The typical primary care physician is incompetent in every measurable respect. This is a huge problem.
Here, I make the case that
- Primary care physicians are broadly, grossly incompetent
- This is due to empty credentialism
- Making it much (~10X) easier to become a PCP is a good solution
Primary Care Physicians are Broadly, Grossly Incompetent
The standard of competence I am comparing primary care physicians against is:
- They should be able to reliably diagnose diseases they are trained to diagnose.
- They should be knowledgeable to a standard similar to what is required to qualify as a doctor
- They should be attentive and empathetic towards patients
- Visiting them is empirically superior to not visiting them
When actually examined according to these standards, PCPs fail on all counts.
Failure to diagnose uncommon diseases is rampant
A survey of patients with rare diseases found that, in about half of cases, patients received at least one incorrect diagnosis, and two thirds required visits to at least three different doctors before being diagnosed. For 30% of them, a correct diagnosis took over five years.
Another survey of children with rare diseases showed that 38% of them needed to see six or more doctors before being diagnosed correctly. 27% received an initially incorrect diagnosis.
If you happen to suffer from a rare disease, the likelihood you will actually receive a correct diagnosis and treatment for it within a year of first setting foot in a doctor’s office is astonishingly low.
PCPs Are not good at physical examinations
Physical examinations are often hailed as a reason for the necessity of PCPs and their rigorous training. However, every time they are tested on their ability to perform these tests and derive accurate conclusions, they fail abysmally.
PCPs detect heart murmurs at sensitivities of 30-40%, with high inter-rater disagreement. This is a worse level of accuracy than just taking self report at face value.
“Crackles” in the lungs are detected at rates ranging from 19-67%
Even abdominal haemorrhages are detected at sensitivities of 30-40% by emergency care physicians’ physical examinations.
Kappa values (inter-observer agreement) for the various physical exams done by PCPs and non-specialists land in the 0.18-0.45 range, which is the statistical equivalent of “barely better than flipping a coin”.
The current state of the evidence suggests that if a PCP performs no physical examinations whatsoever, there would be no detectable decrease in their diagnostic accuracy or patient outcomes.
PCPs are Apathetic and Rude
At the level of basic social skills and interest in their patients, primary care physicians fail in almost every way they are capable of failing. A 1984 study found physicians interrupt their patients on average 18 seconds after they begin to state reasons for their visits, and most patients stop elaborating once interrupted.
This was subsequently replicated in 2019, which found that this takes a mere 11 seconds for primary care physicians to interrupt a patient describing their reasons for coming in.1
Over half of US patients surveyed report their symptoms being ignored, dismissed or not believed. 50% reported their doctor made false assumptions about them.
Physicians also consistently over-rate themselves on empathy and manner relative to patient perception. In fact, the ratings they give themselves correlate inversely with patient ratings.
The reason for the overwhelming consistency of negative anecdotes about experiences with doctors is not some arbitrary mass hallucination. Doctors simply are, by and large, apathetic and rude.
Doctors get substantially worse at their jobs over time
There is a strong inverse relationship between the “experience” of a doctor and the quality of care they provide. A recent review of 62 studies found that more than half showed a decline on all measures as experience increased, and only one indicated the opposite.
A 2025 study on pulmonary/critical care medicine fellows showed that they scored substantially worse than medical students on foundational pulmonary physiology questions.
The average primary care physician in the United States is 48 years old. Medical residency typically finishes at age ~30, implying the typical doctor you will encounter has about 2 decades of “experience” during which their competence has been logarithmically decaying. In expectation, they will have lost approximately half of the knowledge on uncommon presentations they had at the beginning of their career.
The evidence literally indicates that simply plonking a student who just passed the MCAT yesterday directly into a modern PCP office would produce an above average PCP in expectation.
The standard PCP is no better than a layperson with a computer
Primary care physicians are increasingly redundant in view of LLMs. Numerous studies have compared the performance of your standard PCP to frontier language models, and consistently find that GPT 4 (now far surpassed by modern frontier models) is slightly ahead on hard performance metrics, and vastly ahead in qualitative evaluations of empathy and thoroughness.
Modern LLMs obliterate GPT4 on all benchmarks, including (and in fact, particularly) biomedical expertise.
Today, a man on the street with a week-long crash course in physical examination practices (and likely not even that), with access to the latest version of GPT, will outperform a median primary care physician with 20 years of experience.
Doctors cannot detect drug seekers
There is no known method of reliably identifying drug seeking behaviour.
When doctors are shown videos of potentially drug seeking patients, they indicate suspicion of drug-seeking only 3% of the time when the drug itself is not mentioned . Even in the most blatant, prototypical case of a patient making a direct request that specifically names oxycodone, only 21% of the time was drug seeking suspected.
Modern databases designed to flag “doctor shopping” as a means of assisting PCPs in identifying drug seeking behaviour, miss roughly half of genuine presumptive opioid abusers, and have extremely high false positive rates. Only 5% of even the most “extensive” prescription-shoppers are presumptive opioid abusers. 20% of people flagged as “shoppers” actually turned out to have cancer, meaning that you, as a person flagged by the system, are roughly 4X more likely to have cancer than be a genuine opiate addict.
The offense/defense balance for a savvy drug seeker is heavily skewed in their favour. Pain is a fundamentally subjective and largely unverifiable phenomenon. Anyone with half a brain and a functioning mouth can say the right things to get prescribed virtually anything they like.
The image of the shrewd, discerning doctor noticing the subtle body language of an opiate addict and denying him pain meds is a load-bearing caricature that is largely nonexistent in reality.
The role of the doctor in mitigating drug seeking is merely to function as a trivial inconvenience.
Empty, Unmeritocratic Credentialism is A Major Cause For The Inadequacy Of Primary Care Physicians
How hard is being a PCP, really?
PCPs (attempt to) follow standardised decision trees for diagnosis and referral. This is something a web app can do. In fact, databases of diagnostic decision trees (CDSS: clinical decision support systems) already exist for this purpose - just plug in the symptoms and you’re good to go. Give it a try yourself.
Adoption of these systems is low, and the reasons for this are damning. The dominant failure mode is that doctors simply don’t use them. It’s too time consuming to type symptoms into a computer, despite studies consistently showing improved diagnostic accuracy without extending consultation times. There are also potential liability issues if they are suggested a rare condition, ignore it, and it later turns out to be correct. Better to be ignorant of the possibility and keep your hands clean, goes the logic. When required to use CDSS, PCPs routinely ignore the outputs, preferring their own early hypotheses, despite the fact that deferring to these systems produces an improvement in diagnostic accuracy.
Better still than traditional CDSS, modern LLM-powered systems are now capable of transcribing live conversations and making realtime diagnostic recommendations, as well as suggesting follow-up questions.
All you need to do to outperform the vast majority of PCPs in diagnosing patients is plug in their self-described symptoms verbatim into one of many widely available software products, and relay whatever it says on the screen.
With tools like this, what possible justification is there to require ten (or even five) years of training to be the human face of a computer-automated triage process?
The Case for Highly Trained PCPs - Gatekeepers
The “official” reasons for the necessary existence of PCPs are:
- Their ability to diagnose (rare) conditions
- Their ability to prescribe, and deny prescriptions to drug seekers
- Their ability to provide referrals to the proper specialists
- Their ability to perform physical examinations
Let’s look at these reasons one by one. Do these functions require approximately a decade of preparation?
- Diagnose (rare) conditions
The typical PCP routinely fails to correctly diagnose rare (and even common) conditions. They are outperformed by LLMs and their personal diagnostic capability has been largely redundant for decades in view of CDSS. They also get logarithmically worse at this task over time.
- Prescribe medications, and deny prescriptions to drug seekers
The reason prescriptions exist is that some drugs are not suitable for some patients.
Thus, the PCP’s role is to do one of the following:
A: Identify the patient as being mistaken about or unaware of the proper treatment for their condition
B: Identify a patient gaming the system to obtain drugs for illegitimate purposes.
C: Give the patient the drug they want or need
There is no known method of actually performing function B, and doctors are largely powerless to identify all but the most blatant drug seekers.
Which leaves only A as an alternative to simply dispensing the prescription upon request. A, as discussed, is simply a matter of plugging the symptoms into the computer and doing what it says.
While it is reasonable to throw up a tokenistic level of resistance to drug-seeking behaviour (at least you have to visit a physical office), the idea that we must have academic veterans holding down the fort against a tidal wave of detectable drug seekers is a complete fantasy.
- Provide referrals to the proper specialists
Why are referrals necessary in the first place? The thinking is we don’t want to waste the precious time of patients and specialists by allowing patients without relevant symptom profiles to book consultations. Think of the money and time wasted chasing red herrings!
This idea would be more compelling without the knowledge that:
- Following a CDSS or asking a LLM is something that you can do from home in a couple of minutes as a patient, and get comparable (if not superior) accuracy to a PCP, and;
- The status quo already egregiously fails to address this “time wasting” issue.
- Given a preliminary diagnosis, providing a referral is simply a matter of choosing from a predetermined list of specialists - a function that can be delegated to a zapier automation.
Given the baseline unreliability of physicians as a screen, and the trivial task of identifying a specialist for a given presentation, the argument for PCPs being a necessary link in the chain connecting patients to specialists is very weak.
- Their ability to perform physical examinations
The sensitivity of physical examinations in detecting illness and injury is so low, and the cross-evaluator disagreement is so high, that it is not exaggerating to say that completely abolishing the practice of physical examinations in primary care offices and replacing it with more detailed questioning would substantially improve their diagnostic accuracy across virtually all presentations.
You don’t need that much training to do that, actually
The standard career track to become a PCP requires roughly 10 years of full time study in the United States, and 6-8 years in other high HDI countries.
What percentage of this decade-long education is actually applied in practice?
Typically, pre-medical education involves 3-4 years of general study in biology, chemistry, mathematics, or in some localities, any four year degree whatsoever. This functions as a screening mechanism for broad competence and stability. The utility of learning advanced mathematics in order to suggest aspirin for headaches is a difficult thing to square.
Of what use is a decade of training when the function of a PCP is simply to screen for initial indications and provide specialist referrals?
You simply do not need to use a $50-$100k four-year degree to screen for broad competence. A G-loaded entry exam on broad physiology is already used - the MCAT. If you can pass the MCAT, additional screening for broad academic competence is redundant. With tens to hundreds of thousands of prospective doctors every year, signing up to waste four years and spending 5-6 figure sums to pass the first filter of “general academic competence”, one shudders to imagine the sheer scale of the economic loss.
The education required to be a functional PCP in line with the standards we observe and accept in practice, is closer to a single year for a competent, motivated student, rather than a decade of coursework that, after 5-10 years, the typical physician largely forgets anyway.
In fact, factoring in knowledge decay, the uselessness of physical examinations, and the broadly low standards we observe today, simply plonking a student who passed the MCAT yesterday directly into a modern medical office would already produce an above average PCP in expectation.
Making it much easier to become a PCP is a solution
Standards are low largely due to limited competition
In the United States, there is approximately one primary care physician per 2000 people. This ratio, coupled with high inelastic demand for medical care, is a major factor producing the poor standards of care we see today.
The standard 10-minute PCP consultation is not a result of some principled analysis of the optimal standard of care. It is the result of virtually unlimited demand and negligible competition. When you have approximately 3000 appointments per doctor per year, dedicating more than a negligible amount of time and effort to each one is a logistically impossible and financially counterproductive strategy.
The typical primary care physician is burning all of their cognitive bandwidth with constant context switching and churning through a crammed agenda of patients on a daily basis.
The outcomes speak for themselves.
Competition drives costs down and increases utilisation
Lowering the barrier to entry to become a primary care physician increases the supply. Patient costs would fall, and availability of alternatives would increase enormously.
The status quo is that location matters far more than competence and reputation for a primary care physician. This results in the perverse incentives and outcomes we see today.
If we 10X’d the supply of PCPs, we would expect to see:
- Markedly lower wait times
- Greater availability and options for patients, particularly in remote areas
- Longer, more detailed consultations
- Higher utilisation and more pre-emptive care
- Massive reductions in the income of PCPs
The only real concern in doing this would be a reduced standard of care provided by the new entrants. This concern, however, falsely assumes we are living in a world where the standards are not already below the level of a layperson with a software subscription.
The Persistent Cultural Reverence for Doctors
The glue that holds the facade of the necessary “academic veteran” PCP together is widespread cultural reverence toward doctors. Doctors (a label which extends to PCPs in the minds of most people) are an almost untouchable class that is popularly considered to belong at the top of the social and economic hierarchy. They are an essential resource, a trusted authority, and a moral example.
Insulting the quasi religious status of doctors by taking a hatchet to entry requirements for primary care physicians will undoubtedly produce substantial political resistance. However, given the enormous costs involved to the patients (and indeed the doctors themselves) as well as the incalculable scale of physical harm caused by poor access and bad incentives, passively tolerating the status quo is an option that is too expensive to accept.
So, do it gradually. Do it incrementally. Do it with tact and understanding. But do it.
We don’t have much to lose.
Discuss