Ann Intern Med
Hidden incentives are driving residents away from primary care
young female doctor physician sitting frustrated at computer desk
Clinical Takeaway: Payment, training, and administrative reforms may be needed to make primary care a more sustainable career choice.
The U.S. primary care shortage is usually framed as a workforce pipeline problem. A new Annals of Internal Medicine commentary argues the deeper issue is structural: the healthcare system consistently rewards hospital-based and procedural care more than the continuous outpatient work primary care physicians provide.
Their central argument is that the current system effectively trains physicians away from outpatient medicine. Graduate medical education funding flows primarily through teaching hospitals, where residents spend more than 70% of training time on inpatient services that support fee-for-service hospital economics. Outpatient continuity training, by contrast, often occurs in understaffed clinics with fewer resources and heavier administrative burdens. Now, fewer than 9% of internal medicine residents choose primary care, roughly half the rate seen a decade ago.
“The U.S. education, training, and health care system is perfectly designed to deplete the supply of PCPs,” the authors wrote.
They argue that adding more residency slots alone will not solve the problem. The commentary instead calls for reimbursement that better reflects longitudinal outpatient care, stronger multidisciplinary clinic teams, and graduate medical education funding that shifts more training into community settings rather than hospitals.
The paper argues that these incentives begin shaping career decisions early. Medical students and residents often see primary care clinics with fewer resources, less support, and lower institutional status than subspecialty services. While self-reported interest in primary care at matriculation is the strongest predictor of a student ultimately choosing it as a specialty, the authors argue that outpatient mentorship, exposure to a variety of primary care career paths, and tuition incentives fall short during training.
These recommendations also reflect broader changes in healthcare delivery. Value-based care, Medicare Advantage risk adjustment, chronic disease management, and AI tools designed to reduce administrative burden all rely heavily on stable primary care systems that can manage patients over time.
Primary care receives less than 5% of total healthcare spending despite delivering about 35% of ambulatory care services, according to the National Academies of Sciences, Engineering, and Medicine. The commentary argues the healthcare system already knows what good primary care looks like — it simply does not reward it.
The piece stops short of claiming payment reform alone would reverse the workforce decline. But it reframes the primary care shortage less as a failure of physician interest and more as the predictable outcome of how the healthcare system funds training, infrastructure, and clinical work.
Source: Graham KL. Ann Intern Med. 2026 May 12. Revitalizing Primary Care Internal Medicine: Addressing the Hidden Curriculum