After practicing primary care internal medicine for more than 35 years in greater Portland (Westbrook), I feel compelled to comment on the Dec. 30 op-ed in the Press Herald by Dr. Alvarez regarding the delivery of primary medical care.

Access to primary care in a timely fashion is a problem for patients and physicians both. Most primary care offices are not equipped or attuned to addressing acute problems and most of these patients are referred to urgent care centers or emergency rooms, perhaps rightly, as many need ancillary lab or X-ray studies. A bigger concern is the inability to arrange routine care.

I am retired and now a citizen patient consumer. Last April, I noted a conflict with my PCP appointment. I called the office and was offered an appointment with her in January 2025. I opted for an office visit with her office nurse practitioner instead, which worked out well. I can see where some patients may be disappointed with seeing someone other than the physician, but NPs and physician assistants can be essential for enhancing availability, capability and convenience for a primary care office. My experience has found them to competent, responsible and observant.

The author has a valid point about another aspect of medical practice: that of physician burnout (primary care and specialty practitioners), an increasingly recognized problem nationally. The author cites this as a problem in her own experience. The practice of medicine is challenging — intellectually and emotionally. It is difficult to maintain a full office schedule requiring rapid decision-making and giving each situation the full attention it deserves.

Physicians try to deal with this by integrating medical teaching, administrative activity, recreation, vacation and other interests into their schedules, with varying success, but this further diminishes time spent with patients. Again, having NPs and PAs on the office staff can provide the functions of better dialogue, medical education and other longer discussions that patients deserve.

I am opposed to the proposed suggestion of “direct primary care” as described as a model for practice. On the surface the title sounds very desirable, but seems like new terminology for “concierge medicine.” It is ironic that the author expresses concern for the cost of medical care, but proposes a system requiring membership fees for patients to maintain their status as active patients in their primary care offices. These fees are not associated with any medical services rendered.

Past statistics locally in our own multi-site internal medicine practice (and national surveys) have shown an average of 1,400 active patients (defined as having been seen within the last two years) per physician (1,600-plus before the advent of electronic medical records). The practice model of “direct primary care” or “concierge medicine” as described above would require by necessity reduction of these patient panels to allow longer office visits, etc. That figure is sometimes as low as 600 (a commonly used hypothetical figure per physician). This change to seeing far fewer people may leave many with no access to primary care. I have seen this happen. Will ability to pay for membership or selection of healthier, easier patients factor into decisions on who to keep as a patient?

Overall the problem seems one of a supply and demand mismatch. The growing and aging population of Maine certainly demands more services, both for preventive care and all other aspects of acute and chronic medical care. I must cite one program in Maine addressing this: the Tufts Maine Track Program utilizing the affiliation between Maine Medical Center and Tufts University School of Medicine to get more Maine students into primary care medicine as an outstanding example in regard to trying to match supply with ever-increasing demand and need for services.

My conclusions: 1) There is a definite primary care supply and access problem.
2) Utilizing nurse practitioners and physician assistants is a necessity for primary care offices and other medical facilities.
3) Any practice model that reduces the number of patients seen is not oriented toward improving care for the whole population.
4) Reflecting the long-term concern, attempts to increase the limited supply of primary care providers is the only way to address the problem. More physicians in training must be encouraged and convinced to enter primary care careers for care of our growing aging population.