Today I am a urologist, a cardiologist, a psychiatrist, a rheumatologist. But truly, I am a rural family medicine doctor in one of the most underserved counties in the country. And I am tired.
I do not pretend to have the depth of each specialist. What I have is necessity, a toolkit built on scarcity. Practicing medicine on an island, where specialists are rare, calendars are full for months, and visiting clinics are as fleeting as rainbows, means my boundaries dissolve. My role stretches, bends, sometimes nearly breaks, to fit whatever shape my community needs. Yet, insurance companies deny authorizations, not for medical reasons, but because I am not the specialist who is hours or islands away. In rural Hawaii, this punishment is sharper: Adjusting for cost of living, we receive the nation’s lowest physician wages, even as we shoulder some of its widest burdens.
Much of the national conversation about primary care shortages is numerically correct but conceptually misleading. Workforce planners count heads and calculate how many primary care physicians exist per 100,000 people. But those maps assume a primary care doctor in a city with specialists nearby is doing the same job as one who works where the nearest specialist requires hours of travel or months of waiting. On paper, the shortage looks the same; in reality, it’s not.
National projections show deficits in both primary and specialty care. The AAMC estimates that by 2036, we’ll be short up to 40,400 primary care doctors, plus significant specialty shortages. Evidence shows what rural clinicians know: rural family physicians manage a broader range of diagnoses than their urban counterparts. Their scope expands because it must. When specialists are missing, primary care absorbs the work.
The American Board of Family Medicine shows the same pattern: Rural family doctors offer nearly every service measured because the alternative is no care. International research agrees, rural doctors provide a wider range of services because their communities cannot function otherwise.
Rural communities don’t just have fewer physicians; their patients are older and sicker. They face longer travel times, more difficulty getting specialist appointments, and worse outcomes. When you care for a population that is older, sicker, and harder to refer, the burden multiplies.
This is why primary care shortage metrics mislead. An urban area and a rural area might each have 50 primary care physicians per 100,000 people. But the urban doctor can stabilize chest pain and refer, while a rural doctor often has to do the full cardiac workup. The urban doctor refers seizures to neurology; the rural doctor handles every specialty thrown into the void.
I treated uncontrolled pain for a bladder cancer patient waiting a month for urology. I managed wound complications for a patient whose surgeon was 150 miles away. I treated bipolar mania and managed lupus because no psychiatrist or rheumatologist was available. All this happened before the lunch I didn’t have time to eat.
Workforce reports warn that shortages will worsen as physicians retire. Rural clinicians are asked to fill the void by expanding into areas that should have specialty backup. These shortages are invisible in official numbers but overwhelming in the exam room.
Describing a rural area as having a primary care shortage understates the situation. It’s not one shortage; it’s many. Losing one rural doctor removes multiple specialties’ worth of care because those roles are already folded into primary care.
I recently read a report arguing rural primary care doctors are overcompensated. I felt a wave of indignation. We deserve more because we do more out of necessity.
Tomorrow I’ll again step into the roles my community lacks: neurologist, otolaryngologist, and pulmonologist. Most importantly, I’ll be there for my patients because abandoning them isn’t an option.
And we are tired.
It’s time for policymakers and workforce leaders to tell the truth: rural primary care isn’t a narrow job. It’s the entire health care system concentrated in the hands of a few who are still standing. We persist not because we are unbreakable, but because our communities cannot afford for us to do less.
Esther Yu Smith is a family physician.
