In this episode, Drs. Yurkiewicz and Blumenthal explore what power the most powerful person in this country has to enact meaningful reform. Through case studies of three administrations — Obama and the Affordable Care Act, Trump and the Covid pandemic, and Biden and the medical safety net — they unpack: What legislative and bureaucratic obstacles stand in the way? Are ideological differences between the left and right too wide to overcome? If a presidential candidate makes healthcare reform a key part of their platform, is it worth your vote?

Can the president of the United States fix healthcare?

0:06 Opening Monologue: Who Has the Power to Enact Major Healthcare Reform?

2:18 Most Americans Want to Fix Healthcare — and Most Presidential Advisors Say Don’t

5:21 Obama Focuses on the Affordable Care Act

21:41 Did the President Break Electronic Medical Records? Can a Future President Repair Them?

28:46 Trump Faces the COVID-19 Pandemic

40:11 Biden Targets the Medical Safety Net

44:55 Rapid Fire: What’s the Next Whiplash? Is Bipartisan Agreement Possible? Is Loss of Trust Insurmountable?

47:50 Can the President of the United States Fix Healthcare?

The purpose of this episode is not to debunk the myths and grifts of longevity medicine, of which unfortunately there are many. This is a conversation about what works to live longer, healthier lives.

0:06 Opening Monologue: Longevity Medicine as Personalized, Not Population-Based

3:03 What Is Longevity Medicine?

5:22 Understanding Your Cardiovascular Risk

22:22 Insulin Resistance: Tests, Treatments, and Continuous Glucose Monitors

29:18 Are GLP-1s the First Modern Longevity Medicine?

31:51 Four Lifestyle Pillars: Exercise, Diet, Sleep, and Mental Health

45:54 Reducing Dementia Risk

48:25 Do Supplements Work?

51:35 Democratizing Longevity Care and Overoptimizing

54:21 Rapid Fire: What Aren’t We Talking About Enough? What Are We Talking About Too Much?

56:12 What Parts of Longevity Medicine Are Real?

As I told the Times, disseminating medical information to the public is a good thing, as most health changes happen outside the exam room. And, getting an appointment with your doctor is notoriously difficult and only getting harder. My ideal clinic visit is the flipped classroom: a patient comes prepared with general knowledge about their condition, so then we can use our precious time together working through higher-level decisions of how it applies to them.

But of course, not all info out there is good, and popularity does not correlate with accuracy. I shared two stories: one where I was able to ultimately steer a patient in the right direction, and one where I sadly could not.

Thanks to the Times and Jamie Ducharme for the nuanced story.

In this episode of Hard Medicine, Dr. Yurkiewicz speaks with Dr. Azra Raza, oncologist and author of The First Cell, about why cancer medicine still prioritizes treatment over prevention — and the paradigm shift needed to change that. They discuss what stands in the way: massive disparities in research funding, a health care system that flattens prevention into one-size-fits-all, and a medical culture favoring incremental advances over radical change. They also explore solutions, from targeting cancer precursors in the bloodstream to tailored screening for people at high risk.

This is a conversation about cancer that is both deeply critical and optimistic.

0:06 Opening Monologue: From Treatment to Prevention — Cancer Needs a Paradigm Shift

2:49 Why Focus on Prevention?

8:33 Cancer Is Too Complex to Cure

14:45 95% of Cancer Drug Research Fails

18:47 What’s Wrong With Mouse Models?

27:40 Building Biobanks From Human Samples

30:18 The “Stentinel”

37:21 The Limits of One-Size-Fits-All Screening

44:43 Rapid Fire Q&A: Blood Tests for Early Detection, Full-Body MRIs, and Rising Cancers in Young Adults

50:31 Is Cancer Preventable?

They dissect several sources: payment that rewards episodic care over long-term relationships, outdated residency funding that favors hospitals over clinics, and underutilizing internationally trained physicians already living in the U.S. They also discuss hopeful initiatives, such as a bipartisan bill that would let Medicaid support a model known as direct primary care.

How can policymakers rewrite incentives to reflect workforce needs? How can we help more doctors choose to practice where they’re needed most?

0:06 Opening Monologue: Where Doctors Go Is a Policy Choice

1:52 Why Are Primary Doctors Paid Less Than Specialists?

19:20 Lobbying from the AMA and Unintended Consequences

24:18 The Pipeline In: Residency Funding Is Outdated

39:39 Wasting International Physicians’ Time

45:26 Bipartisan Support for Direct Primary Care

51:04 How Do We Get Doctors Where They’re Needed Most?

Whenever I speak on this topic, I ask the audience three questions.

1. Do you have a doctor you like and trust?

2. Do you find it easy to reach that doctor when you need to?

3. When you can’t reach your doctor, have you turned elsewhere for health information?

Invariably, the majority of hands go up for questions 1 and 3. Fewer and fewer raise their hands for 2.

Most ideas to combat misinformation focus on communication. We have toolkits, workshops, and scripts to persuade when the stakes are high. We also tend to focus on curbing sources of misinformation. But both are losing strategies if we don’t address the elephant in the room; how can we employ even the best tactics of communication when we can’t get a patient in front of us for months?

As I wrote in the piece:

Put the doctor you know against the most charismatic TikToker, and the doctor will usually win. I’ve been able to coax uncertain patients into essential tests and treatments and out of depleting their limited time and savings…. Most are not combative; they’re grateful for clarity. They don’t prefer Option B; they settle for it when Option A is unavailable.

This should be reassuring, in a way; we don’t need to tackle the gargantuan task of restoring trust in a profession. People already trust their doctors more than any other source of health information. The focus must be on restoring access as the life-saving antidote it is.

They discuss the vulnerabilities that even healthcare struggles to hold — chronic illness, pregnancy, end-of-life — and the costs of treating these as exceptions: financial loss, employment discrimination, and compassion fatigue. What would it take for medicine to meet real human need?

0:06 Opening Monologue: Healthcare’s Blind Spots on Dependence

1:22 What Is Dependence?

2:29 Does Medicine Overlook Need?

7:22 What Economics Misses About Caregiving

10:14 Workplaces Don’t Accommodate Being Human

17:57 Nine Months of Illness: Failing to Account for Pregnancy

23:21 The Myth of the Invincible Clinician

29:02 The Range of Human Experience and Tradeoffs

36:45 The Dignity of End of Life

39:16 What Is Our Obligation When Quality of Life Is Irreversibly Lost?

44:08 Compassion Fatigue

46:25 Is Physician Aid in Dying Dignified?

55:30 Can Medicine Make Peace With Dependence?

Cancer is one word, but it’s not one disease. Thanks to targeted therapies and evolving treatments, some people live for years with metastatic illness. They must make ongoing choices about work, relationships, and meaning, without knowing how many days they have or what those days will look like.

In this episode of Hard Medicine, Dr. Yurkiewicz sits down with Dr. Bryant Lin, a primary care physician and clinical professor who was diagnosed with stage IV lung cancer just shy of his 50th birthday. How did he decide what to continue and what to let go? How much detail about prognosis did he seek? Does time itself pass differently when you know there’s less of it?

0:06 Opening Monologue: Living with Compressed Time

1:43 Life Before Cancer

4:01 Lung Cancer in Non-Smoking Asians

8:09 First Symptoms and Getting Diagnosed

18:27 How Much Did You Want to Know About Prognosis?

22:14 Making Decisions Under Uncertainty

27:42 Finding Joy and Passing Time

38:25 Choosing Hospice or Clinical Trials

41:29 Insurance Hell

50:20 “Sunshine” — What Makes a Good Life with Stage IV Cancer?

In practice, I reached 160% before I slowly but surely got back “down” to 110% — not through attrition, but through an active effort of redistribution when a new doctor joined our group.

This is the problem with primary care.

There is a reason it’s standard to over-panel doctors. There are perverse incentives to keep every minute of our day filled with patient visits and every appointment slot occupied.

It’s an old adage in systems engineering that every system is perfectly designed to get the result that it does. In primary care, waiting months to get an appointment is not an unfortunate byproduct, but a direct and entirely predictable result of the structures in place.

How much of primary care even needs to be visit-based vs. asynchronous (such as calling or messaging) will be the topic of another post. This one is focused on visits themselves. There is a profound mismatch: The worst-case scenario from an administrator’s perspective is an empty slot. The worst-case scenario from a patient’s perspective is no empty slots.

To satisfy the former, primary care practices run at or above capacity by design.

Fill Every Slot

Traditional primary care in most organizations is reimbursed one way: by the visit. From a health care administrator’s standpoint, the formula for revenue is simple. The more patient visits per day, the more the organization makes. And because primary care services such as prevention visits are generally reimbursed less than procedures or specialist visits, administrators will often make the case that a certain high number of visits per day are needed just to stay afloat.

As such, controlling the primary care purse strings translates into one goal — fill every slot. An empty appointment is money left on the table. This is why primary care runs like an assembly line, our days filled with back-to-back patient visits. Time spent on anything else — reviewing charts, writing notes, answering patient messages, reviewing test results, placing new orders, communicating with other team members, refilling medications, calling insurance companies — is mainly absorbed into doctors’ off hours.

This is also why doctors’ schedules are filled months in advance. To ensure every slot is filled, most primary care practices operate via a straightforward system: Appointment slots open, and they fill on a first-come, first-served basis. The reason for the appointment is largely irrelevant. It goes to whoever calls or clicks the fastest.

The fill every slot approach, where all care is flattened into visits of identical length, scheduled for whenever by whomever, is obviously not ideal primary care. I may see someone for an appointment before they get their blood drawn, only to have them come back to review abnormal results and draw more. I may evaluate a patient’s pain over a video visit and decide they need an in-person evaluation with an ECG and cardiac monitor. In this system, what happens during a visit doesn’t matter. Resolution of issues doesn’t matter. A packed schedule creates the illusion of care without necessarily delivering it.

Good primary care is not a free-for-all of interchangeable visits. Good primary care is getting people to their doctor at the right time.

“Fill every slot” also incentivizes problematic workarounds. My patients often ask me for tricks to get appointments. I wish I had them. So they do what anyone would do in their situation — they send me messages, which spill into my off hours. Some book more than one appointment — say 2, 4 and 5 months in advance — just in case they need it, further blocking access for others. A handful who can afford it leave for concierge or direct primary care.

This system is generally disliked by doctors as much as by patients. After all, we’re the patient-facing ones; we’re the ones who bear the fallout when a sick day becomes a catastrophe because everything was set up four months ago, and cancelling means pushing another few months. But it’s mostly accepted. We absorb endless messages. We develop our own workarounds. We apologize for delays outside our control.

Primary care is a textbook, real-life example of queueing theory: As utilization approaches 100%, average wait times increase dramatically. The most common understanding of long primary care waits is a doctor shortage. But that explanation is very incomplete. Primary care is perfectly manufactured to have impossibly long waits. It is a mathematical certainty that when each doctor runs at or above 100% capacity, there will be waits.

Hiring more doctors into the same system will produce exactly the same outcomes. When the problem isn’t scarcity, but artificial scarcity, any new hire quickly fills and overfills — and simply gets booked months out, too.

No Consequences

Primary care is hardly the only industry financially motivated to squeeze as many through the assembly line as possible. Why don’t other industries face the same problem of impossibly long waits?

Restaurants, airlines, and really any service industry face similar pressures to fill: Fill the tables. Fill the seats. The difference is that there is direct and immediate negative feedback if the wait is beyond reasonable to receive the service. For example, I often stop at Starbucks on my drive to clinic each morning. If my morning coffee arrived the next day, or a 6 PM dinner reservation seated me at midnight, I’d stop going. I wouldn’t be alone. The market would impose its own consequences, quickly and decisively.

Thus, places like restaurants and coffee shops are incentivized to use timely access as a metric critical to their success — as important as the quality of the food and ambience. So they keep some slots open and don’t routinely overbook. Their formula optimizes throughput while also maintaining access.

By contrast, there are no market forces penalizing delays in primary care. Everyone needs a primary doctor. So they’ll wait for one.

And yet, other parts of health care don’t overbook by design. Emergency rooms and hospitals operate with a magic number of around 85%. This is considered a critical threshold; if more patients need care, surge backup comes into play. When I worked on the hospital side, I experienced this regularly. We predicted surges. We had good days and bad days. And when patient volume became too high to manage, the system worked hard to adapt.

There is no equivalent magic number in primary care.

But why? Do hospitals and ERs just do what’s right for patients regardless of financial incentives? Perhaps, and I sure hope that’s part of it. But it’s also because there is a negative feedback loop here, too.

If the wait to treat a stroke requiring blood thinners within six hours stretched to four days, patients would die or suffer permanent disability. The consequences would be immediately catastrophic, highly visible, and entirely unacceptable.

That primary care runs differently shows a fundamental misunderstanding of the value of primary care. The consequences of delayed primary care are just as damning; they’re simply more distant, less linear, and thus hard to trace back. A young man with slowly worsening anemia waits a month to see his doctor, and a colonoscopy and scans ultimately show stage IV colon cancer. Was the wait to blame, or is this just the devastating reality of cancer? A man messages about a “rash” on his leg and waits patiently to see his doctor, who diagnoses cellulitis and sends him to the emergency room for bacteria that spread into his bloodstream. He develops an acute kidney injury, which persists as chronic kidney disease. Later, kidney disease is a footnote in his chart — treated as an inevitable fact of this man’s medical story, rather than a complication that timely access to his primary doctor could have prevented.

This is how primary care became the only high-stakes service operating at or above capacity by design. It’s precisely because those stakes are underestimated. From a health care administrator’s perspective, there are no consequences. The patients keep coming back. The medical care is the same.

So why fix it?

The Limits of “Advanced Access”

On the surface, there is a solution that fulfills both administrators’ incentives to fill every slot and patients’ need to access them. It’s called “advanced access,” and primary care researchers have been making the case for it since the 1990s.

The idea is simple. Instead of booking out months in advance, keep most appointments open for same-day scheduling. (There are variations of this with different time intervals such as same week visits.)

A JAMA paper described how such a system was implemented at Kaiser and a few other places with remarkable results. Murray and Tantau wrote in the year 2000:

As it turns out, demand is not insatiable, as many practices believe…. When practices enact such a system, several magical things occur:

• First, the wait time for a routine appointment is today. No one can beat that.

• Second, practices no longer have to hold appointments in anticipation of same-day needs, so they’ve maximized their schedules and gained capacity (or appointment availability) they didn’t have before.

• Third, the likelihood that patients will see their own personal physician has increased, which means greater efficiency, a greater sense of control for the physicians and improved satisfaction for everyone.

This approach is directionally right. But in modern primary care, it only partially caught on and therefore hasn’t quite worked out.

The first problem is cannibalization. While my group, for instance, opened a handful of same-day slots, they were the first to go. Because these slots were rare gems and not the norm, they ended up becoming a workaround for desperate doctors to overbook a patient into. I admit I did this routinely. Say I got a scan back showing a recurrence of cancer on a long-time patient. Obviously I wanted to discuss that result, and obviously it needed to be soon. If my schedule had a wide open “same-day” slot next week, I filled it.

The second is continuity. The authors advise that when a patient calls in, they should first be asked “Who’s your doctor?” rather than “What’s your issue?” This doesn’t happen in practice. Same-day slots, when they exist, mostly become an interchangeable stopgap to see other doctors’ patients, even as we all struggle to see our own. Hiring dedicated same-day providers, as my practice did, creates a mini parallel urgent care clinic, but doesn’t advance primary care. Unless these slots are in primary doctors’ own schedules and prioritize their own patients, they exchange access for continuity — when good primary care is both.

The final is the most problematic, and it goes back to the 1,500 (or more) patient cap. Based on the number of slots I had per year, I calculated that my cap allotted two visits per patient per year. But this number underestimates reality. Many of my chronically ill patients require more. As authors Murray and Berwick wrote:

“Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments.”

Triaging appointments away from a free-for-all is a bare minimum — a necessary but not sufficient solution. It’s the floor on top of which any other rewiring of doctors’ time can be implemented. If our patients’ need for visits is greater than visits available, no amount of rearranging how they’re filled will reduce waits.

Taking the Leap

It may seem unsavory to speak of care for people in stark economic terms. But unfortunately that is how medicine runs — as a business — meaning a business case must be made that long waits are problematic to change any of the underlying structures driving them. As a primary care doctor, I am rewarded on many metrics: flu vaccinations, mammograms, diabetes control. Waits are not one of them. My patients being able to access me, their doctor, when they need to, is not captured in any metric.

It would be wrongheaded to hold overworked primary care doctors accountable for yet another outcome we cannot control. It would be worse to think up hacks that make the problem worse, such as shortening visit lengths. But until the consequences of delayed primary care are more visible — that incentivize access to one’s own doctor, or dis-incentivize waits — I’m not sure health care administrators will just override existing incentives and do what’s optimal for patients.

This requires a leap of faith: that the solution is not squeezing more in, but less. Even within our current payment model, medical leadership can work with administrators to make the case for leaving slots open and reducing total patients per doctor. In the short-term, they will balk: What if the visits don’t fill? How can we leave money on the table? But they will fill. They’ll always fill. And care will be infinitely better when they fill based on medical need rather than who clicks fastest. Fixing this is not only a matter of queueing theory, but of courage.

More on the “fake math” of primary care: here and the Hard Medicine podcast, Episode 1.

They unpack the structural mismatches driving this crisis: payment for visits but not the work in between, patient practices in the thousands, and the ever-expanding burden of electronic medical records. They also explore solutions: What is the ideal team, and is AI part of it? What’s the right number of patients for one doctor to see? And is fee-for-service payment simply incompatible with primary care today?

0:06 Opening Monologue: Primary Care Is a Design Failure

2:01 The Good — Why Doctors Choose Primary Care

6:15 What’s Wrong with Primary Care?

8:47 Distorted Math: 2,500 Patients and 27-Hour Days

13:56 Electronic Medical Record Burdens

21:44 When “Part Time” is Full Time

24:43 Consequences of an Unsustainable System

27:09 Is Fee-for-Service Payment a Non-Starter?

31:00 The Ideal Team and Continuity

37:29 What AI Can and Cannot Fix

44:08 Direct Primary Care

48:34 Can Primary Care Be Saved?

This show grows out of the same work many of you know from my writing here and from Fragmented: taking on the problems of American medicine without flattening their complexity. Each episode centers one hard question facing health care today and examines it carefully with guests.

New episodes will be released monthly, starting January 12. Most will be free; some will be available to paid subscribers. Paid subscriptions are open at $5/month for the first 100 subscribers, locked in at that rate.

You can listen and subscribe here on Substack, or wherever you get your podcasts.

With many thanks to the founding members and early subscribers who have already supported this work. I’m looking forward to the conversations ahead.

Hosted by Ilana Yurkiewicz, MD, Stanford physician, professor, and journalist, and the author of Fragmented: A Doctor’s Quest to Piece Together American Health Care.

First episode drops January 12.

My advice centered on one theme: In our fragmented medical system, you are the only guaranteed source of continuity in your own care.

Here are three ways to own it.

1. Have your medical elevator pitch ready.

Do not assume your doctors have your complete medical history, or that if they do it’s in a readable format. About a third of healthcare facilities don’t integrate medical records from outside doctors’ offices and hospitals. Even when all your care lives in one system, electronic medical records are not written like a book. They are cluttered, disorganized, and repetitive, and it takes cognitive work to stitch the pieces into a meaningful narrative. Thus far, AI has not made significant progress in unscrambling this mess.

I recommend everyone create and maintain a three-page checklist of their medical highlights and bring it to every appointment. Think of it as your medical elevator pitch: a concise, high-yield synopsis of what your doctors need to know, easily digested when you only have 15 minutes face-to-face. Do not waste those precious minutes on data collection or chart clean-up. (The full checklist appears as an appendix in Fragmented.)

For some, I also recommend a wallet card. This is useful if something in your history would immediately change standard medical care. If you pass out on a plane and can’t tell the kind doctor kneeling over you your medical story, what must she know? Are you on a blood thinner? Do you have a DNR/DNI? A life-threatening allergy? The card should always include the name and number of your healthcare proxy who can speak on your behalf.

The final piece of owning your medical elevator pitch is knowing how to access your full dataset, as you can’t always predict what your doctor may need to see. Thanks to the ONC Final Rule of the 21st Century Cures Act, many test results are now available through patient portals and can be pulled up on your phone or computer. In practice, I often have my patients pull outside records during our visits so we can review them together in real time. While you can request full copies through medical records departments and have them faxed (yes, faxed) to any doctor’s office, these are easily lost or ignored. If you want the complete record, I strongly recommend having it sent to yourself. You are its ultimate keeper.

2. Find a primary care provider, even if you adore your specialist(s).

In an ideal world, your primary care doctor is your medical quarterback: the person who knows your full story, adapts to its changes over time, and looks for the big picture in contrast to specialists focused on body parts and organ systems.

I write a lot about the systemic challenges that obstruct even the best primary care doctors from doing this work (see here and here). Many people struggle to find a primary care doctor at all. Even if you find someone you like and trust, you can’t reach that person when you need to.

But there is something in your control: prioritizing the relationship. I see this all the time; people neglect to find or lose touch with existing primary doctors when going through something requiring specialists. But inevitably, without a primary, there will be gaps in your care. Don’t expect your oncologist to give vaccines or oversee your diabetes. Don’t expect your OB-GYN to control your cholesterol.

In my work with cancer survivors, the data are clear. While oncologists are more adept at looking for cancer recurrence and managing the long-term effects of treatment, primary care doctors are better at chronic disease management and prevention. It’s not an either-or, but different skill sets that complement one another.

Who should you look for as a primary? Your options include an internist or a family medicine doctor, or a geriatrician if you are over 65. Depending on your medical complexity, you may also see a nurse practitioner or physician assistant. Make annual appointments with your primary, no matter how frequently you see your specialist(s).

3. Get your team to talk — or be the intermediary.

Interact with medicine in any way, and you’ll quickly notice that the days of one doctor and one patient are long gone. Today, medicine is a team sport. Doctors can specialize and sub-specialize in more than 135 fields. You’ll likely encounter nurses, pharmacists, social workers, therapists, dietitians, nurse practitioners, and physician assistants.

But for both systemic reasons (no compensated time, rotating schedules) and cultural ones (specialists encouraged to stay in their lane, even when zooming out is needed), there’s a good chance we’re not talking. The big picture can easily get lost amidst a sea of siloed experts.

Fragmented tells the story of a woman I cared for with leukemia and lung disease. Three teams of doctors were on the case. Each, through the lens of its own specialty, was logical. But three perfectly logical narratives added up to a patient getting worse — to the point that I had to have a frank conversation with her about going on a ventilator in the ICU.

Trust your gut. If it feels like different team members are talking past one another, they probably are. Be polite, but persistent. On the hospital side, ask for a team meeting to get your doctors in a room together. On the outpatient side, with the luxury of time, it’s often most effective to act as the intermediary yourself.

Delineate what each person on your care team does (“Who prescribes my Plavix?” “Who will follow up on my stress test?”). Then be the glue. When you see your primary doctor, be proactive: “I’m seeing my cardiologist next month. What should I ask?” Or: “Is this flecainide you prescribed okay to take with the Lexapro Dr. B prescribed?” “My hepatologist wants me to get an ultrasound, but you already ordered a CT scan — do I need both?”

I recognize the limits of this advice. It’s neither just nor right for the burdens of record-keeping and communication coordination to fall on the person who is sick. Not everyone can manage logistics to this degree; I’ve witnessed countless times the disparities in outcomes that can spiral based on whether a patient or a family member can be on top of this full-time job. This field guide is not intended as a replacement for systemic reform, but actionable steps while we wait.

I wish you strength and clarity as you advocate for someone you care about.

The book — Amazon affiliate link:

Coming soon: The Hard Medicine podcast launches in January! My next post will be the official trailer from the first few episodes. One deep dive per month with a brilliant guest on the most pressing, most consequential, and dare I say most solvable issues facing healthcare today. We tackle one hard question and work through it together. I can’t wait to see you there.

I want to start with an assumption: Primary care is the crux of good medicine. A primary care doctor knows you, your medical history, and your values. A primary care doctor is your first point of contact for any changes in your health. A primary care doctor looks for the big picture. I built my own primary care-based cancer survivorship practice because of a firm belief that primary care can be all of the above. My views on its importance have only cemented as I’ve been in practice for the last few years.

But as I’ve written extensively before — here and here, for example — primary care has strayed so far from that ideal it’s almost unrecognizable. Modern primary care is a lose-lose situation where doctors are working harder than ever — and doing the wrong kind of work — all while patients can access us less.

To understand why, we have to dig into the numbers. Primary care is built on a host of numerical assumptions. How many minutes does a patient need per appointment? What percent of the job happens in between appointments versus during them? How many patients should a single doctor be responsible for? The problem is that many of these assumptions do not remotely match modern realities. Primary care is a design failure built on distorted, outdated math.

This post goes into one source of that math: How many hours per week do primary care doctors need to do the job? And how does that square with the hours they’re actually spending?

How Many Hours Per Week Do Primary Care Doctors Need?

Last month, Dr. Lisa Rotenstein and colleagues published a paper in Annals of Internal Medicine showing that full-time primary care doctors spend a median of 61.8 hours per week caring for their patients. They also found that part-time primary care doctors spend more time on each patient than full-time physicians: 2 hours per patient per year, compared to 1.7 hours. Of note, the median total practice size of full-time doctors in this study was 1,668 patients — significantly below the typical 2,000 to 2,500 range nationwide.

Where does all that time go? Using the estimate of 5.5 hours of electronic chart work for every 8 hours of patient-facing care from a separate JAMA paper by Dr. A. Jay Holmgren and colleagues, that comes out to 22 hours per week in electronic charts on top of 32 hours of face-to-face appointments: documenting patient encounters, clicking orders, reviewing test results, refilling prescriptions, messaging other team members, and answering patient messages. The remaining ~8 hours involve all the non-electronic administrative work that a primary care doctor must do to move care forward, such as peer-to-peer phone calls with insurance companies and filling and signing paper forms.

Remarkably, working 62 hours per week leaves work undone. Another paper by Dr. Justin Porter and colleagues in the Journal of General Internal Medicine mapped out that if primary care doctors did everything expected of them for a standard 2,500-patient practice, they’d be working 26.7 hours per day. That totals 133.5 hours in a five-day workweek. If we use the 1.7 hours per patient per year figure from Rotenstein’s paper and apply it to 2,500 patients, primary care doctors would work about 92 hours per week (over 46 weeks in a year). That leaves a difference of about 41 hours each week — work that should be done but simply cannot.

In short, even when working over 90 hours per week, primary care doctors can only accomplish less than 70% of the work asked of them. Using the part-time data of 2 hours per patient per year, they’d be able to meet about 81% of the job description.

What This Means for Primary Care

These findings back with data what primary care doctors already know: Going part-time is the only way to meet our patients’ needs. Full-time primary care is neither doable nor sustainable in its current form. When I began as a full-time attending, while I didn’t track how many hours I worked per week, it was far higher than 40; work always spilled into nights and weekends, and I still was never caught up. This also jibes with nationwide data showing that primary care doctors are going part-time more now than in previous years. The Wall Street Journal has cited older doctors bemoaning this generation’s desire for work-life balance as the reason, but the data don’t fully support that. Primary care doctors aren’t necessarily going part-time to spend time with their families or pursue other hobbies, although these are obviously important. They’re going part-time to be able to do the job.

This calls for a radical redistribution of labor. In the Porter paper, with team support from nurses, nurse practitioners, and others, the 26.7-hour day decreased to 9.3 hours. The other option is reducing total practice sizes, as these numbers were developed when there was less chronic illness, fewer administrative tasks, and no electronic portals allowing constant asynchronous communication. I don’t have the perfect number for how many patients a primary care doctor should care for today. But 2,500 or even 1,668 isn’t it.

Coming soon: Dr. Rotenstein joins me on the Hard Medicine podcast (airing January 2026) for a deep dive into the question: Can primary care be saved?

The case I shared was adapted from the last chapter of Fragmented. Marisol (name and certain details changed) was 33 and pregnant with her fourth child. She was overjoyed, but odd things were happening. She noticed blood in the toilet bowl after every bowel movement. Instead of gaining weight during pregnancy, she was dropping pounds. She stashed her well-worn maternity pants, which she somehow didn’t need this time.

Marisol was previously healthy and didn’t have a primary care doctor. But she knew something was off. So she was proactive, and she sought care from three different clinicians. The urgent care doctor advised she come back if the bleeding persisted postpartum. The gastroenterologist took one look at her pregnant belly and concurred. The obstetrics nurse practitioner reassured her the baby was doing fine.

Eight weeks before her due date, Marisol went to the emergency room. She had developed a deep ache in her abdomen, which she assumed was labor. It wasn’t. An MRI was finally done. To everyone’s horror, next to the baby had been growing a massive colon tumor.

Labor was induced, and then Marisol and her baby were immediately split up. The baby went to the NICU, while Marisol was wheeled on a gurney to the oncology ward. That was where we met.

I asked what she had been told about why she was there. She knew she had colon cancer, she answered. What she didn’t know was that her scans also showed tumor creeping into other organs—the small bowel, uterus, and bladder, I listed slowly.

A wail escaped her that I’ll never forget. Then Marisol asked: “Am I going to die?”

As doctors, we get asked the hardest questions imaginable: “How long do I have to live?” and “Am I going to die?” Sometimes they’re from patients we know well; sometimes, like in Marisol’s case, we’re meeting for the first time. Developing an approach to answering them is necessary to be a good doctor. I shared some of my general principles:

Establish emotional safety. Listen more than you talk. Look for the question behind the question. Don’t overload with information. Validate the patient’s emotions, and affirm you are on the same team, such as by saying, “I wish things were different.” When discussing prognosis, give a range that includes the best-case, worst-case, and most likely scenarios. Address a Plan B: “We hope for the best but prepare for the worst.”

But then in comes the rub: The unexpected is expected. The challenge is not learning how to speak kindly and candidly, as is the common teaching in medical education. The real challenge is recognizing the truth is not easy to ascertain in the first place. How can we convey what isn’t known?

The reasons for this are several. First, doctors get it wrong. One much-cited study asked doctors how long they anticipated their terminally ill patients would survive. Only 20 percent were accurate. Moreover, the longer the doctor-patient relationship, the less accurate were doctors’ predictions. This suggests that the downside of knowing and liking our patients—a desirable interaction, of course—is that it may color our ability to prognosticate.

Patients change their minds, too. This JAMA paper compiled other studies exploring how steady patients’ end-of-life preferences stayed over years. There was great variability. And, people without serious illness were likelier to change their minds compared to those living with serious illness.

Finally, there’s the compounded uncertainty from a fragmented medical system. Fragmented medicine means not having a continuous relationship with the same doctor. It means many specialists, which can lead to too many cooks in the kitchen. And it means a lack of clarity over who else is having these conversations and when.

I shared this excerpt from a gut-wrenching essay by Amy Caruso Brown to show the consequences of having hard conversations in a fragmented medical system.

Radical uncertainty complicates the best-laid plans for clear and honest communication. It single-handedly debunks myths about overspending near the end of life. For example, it’s a well-known statistic that one-quarter of Medicare spending in the United States occurs in the last year of life. This fact is so often invoked because it is bemoaned as waste. However, this paper brilliantly showed that less than 5 percent of spending in the last year of life is on patients with a predicted mortality above 50 percent. In other words, doctors are not overtreating people who we know are dying. We treat patients who are sick; it isn’t clear which way it will go.

Radical uncertainty is also the reason advance care planning doesn’t work, no matter how well-intentioned. This JAMA review analyzed dozens of papers and found no evidence that advance care planning improves decision-making near the end of life or quality of life. The reason, as I show on the right, lies in how these directives are written. Give a healthy person one of these and they will struggle to answer it because the devil is in the details. I’ve had thousands of difficult conversations with patients. But even I’d struggle to answer this for myself. It depends, I’d write in. What is “soon”? What’s my underlying illness? What treatment options remain? How am I able to spend my time?

Preparation is helpful, but the hardest choices must be made in real time. As I wrote in Fragmented:

In reality, no matter how much one prepares, there will often be a moment when a decision must be made. A man with advanced lung cancer presents with shortness of breath and hypoxia, and the CT scan shows possible pneumonia. Is this a treatable setback with antibiotics and intubation, or is this how he dies? A woman with severe heart failure develops critically low blood pressure. Do you recommend going to the ICU, placing a central line, and starting vasopressors in the hopes of finding something reversible? An older man who has endured a long list of medical complications has an abdominal perforation. Do you offer to take him to the operating room and close the hole, or is this his final complication?

These are the moments someone must choose: yes, now, this is it, stop. We navigate this moment in different ways. Loved ones ask the doctor, what is the prognosis? Doctors defer to the patient or her family: what would she want? The hard truth is that uncertainty can persist right up until the end. Years of being called in and guiding so many patients through these instances—rapidly assessing the landscape, sometimes offering choices and sometimes deciding for patients when I sense they need it—I do not believe there is a way to get comfortable with the final branch point. The best we can strive for is making decisions we can stand by.”

All of this leads to the central question I posed to the group: How can we tell the truth and help someone plan as well as possible, knowing our ability to do so is limited not so much by communication deficiencies, but by anticipated curveballs?

We then broke out into small groups to tackle the questions below. Students came up with a wonderful range of strategies, from involving family members, to doling out information over time, to avoiding the dual traps of reflexive reassurance and information overload. One of my favorite responses was one student’s pithy reply: “Find her a primary care doctor.”

Finally, I shared my approach to radical honesty.

In the face of radical uncertainty, I have landed on an approach of radical honesty. “Let me tell you exactly what I’m thinking,” I say. I ask patients how they prefer to hear information. Then I share what I know, with caveats: New facts will emerge. Twists are expected. We will take each decision as it comes. And when I have the gift of continuity with patients, I promise I will always be honest, based on the information we have and to the best of my ability.

We then returned to Marisol’s outcome, which defied everyone’s expectations. Her full story lives in the final chapter of Fragmented.

Thanks, as always, for reading and thinking through Marisol’s extraordinarily challenging case with us.

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Coming soon: I’m thrilled to share that the Hard Medicine podcast is launching soon! Each episode, I bring one hard question and one guest to think through it with me. Together, we confront the most urgent problems in medicine—grounded from the front lines and dissected with rigor and depth. No oversimplification. No safe padding. Just hard medicine. Hope to see you there.

Last month, I spoke at the Women in Medicine Summit in Chicago on pitching and publishing medical journalism. I’ve given a version of this talk many times because writing is one thing; getting published is a whole other. My goal was to draw back the curtain and share actionable tools for any doctor hoping to get their words out into the world — from first-time writers to seasoned veterans, and across formats from op-eds and reported features to books and narrative essays.

Here are a few takeaways, adapted from the one-page PDF summary I made available to conference attendees.

1. Why Write About Medicine?

• Writing is impactful, and writing from the inside can be a powerful agent for change.

• Most people get health information from general outlets, not academic journals.

• By the numbers: publishing in lay outlets can expand reach dramatically.

  • Academic article: often read by several hundred people

  • Lay article: often read by thousands or tens of thousands

• Good writing is the bridge between medicine and the public — it humanizes a profession, connects research to the public, and can change policy and practice.

2. What Makes a Good Story?

3. How to Pitch — a step-by-step guide:

a. Choose the right outlet — read tone, length, topics.

b. Look for a submissions process — e.g. do they want a pitch, or a completed piece?

c. Address the right editor — by name/title

d. Keep it concise — a few short paragraphs

e. Pitch — a good pitch must answer:

1. What is the story you have to tell?

2. Why would anyone care to read it?

3. Why should you be the one to write it?

4. Why there?

5. Any important practicalities (anticipated word length, timeliness)

Resources: For article pitches, I recommend The Open Notebook, which houses a repository of successful science pitches. I also shared several examples of my own pitches during the talk — including one on fragmented medical record-keeping that later became the first chapter of my book.

For book proposals, I suggest Susan Rabiner and Alfred Fortunato’s Thinking Like Your Editor and Before and After the Book Deal by the great Courtney Maum — excerpt from the latter below.

4. Navigating Challenges

• Respect privacy — doctoring and writing should never be at odds.

  • When writing about patients, get explicit permission or anonymize details.

  • Litmus test: imagine patients, colleagues, and family members reading.

• You can be critical. Focus on systems over individuals. Reach out for comment from those you critique. Consider opposing perspectives; be nuanced and fair.

• The modern “pink box”: While we’ve fortunately moved past the old “pink topics,” a 2025 version persists. Women physicians face subtle and overt pressures to write about certain topics (e.g. burnout, guilt, sexism in medicine), with a certain tone (e.g. confessional over decisive) or analytical lens (examining self over science or systems).

• These stories matter, but they aren’t the only ones physicians can or should tell.

  • Do it anyway. Claim authority across the spectrum: blend emotional intelligence and big-idea, systems-level analyses.

  • Find the right editor and outlet. Always prioritize fit over prestige.

  • Define impact. Aim for staying power, engaged readership, and downstream change over clicks (i.e. choose value over viral).

Finally, I tried to preempt the questions I’m frequently asked.

I ended with a quote from writer Annie Dillard that was one of my inspirations when I started out and still motivates me deeply.

While I didn’t go into detail about self-publishing in this talk, I’d be remiss if I didn’t note it here. It’s hard to break into an industry that is losing funding and taking fewer risks on less tested writers. Being agile in today’s landscape means you can curate your own work and audience; right here on Substack, of course, is one great option.

To all the medical professionals with stories to tell and deeply informed insights to share, I wish you the best of luck. We need your voices now more than ever.

In Chapter 3, I wrote: “The computerized charts we use as doctors are not merely electronic filing cabinets. In addition to storing data, they also embed certain tools to help make sense of that information.” Right after “tools,” an early draft included the words “of artificial intelligence.” I deleted it. I added it back. I deleted it again. Those three words now live in the folder called “extra” that also contains a quote from a government source and an entirely new patient story.

I ultimately chose to remove those words to keep the conversation of technology in medicine broad. Then Fragmented came out in 2023, just as generative AI emerged into the mainstream. I went on book tour, and it was the question I was asked at nearly every event. Will AI help? Will it hurt? Is this the solution to medicine’s fragmentation problems?

Earlier this month, I spoke at Stanford’s Future of Medicine workshop to answer these questions.

(Photo credit: Steven Duy Truong)

First, I made my case that disorganized medical record-keeping via a cluttered, disconnected electronic ecosystem is a root cause of medicine’s failings. I told the story of my patient I called Mitch, a young man with a rare congenital kidney disease that caused dangerous swings in his potassium. Mitch had been hospitalized nearly one hundred times by the time he was 25. When I received the call to admit him from the emergency room, I thought: Mitch’s optimal treatment plan surely had been worked out. All I needed to do was scour his chart and find the formula.

It wasn’t simple. I zoomed out to explain how doctors approach the history-taking part of a new patient’s case, clicking and clicking through a morass of data to try to piece it together. Here are the stats: It takes doctors 62 clicks to order Tylenol. It takes 4000 clicks to get through one emergency room shift. Nearly 60% of notes in the charts are repeated. All the while, records from different hospitals or doctors’ offices are often transmitted by fax — if they arrive at all.

As I wrote in Fragmented,

“When a patient with a complex medical history… arrives under my care, it’s like opening a book to page 200 and being asked to write page 201. That can be challenging enough. But on top of that, maybe the middle is mysteriously ripped out, pages 75 to 95 are shuffled, and several chapters don’t even seem to be part of the same story.”

As I embarked on this familiar process for Mitch, I learned from his chart that sometimes his hospital course was smooth and he went home a day or two later. Other times his potassium yo-yoed to the point that he needed ICU admissions and extra medications to get it down. Where was the formula?

With no time left to dig, I started treating Mitch anyway, and fortunately he did well. It was only as I was about to discharge him that I found it. It was a few short sentences from his regular nephrologist, not in the discharge summaries as I had expected, but buried in a different part of the chart called the problem list.

The consequences of disorganized medical record-keeping span burdens to errors. Astonishingly, the same technology intended to reduce doctors’ workload by gluing patients’ data together has drastically increased it. Doctors today spend over five hours on patients’ charts for every eight-hour day actually seeing patients. Half of primary care doctors believe the charts make it easy to miss abnormal findings, with 30 percent reporting personally missing them. Bureaucratic work is the number one source of physician burnout, even during the peak of Covid. Add in bureaucratic tasks outside the charts — peer-to-peer calls to insurance companies, paper forms, and messages between care team members — and primary care doctors like me squeeze 26.7 hours of work into a single day.

At the same time, patients are burdened with keeping these pieces together themselves — and often when they’re sick and least equipped. Those who can’t do this undeniably receive worse care. Below is a blog post I appreciated from Laura Stratte, who documented her time undergoing treatment for cancer. In between chemotherapy dripping through her veins and radiation searing her skin, 17 percent of her time was spent on administrative tasks. This totaled nearly four hours each month.

With that as the backdrop, I then moved into what I believe is the critical question facing medicine today: Can AI be the team member medicine desperately needs? Specifically, can AI be employed where it’s needed most — to transform this data mess into a meaningful narrative that helps both patients and doctors?

The ideal, for me, is this. It’s taking the tattered pages of Bleak House, pasting them back into a book, and then giving me a CliffsNotes version. Practically, whenever I see a patient in my clinic, I want the same things: An up-to-date medication list. Who started that medication, when, and why? Why was the aspirin stopped? Over the last six months, what clinicians did you see, for what reason, and what changes were made? For Mitch, it would look like this:

I then went through several examples of AI being used in administrative capacities in medicine now. They include AI as scribe (listening in on patient visits and transcribing notes), AI as letter-writer (drafting letters to get treatments approved by insurance), and AI as inbox assistant.

The last one deserves pausing on, because I included it as an example of AI being deployed in the wrong spot. But why? With a steady deluge of patient questions, staff messages, results to review, and prescription requests flooding my and other doctors’ inboxes every day, why wouldn’t we want AI’s help to lighten the load?

Already, we see the opposite happening. Using AI to draft messages leads to doctors spending more time in their inboxes. It also incentivizes more replies, leading to a greater back-and-forth that results in a higher inbox burden. This is eerily reminiscent of the advent of electronic medical records. The same technology that aimed to reduce logistical work has counterproductively increased it.

The problem with this AI rollout is that it skirts the real issue: Doctors’ inboxes house unpaid work that isn’t accounted for in nearly all reimbursement models. Using AI to try to chip away at it — with no concomitant increase in time bought out to actually deal with its contents — will never solve the problem. Moreover, AI in this capacity crosses a blurry ethical line — is answering patient messages a medical task, or a bureaucratic one? I’d argue it’s more of the former. If one of my patients asked their same question to ChatGPT, it would advise them to ask me — only to ask me and have ChatGPT’s cousin answering in my name.

This leads back to a core concept for me. The quote on the left is from writer Joanna Maciejewska (found via Substack). The right is my medical rendition of it. I can’t emphasize this enough: in our current fragmented healthcare system, there is no shortage of work to be done. Encroaching on the parts of medicine that bring meaning and purpose to doctors and patients — and are not riddled with errors — is far from the use case we need.

Getting it right means tracking metrics — including the ones that were not tracked when electronic charts began. It means examining workloads, how doctors’ and patients’ time is spent, and medical errors and near-misses (who is making them? who is catching them?). It means iterating in real time, not ten years later when things are too calcified to rein in. I believe the best-case scenario of AI in medicine is on the left. The worst case is on the right.

Using AI to patch the holes of disjointed records may still seem like a Band-Aid solution. After all, most doctors feel medical charts need a complete overhaul, and AI is far from it. However, I’d argue that when a complete overhaul is not feasible (and by now, it’s so entrenched that it often isn’t), we should settle for incremental fixes of stitching clutter together, even when it’s admittedly not the most elegant solution.

My final point is that the right division of labor between doctors and technology will help us return to what matters. I wrote in Chapter 3:

“The electronic charts hold the potential to consolidate data into narratives and augment doctors’ decision-making in astonishing ways. Or they can insert detours and bury critical information to slow us down and incubate mistakes. This is one of the great puzzles medicine is grappling with today: How can we realize the full potential of automation?”

Generative AI in medicine feels like a restart. We’ve gone back in time to when electronic records were the shiniest new gadget on the medical block. This is an opportunity, but with the best- and worst-case scenarios a hair’s breadth away. We can and we must get it right this time.

Thanks for reading.

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Coming soon:

Next up, I’m excited to share some pearls from my talk on pitching and publishing medical journalism. This is a talk I’ve given many times, and most recently I gave it at the Women in Medicine Summit in Chicago. It’s a behind-the-scenes look at the nuts and bolts of getting your writing out there, from the privacy of your laptop to readers’ hands.

Here’s the full video:

(If the player doesn’t load on your device, watch directly here: https://youtu.be/FRO0lUbseas)

Medicine today faces a perfect storm: when doctors are least available, bad information is most available. I unpack the push — access to professionals at an all-time low — and the pull — the alluring alternatives of three disruptors: influencers, AI chatbots, and political movements.

I argue that in this new world of medicine, honest conversation is the sharpest scalpel we have. I dedicate this work to my patient, Mike.

Thanks for watching and engaging.

As conference chair, I’ll open with remarks that build on this theme. If you’d like to hear those live and join the larger conversation on September 5–6, you can register here. This conference is truly the highlight of my year, and I can’t wait to share the stage with the extraordinary speakers we’ve spent the past year curating.

Listen here:

Who Can We Trust?

By Ilana Yurkiewicz, M.D.

“I need you to tell me if I’m going off the deep end,” Mike began. It was our first appointment. He had come across an article about my cancer survivorship clinic and liked the sound of it. “I’m here to survive,” he told me. Mike had prostate cancer that had spread to his lungs and bones. Several types of therapy failed to slow it.

One month earlier, he told his oncologist he was done. Done with the chemo that zapped his energy. Done with the hormone blockers that induced hot flashes and brain fog. Done with the radiation that tethered him to early-morning appointments when he’d rather be anywhere else, doing anything else.

None of it worked. Now, he was on a mission to find something else.

The only problem was that I worried the deep end was already here. We agreed that more chemotherapy and radiation would not help him live longer or better. We disagreed on what came next. I spoke about managing symptoms with palliative care and hospice. He spoke of blue scorpion venom and mistletoe. I pointed to prescription medications. He pointed to expensive supplements. I cited PubMed. He cited TikTok.

The challenge now was to find some middle ground. To tell him the truth, without pushing him away. To find a way to help, even when he had lost faith in the kind of help I was trained to offer.

At each appointment, I struggled. “Those supplements are not FDA-approved,” I would start, and he’d launch into a soliloquy decrying those three-letter organizations. “There’s no evidence to support that,” I’d say, and he would counter with biases in how evidence is generated.

Yet I still enjoyed seeing him. Mike was polite. He was authentic. And we shared a dry humor that somehow found its way into conversations about incurable cancer. “I feel like a guy running for president,” he told me in the summer of 2024 to describe his foggy thinking.

“It’s the great Dr. Yurkiewicz!” he greeted me another morning.

“If you really believed that,” I said with a smile, “maybe you’d listen to me once in a while.”

“I do!” he grinned back. “Once in a while.”

He wasn’t wrong. When things got serious, Mike tended to follow my advice. Once he came in with a fast heart rate, and the ECG I ordered showed a new arrhythmia. The treatment was IV medications. “I hate to do this to you, but you need to go to the emergency room,” I explained. He didn’t protest. He quietly packed his keys and the printouts on coffee enemas he wanted to show me, and he went.

But when it came to managing his health over the longer term, he was skeptical. In the murky gray zones of chronic illness, I dispensed medications and advice into black holes.

It was frustrating, and not only because I wasn’t getting through to him. The truth is, I am a scarce resource. Every time I saw Mike’s name on my schedule, I thought of my hundreds of other patients waiting to be seen. I weighed how much more valuable a session would be to one of them. So I posed it to Mike directly: “Why do you keep coming back if you don’t agree with what I tell you?”

“Because,” he answered, “maybe today will be the day I will.”

It was a damn good answer. It became my motivation. Today will be the day. In 20-minute blocks, I pulled out every strategy of persuasion I had.

Empathy: I listened to how the cancer therapies stole his physical and psychological well-being.

Transparency: We used to treat breast cancer with bone marrow transplants, I admitted. We studied outcomes. We learned.

Prioritization: It’s OK to skip the Covid booster. If you’re going to take something, let it be the blood thinners so you don’t have a stroke.

Appeal to the greater good: “Think of the poor doctor on the plane who’ll try and save you,” I warned, when he wanted to fly out for hyperbaric oxygen therapy while refusing to take his portable oxygen. “You’ll ruin her vacation.”

It was a dark, morbid joke I wouldn’t have made to 99% of my patients. But, as expected, Mike laughed — hard enough that it turned into a coughing fit, which culminated in a glob of blood-tinged sputum landing on the exam room floor. It was a stark reminder of reality.

A few weeks later, Mike passed. It wasn’t a surprise. But it hurt deeply. He was too young, and he had been dealt a cruel hand.

I also understand why he turned to what he did. I’ve been a doctor for ten years. The untruths people are bombarded with today are on a scale that is different from ten years ago, five years ago, and even one year ago. From what my patients ask, I know exactly what’s circulating on the Internet without clicking. I know what Washington officials are saying even if I try not to waste energy reacting. Sometimes, bad information comes from misguided opinions expressed in good faith. Sometimes it’s pure grifting, capitalizing off lack of regulations and the vulnerability of people desperate for a cure.

Those who peddle bad information are charismatic. They’ve hijacked nice-sounding terms like holistic and natural. Perhaps above all else, they are available. Medicine is facing a crisis of trust in large part because of a crisis of access. The wait to see a new doctor is 38 days and counting. Patients can’t even get in to see their own. Doctors’ bureaucratic workloads are exploding while time with patients is shrinking, leaving little left for complexity.

It’s a perfect storm. You can’t get your doctor on the phone, all while a hundred others are calling you, promising to help.

The day after Mike passed, I called his brother to offer my condolences.

“He didn’t suffer,” he said.

“I’m relieved to hear that.”

“He was right here, at home.”

“I know that was important to him.”

“And those medicines really helped.”

“Medicines?” I repeated.

“Yeah.” I could hear him rummaging through pill bottles, and he started sounding out names I instantly recognized. “For pain, for nausea… those ones so he wouldn’t stroke out.”

I was silenced.

“If it had your name on it, he took it,” he continued. “No questions asked.”

In this new world of medical distrust, I believe the one-on-one remains our strongest weapon — and opportunity. When a patient disagrees, do we shut it down, or try to understand? When someone has been hurt, do we move on, or acknowledge the wound? When we recommend against something, do we distinguish whether it causes harm, or simply doesn’t help? It doesn’t always work. Some people are fully submerged in the deep end; others have dipped a toe. But in this world, among all our medical tools, the honest, measured conversation is our sharpest scalpel.

Mike taught me many things. He taught me about the deepest recesses of bad information online. He taught me that smart people going through tough times can succumb to their allure. And he taught me that despite all of healthcare’s flaws, and all the glamour of that allure, trust in medicine is a fragile, precious gift that just might be restored.

Author’s note: Names and certain details of this story were changed to protect patient confidentiality.

This topic is so critical because while we have evidence-based, guideline-backed screening and prevention strategies, only a minority of people receive them. Implementing what we already know carries enormous potential for both preventing and catching cancer in its earliest stages, when it’s most treatable.

Here are some highlights.

We started with the limitations of routine cancer screening. The USPSTF recommends just four: Pap smears for cervical cancer, mammograms for breast cancer, colonoscopies or stool tests for colon cancer, and low-dose CT scans for lung cancer (if a patient has a smoking history). Only around 14% of cancers are detected this way; it’s 25% if we include prostate cancer screening with PSA blood tests (this is not a strong recommendation from the USPSTF, but rather a recommendation to discuss risks and benefits). There are multiple reasons for these low numbers: Not everyone gets routine screening. Many cancers lack effective screening. And — the focus of this talk — a one-size-fits-all approach doesn’t capture those who need more.

Five to ten percent of all cancers are due to hereditary cancer syndromes, or genetic mutations conferring elevated risk such as BRCA and Lynch syndrome. People who carry these mutations but haven’t developed cancer are sometimes called “previvors.”

Unfortunately, the majority of previvors go undiagnosed. It usually takes a devastating family history of early deaths from cancer or a personal diagnosis that may have been avoided before someone is referred for genetic testing. In addition to genetics, there are a slew of other factors, such as a strong family history (even with negative genetic testing), personal medical history, and lifestyle that go into determining elevated risk. The following is my framework for making that assessment, with risk factors on the left and ways to manage those risks on the right.

What should trigger a primary care doctor — or a patient — to think of genetic testing? Here are some red flags: A cancer diagnosis before age 50 (either personal, or in a first- or second-degree relative). Multiple different cancers in the same person. Multiple relatives with cancer on the same side of the family. Certain tumor types that are more linked with genetic mutations (ovarian cancer, pancreatic cancer, and endometrial cancer are some examples). Ancestry — while BRCA mutations affect 1 in 400 people overall, for instance, they affect 1 in 40 people of Ashkenazi Jewish descent.

Here’s a cancer screening and prevention plan for people with BRCA1 and BRCA2 mutations. It’s far more intensive than run-of-the-mill screening.

Next, we discussed factors in someone’s medical history that warrant more. Broadly, my buckets include infections, chronic inflammatory conditions, immunosuppression (as patients are less likely to clear viruses that are linked to cancer), precancerous lesions, and treatment for prior cancers.

It’s worth zooming in on that last one — 20% of cancers are new, separate tumors diagnosed in someone who has already survived cancer. Why? In addition to everything already discussed — genetics, family history, and lifestyle factors that predispose to different cancers — it’s also important to know that some treatments for one cancer increase the risk for others. Radiation increases risk anywhere in the radiation field. That means increased risk of breast cancer from chest radiation, colon cancer from abdominal radiation, and skin cancer.

In terms of lifestyle, a paper from the American Cancer Society found that a substantial 40% of cancers could be attributed to modifiable risks — meaning they are, at least in theory, preventable. Smoking cigarettes remains far and away the #1 risk, causing at least 16 different cancers. Others to be aware of include high alcohol intake, being sedentary, and carrying excess body fat.

There are medically validated risk calculators that can help tailor treatment plans. In breast cancer, we typically use Tyrer-Cuzick to determine screening; if a person’s lifetime risk is 20% or higher, she should have both annual mammograms and breast MRIs (staggered every six months) starting at age 30. We typically use the Breast Cancer Risk Assessment Tool, or Gail, to determine whether preventive chemotherapy should be offered. If the five-year risk is 1.7% or greater, or if there is a history of lobular carcinoma in situ (LCIS) or atypical hyperplasia on a prior biopsy, five years of chemoprevention can be considered. Uptake in the real world is quite low; fewer than 10% of patients eligible for chemoprevention receive it.

Finally, I reviewed trends to be cognizant of that haven’t yet changed guidelines. One is the rising rates of cancers in young adults. Seventeen cancers are climbing; many are gastrointestinal. The pattern is called a birth cohort effect, beginning among those born around 1960 and increasing with every generation. But with the exception of lowering the age of colorectal cancer screening from 50 to 45 in 2021, guidelines have largely flatlined. For both clinicians and patients, this means being aware of symptoms and having a lower threshold for evaluation and testing. For instance, as I tell my own patients, blood in the toilet bowl should not automatically be chalked up to hemorrhoids.

Direct-to-consumer options include liquid biopsies that look for circulating tumor DNA (called multicancer early detection tests, or MCEDs) and full-body MRIs. While the hope is that these can detect cancers for which we lack good screening, no professional medical organization currently recommends them (with the exception of full-body MRIs for certain hereditary cancer syndromes such as Li-Fraumeni syndrome). Screening must balance the benefits of early detection with risks of over-diagnosis, false positives, and procedure complications from subsequent confirmatory tests such as biopsies.

My final takeaway — if you see yourself in any of these higher-risk categories, it’s worth asking your primary care doctor whether your screening plan should go beyond the basics. Genetic testing in particular is widely available now; the bottleneck is knowing who should receive it.

As always, thanks for reading.

Disclosure: I’m an advisor to the startup Previvor Edge, working to scale this model.