A few years ago, I started noticing a concerning pattern, not just in my own experience as a patient navigating a complex health condition, but in conversations happening in thousands of patient communities.
People with chronic conditions weren’t just struggling to get diagnosed; they were struggling to find physicians willing to spend the extra time required to diagnose the root cause of their health issues.
There’s a reason why this pattern exists, and understanding it might be the most important thing anyone struggling with chronic health issues can do today.
You have probably already experienced how difficult it can be to find a physician who will take you on, stick with you, and coordinate your care if you have a chronic pain condition or any complex illness that requires ongoing management.
Chronic pain patients face a unique set of challenges as pain management isn’t a one-and-done prescription. It requires longitudinal relationships, careful monitoring, and a physician who knows you well enough to recognize when something regarding your health changes.
Patients fall through care gaps in ways that have real, lasting consequences when a healthcare system fails to provide the long-term care patients with complex conditions require. Every appointment is with a new provider.
The numbers paint a grim picture. Recent Health Resources and Services Administration (HRSA) projections estimate the total shortage of physicians in the United States will reach 124,180 by 2027, and 187,130 by 2037. The shortages are projected to be most extreme in non-metro areas and impact primary care disciplines the most. The Association of American Medical Colleges estimates the shortage of primary care physicians specifically could be as much as 86,000 by 2036. The impact will be devastating for chronic pain patients suffering from complex conditions.
[Related: What Is a Pain Management Doctor Called?]
The reality that patients with chronic pain conditions are forced to live with is that primary care physicians are stretched thin, which, in turn, makes them more reluctant to manage patients with conditions that require significant amounts of time with patients, documentation, and interdisciplinary coordination.
People are repeatedly referred out, dropped from practices, or left to navigate access to comprehensive care for serious health conditions without any meaningful continuity.
So, why are there no doctors accepting new patients in so many communities? The straightforward answer is that there simply aren’t enough physicians to go around.
Democrats and Republicans alike have signaled bipartisan interest in expanding and improving graduate medical education (GME) to address workforce gaps. Rural areas in the U.S. have far fewer physicians per capita, yet only about 2% of residency programs are based in rural communities. That’s a structural problem.
The opioid crisis led to necessary conversations about prescribing practices, but how those discussions have translated into policy has had consequences that extend well beyond the patients' driving concern.
U.S. physicians have become more risk-averse across the board. Some patients who had been stabilized in pain management with their prescriptions lost access. Care hasn’t become more careful following these changes; it’s become more absent.
Physicians who might have continued managing chronic pain patients chose to refer them out, limit their panels, or stop taking new patients with certain conditions instead. This has created a second crisis laid on top of the first for patients struggling to find continuity.
The Merck Manual of Diagnosis and Therapy defines chronic pain as any pain that lasts or recurs for typically more than three years or more than a month after the injury that caused it has healed. The inability to find consistent care can be dangerous for the millions of people in the U.S. living with conditions like arthritis, spinal CSF leaks, or chronic back pain.
The chronic pain caused by such conditions can lead to depression, anxiety, sleep disturbances, and physical deconditioning. Treatment typically requires a multidisciplinary approach that includes medication, physical therapy, psychological support, and interventions at times, such as epidural blood patches, which is extremely challenging to coordinate without a consistent relationship with a primary care physician.
Chronic pain patients have been increasingly funneled toward procedural interventions as primary care pulled back. Many patients aren’t adequately educated about the risks of these procedures, such as epidural steroid injections and spinal cord stimulators, and the possibility of safer alternatives. As such, many patients may find themselves dealing with healthcare providers whose training and incentives aren’t aligned with patients’ long-term well-being.
It has become common to see people describing complications from such interventions in patient communities, particularly online. Patients often learn more about the risk of these procedures from conversing with one another long before their physicians acknowledge them–if ever. That gap between patients’ lived experiences and what providers are prepared to recognize is where significant harm accumulates, outside the official record.
The problems facing patients with chronic pain conditions aren’t the result of individual physicians failing their patients, though that’s an issue as well. It’s the result of a healthcare system that’s under sustained pressure, adapting in ways that serve its own survival rather than the people it exists to serve.
When the supply of physicians is constrained, the system prioritizes the patients who are easiest to treat, the most reimbursable conditions, and the interactions that take up the least amount of time. Patients with complex, time-intensive, difficult-to-document conditions, such as chronic pain, thyroiditis, or multi-system disorders, are structurally disadvantaged by a healthcare system optimized for volume and simplicity.
The physician shortage in the United States falls hardest on patients who need the most consistent, comprehensive care, and the rural-urban divide makes it worse. A congressional hearing on rural physician shortages highlighted that physicians are more likely to practice in rural areas if they complete their residency there. However, persistent barriers include 1990-era Medicare GME caps, limited rural training infrastructure, and high startup costs for new programs.
As a result, there’s a physician shortage in rural areas and a healthcare system that actively discourages physicians from practicing there.
[Related: Why Are Doctors Always Running Late? It’s Not the Reason You Think]
There are thousands of unmatched medical graduates in the United States who can’t practice medicine at all. The residency system, which is governed by federally capped slots, has not kept pace with the rising number of graduates. The number of residency slots available and the physician shortage are directly connected.
The federal government caps the number of residency positions it funds each year through Medicare. The policy dates back to the 1990s, and it hasn’t been meaningfully updated since.
These unmatched medical school graduates (MSGs) have completed training at accredited medical schools and had their credentials verified through internationally recognized bodies. They are not undertrained or unvetted. These MSGs are ready to enter supervised training, but the system simply has no open doors for them in the United States, which has an all-or-nothing type system.
That closed door does something that rarely gets named directly. It takes a person who has spent years learning medicine and is prepared to care for patients, and tells them to go home and wait for the next annual Match cycle, which is when medical school graduates apply to and attempt to enter a residency program in the United States. Wait while their clinical knowledge sits unused. Wait while studying for entrance exams again to be more quantitatively competitive on a test, not to build practical skills, but to improve a score that might unlock a slot that may or may not exist when the cycle comes around again.
In the meantime, these MSGs can’t apply what they learned. They can’t see patients, so they can’t develop the hands-on judgment that only comes from working with patients under supervision.
The United States graduates MDs and DOs without guaranteeing their ability to practice medicine in any capacity. It’s a striking contrast to how other countries handle the same transition from graduation from medical school to entry into the healthcare workforce.
When people think about becoming a doctor, they often imagine a simple path where a person goes to medical school, graduates, and starts treating patients. But in reality, different countries have very different systems for what happens after medical school. The biggest difference between countries like the United States, Canada, the United Kingdom, and Colombia is this: When are you actually allowed to work as a doctor? The answer to that question shapes everything else, including where “bottleneck” problems happen in the system. We can review where each bottleneck takes place in each of these four countries.
In the United States, graduating from medical school does not mean you can work as a doctor right away. After finishing school, students must get into a training program called a “residency.” This is where they learn a specialty, like family medicine or surgery. The problem is that there are not enough residency spots for everyone who graduates.
So every year, during the annual Match cycle, some students do not get placed. When that happens, these medical school graduates are stuck. Even though they have a medical degree (such as an MD or DO), they usually cannot practice medicine at all. This creates a major bottleneck right after medical school. It’s like finishing college but not being allowed to work in your field unless you next complete an internship where there aren’t enough spots for everyone, and biases are heavy.
This can lead to discrimination against students’ alma mater for medical school, even if these medical schools are accredited, and issues such as an overreliance on test scores as a quantitative marker where a younger student with perfect test scores and a prestigious alma mater but a less diverse work background might be chosen over an older student with very good (but not perfect test scores), a less prestigious alma mater, but very impressive and diverse previous work experience, including as a caregiver of a sick family member in their personal lives.
Canada has a similar system but on a smaller scale. Like in the U.S., students must get into residency to become working doctors. Canada carefully controls how many students enter medical school and how many training spots exist. Because of that, fewer people go unmatched compared to the U.S. However, the Canadian system still has problems. Sometimes, there are empty training positions in areas like family medicine or rural locations, while students go unmatched because they applied to more competitive specialties. So Canada’s issue is not just about numbers; it’s about mismatches. Still, just like in the U.S., if you do not get a residency spot, you usually cannot work as a doctor.
The United Kingdom works differently. After medical school, almost all graduates enter a two-year program where they work as doctors under supervision. This means they don’t face an immediate dead end like in the U.S. or Canada. However, after those two years, they must apply for specialty training if they want to advance in their careers. This is where the bottleneck happens in the UK. Not everyone gets into these training programs.
The key difference is that, even if they don’t get in, they can still work as doctors in other roles. They may not move forward as easily in their careers, but they are not shut out of medicine entirely. So the UK avoids wasting trained doctors, but it can create a situation where some doctors feel “stuck” without clear advancement.
Colombia takes a very different approach. In Colombia, when you graduate from medical school, you are already considered a general doctor. You can start working, seeing patients, and prescribing treatments. Many graduates also complete a required year of service in rural or underserved areas. If they later want to specialize, they can apply for additional training programs. These programs are competitive, so there is still a bottleneck, but this bottleneck only affects specialization and not general practice. This means that no one who graduates from medical school is left unable to work. The system separates being a doctor from being a specialist.
When you compare all four countries, you can see the range of barriers that occur in each approach. The United States and Canada place the main barrier very early. If you don’t pass that step of matching into a residency, you simply can’t practice medicine. The United Kingdom allows people to work in a range of roles with more options, but limits who can move up later. Colombia allows everyone to work as a general doctor from the start and only limits access to specialized careers.
Each system has tradeoffs. The U.S. and Canada can maintain tighter control over training quality, but risk wasting educated professionals. The UK makes better use of its doctors in a variety of roles, but it can leave some doctors without clear career growth. Colombia ensures that all medical school graduates can contribute to healthcare, but specialists are still limited in number, and general doctors may have a lower status or pay.
In the end, these systems reflect different beliefs about what it means to be a doctor. Should someone be allowed to practice as soon as they graduate from medical school, or should they need more training first? There is no single correct answer. But understanding these differences makes it clear that the way the system is designed, and not just the number of doctors, plays a huge role in whether people can get care and whether trained doctors are able to do their jobs.
[Related: Which Country Has the Best Medical Education System?]
New legislative efforts in the United States are beginning to push back against the structures that make it challenging for chronic pain patients to receive comprehensive care. For example, the Physician Graduate License Act in California is one such measure that’s currently moving through the state’s legislature. It proposes a structured, supervised care pathway that would allow credentialed graduates to practice in defined roles, particularly in primary care and underserved areas, with oversight requirements built in from the start.
This is not a proposal to lower standards; it’s a proposal to stop wasting human talent in an overly rigid system.
Google search data shows users searching phrases like “accelerated medical school programs for rural care” and “accelerated medical school programs for primary care.”
The goal of alternate pathways isn’t to “accelerate” anything. What alternate pathways for doctors offer is a chance to have some responsibility and apply what physicians have learned in medical school to help retain their knowledge, rather than solely studying endlessly for the multiple steps of the United States Medical Licensing Examination (USMLE).
These alternative pathways provide a gradual introduction to more responsibilities. This is how Colombian medical schools are structured, based on what Colombian doctors have told me during medical school, where they have more hands-on practice than most U.S. medical school students. There’s currently an all-or-nothing component for MD and DO graduates in the U.S. who have completed medical school but haven’t gone through a residency program. They can’t even perform duties as simple as ordering lab work.
An alternative pathway could be shorter than a five-year residency, but the key point is that it allows medical school graduates who can’t match into residency spots to put their knowledge from medical school to use. It puts these MDs and DOs in a setting where they serve as support staff while learning on the job, allowing them to avoid the all-or-nothing trap.
This approach:
Notably, for this last factor, many Colombian physicians have reported to us that their post-graduate rural service year was the most influential part of their medical education and truly put their abilities to the test as they had to figure out how to provide care resourcefully when resources were limited. This is also a point that comes up in the non-fiction book Unaccountable by Dr. Marty Makary, which the show The Resident is based on.
In this book, Dr. Makary compares rural health systems to metropolitan health systems and highlights the innovation present in working with less, as it often equates to improving health systems. One example given was fewer beds available in rural hospitals, leading to physicians using endoscopic surgeries rather than opting for more invasive surgeries. Endoscopic refers to a medical procedure, device, or technique involving an endoscope, which is a thin, flexible tube with a camera and light, to visualize, diagnose, or treat internal body structures without major surgery.
This allowed the patients to heal faster from surgery and leave the hospital faster. In contrast, in larger hospitals with more beds, Dr. Makary gave examples of the same surgical needs, but physicians opting for invasive surgery, such as completely cutting open the abdomen to view the internal organs, is medically known as a laparotomy to diagnose an unexplained condition. A laparotomy is a major surgical procedure involving a large incision with significant healing time and a higher infection risk.
How is it that such resourcefulness occurs in certain regions and contexts, but this resourcefulness is not applied unilaterally to reduce risk across the United States? Often, there is simply the response of “this is how we’ve always done it.” One U.S. nurse reported to us her training watching surgeons perform, and how one surgeon took pride in how quickly he performed surgery in C-sections. For the sake of speed, unlike the other surgeons, he did not communicate with the female patient, he cut quickly, extracted the baby, flourished his hands proudly to announce his termination of the procedure with speed, and then left the closure of the wound to his assistants as he moved on to the next patient, desiring to maintain his reputation for volume.
And that’s where the key issue lies largely in the U.S.: a culture focused on volume of billable encounters and procedures. Health insurance companies influenced this culture, but many physicians are also culpable in taking a volume-based mindset and proudly running with it to an extreme, passing this mindset on to their trainees in large health centers in metropolitan areas.
Let’s examine the case of a theoretical nurse, Anne, who goes to a Caribbean medical school later in life, when her children are grown. She brings valuable knowledge with her, including years of bedside experience, her own experiences as a patient navigating hospital systems, and the perspective of a non-traditional student who has seen healthcare from other angles.
Caribbean medical schools typically offer four-year MD programs similar to U.S. and Canadian medical schools. The curriculum consists of two years of pre-clinical basic sciences on a Caribbean campus and two years of clinical rotations, often at U.S.-affiliated hospitals. Our nurse chose this path because of lower tuition costs and more flexible entry requirements.
Younger medical school students have told us that nurses in their medical schools often help them with learning due to the nurses’ extensive bedside experience. Our nurse has acquired valuable skills from her years in practice that she passes on to her classmates.
Now, let’s say Anne doesn’t match into a U.S. residency program. Caribbean medical school graduates have lower match rates for graduates than if these graduates had attended a U.S. medical school.
The reported data gives an uncertain picture. Top Caribbean schools report high match rates, often claiming 90 to 97% for students who reach the final steps of training. However, according to the National Resident Matching Program (NRMP) data, only about 50 to 67% of foreign medical graduates (FMGs), U.S. citizens who completed medical school outside of the United States, a group that includes many Caribbean students, successfully secure a residency spot in the main match.
Matching is heavily dependent on passing USMLE Step 1 and Step 2 exams, and not just passing but passing with high scores and securing clinical rotations in the U.S. A large percentage of Caribbean graduates who match do so in primary care specialties like Internal Medicine or Family Medicine, at approximately 65% of Caribbean graduates.
At 40 years old, Anne now has:
She now has a time limit on her USMLEs. Most state medical boards in the U.S. require the completion of all three USMLE steps within a seven-year time limit, starting from the date the first passed step was taken. Some states extend this to ten years or have no time limits.
Our nurse’s USMLE scores were good, but not perfect. She might also face some discrimination against her alma mater as a U.S. citizen who’s a graduate of a Caribbean medical school.
The options Anne has available are:
In the meantime, Anne can’t put her MD knowledge to use. She can still practice as a nurse, which is better than nothing, but the scope of practice and decision-making processes are very different between the two roles.
We don’t want to waste that talent.
We want to give Anne a way to practice medicine, even if it’s not the full responsibility of a licensed physician who has completed a five-year residency. She would be a valuable member of a medical team in rural care settings, helping to address the physician shortage in the United States, with oversight and the ability to perform tasks such as seeing patients, ordering lab work, and making decisions under the supervision of a licensed physician.
The Physician Graduate License Act in California is currently working its way through the state’s legislature. It proposes structured, supervised pathways that would allow credentialed graduates to practice medicine in defined roles, particularly in primary care and underserved areas, with oversight requirements built in from the start.
There is also GA SB427 in Georgia. It addresses internationally trained physicians (IMGs) and proposes alternative pathways, which is a step forward, but there needs to be alternative pathways for U.S.-trained and Caribbean-trained medical school graduates who did not match into a U.S. residency.
This group remains under-addressed, as the popular media narrative focuses more on “poaching” highly qualified international doctors and less on the reality that we’ve created a bottleneck that has failed Americans as well.
Other states are also working on similar legislation. These bills represent a growing recognition that the current system is broken, and we need to think differently about how we train and deploy physicians.
The frustration most patients describe about their difficulty receiving comprehensive care goes beyond access. The most common complaint is feeling disconnected from healthcare providers.
Patients are left feeling like they’re the only one who sees the entire picture while the specialists they’re referred to only see fragments. Every appointment feels like starting over from scratch, and patients are the only ones who remember what happened a few years ago.
Fixing that problem requires more than deploying more physicians. It requires training pathways that produce physicians equipped to manage complex cases, starting from the first encounter in primary care.
Right now, there is a rare moment where policy, workforce, and patient advocacy conversations have the opportunity to converge. Legislation is moving, the data on the bottleneck is clear, and patients, who have the most to gain and the clearest view of what the shortage actually costs, have a voice in what comes next.
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So, what do you do when you can’t find a primary care doctor? Some of your options include:
Doing these things can help chronic pain patients suffering from the healthcare system’s failures to get the care they need while we push for structural changes that will fix the problem for good.
The physician shortage in the United States can be effectively addressed by rethinking how we train physicians, who we allow to practice, and where they’re deployed. The demand is there. The talent exists. What’s missing is the will to connect them.
Let’s change that together.