Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations

To the Editor,

We read the paper by Rittenhouse and colleagues (1) with close attention, not only because of its careful mixed-methods design but also because its findings echo professional dilemmas we meet daily in Spain’s public National Health System (SNS). As family physician researchers with longstanding experience working in areas with deprived urban neighbourhoods and on short-term placements in sparsely populated rural areas (“zonas de difícil cobertura”), we recognise the portrait of clinicians who operate at the intersection of biomedical need and social disadvantage (2). Although our working contexts differ (the Spanish SNS offers tax-funded universal coverage and salaried employment within public primary-care teams) the challenges of serving communities that face poverty, linguistic barriers, insecure housing or violent environments resonate strongly with the experience reported in the United States study.

The inspiring article (1) from Rittenhouse team reminds us that the international evidence base has long described how robust, first-contact, longitudinal and person-centred primary care contributes to better population health, greater equity and lower costs (3). The National Academies’ 2021 blueprint to “rebuild” primary care frames these attributes as infrastructure requiring sustained policy attention (4). Europe’s comparative PHAMEU project reached similar conclusions, showing that countries with stronger primary-care orientation tend to perform better on avoidable hospitalisation and equity indicators (5). Rittenhouse et al. extend this literature by illuminating how much extra work is needed when physicians practise in micro-organisations outside large systems. Their quantitative trend, shrinking numbers of small independent practices in urban settings, adds an empirical signal to a discussion often fuelled by anecdote, and their qualitative themes render the numbers meaningful.

The first theme in their interviews, the time devoted to social determinants and access logistics, mirrors our daily activity in the SNS. In theory, universal coverage should minimise financial barriers, yet in practice many Spanish patients in low-income districts still delay attendance because of unstable work, transport costs or caring duties. As front-line clinicians we frequently become the “last link in the chain”, completing liaising with municipal social-service officers. Recent participatory work in a rural Valencian comarca (Proyecto Alifara) confirms that these community-centred functions belong naturally to primary care but require organisational headroom to flourish (6). The clinicians in the US study tackle similar tasks in offices devoid of external scaffolding; in our public centres the scaffolding exists on paper but is often weakened by staff rotation or underfunding, so the operational burden again falls on the consulting room.

Autonomy emerges in the article as a double-edged sword: it allows physicians to schedule longer visits and nurture trust, but it also isolates them from collective bargaining or technical assistance. In our Catalan region, different management models (public “ICS”, integrated organisations and physician-led “EBAs”) coexist. A recent survey of 542 doctors showed that administrative overload is a major threat to intrinsic motivation, whereas perceived autonomy and peer feedback buffer burnout (7). The paradox is that public teams can enjoy job stability yet feel administratively constrained, while US independent practitioners enjoy scheduling freedom yet face financial fragility. Both realities support a common policy message: autonomy should be cultivated deliberately inside supportive networks, not left to chance.

The US authors voice anxiety about future workforce supply; we share that concern. Spain’s rural and peri-urban areas already experience what international literature terms “medical deserts”. The 2024 WHO-European Observatory review of the Spanish health system notes persistent difficulty filling primary-care posts in low-density provinces despite an overall doctor-to-population ratio above the EU average (8). Qualitative work with residents trained in a rural teaching unit in central Catalonia identified lifestyle considerations, family opportunities and career progression as decisive for retention (9). Without targeted measures the demographic cliff is near: one-third of rural family doctors may retire within five years, according to the Spanish Medical Council’s national survey (10). In this light, the decline in US independent practices is a transatlantic warning: when the practice setting becomes unsustainable, communities lose access long before replacement structures are in place.

Another insight from Rittenhouse et al. deserves emphasis: the preservation of patient dignity. Their interviewees describe how a discreet waiting room or a familiar receptionist can soften the stigma of “poor clinics”. In our public centres we observe the same phenomenon: continuity with a named professional and small gestures such as flexible appointment slots often matter more to patients than high-tech interventions. The relational continuity underpinning this dignity is repeatedly associated with lower mortality and hospital use, yet it is fragile when organisational churn accelerates, as the Milbank analysis of continuity determinants reminds us (3).

Financial architecture naturally differs between a fee-for-service US micro-practice and a salaried Spanish team, but both systems wrestle with resource mismatch. In the United States, inadequate Medicaid rates threaten viability; in Spain, real-term primary-care budgets have lagged behind hospital expenditure for over a decade. The qualitative testimony of clinicians limiting their remuneration to preserve their service finds an echo in our colleagues who forgo leave to maintain rota cover. International evidence on educational and contractual incentives, synthesised in a 2023 systematic review of strategies to reduce physician shortages in underserved areas, indicates that multifaceted packages—rural background selection, scholarships tied to service, supportive supervision—are more effective than isolated salary uplifts (11). Spanish regions have begun experimenting with housing allowances, accelerated career steps and mentoring schemes; the recent semFYC “Mentoring Rural” network illustrates professional-led innovation, though evaluation is still pending (12).

The US article proposes a Primary Care Extension Program to provide technical and community-linkage support for small offices. That concept aligns with long-standing calls to strengthen Spain’s district-level “unidades de apoyo” and to integrate social-care workers and cultural mediators into primary-care teams. Community Health Centres in the United States demonstrate how such wrap-around models can function at scale when endowed with dedicated federal grants. Translating that lesson to our publicly funded context would mean earmarking a predictable budget line for multidisciplinary community-oriented teams, rather than relying on short-term project money.

Finally, Rittenhouse et al. show that vocation, rooted in personal history or ethical conviction, still draws physicians to serve vulnerable areas, yet vocation alone cannot guarantee sustainability. The Catalan qualitative study cited above found that residents value meaningful patient relationships and community embeddedness, but also weigh work-life balance and institutional recognition (9). If policymakers wish to preserve the social contract on which universal systems rest, they must reconcile these professional expectations with service needs. This entails reducing avoidable paperwork, ensuring protected time for community engagement, funding the necessary technology infrastructure and offering career pathways that do not require abandoning deprived postings for advancement.

In our opinion, the careful work of Rittenhouse and colleagues provides timely evidence that the capacity of primary care to advance equity is contingent not only on financing mechanisms but also on organisational form, professional agency and community links. Spanish experience shows that a universal insurance scheme does not abolish vulnerability, and that staffing deficits can erode equity even when formal coverage is assured. Cross-national dialogue can therefore enrich solutions: the US Primary Care Extension proposal parallels European primary-care implementation science; US small-practice autonomy invites reflection on Spain’s management models; and the shared imperative to retain motivated professionals in underserved settings is universal. We hope this letter helps situate their findings within a broader international conversation and encourages stakeholders on both sides of the Atlantic to design policies grounded in the everyday realities of the consultation room rather than abstract organisational charts.

REFERENCES:

1. Rittenhouse DR, Peebles V, Mack C, Alvarez C, Bazemore A. Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations. Ann Fam Med. 2024 Mar 1;22(2):89–94.

2. Tenajas R, Miraut D. A Shared Struggle: The Recruitment and Retention of Family Doctors in Deprived Areas of Japan and Spain. Ann Fam Med. 2024 Sep 30;22(5):eLetter.

3. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005;83(3):457–502.

4. National Academies of Sciences, Engineering, and Medicine. Implementing high-quality primary care: rebuilding the foundation of health care [Internet]. The National Academies Press.; 2021. Available from: https://doi.org/10.17226/25983.

5. Kringos D, Boerma W, Bourgueil Y, Cartier T, Dedeu T, Hasvold T, et al. The strength of primary care in Europe: an international comparative study. Br J Gen Pract. 2013 Nov 1;63(616):e742–50.

6. García Carbó C, Cassetti V, Monfort Lázaro M. Proyecto Alifara: experiencia de un análisis de salud participativo en comunidades rurales de la Comunidad Valenciana. Gac Sanit [Internet]. 2024 Jan 1 [cited 2025 Apr 26];38. Available from: http://www.gacetasanitaria.org/es-proyecto-alifara-experiencia-un-analis...

7. Ballart X, Ferraioli F, Iruela A. Carga administrativa, motivación y bienestar entre médicos de atención primaria. Comparación entre modelos de gestión. Gac Sanit. 2023 Jan 1;37:102306.

8. European Observatory on Health Systems and Policies. Spain: health system review 2024. Health Syst Transit World Health Organ. 2024 Sep 16;26(3):216.

9. Tort-Nasarre G, Vidal-Alaball J, Pedrosa MJF, Abanades LV, Arcarons AF, Rosanas JD. Factors associated with the attraction and retention of family and community medicine and nursing residents in rural settings: a qualitative study. BMC Med Educ. 2023 Sep 13;23(1):662.

10. Roy PC. Univadis. 2022 [cited 2025 Apr 26]. El médico rural en España necesita visibilidad, reconocimiento y buenas condiciones laborales. Available from: https://www.univadis.es/viewarticle/el-m%25C3%25A9dico-rural-en-espa%25C...

11. Figueiredo AM de, Labry Lima AO de, Figueiredo DCMM de, Neto AJ de M, Rocha EMS, Azevedo GD de. Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review. Int J Environ Res Public Health. 2023 Jan;20(11):5983.

12. Sociedad Española de Medicina de Familia y Comunitaria (semFYC). La semFYC lanza “MENTORING RURAL” el primer proyecto para apoyar mediante una red profesional de apoyo a los y las médicas de familia en zonas rurales [Internet]. 2024 [cited 2025 Apr 26]. Available from: https://www.semfyc.es/actualidad/la-semfyc-lanza-mentoring-rural-el-prim...