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Family physician Grace Yu discusses her article “The backbone of health care is breaking.” In this episode, Grace reflects on the urgent decline of the primary care workforce and the growing crisis facing family medicine. She shares personal stories from more than two decades of practice—delivering babies, guiding families, and caring for patients across generations—to illustrate why strong, relationship-based primary care remains essential for equitable and effective medicine. Grace explores how debt, burnout, and institutional culture drive medical students away from primary care and calls for reforms in education, payment, and technology that honor its value. Viewers will learn how revitalizing primary care can restore trust, sustainability, and humanity in health care.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Grace Yu. She’s a family physician. Today’s KevinMD article is “The backbone of health care is breaking.” Grace, welcome to the show.
Grace Yu: Thank you. Glad to be here.
Kevin Pho: All right. Let’s start by briefly sharing your story and journey.
Grace Yu: I was born in Taiwan and relocated to the United States when I was about a year and a half. I came from a family of physicians and grew up in Mississippi, and then I relocated to California for medical school. That’s where I really fell in love with primary care and family medicine and saw the impact of family physicians and continuity of care and developed my love of teaching as well. Following medical school, I stayed in the area for the residency program in family medicine, then affiliated with Stanford. Upon my graduation, I joined the family medicine residency faculty here. Nine years ago, I became the program director of the program that I used to train in.
Kevin Pho: Wonderful. And your KevinMD article is, “The backbone of health care is breaking.” Tell us what led you to write this article and then talk about the article itself.
Grace Yu: It came up in March. I was at this national Residency Leadership Summit, and it’s an annual meeting of all family medicine program directors across the country. There are 800-plus program director leaders across the United States. Of that group, I am on the board of the Association of Family Medicine Residency Directors, and it’s a group of about twelve program directors. We’re all sitting around talking about the 2025 match results.
Although there was some excitement that there were an increased number of spots that would help eventually fill this primary care workforce shortage that is purported to be an even bigger issue in the next five to ten years, we were facing this issue that more programs had gone unfilled in the match.
That news of trying to figure out, “Well, on the one hand we’re expanding the number of positions. On the other hand, our programs are really struggling in competing with one another for faculty recruitment and talented medical students who are applying to all of these different residency programs.” Really what we should be doing is not competing with one another for these resources, but putting together a bigger campaign towards changing some of the structural barriers that have led us to this position that we’re in now.
It was this realization that we can’t just keep relying and assuming that family medicine and the other primary care specialties will be there to fill the primary care workforce shortage by expanding slots when you’re just putting too much competition for few resources and overworking those that you already have in the system.
Kevin Pho: So take us behind the scenes into that meeting of program directors. What did you guys conclude were some of the root causes that some of these family medicine spots went unfilled?
Grace Yu: I think it goes down to three issues, which are the three Ps. The first one is going to be payment reform, the second one is practice redesign, and the third one is pathway. I think there are other components as well, but those three highlight the biggest issues.
With regards to payment reform, I didn’t know this until I was a practicing physician that the same procedure can be done by two different specialists, a primary care physician and another specialist, for the same outcome. Yet they are reimbursed at completely different rates, with the primary care specialist procedure at a much lower rate.
Our system is really built on this fee-for-service model where the more patients that you see, the more procedures that you do on them, the longer the hospitalization is, for the most part, the system gets more reimbursement for that. Whereas really we should be thinking about a much more accountable care organization type of model, value-based, where the better you care for these patients to keep them from developing those consequences and complications, the better the health system is reimbursing those groups that are caring for those patients.
That needs to be an issue because that trickles down. Students are paying so much for medical school tuition right now. If there is not an option to be able to recoup some of that loss or loan forgiveness programs, some way to even the playing field, it will become very easy for students to just not even consider the positions where they will not be able to pay back those loans and get the same type of financial or academic prestige that is necessary.
The second piece of it was practice redesign. I’ve been practicing in my clinic, and I work very closely in our residency clinic, and it’s a lot of work. You’re seeing patients, and we are fortunate to be in a system that gives us a lot of individual clinic flexibility for the number of patients that we’re seeing per half day, as long as we meet certain targets. But I do know that there’s a push to just always see more, and yet there’s a lot of, for every patient that you’re seeing, all the labs and imaging follow-up results that you have to take care of, all the messages that patients are now able to very easily email back and forth with the physician. None of that is compensated care.
Students see this. Residents are seeing this and thinking, “How is this going to be sustainable?” I frequently have students work with me when they’re sometimes even in college, just trying to get a sense for if this is a field for them. I have not ever had one who said, “I don’t love the work you do,” but I had one recently who said, “I love the work that you do. It’s so amazing. And yet I keep hearing about all of the after-hours work and in-basket.” These were not things that students had ever thought about or considered before, but they are a considerable issue now.
There are options, like AI, the transformative ways that it can make the clinician’s work-life a little bit easier so they can focus more on patient care. That is huge. We’re starting to see some of that in my practice and support for some of the answering of messages and things like that. But at the end of the day, everything falls to the PCP. It is the drug prior authorization that needs to be done for that patient of yours to get the medication they need, etc.
The last P is pathway or pipeline. Students often don’t see the true value and joy of continuity of care in their medical school rotations, whether it’s in family medicine, internal medicine, or pediatrics. I remember when I was going through medical school, family medicine was not a required clerkship during your third year. Most people were doing it fourth year, way past the time that they’re selecting their specialty choice. Even when you did, you didn’t have the opportunity to work with the same clinician for a long period of time. You’re working with a different clinician every half day, so you don’t get a sense. “What does it mean when a doctor has been with a patient for 10 years, has taken care of their grandmother, has delivered their baby?” All of the intangible benefits of that relationship that occur.
In most IM and peds clerkships, those are very hospital-based. The outpatient component of it is not very big at all. Then there are also some of these elite schools. Mine is one of them that we call orphan institutions because they don’t have a department of family medicine. If you have students who don’t see leadership in family medicine at the medical school level, they’re not going to even consider that as a practice possibility for them.
Kevin Pho: I’m in primary care as well. I do internal medicine, and I can’t believe I’ve been doing this for 23 years now. A lot of the same solutions that you talked about, we’ve been talking about every year. Every year it’s a primary care crisis. What makes this time different? Why haven’t some of the suggestions that you and your committee came up with, why haven’t they already been implemented? I’ve heard that these solutions need to be done years before. Why hasn’t it happened yet?
Grace Yu: There is this fundamental mismatch that I didn’t realize until that March meeting that ACGME, the accrediting body that allows new programs to start or programs to expand, they don’t look at all to what is the need in a particular community. You’ve got different incentives that hospitals have to start a new residency program. Maybe it’s completely in an area that is saturated with family physicians and family medicine residency programs already, and there are other areas that have very few of those.
There’s this fundamental mismatch that right now they don’t speak to each other at all. I think having some way, some regulating body, to say the two have to be working in concert with one another. Most program directors do not know about that at all. I think that’s one piece.
I’m seeing a lot of change that is starting with our younger generation of residents and students, and it’s refreshing because in the era that I trained, we did what we were supposed to do. We knew what we would ultimately get to, and it was worth it. I loved the mentors that I worked with, and I would never have questioned that the things that they told me to do as hoops to go through in residency were the things that were needed to achieve my final goal of being a family medicine educator and clinician.
There’s a lot more questioning of that now, and sometimes that’s for a really good tension for change. Maybe it will come. As resident unions talk about this, or physician unions talk about the practice redesign piece of it that needs to occur. I’m not really sure what the answer is to get the payment reform piece, but that is one of the most important things that needs to be addressed head-on.
Kevin Pho: From a practical standpoint, what happens when a family medicine residency goes unfilled? What are some of the options that they have?
Grace Yu: There’s this time period after they find out where they can go through something called the Supplemental Offer and Acceptance Program, or SOAP. All the programs, whether it’s in family medicine or another specialty, get a list of all the unmatched applicants. All the unmatched applicants see the list of the programs that have not filled. They do this match process and interview process again, but it is in a very concentrated, four-day period of time. It is incredibly stressful for the applicants and the programs and very time-consuming during this period.
Eventually, what the general public hears is what are the match results at the end, what are the filled spots? It is true in family medicine and the other primary care specialties, the ultimate filled rate at the end of SOAP is high. It is this unnecessary time period of stress. Also, why does that need to occur in the first place?
Ultimately, there will be a lot of people who may end up choosing a specialty that they didn’t initially plan to apply and match in. Then they choose that. That might be in family medicine, it might be internal medicine, it might be peds, or it might be something else. There’s a little bit of a pendulum that shifts. We knew that right after the pandemic, there was a decrease in ER, probably because of what people were experiencing or imagining what ER physicians had gone through during that COVID-19 time period, and then it got better.
What is alarming is that I don’t see a way for this next match to change considerably unless there’s a reduction in the number of slots or there is a significant change in the number of interested applicants. That worries me.
Kevin Pho: When you talk to the medical students who match to your program, for instance, they chose family medicine despite all the obstacles that we are talking about today. What are some of the major themes why they chose family medicine in the first place, despite everything and all the impediments that we talked about in our conversation?
Grace Yu: Oh, it’s so wonderful. If you just listen to our residents as well as our faculty talk about why they chose family medicine, it’s for all the right reasons. They believe in health equity. They believe in the power of a long-term relationship with patients. They believe in being able to do many different things in the scope of care. In our program, we train people to be able to do inpatient work, to deliver babies, and to do outpatient medicine really well. Many of them continue that full scope afterward.
I feel like if everybody heard this message, this would be so motivating in and of itself. That’s why I’m about to head into recruitment season when we start interviewing applicants. While it’s a busy time, it’s one of my most favorite times of the year because you hear every single day with every interview affirmation of why this field is so important.
Kevin Pho: So what about the future of clinics? There’s a lot of uncertainty out there. In non-academic settings, you have things like private equity buying up practices and cutting costs. I hear stories of physicians sometimes being replaced by advanced practice practitioners, and that makes the future of primary care a little bit uncertain. When I talk to medical students, it’s that uncertainty that is one of the reasons that prevents them from applying. In terms of the future, given the current climate, how do you address that uncertainty some medical students have about the field of primary care in general?
Grace Yu: I think a lot of people have asked, “Are primary care clinicians going to be replaced by machines or robots?” The power of that human connection is not going to ever be replaced by a machine. There can be efficiencies that are gained. There can be a different way of practicing that will be available to us in the very near or not-so-distant future.
The very reality that our graduates have no problem at all finding jobs because there is such an immense need for more primary care physicians in this area, and some of them relocate to other parts of the United States, is proof that there will be jobs for them. They may look slightly different, and they may be asked to have different types of skill sets than what we have traditionally trained for in the last 50 years of medicine. But that’s the case for all medicine, I think. I think the future still is bright.
Kevin Pho: We’re talking to Grace Yu. She’s a family physician. Today’s KevinMD article is “The backbone of health care is breaking.” Grace, let’s end with some take-home messages you want to leave with the KevinMD audience.
Grace Yu: I think that if you are a clinician who is not a primary care physician, but you work with one, just appreciate them. Work, partner with them. That is a very important piece, to feel like we’re working together towards the same goal, not competing.
I think if you have influence, whether it’s in your church, whether it’s in your school, whether it’s in a medical school system or health care system policy, we need to hear all those voices for why it’s important to invest in physicians and in specialties that are really taking care of our entire populations.
Then I think for family physicians who are practicing, my colleagues, I think it is important to know that you have so much immense value. Your patients adore you and appreciate you. Your students do too. Have joy in the medicine that you chose to do. Share your value openly, out loud, and make people stand up and listen and appreciate the work that you’re doing behind the scenes all the time.
Kevin Pho: Grace, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Grace Yu: Thank you.