Earlier this year, American life expectancy dropped to a two-decade low of 76.4. Infant and maternal mortality rate drove some of this drop, but so too did a lack of access to care. For the richest major country in the world, the number of physicians as a ratio to population has declined along with life expectancy.

Worryingly, the gatekeepers to the healthcare system are thinning. Primary and critical care residencies go unfilled at a rate of nearly 2,000 a year. Healthcare professionals (HCPs) experience occupational burnout at alarmingly high rates, especially among primary and critical care physicians. Many leave the profession outright. Almost 100 million people in American don’t have access to a PCP. Almost 84 million live in regions with a recognized shortage of PCPs.  Anywhere you turn, the situation looks dire.

There’s plenty of blame to spread around. The American Medical Association (AMA) persisted with claims of an impending doctor surplus from the 70s to the early 90s, inhibiting the growth and establishment of additional medical schools.  Physician culture has embraced a cult of the specialty and chosen to look down on those who choose general practice as their calling.  Administrative tasks like updating electronic medical records, requesting prior authorizations, or other compliance-related work consumes up to 30% of a physician’s day, reducing the hours spent seeing patients. Congress has refused to incentivize filling GP residencies, even when they have been warned by the American Association of Medical Colleges that their graduating students are not seeking residencies because of low future pay (PCPs and Critical Care earn significantly less than other specialties).

But this slow-motion car crash isn’t anything new. The country as a whole has struggled with maintaining an adequate supply of trained physicians for over a century.

When medicine professionalized around 1900, state licensing laws swept aside a large proportion of those calling themselves doctors. In these instances, the old apprenticeship system from the 1800s disappeared as medical school became a post-graduate degree requiring scientific fluency, laboratory expertise, supervised practice, and rigorous examination. Humors were traded in for germ theory and speculation for clinical testing.

Although much safer and efficacious, evidence-base medicine exploded costs onto American families. In the 1910s and 1920s, as these long-schooled and debt burdened men of science became the norm in the nation’s hospitals, medical costs for the average family nearly tripled. Those prices also reflected new laboratory facilities, redesigned wards, and a bevy of new instruments to augment the diagnostic and therapeutic endeavors of the country’s doctors. In 1923, Charles Mayo of Mayo Clinic fame worried that if overhead and prices continued to rise, the average family might not afford basic care by 1940.

In the post-war decades, medical schools grew to meet the demands of the Baby Boom but did so by less than 10% of their exiting enrollment. In the 1960s, it already looked as if the nation might fall short of doctors. Healthcare systems began to recruit physicians from abroad to work in the US, a pattern repeated so much that by 1975, nearly 1 in 5 physicians was foreign born. Although women began to enroll in medical school at much higher rates in the 1970s, this didn’t significantly grow the number of graduates, just diversified their backgrounds.

Physician in-migration helped create the mirage echoed by the AMA, AAMC, and Congressional Reports through the 1970s: unless medical schools limited their expansion, medicine would soon face a physician surplus.  Whether or not the math added up to these reports, the surplus never materialized because a wave of concurrent changes that changed the character of medical care in the country:

1. Medicare brought greater access to the exam room to a vastly larger and older population across the country. As life expectancy grew, older, sicker Americans visited the doctor more than ever before.

2. The Nixon administration allowed for-profit health insurance models for the first time, a decision that has spurred the growth of a massive administrative apparatus across all levels of healthcare.

3. Life-saving advances in many of the major killers in the country. Today, it means patients expect long-term management of their conditions. In the 70s, prostate cancer could kill. Today, it’s easily put in remission or managed in its metastatic form.

By the late1990s, medical schools finally began to increase enrollments again. Others began to open. But the greying generations, administrative demands on doctor’s time, and maldistribution of practitioners in relatively few urban areas had already gained interminable momentum.

Today, there are fewer easy solutions. With other countries industrializing and offering higher salaries, physician shortages cannot be so easily abrogated by bringing in foreign doctors. (Nor is the political climate in certain states always friendly to this). Unlike the 1970s, many foreign-trained doctors must have a US-based residency to apply for state licensure, and fewer states are recognizing for profit and Caribbean medical schools and other historic ‘alternative paths’ to practice domestically.

Today with the pressures of profit weighing on the medical-industrial complex, the lack of GPs and PCPs has forced others to provide services, like physician assistants and nurse practitioners. Urgent cares, telehealth, and mail order pharmacy services shorten the time to see doctors at the cost of reducing the doctor-patient relationship to being largely transactional. There are countless ways to make do in the fractured medical landscape now, none of which is satisfactory to patients, few to insurers, and scant little to providers – and all for different reasons.

Increasingly, patients will be seeking piecemeal or transactional treatment at a young age and more consistent care as they age. For both groups, that means receiving medical advice from a variety of professionals and taking a more central role in the management of their own treatments and communication of their symptoms.

Pharmaceutical companies and advocacy groups hoping to educate and communicate with HCPs and patients in this fragmented landscape will need to constantly reassess how and where HCPs communicate with patients and even embracing a broad vision of who constitutes an HCP.

The days of longitudinal GP and PCP-centered medicine are quickly fading. Blame it on a problem America hasn’t solved for more than 100 years.