I have sat in a lot of rooms where smart, well-meaning people puzzle over why American medicine keeps producing the same outcomes: Too few doctors in too many places, primary care is underfunded, and rural hospitals are consistently closing. The answer, frustrating as it is, comes down to a single systems principle: Every system is perfectly designed to get the results it gets. By that standard, we should not be surprised by what we have built. We have constructed a medical education and reimbursement ecosystem that funnels talented, debt-burdened doctors toward affluent areas and high-paying specialties, then expresses disappointment when rural hospitals struggle to recruit physicians and community health centers go unstaffed. The problem is not with the physicians; the problem is the pipeline we have asked them to walk through.
A workforce drawn increasingly from one economic stratum
Whether we like it or not, medicine has always skewed toward the privileged in this country, and the gap continues to widen. Since 1987, approximately half of entering U.S. medical students come from families in the highest income quintile, and more than three-quarters of medical school matriculants come from the top two quintiles of family income. This is not an indictment of any individual. Families with resources invest in their children’s futures, and the pipeline into medicine (i.e., academic enrichment, test preparation, research opportunities, unpaid shadowing, gap years, etc.) is expensive long before the first medical school application is submitted. But it does mean that the physicians we are training increasingly come from communities that look very different from the ones most in need of care.
Debt as a compass
The physician shortage narrative is, in many ways, imprecise. What the U.S. faces is less a shortage of doctors than a maldistribution of them. As of 2023, 7.2 percent of U.S. counties had no primary care physician at all. As of mid-2024, the Health Resources and Services Administration (HRSA) designated more than 7,500 primary care health professional shortage areas across the country, covering roughly 75 million people (approximately 22 percent of the U.S. population!) with more than 66 percent of those designations in rural areas. Simultaneously, graduates finish medical school carrying, on average, more than $216,000 in student loan debt. By the time residency or fellowship training concludes, which can be six to eight years after that, the financial pressure to maximize earning potential is not a preference. It is a mathematical reality.
When a physician completing residency holds a quarter of a million dollars or more in debt, the decision about where to practice is not made in a vacuum. It is made against the backdrop of a reimbursement system in which primary care physicians earn significantly less than procedural specialists, and in which rural and safety-net practices operate on margins that make competitive compensation structurally difficult. More than 140 rural hospitals closed between 2005 and 2023. The communities that need doctors most are frequently the same communities where the institutional infrastructure to support a physician’s career is most fragile. This is not a moral failure. It is arithmetic. And when we design a system that pairs high debt with low reimbursement in the places we say we most want doctors to go, we should not be shocked when doctors go elsewhere.
The newest policy layer
Proposed changes under the One Big Beautiful Bill Act will cap federal student loans for medical school at $200,000 and eliminate Grad PLUS loans, forcing many students to turn to private lending. Private loans carry higher interest rates, lack income-driven repayment options, and do not qualify for Public Service Loan Forgiveness, the program that has historically made practicing in high-need areas and public health careers financially viable for graduates who choose them. These changes will not reduce the desire of medical students to serve underserved communities, but they would reduce the number of graduates for whom that desire is economically survivable.
A recalibrated conversation
The generational argument that today’s doctors view medicine as a job rather than a calling is one I have heard, and one I reject. It is a false dichotomy, of course; it is not just “a job.” It is not simply “a calling.” It is both. And we should recognize that the previous generation of physicians practiced in a materially different financial environment. Reimbursement was more favorable. Debt burdens were lower. Administrative overhead was less crushing. The conditions that allowed medicine to feel more financially secure were structural, not necessarily spiritual. The physicians I know in training and in early practice are navigating a system that is simultaneously less lucrative and, in some ways, more demanding than the one their predecessors entered. They are choosing primary care when the income differential versus subspecialty medicine has never been wider. They are choosing rural practice when rural health care has never been more financially precarious. That physicians still make these choices at all speaks to something durable and genuine in the people making them.
Doctor’s Day 2026
National Doctor’s Day falls on March 30, and it offers an occasion for something more than appreciation, an occasion for honesty. The physician sitting across from a patient at the most vulnerable moments of that patient’s life has invested a decade or more of training, carries substantial financial risk, and operates within a reimbursement and bureaucratic environment that grows more complicated each year. Patients may see the doctor for 15 minutes. But they cannot see the decade-plus of hard work and long hours that led to the privilege of being a doctor. They do not see the massive debt, the insurance games physicians navigate, or the documentation burdens that extend well past the end of that 15-minute visit. What the patients do see is someone who showed up. Someone who cares. Someone who is trying their best to provide healing.
Physicians are choosing to care every day. Choosing to practice in places the market does not reward, choosing to care for patients despite their financial means, and choosing to help communities that need it most. They are doing so in spite of a system that does not properly support them. That fact deserves recognition not just once a year, but in the policy conversations and reimbursement structures and loan frameworks that shape what is and is not possible. Every system is perfectly designed for the results it gets. And it is past time to design a different one.
Michael Jerkins is a physician executive.
