Anatomy of Good Primary Care Part I: Access

I’ve been thinking a lot about the state of primary care this week after experiencing it as a patient myself. Even though I am a primary care doctor, I was shocked by how long the wait time was to see my own established PCP for a preventive care appointment, and the implications it had on my healthcare.

I recently got my first mammogram and thankfully, I was able to self-schedule without a doctor’s order because on September 15th 2026, the next available appointment with my PCP for a wellness visit was 4 months away in January of 2027! Since my family has met our deductible this year, I was really hoping to get all anticipated medical care done before December 31st. Here I was planning ahead in September, only to realize PCP appointment scarcity might have prevented me from utilizing the benefits of meeting my deductible and delayed my recommended cancer screening by 4 months.

When I think of "Primary Care,” I expect my doc who knows me to be relatively available to help with everyday medical issues and preventive care. I expect my concerns to be addressed correctly and thoroughly. I expect bills to be fair and accurate. I expect my prescriptions and referrals to be sent correctly, and if I call the clinic later with a follow-up question, I expect a capable staff member to help me without difficulty.

If you’ve tried to engage with healthcare in the Seattle area lately like me, you might be chuckling at the irrational optimism of that vision. While primary care used to be like that, it has significantly deteriorated over the last several years. Now, the current experience is unrecognizable from times past, even at the same facilities. For many patients, the service being offered isn’t meeting our primary care needs at all.

Primary Care Access

I want to focus now on the first barrier to receiving good primary care- the one I ran into this week: access. In a traditional sense, access is a general term reflecting the ability for a patient to be seen the same or next day for urgent issues and within a few weeks for routine non-urgent issues at their home clinic ideally with their own PCP.

To clinic administrators and healthcare CEOs, "access" has become a corporate buzzword. Administrators view “access” as a metric to gauge efficiency, provider availability, and practice growth. In my opinion, the term “access” has been co-opted by them to justify shorter appointment times in order to generate increased “patient volume” or billable visits per year; not to increase availability of appointments to patients as touted. In health systems across Seattle and the US, in the name of creating “access” they cut charting breaks, eliminate team meetings, and shorten appointment slots to 15-20 minutes per patient. They say more appointments are imperative to “increase access” and reduce long wait times, but this is not true because appointment length is only half of the access equation, and they simultaneously are increasing the panel sizes of physicians. If you ignore the second half of the equation, you still have an access problem AND short appointments. A doctor only has a finite number of hours in a day which means more patients per day = less time per patient. Less time per patient means either poorer quality evaluation of the same concerns, or fewer concerns addressed per visit.

The Secret Equation to Physician Appointment Access

Lets look at the numbers. A physician can offer four 15-minute appointments in a one-hour block, or one 60-minute appointment which delivers thorough care but leaves 3 other patients without being seen. For the 60-minute per patient physician, the other 3 patients need to be pushed out to later slots. However, if only 4 people need appointments that day, everyone can be seen in a 6-hour patient-facing workday (patients have “access” to their doctor.) The 60-minute appointment patients get to discuss all their concerns and the 10-minute appointment patients have to schedule another appointment to discuss the rest of their concerns another day. But if 20 patients want to be seen that day, the 10-minute doc can see them all, and the 60-minute doc starts booking out. So, you can see, the number of patients who need appointments starts to really impact wait times making it the critical other half of the access equation.

The Importance of Finding the Right Panel Size

This brings us to the concept of empanelment—the total number of patients assigned to a single doctor. With most patients seeing their PCP 2-4 times per year or less, the number of appointments available per provider has to match the number of patients expecting to be seen that year.

Example calculation:

A full-time doctor with a schedule template of 15-minutes per visit can offer a maximum of roughly 5,500 appointment slots per year. If those patients need to be seen 4 times per year, the doctor can carry 1,375 patients and meet the needs of those patients. This is of course an overestimation of how many appointments are available because new patients, procedures, complex patients, wellnesses all take longer than ten minutes. Most US primary care doctors in reality conduct roughly 4,500 appointments per year which means a primary care doctor can only offer enough appointments to 1,125 (panel size of 1,125.)

But here is the scary thing, the average panel size for a full-time family doctor in the US is roughly 2,500 with an average appointment length of 15-20 minutes. These doctors can’t see everyone assigned to them which is what we observe.

An article in the Journal of the American Board of Family Medicine recently highlighted what most career Primary Care doctors have been feeling for years. “At a panel size of 2500, a physician would have to work 21.7 hours per day to provide proper care to each patient.” This was after looking at the time it takes to follow all of the recommended guidelines for primary care. A re-review of the data in the Journal of General Internal Medicine in 2022 increased this, “PCPs were estimated to require 26.7 h/day.” Now for those of you who are getting sleepy with the numbers, there are only 24 hours in a day!

When doctors manage complex patients who require frequent follow-ups, the traditional system breaks even more. In high-demand markets like Seattle—where major health networks demand panels of 2,000+ patients per physician just to keep up with regional overhead—the math simply stops working and patients do not get the care they are seeking. The schedule backs up for months, urgent needs get routed to overstretched urgent cares or ERs, and "access" becomes an illusion.

The Right Ratio: Direct Primary Care Panel Size <400 patients with 60 minute appointments

The uncomfortable truth is that under the traditional, insurance-driven clinic model, you cannot have both high-volume access and high-quality care. The system has evolved to optimize volume of billed appointments, not you, sadly. What this means is even a ten minute appointment with your PCP may not be available for months, Achieving a balance of visit length and panel size depends entirely on the quality of care desired or needed. If the physician has no control over the numbers of patients or the time they get to spend with each patient, they cannot help fix the equation.

As a DPC Doc who recently hung my own shingle, I am biased to think Direct Primary Care is the antidote to factory-line medicine because I can finally decide how long and how many patients are reasonable to provide high-quality care. Not to mention, DPC docs can adapt to the complexity of their panel. If most patients need appointments 2 times per month, the panel size needs to be smaller, and the DPC doc can adjust new patient intakes to accommodate the needs of their current patients. Especially after my own experiences in the traditional system, I am more convinced than ever that Direct Primary Care is the only way to reliably see your doctor in a time frame that meets your needs.

In Part 2 of this series, we’ll look at the financial impact of long appointment wait times.

·  Raffoul et al. (2016): A Primary Care Panel Size of 2500 Is Neither Accurate nor Reasonable

·  Delaware Journal of Public Health (2023): Considerations for Patient Panel Size

·  Porter et al. (2022/2023): Revisiting the Time Needed to Provide Adult Primary Care