An excerpt from METACINE: Essays on Health Care in a Changing World.
Primary care is meant to be medicine’s front door: the familiar place where a patient can discuss a new symptom, a lingering worry, a medication question, or simply the uneasy sense that something is not right. It is meant to be a relationship, not merely a point of entry into a larger system.
Yet as hospital chains acquire more primary care practices, I worry that this front door is becoming harder to find and, once found, even harder to open.
The promise of consolidation is understandable. Large health systems can offer practices that might otherwise struggle to survive integrated electronic records, referral networks, access to specialists, and financial stability. These are tangible benefits. But integration also carries a less-acknowledged burden: layers of technology, centralized call centers, and administrative gatekeeping that mediate the relationship between a patient and a primary care physician.
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The patient may still have a physician. What is increasingly uncertain is whether the patient can reach the physician’s office.
Over the past year, I have encountered this problem twice, in two separate health care systems. I called my doctor’s office and didn’t reach my physician or the office staff. Instead, a coordinator answered who seemed unfamiliar with the practice, didn’t clearly understand my concern, and lacked the ability (or the willingness) to connect me to an internal office line.
The message was clear: Do not call your doctor’s office. Use the portal, or have the coordinator message them.
Patient portals can be useful. They provide convenient access to test results, medication lists, appointment scheduling, and secure messaging. For many routine matters, they may work well. The problem arises when portals are no longer optional and become the only sanctioned route to care.
A portal is not a relationship. It cannot hear urgency in a patient’s voice. It cannot easily distinguish between a straightforward refill request and the anxiety behind a message that reads, “I need to speak with someone.” It may require a patient to remember passwords, navigate poorly designed interfaces, translate a complex concern into a few typed sentences, and then wait, sometimes without knowing who received the message or when a response will arrive.
For many patients, these are not minor inconveniences. Older adults, people with limited digital literacy, patients with disabilities, individuals who do not speak English fluently, and those without reliable internet access may view the portal not as a convenience but as a barrier. Even digitally proficient patients can be poorly served when a matter is time-sensitive, emotionally charged, or too nuanced for asynchronous messaging.
The problem is not technology itself. It is using technology to replace access.
When patients call a primary care office, they often seek more than an appointment. They may need clarification about a referral, guidance after an emergency department visit, help with a medication issue, or reassurance that someone familiar with their medical history has heard their concern. A well-trained, adequately supported office team can provide that connection. They can triage appropriately, recognize when direct communication is necessary, and ensure the patient doesn’t get lost in an administrative queue.
But centralized systems can distance these staff members from the practices they serve. Coordinators may be asked to manage high call volumes across multiple offices, follow scripts, and direct patients to digital channels regardless of individual circumstances. They may be doing their best within a system that has not adequately trained or empowered them. Still, patients may perceive this as a closed gate between them and their care team.
This is not merely a customer service problem. It is a clinical issue, especially when the coordinator cannot pronounce the medication name or assign the correct dosage, as happened in my case.
Primary care depends on continuity, trust, and timely communication. A patient who cannot reach the office may delay reporting a worsening symptom. A confusing portal exchange may replace a brief conversation that would have clarified the next step. A patient repeatedly turned away may seek care in an emergency department or urgent care center, or not seek care at all. Each missed connection weakens the relationship that primary care is meant to protect.
As health care becomes more consolidated, efficiency can too easily become the dominant value. Call deflection, portal adoption, and centralized scheduling may look like operational improvements on a spreadsheet. But a health care system should not measure success solely by how many calls it redirects or how many patients it persuades to use a digital platform. It should also assess whether patients can reach a knowledgeable person when they need one and whether that person can reliably connect them to their care team.
Patients do not expect unfettered, immediate access to their physicians for every concern. Physicians also shouldn’t be expected to answer every call personally. Good primary care has always relied on skilled teams. But teams must be designed to facilitate access, not obstruct it. Patients should be able to contact their physician’s office by phone, speak with trained personnel who understand the practice, and escalate a concern that cannot be resolved through a portal or a centralized call center.
The digital front door should be open, but it should not be the only door.
Hospital systems that acquire primary care practices have both an opportunity and an obligation to preserve the human infrastructure of care. That means investing in well-trained office staff, maintaining direct, functional telephone access to practices, establishing clear triage protocols, and treating portal communication as one channel among several rather than as a universal substitute for human contact.
The most advanced health care system is not the one that sends patients into an app most efficiently. It is the one that ensures a patient, at a vulnerable moment, can still reach someone who listens, understands, and helps them find their way to care.
Arthur Lazarus is a physician-author whose work spans narrative medicine, physician leadership, artificial intelligence, health care ethics, medical culture, and fiction. He has published more than 500 articles and essays across scientific journals, professional publications, and online platforms.
He is the author of numerous books on narrative medicine, AI in medicine, career development, and the changing moral landscape of health care, as well as fictional series including Rounds Never End, Sick and Systemic, and Real Medicine, Unreal Stories. His writing explores the forces reshaping modern medicine while preserving a central commitment to story, meaning, judgment, and the human relationship at the heart of care.
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