Health care keeps asking how to recruit more clinicians.

That question matters. But it is not the only one. We should also be asking why fewer clinicians are staying.

Across the country, health care leaders are sounding alarms about workforce shortages, access challenges, burnout, and turnover. The proposed solutions are familiar: increase reimbursement, recruit more clinicians, expand training programs, and improve efficiency.

All of those efforts matter. But much of the conversation still focuses on bringing more people into health care. We spend far less time asking what helps them remain there.

Not long ago, many communities had physicians, physician associates/assistants, nurse practitioners, and nurses who spent decades caring for the same patients. They became trusted members of the community. They cared for families across generations. They knew the local schools, employers, neighborhoods, and stories. They were not simply clinicians working in a community. In many cases, they became part of the community.

This is not nostalgia. Independent practices had plenty of challenges. They faced financial pressure, uneven support, limited infrastructure, and all the difficulties that come with running a small health care business.

Still, many of those settings created something modern health care often struggles to recreate: a sense of belonging. Mentorship happened in daily conversation. Professional identity developed over time. New clinicians learned not only how to practice medicine, but how to become part of a team, a practice, and a place. Continuity was not always described as a strategy. It often emerged naturally from the environment.

Over the past two decades, health care has changed dramatically. Many practices have been acquired by larger health systems. In many ways, this was understandable. Independent practices faced growing administrative burden, technology costs, payer complexity, staffing challenges, and shrinking margins. Larger systems can offer resources, technology, compliance support, and operational stability that small practices may not be able to sustain on their own.

But something may have been lost in the transition.

As care has become more consolidated, the relationship between clinicians and their work has changed. Decision-making is often farther from the exam room. Productivity expectations are more visible. Teams change more frequently. Leadership structures are larger and more complex. A clinician may feel connected to an employer without feeling deeply connected to a professional community.

None of this means large systems are the problem. Many are trying to preserve access under extremely difficult conditions. But if clinicians are leaving more often, burning out sooner, or feeling less rooted in their work, we should ask whether the structures that once helped people stay have weakened.

The question is not only why clinicians leave. It is why so many used to stay. That difference matters.

If health care wants continuity, access, and trust, it cannot focus only on recruitment. It has to rebuild the conditions that make clinicians stay.

When clinicians leave, patients lose more than appointments. They lose memory, trust, and continuity.

Historically, those conditions were supported by things we rarely labeled as infrastructure: mentorship, role clarity, professional development, community connection, autonomy, belonging, and longitudinal relationships. These were not soft extras. They helped clinicians stay long enough to become trusted, experienced, and deeply effective.

Today, those conditions cannot be assumed. They have to be built.

This is especially important for early-career clinicians. New graduates are entering increasingly complex health care environments and are often expected to carry significant responsibility quickly. Yet structured onboarding, mentorship, transition-to-practice support, and professional integration remain highly variable. In some settings, clinicians are expected to adapt largely on their own.

When turnover follows, we often interpret it as an individual decision. Maybe we should also see it as a systems signal.

Stable health care systems depend on stable clinicians. Stable clinicians do not emerge by accident. They develop in environments that foster competence, confidence, connection, and purpose over time.

Every discussion about access, continuity, primary care capacity, and workforce shortages is also a discussion about retention. So yes, health care needs reimbursement reform. It needs stronger training pipelines. It needs better recruitment strategies.

But it also needs to ask a deeper question: What infrastructure are we building to help clinicians stay?

Before we assume the solution is simply to produce or recruit more clinicians, we should examine whether we have unintentionally dismantled some of the conditions that once made long-term retention possible. Because when clinicians leave, health care does not only lose labor. It loses relationships, local knowledge, trust, and continuity.

And continuity is infrastructure.

Kenneth Botelho is the founding program director of the doctor of medical science (DMSc) program at the College of St. Scholastica in Minnesota. A primary care clinician, educator, and national advocate for postgraduate PA training, he leads initiatives focused on strengthening early-career mentorship, improving workforce stability, and addressing the growing gap in clinical apprenticeship models across U.S. health care.

He is the founder of Paving Practices, a workforce innovation initiative dedicated to developing scalable training pathways that support retention, system readiness, and leadership development for PAs and NPs.

Dr. Botelho serves as president-elect of the Society of PAs in Family Medicine and collaborates with health systems nationwide to integrate structured postgraduate training with doctoral-level academic progression. His work centers on building sustainable models that reduce burnout, enhance clinical preparedness, and better align education with the realities of modern health care.

His scholarship appears in the Journal of Medical Science, Medical Teacher, and the AAPA Career Central. He engages with colleagues through his LinkedIn profile.