A student can complete four years of American medical school without ever being required to spend time in the kind of clinic where most primary care actually happens. A group of medical educators argues that this gap is one reason the country keeps failing to produce the primary care doctors it needs.
The argument appears in a perspective piece in the Journal of General Internal Medicine, written on behalf of the Society of General Internal Medicine and the Association of Chiefs and Leaders of General Internal Medicine Hess Initiative Work Group. The lead author is Tovah Tripp, M.D., associate professor of internal medicine at the Hackensack Meridian School of Medicine, the school's internal medicine clerkship director, and a practicing primary care physician.
For readers, the stake is straightforward. Finding a primary care doctor accepting new patients is difficult in much of the country, and the supply of those doctors is decided years earlier, inside medical schools.
A Requirement That Exists in Residency but Not in Medical School
The specific gap the authors identify is a mismatch between two stages of training.
Graduate medical education, meaning residency, mandates ambulatory training. Undergraduate medical education, meaning medical school itself, does not. According to the announcement from Hackensack Meridian Health, neither the Liaison Committee on Medical Education nor the Association of American Medical Colleges requires specific outpatient exposure during medical school.
Much of a medical student's clinical training happens on hospital wards, caring for people who are acutely ill. That is a legitimate part of training, but it shows students almost nothing of what a primary care physician's working life looks like, which involves longitudinal relationships, prevention, and management of chronic conditions over years.
The authors argue that specialty preferences are often settled long before residency applications, which makes exposure during medical school the point where an intervention could still matter. They call for medical schools and accrediting bodies to mandate minimum ambulatory rotation requirements.
The Access Problem Behind the Argument
The scale of the shortage is not in dispute, and federal records document it in detail.
The Health Resources and Services Administration counted 9,003 designated primary medical Health Professional Shortage Areas as of June 30, 2026. Those designations cover a population of about 108.6 million people. The agency calculates that roughly 47 percent of the need in those areas is currently met, and that 18,541 additional practitioners would be required to remove the designations entirely.
The burden is not evenly spread. About 61 percent of these designations are rural, covering roughly 28.9 million people and requiring some 4,965 additional practitioners.
Those designations are updated frequently in a federal data warehouse, and federal law requires an annual notice listing them. The most recent notice directs readers to the agency's data warehouse, where the lists are posted and arranged by state and county. Readers who want to know whether their own county carries a designation can find it there, which is the most concrete step available from this story.
A designation describes structural access across an area or population group. It does not predict whether any individual can get an appointment, and it does not mean a community has no doctors. It describes the conditions that produce long waits and patients defaulting to emergency departments for problems a primary care office would handle.
Three Levers the Authors Propose Pulling
The paper synthesizes existing published literature rather than reporting new findings, and it groups its proposals into three connected pathways.
The first concerns the working conditions of primary care itself. The authors argue for reducing administrative burden and mitigating debt, while using artificial intelligence and team-based models to make the clinical role more appealing to students watching from the outside. Students who observe an exhausted, paperwork-buried physician draw conclusions from that.
The second concerns faculty. Teaching in a clinic slows a physician down, so the authors propose incentives including educational relative value units or tax credits, plus protected time and flexible schedules. Without someone willing to teach, a mandated rotation has nowhere to happen.
The third concerns the student's own experience, enriching clerkships and mentorship so that primary care is encountered as a substantive discipline rather than a fallback.
Investing in medical school experiences, the authors write, is essential to rebuilding the primary care pipeline and creating a generation of physicians who understand the value of primary care regardless of the specialty they eventually choose.
Tripp was careful about how much any of this would accomplish. "There is not a single 'fix' for this kind of systemic problem," she said, adding that well-considered strategies can still nudge the trend in a positive direction.
An Argument, Not a Study, and the Difference Matters
The format of this publication shapes how much weight it can carry.
The paper is classified as a commentary and editorial. It is not a clinical trial, an observational study or a survey. It reports no new data. What it offers is a professional argument built from existing literature, advanced by educators with a direct stake in general internal medicine.
That does not make it wrong. Perspective pieces are how specialty societies put proposals into circulation, and the accreditation gap they describe is a verifiable fact about how medical schools are regulated. But nothing here demonstrates that adding a required outpatient rotation would increase the number of students who choose primary care. That question would need to be tested.
The authors report no funding or financial support for the paper. The work was produced on behalf of two general internal medicine organizations, which readers should weigh as they would any professional society advocating for its own field.
One timing note. The paper itself was published on August 10. The institutional announcement that brought it wider attention came in early September, so this is a recent argument rather than a brand-new one.
Nothing here changes what a patient should do today. Anyone struggling to find a primary care physician can ask whether a local federally qualified health center is accepting patients, since those centers are placed in designated shortage areas, and can ask about nurse practitioners and physician assistants, who deliver much primary care in underserved communities. The next thing worth watching is whether either accrediting body responds, which would be the point at which an argument starts becoming a requirement.
Key Questions Answered
What gap are the authors describing? Residency training mandates ambulatory experience, but neither the Liaison Committee on Medical Education nor the Association of American Medical Colleges requires specific outpatient exposure during medical school itself.
Who wrote the paper? Medical education experts led by Tovah Tripp, M.D., of the Hackensack Meridian School of Medicine, on behalf of the Society of General Internal Medicine and the Association of Chiefs and Leaders of General Internal Medicine Hess Initiative Work Group.
Is this a study? No. It is a perspective and commentary piece that synthesizes existing literature. It reports no new data and does not demonstrate that a required rotation would change specialty choice.
How large is the primary care shortage? Federal records counted 9,003 designated primary medical shortage areas covering about 108.6 million people, with roughly 47 percent of need met and 18,541 additional practitioners required to lift the designations.
Where is the shortage worst? About 61 percent of primary care shortage designations are rural. Rural designated areas cover roughly 28.9 million people and would need about 4,965 more practitioners.
What do the authors want changed? Mandated minimum ambulatory rotation requirements in medical school, alongside reduced administrative burden, debt mitigation, faculty teaching incentives, and stronger clerkship and mentorship experiences.
What can a patient do about any of this? Check whether your county carries a federal shortage designation, ask whether a local federally qualified health center is accepting patients, and consider nurse practitioners and physician assistants, who provide much primary care in underserved areas.
