Ever since her favorite doctor retired and another left the community health center in Pawtucket, R.I. where she is a patient, Piedad Fred has developed a new chronic condition: distrust in the American medical system.

At 71, she has never been vaccinated against COVID-19. She no longer gets an annual flu shot. And she hasn’t even considered whether to be vaccinated against the respiratory syncytial virus, or RSV, even though her age and asthma put her at higher risk of severe infection.

“It’s not that I don’t believe in vaccines,’’ Fred, a Colombian immigrant, said in Spanish, “it’s just that I don’t have faith in doctors.’’ 

Rather than any single medical failing, she recounted a series of frustrations – repeated phone calls for a same-day appointment only to be told that none were available, try again tomorrow; a prescription that never made it to the pharmacy; a 40-minute wait in an exam room for a visit with a physician assistant who said she couldn’t give Fred a cortisone shot in her sore knee, like her doctor use to do – that culminated in disillusionment and distrust.

“I don’t know,’’ Fred said, eyes filling up. “To go to a doctor that doesn’t know who you are? That doesn’t know what allergies you have, the medicines that make you feel bad? It’s difficult ... I know that I feel cheated, sad, and like I have my hands tied.’’ 

The loss of a trusted doctor is never easy. But it’s increasingly common as more physicians retire or stop practicing medicine, leaving clinical practices unable to find replacements.

The American Medical Association’s president, Dr. Jesse M. Ehrenfeld has called the physician shortage a “public health crisis.” 

“The physician shortage that we have long feared and warned was on the horizon is already here,’’ Ehrenfeld said at an Oct. 25 address to the National Press Club. “It’s an urgent crisis, hitting every corner of this country – urban and rural – with the most direct impact hitting families with high needs and limited means.’’

Rhode Island has a higher percentage of doctors and other primary care clinicians than in most of the country. But high turnover rates and staffing shortages, accelerated by the pandemic, are hitting especially hard on people who rely on federally qualified health centers – including the eight nonprofit community health centers in Rhode Island – which provide care to medically underserved areas.

Workforce shortages, labor unrest  

Nationwide, 67% of community health centers lost between 5% and 25% of their workforce during a six-month period in 2022, according to a report by the National Association of Community Health Centers. Another 15% of centers reported workforce attrition at 25% to 50%. And it’s not just doctors. The most severe shortage, the survey said, was among nurses.

The shortage of clinicians has left other staff, such as medical assistants, or “health care associates,” taking on extra tasks such as “sterilizing equipment, keeping more logs, keeping more paperwork, working with larger patient loads,’’ said Jesse Martin, executive vice president of the Service Employees International Union 1199 New England. “When you add that work to the same eight hours worth of a day's work,’’ he said, “you can't get everything done.”

Last month, scores of SEIU members who work at Rhode Island’s largest community health center operator held an informational picket outside six of the Providence Community Health Centers’ nine clinics, demanding improvements in staffing, work schedules and wages.

The union filed a complaint on Oct. 11 against the PCHC with the National Labor Relations Board alleging contract violations and anti-union tactics.

Brett Davey, a PCHC spokesman, declined repeated requests for comment for this story. 

This discontent among staff has rippled through community health care centers across the country. In Chicago, workers at three health clinics began a two-day strike, demanding higher pay, benefits and a smaller workload. And at Washington, D.C.’s largest federally-qualified health center, doctors and other medical providers are trying to unionize, saying that they are being forced to prioritize patient volume over quality of care, leading to burnout and turnover.

Fewer providers, more patients

The staffing shortages come as community health centers are trying to care for a growing population of patients with more complex medical needs. The number of people served by community health centers from 2015 to 2022 increased by 24% nationally, and 32.6% in Rhode Island, according to RIHCA. 

“As private practices close or get smaller, we are seeing patient demand go up at the health centers,’’ said Elena Nicolella, president and CEO of the Rhode Island Health Center Association. “Now with the workforce challenges, it’s very difficult to meet that patient demand.”

 In Rhode Island, community health centers in 2022 served about 1 in 5 residents – more than twice the national average of 1 in 11 people, according to the RIHCA.

Community health centers tend to attract clinicians who are mission-driven, said Nelly Burdette, who spent years working in health centers before becoming a senior director of the nonprofit Care Transformation Collaborative of Rhode Island. They want to “give back” to the community, she said, “or practice a kind of medicine that is maybe less corporate,’’ where they develop close relationships with patients and multigenerational families. 

So when these clinicians are unable to meet their patients’ needs because of whatever is going on in their workplace, Burdette said, they may be “at a higher risk of burnout.’’ Among the biggest drivers of burnout, research shows, are workload and job demands.

Job vacancy rates at Rhode Island’s community health centers are at 21% for physicians, 18% for physician assistants and nurse practitioners, and 10% for registered nurses, according to six of the state’s eight health centers that responded to a survey conducted by the RIHCA for The Public’s Radio. Pediatricians are also in short supply. The centers reported that 7 of the 15 pediatricians on staff last year who left their jobs have not been replaced.

In Providence, a nurse practitioner who quit her health center job nearly a year ago, was only recently replaced, so her patients are still being seen by various “floating” physicians or nurse practitioners, according to several doctors interviewed who asked not to be identified for fear they could lose their jobs. New patients, they said, also have a hard time getting appointments at the centers. One new patient referred to PCHC’s Randall Square center in October was told the clinic had a 200-patient waiting list. 

Urgent visits for primary care

When a doctor quits or retires, health centers may ask a “per diem” physician to fill in. Dr. Carla Martin has been filling in at PCHC’s urgent care clinics, called Express Clinics, on Providence’s south side and Olneyville neighborhood.  

“We're seeing a lot of people coming in for things that are really primary care issues, not urgent care issues,’’ Martin said, “just because it's really hard to get appointments.’’ 

Patient call volume at one community health center last month was up 30% from October of 2022, according to the Rhode Island Health Center Association’s survey. (The survey did not identify the health centers by name.)

Colds, coughs, back pain and knee pain are among the most common reasons people show up at PCHC’s urgent care clinics, Martin said. One patient recently came in asking for a refill of her asthma medication. 

“She said, I ran out of my asthma medicine, I can't get a hold of my PCP for refill, I keep calling, I can't get through,’’ Martin said. The woman told the doctor that she’d been borrowing a friend’s medication so she could use her nebulizer.  

One day when she was filling in for a doctor who retired, Martin said, patients kept asking her, “Are you going to be the doctor here?” She had to explain that she was just filling in until they found a replacement. 

“It's heart wrenching,’’ Martin said. “It's just tough for the patients to try to make a connection with someone new.’’

More than 100 million Americans —nearly one-third of the country— do not have a regular source of primary care due to a shortage of providers in their local community, according to a 2023 report by the National Association of Community Health Centers. In Rhode Island, about 338,000 people are “medically underserved” and 80% of them – nearly 270,400 Rhode Islanders – are at risk of being unable to access primary care due to an inadequate supply. 

Communities that are predominantly black and Hispanic tend to have fewer primary care providers than predominantly white communities. In Rhode Island, 29.3% of Rhode Island’s Hispanic residents reported they have “no doctor,’’ compared with 9.9% of white and 21.2 % of Black residents, according to 2018 state health data.

Research shows that having a familiar place where people feel connected to their medical care is associated with better overall health outcomes and fewer costly emergency department visits. And yet a higher proportion of Americans reported they have no “usual source of care,’’ according to a recent report by the Milbank Memorial Fund, a New York-based nonprofit philanthropy focused on health policy.

“When people say, 'I can't get an appointment with my doctor,’ that means they don't have a usual source of care anymore,’’ said Christopher F. Koller, Milbank’s president.

And when patients feel they can no longer rely on seeing their provider when they need to, Koller said, that jeopardizes the core principle of medical care: a trusting relationship between clinician and patient.

“Distrust is infectious,’’ he said. “When you have distrust in the system it spreads.”

A primary loss of trust

For Fred, her loss of trust was gradual. It started when her gynecologist of many years retired, the clinic where he worked was sold, and her primary care doctor left for the Blackstone Valley Community Health Center in Pawtucket. Fred followed her physician to the health center. But then her doctor left, too.

Blackstone Valley Community Health Center has been experiencing “higher turnover rates” and more “difficulty in attracting new providers,’’ Sandy Pardus, the organization’s interim CEO, said in an email. “Our team has worked diligently at recruitment efforts and has succeeded in replacing almost three quarters of our providers who departed over the last year.”

Pardus said that BVCHC also “has taken many steps to improve our patient experience so that we can meet their needs with high quality care while we continue to work toward full staffing.”

The last time Fred visited the health center was for her bad knee. She has arthritis, she said, and her knee has been bothering her more since last August, when she tripped and fell down the last three steps to her basement. 

So in October, she finally called the health center for an appointment. By then, she knew that her doctor had left but she was told someone else would see her. 

On the day of her visit, she said, she waited 40 minutes in an exam room. When a physician assistant showed up, Fred said, she told the woman that her doctor used to give her injections on her knee for the pain. “That’s nothing I can do,’’ Fred said the woman replied.

Instead, the clinician wrote a prescription for an anti-inflammatory medication, Fred said, and agreed to refill a prescription for an albuterol inhaler for her asthma. But when Fred went to the pharmacy, she said, they didn’t have her albuterol prescription. 

Fred said that she won’t be going back to the health center.

So what will she do the next time she gets sick or injured and needs medical care?

“Bueno, será ir a un hospital.”

“Well, I’ll be going to a hospital.”

Health reporter Lynn Arditi can be reached at larditi@thepublicsradio.org. Follow her on X (formerly Twitter) @LynnArditi