First, her favorite doctor in Providence, R.I. retired. Then her other doctor, at a health center a few miles away, left the practice. Now, Piedad Fred has developed a new chronic condition: distrust in the American medical system.
"I don't know,'' she 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.''
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, at her home one morning last fall. "It's just that I don't have faith in doctors.''
The loss of a trusted doctor is never easy. But it's an experience that is increasingly common.
The stress of the pandemic drove a lot of health care workers to retire or quit. Now, a nationwide shortage of doctors and other professionals who provide primary care is making it hard to find replacements. And as patients are shuffled from one provider to the next, it's eroding their trust in the health system.
The American Medical Association's president, Dr. Jesse M. Ehrenfeld recently called the physician shortage a "public health crisis."
"It's an urgent crisis, hitting every corner of this country – urban and rural,'' Ehrenfeld told reporters at a press conference in October, "with the most direct impact hitting families with high needs and limited means.''
In Fred's home state of Rhode Island, the percentage of residents without a regular source of routine health care increased from 2021 to 2022, though Rhode Islanders still do better than most of the country.
Hispanic residents and those with less than a high school education are less likely to have a source of routine health care, according to the nonprofit Rhode Island Foundation.
Workforce shortages stir labor unrest
The community health centers known as federally qualified health centers (FQHCs) are the medical safety net of last resort, serving the uninsured, the underinsured and other vulnerable people.
There are more than 1,400 community health centers nationwide, and 67% of them 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 FQHCs reported workforce attrition rates of 25% to 50%. And it's not just doctors: the most severe shortage, the survey found, was among nurses.
In a domino effect, the shortage of such clinicians has placed additional burdens on support staffers such as medical assistants and other unlicensed workers.
Their extra tasks include "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 you can't get everything done," Martin added.
Last October, scores of SEIU members who work at Providence Community Health Centers, Rhode Island's largest FQHC, held an informational picket outside the clinics, demanding improvements in staffing, work schedules and wages.
A spokesman for PCHC, Brett Davey, declined to comment.
This staff discontent has rippled through community health care centers across the country.
In Chicago, workers at three health clinics held a two-day strike in November, demanding higher pay, benefits and a smaller workload.
At Unity Health Care, the largest federally qualified health center in D.C., doctors and other medical providers voted to unionize just before Thanksgiving, saying that they are being forced to prioritize patient volume over quality of care, leading to burnout and turnover.
Fewer providers for more patients
The staffing shortages come as community health centers are caring for more patients. The number of people served by community health centers between 2015 and 2022 increased by 24% nationally, and by 32.6% in Rhode Island, according to the Rhode Island Health Center Association (RIHCA).
"As private practices close or get smaller, we are seeing patient demand go up at the health centers,'' said Elena Nicolella, RIHCA's president and CEO. "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 RIHCA.
Job vacancy rates at Rhode Island's community health centers are 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 and NPR.
Pediatricians are also in short supply. Last year, 15 pediatricians left staff positions at the health centers, and 7 of them have yet to be replaced.
Research shows some of the biggest drivers of burnout are workload and job demands.
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.
These clinicians often want to "give back" to the community, she said, and are motivated to practice "a kind of medicine that is maybe less corporate,'' and through which they can they develop close relationships with patients and within multigenerational families.
So when workplace pressures make it harder for these clinicians to meet their patients' needs, they are even more likely to burn out, Burdette explained.
Urgent care visits instead of primary care
When a doctor quits or retires, Dr. Carla Martin often gets called to fill in. The week before Thanksgiving, she was filling in at two urgent care clinics in Providence.
"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.''
One patient recently came to urgent care 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.
Stories like that worry Christopher F. Koller, president of the Milbank Memorial Fund, a 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,'' Koller said.
Koller points to research showing that having a consistent relationship with a doctor or other primary care clinician is associated with improvements in overall health and fewer emergency room visits.
A primary loss of trust
When that relationship is broken, patients can lose trust in their health care providers.
That's how it felt to Piedad Fred, the Columbian immigrant who stopped getting vaccinated.
Fred used to go to a community health center in Rhode Island, but accessing care there began to feel really frustrating.
She described making repeated phone calls for a same-day appointment, only to be told that none were available, try again tomorrow.
She recalled how after one visit, one of her prescriptions never made it to the pharmacy.
And there was another time when she waited 40 minutes in the exam room to consult with a physician assistant — who then said she couldn't give her a cortisone shot for her knee, like her doctor used to do.
Fred says that she won't be going back.
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."
But experts warn that more people crowding into hospital emergency rooms will only further strain on the health system, and the people who work there.
This story comes from NPR's health reporting partnership with The Public's Radio and KFF Health News.
