflection of American medical students’ values—it’s a rational response to a system that has spent decades sending a clear signal: if you want to be respected, don’t go into primary care.
The reimbursement structure doesn’t just undervalue PCPs financially. It validates every other form of devaluation in this piece. It gives institutional weight to the idea that what PCPs do is less important, less skilled, and less worthy of investment. When the system itself says so in dollars, why would patients, specialists, hospitals, legislators, or medical students conclude anything different?
A NOTE ON GRIEVANCE VERSUS CONSEQUENCE
Some readers will dismiss this as sour grapes—just another disgruntled PCP having a pity party. That framing is exactly the problem. When physicians articulate how systemic devaluation affects their profession, the response is to recast it as personal grievance rather than structural analysis. But this isn’t about wounded egos or professional jealousy. This is about what we’re dismantling and what happens when it’s gone.
The point isn’t that primary care physicians deserve more respect for its own sake—though they do. The point is that we’ve built a healthcare system that tells the brightest medical students primary care isn’t worth it. We’ve constructed economic, administrative, and professional structures that make primary care an irrational career choice. And when the last talented medical student looks at the debt, the administrative burden, the lack of autonomy, the equivalency with less-trained clinicians, the disrespect from specialists and patients alike—and chooses dermatology or radiology instead—we’ll have no one to blame but ourselves.
This isn’t self-pity. This is a warning. The funeral isn’t hypothetical. The mourners are gathering.
SO WHAT ARE YOU GOING TO DO ABOUT IT?
The original piece in JGME ends with a call for advocacy and systemic change. Fair enough. But let’s be more specific, because “systemic change” is where accountability goes to die.
If you’re a patient: ask your PCP what they actually do. Let them manage your blood pressure before you demand a cardiology referral. Stop googling your symptoms and asking your sister the nurse to override your physician’s recommendations. And when someone in a clinic introduces themselves as “doctor,” it’s okay to ask what kind.
If you’re a specialist: the next time your office is about to send a task to a PCP that your MA could handle, stop. And if a PCP pushes back on an unreasonable request, don’t tell the patient they won’t help you. That’s not a collegial relationship—that’s sabotage.
If you run a healthcare organization: retire the word “provider.” It costs you nothing and it means something to the physicians you’re asking to carry your institution. Stop making PCPs log skills they’ve been performing longer than some of your administrators have been alive. And if you celebrate Doctor’s Day, celebrate physicians on that day.
If you’re a state legislator: before your next scope of practice vote, ask one question. Would you be comfortable being treated independently by someone with 600 clinical hours? If the answer is no, vote accordingly.
If you’re a medical student still deciding: primary care is not the consolation prize. It is the hardest, most intellectually demanding, most consequential specialty in medicine. The specialist who can’t solve the puzzle sends the patient back to primary care. That should tell you everything.
The eulogy has been written. Whether it gets read at an actual funeral is still up to us.