The first day I walked into my residency clinic, I realized this was the part of medicine I understood the least. The waiting room was full, and every patient carried not just a diagnosis but the weight of a system already stretched thin. We learned to triage, to document, and to move quickly. But we did not learn how to lead, how to build continuity, or how to see the clinic as the heart of medicine. In training, the hospital was where the “real” work happened. Outpatient care was quieter, smaller, somehow less important. I realize now how wrong that assumption was.

Today, as chair of internal medicine at a large clinic in Georgia, I spend much of my time recruiting new physicians. It is not easy. Candidates are scarce, and many arrive with preconceived notions of what primary care is, imagining a slower pace, simpler medicine, a gentler refuge from the chaos of the wards. What they find instead is a field that demands everything they have: emotional endurance, clinical breadth, patience, and humility. They discover that primary care is not a fallback. It is a calling.

But it is a calling fewer and fewer are answering. Only about a quarter of medical graduates now choose primary care, and fewer still remain in it. Even among internal medicine residents, most move on to subspecialties or hospitalist roles within a few years. The math of modern outpatient medicine is unforgiving: declining reimbursement, rising overhead, and inboxes that never rest. It is the part of medicine that demands the most humanity and rewards it the least.

We have built a system that makes it harder to practice the kind of medicine most of us went into the profession to provide. To fill widening gaps, hospitals increasingly rely on nonphysician clinicians, capable, compassionate, and overextended themselves. The result is a quiet shift, a slow dilution of continuity and physician presence. It is not just about cost. It is about what happens to the profession when the very idea of a personal doctor begins to fade.

I see it every week in my own clinic. Patients drive hours because they cannot find another internist taking new patients. More and more, they ask if I am staying. It is an odd question to hear, but an understandable one. Patients have grown conditioned to expect that their doctor, the person who knows them best, might disappear. That uncertainty has become part of what people now accept as normal in American health care.

Primary care was once the foundation of American medicine. Now it risks becoming its afterthought. The AAMC projects a shortage of up to 86,000 physicians within the next decade, nearly half of them in primary care. The consequences are not abstract. Communities without enough primary care doctors have higher mortality, more hospitalizations, and higher costs. The presence of just 10 additional primary care physicians per 100,000 people can extend life expectancy by more than a month. Those numbers reflect something real: continuity, prevention, and trust, the things that do not show up in billing codes but define whether a system heals or simply functions.

What worries me most is not just the shrinking numbers. It is the story we are telling the next generation about what matters in medicine. In most training programs, the message is subtle but clear: The hospital is where doctors prove themselves, and the clinic is where they slow down. If we do not rewrite that story now, if we do not show young physicians that leadership, intellect, and impact live in the outpatient world, we will face a shortage from which it will be hard to recover. You cannot rebuild a workforce once the calling itself has been devalued.

We do not just need more doctors in primary care. We need to rebuild the story around it. We have to stop framing it as a consolation prize and start describing it for what it is: the purest form of medicine, the place where skill meets presence, where knowing the person matters as much as knowing the disease.

Every young doctor I have mentored who chooses primary care does so for one reason: connection. The moment they realize that no algorithm can replace the quiet truth uncovered in a conversation. That a 15-minute visit, done with full attention, can carry more healing than any admission.

There is no single policy fix for this. Payment reform matters. So do training, team support, and debt relief. But meaning matters most. We need to remind ourselves, and the next generation, that primary care is not the end of the road. It is the beginning.

When I look at the physicians who stay, the ones who find purpose in the long days and the endless inboxes, I see something that gives me faith. They do not stay for the pay or the prestige. They stay because they still believe that medicine, at its best, is about bearing witness, about showing up for people again and again until they begin to trust that they are not alone.

If we can preserve that, if we can make space for that kind of doctoring to thrive, then primary care will endure. Not because of policy or politics, but because it represents something medicine cannot live without: the relationship between two human beings trying, together, to stay whole.

That truth, steady, simple, and slipping from view, is worth rebuilding for.

Ryan Nadelson is chair of the Department of Internal Medicine at Northside Hospital Diagnostic Clinic in Gainesville, Georgia. Raised in a family of gastroenterologists, he chose to forge his own path in internal medicine—drawn by its complexity and the opportunity to care for the whole patient. A respected leader known for his patient-centered approach, Dr. Nadelson is deeply committed to mentoring the next generation of physicians and fostering a culture of clinical excellence and lifelong learning.

He is an established author and frequent contributor to KevinMD, where he writes about physician identity, the emotional challenges of modern practice, and the evolving role of doctors in today’s health care system.

You can connect with him on Doximity and LinkedIn.