Her team tends to “cringe” anytime they hear about patients having to fill out lots of paperwork, like when applying for Social Security Disability payments, because it can be a difficult, burdensome process.

Thornton tries to support her patients, she said, but understands the limits of her training.

“A lot of times the forms are so complex that I don’t really know what’s the true definition of what this form is asking me,” she said. “We refer them to a disability provider.”

Doctors including Thornton worry they’ll see more of those kinds of requests because of coming changes to Medicaid, the government health insurance program for people with low incomes or disabilities. Starting Jan. 1 in most of the country, some enrollees — mainly adults without dependents — must prove they’re working or performing other qualifying activities 80 hours a month.

issued in June say people can obtain an exemption if they’re “medically frail,” or too sick or disabled to work, which may require them to submit documentation from a medical professional. That standard prompted a lawsuit at the end of June from dozens of mostly Democratic-led states and has Thornton worried it could force her and her staff to assess things like how much a patient can lift or how far they can walk.

“If I’m asked, ‘Is this person medically frail?’ What does that even mean?” Thornton said. “I don’t know, and I’ve been doing this for 25 years.”

Last year’s GOP tax-and-spending law known as the One Big Beautiful Bill Act established the work rule, which will affect an estimated when more states start enforcing it. The mandate is expected to cause a larger increase in the number of people without health insurance than any other part of the law, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.

“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.

The Centers for Medicare & Medicaid Services declined to respond on the record about doctors’ concerns. But the agency confirmed that enrollees may need to get documentation from a clinician to prove they’re too sick to work and said states would make final determinations.

The Trump administration has previously said states should use available data sources — such as medical claims and payment data — before making patients submit proof of medical frailty from a provider.

“Documentation should be relatively easy to provide,” Mehmet Oz, the CMS administrator, said during a June 1 press call.

But deciding whether a patient is too sick to work is a subjective, high-stakes decision, said Chen, who also practices as a hospitalist at Valley Medical Center in Renton, Washington.

“We’re trained to take care of people,” he said. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We’re not trained to make these kinds of work determinations.”

When they apply and every six months after, Medicaid enrollees subject to the rule will have to prove that they’re performing the minimum monthly hours of qualifying activities — or will likely have to prove as frequently that they qualify for an exemption.

If states can’t find sufficient evidence that someone is too sick to work, that person will be able to self-attest to it under penalty of perjury — but only for a short time. States may take someone’s word that they’re medically frail twice in 2027 and only once in 2028.

Last month, 25 mostly Democratic-led states over the final regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.

The standard, they argue, requires state Medicaid agencies to “take on the role of occupational medicine experts” or adds that burden to physicians who are not necessarily trained in occupational medicine.

CMS declined to comment on the litigation.

The Trump administration has crusaded against fraud in government health programs including Medicaid. It recently — including medical professionals — over more than $6.5 billion in alleged fraud schemes.

CMS has said it will keep a close watch on how states administer the work requirements and may take corrective action if states step out of line.

That has doctors concerned about the potential repercussions if they incorrectly assess whether someone is too sick to work, as farfetched as those worries might be, said Rahul Vanjani, a primary care and addiction medicine physician and researcher at Brown University.

“We, using our imaginations, wonder if someone is auditing these forms in the background and if they’re going to reach out to the licensing board.”

The country is short of primary care providers, and it could be hard for people seeking an exemption to find a clinician to help them document that they’re too sick to work, doctors said.

It will be even more challenging for someone without insurance, said Jennifer Wagner, who researches Medicaid eligibility at the left-leaning Center on Budget and Policy Priorities.

“How could an applicant who doesn’t have health coverage get a doctor’s note?” she asked.

The American Medical Association, the nation’s largest professional association of doctors and medical students, lobbied federal officials to change the standard for documenting medical frailty in the days before the final regulations were made public.

In May, the AMA sent to Oz, the CMS administrator, arguing that forcing doctors to attest to their patients’ ability to work wouldn’t just be an administrative headache but would affect the way they interact with those in their care.

In a statement, the association’s president, Willie Underwood III, said the work rule “transforms the clinical encounter into an eligibility gatekeeping process.”

“Patients will likely sense that shift,” he said. “And if they begin to suspect that what they share with their physician could affect their coverage, the conditions for open and honest communication will start to break down.”

Doctors have a fixed amount of time to spend with patients and would rather focus on treating medical conditions than filling out forms, especially ones that put them in a position to “represent the state,” said John Ayanian, an internal medicine physician and researcher at the University of Michigan.

“Their first obligation is to serve the best interest of their patients,” Ayanian said.

Lauren Davis, an attorney with Community Legal Services of Philadelphia, helps clients navigate other public benefit programs, such as the Supplemental Nutrition Assistance Program, which has a similar work rule. Enrollees can get an exemption from it if they’re too sick to work.

She recalled a client with a cognitive condition that affected her memory. The client’s doctor wasn’t comfortable filling out an exemption form without seeing her in person, but she kept forgetting to make an appointment and eventually gave up, said Davis, who worries Medicaid enrollees could face similar barriers to getting exemptions.

“This person is eligible,” Davis said. “The reason that they’re not able to get what they need to show that they’re eligible is because of their medical condition.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The drug is now marketed and sold across the state in roadside shops and small-town strip malls with little oversight from health authorities. Highway billboards advertise ivermectin as “Available Without a Prescription in Tennessee!” while dozens of pharmacies offer highly concentrated pills, sometimes at 10 or 20 times the potency of a standard tablet.

Ivermectin is a approved by the FDA for treating , which can generally be done with a single dose of three or four prescription-strength tablets. It is also used as a dewormer for horses and other livestock.

Its popularity surged during the pandemic as fringe doctors and anti-vaccine activists promoted it as a treatment for covid. have shown that ivermectin is against covid.

Nonetheless, it has since become a symbol of resistance against the medical establishment among conservatives and followers of the Make America Healthy Again movement, championed by Health and Human Services Secretary Robert F. Kennedy Jr.

Timothy Caulfield, a professor at the University of Alberta who studies health misinformation, said ivermectin became an “ideological flag” during the covid pandemic, opening the door for influencers to push the drug for other ailments to a “captured audience” even without proof it works for those conditions.

“This is really about profit. This is about political identity. This is about creating distrust in the existing biomedical community. This is about money,” Caulfield said in an interview with ABC News, which partnered with ºÚÁϳԹÏÍø News to report on ivermectin.

After a hantavirus outbreak on a cruise ship earlier this year, unproven claims that ivermectin is effective against the virus have been spread by some popular social media accounts and right-wing figures, including former congresswoman . The World Health Organization says it has seen that shows ivermectin is an effective hantavirus treatment.

Tennessee’s ivermectin bill was shepherded by a Republican supermajority in 2022. Its passage blindsided state medical officials and handed a victory to medical groups that spread covid misinformation.

Some pharmacy websites now offer the drug as a treatment for covid, “long haul vax symptoms,” diabetes, or cancer — despite no evidence of its effectiveness for those purposes — while the largely gives pharmacists immunity from lawsuits or professional sanctions related to ivermectin.

The law was also a harbinger of legislation to come: More than two dozen states have since considered look-alike bills that would make the politicized medication available without a requiring a doctor visit. 

John Mafi, a UCLA internal medicine physician who has studied the rise of ivermectin among cancer patients, worries it will lure people away from proven treatments. He co-authored a new study in prescribing rates for ivermectin and another antiparasitic drug, particularly in the South. The rise followed a January 2025 episode of the Joe Rogan Experience podcast in which actor Mel Gibson claimed ivermectin and other drugs cured three friends with stage 4 cancer.

“It’s going back to 19th-century quack science,” Mafi said about off-label use of ivermectin. “It is alarming that I’m seeing this really unproven therapy being touted to so many potentially vulnerable Americans.”

The FDA says ivermectin can be . Tennessee has seen a small but concerning rise in signs of overuse. The Tennessee Poison Center, which fields calls from people exposed to drugs or toxic substances, received more than 60 calls for possible ivermectin poisoning in 2025, the most since 2021. They included reports of vomiting, blurred vision, neurological problems, and difficulty walking.

“People are taking this because they just feel unwell. It’s almost like a panacea now,” said Rebecca Bruccoleri, the poison center’s medical director. “I’ve heard rumblings on the internet of using ivermectin for an alternative cancer treatment, and we’re seeing it definitely in here.”

Pharmacist Paul Hughey has dispensed ivermectin under the new law at two Tennessee pharmacies: Mt. Juliet Pharmacy and Compound Rx. He estimated that “up to 20 people in a week” are buying ivermectin but that peak demand was double or triple that amount.

For years, Hughey said in an interview, customers have relayed emotional “testimonies” about the drug healing the sick, “especially with the cancer patients.”

“I’ll get a doctor call in and they say: ‘Guess what. So-and-so is cured.’ And it’s just amazing to hear that. So anybody who doubts that,” Hughey said, “I don’t really know that they’re practicing medicine. I think they’re just following the narrative.”

‘I’ve Taken Bucketloads of This Stuff’

The linchpin of Tennessee’s ivermectin market is , a conservative doctor to the creation of the 2022 ivermectin law. She has with pharmacies across the state empowering them to sell the drug.

Tennessee’s law to dispense ivermectin without a specific prescription for each patient, through a “collaborative pharmacy practice agreement” with a doctor who provides what is functionally a pre-written, nonspecific prescription for all potential customers.

In podcast interviews, Sibley has said she has made as many as 40 of these agreements with Tennessee pharmacies, which she said forward her the paperwork on each ivermectin customer. Before selling the drug, pharmacies are required to ask customers questions about medical conditions and medications that could cause complications if taken with ivermectin. Afterward, the collaborating physician also is expected to receive a record for each person who purchases ivermectin.

“We literally have folks coming from all over the world to get our ivermectin,” Sibley said on in February 2025. “As the collaborator for these pharmacies, I get every person’s sheet.”

“They’re from every state,” she said. “They’re from Canada. They’re from Europe.”

Sibley did not respond to requests for comment.

ºÚÁϳԹÏÍø News has independently confirmed that Sibley signed agreements with at least 10 pharmacies. The agreements say pharmacists shall dispense ivermectin only in Tennessee, where Sibley is licensed, although one of those pharmacies said friends and family in Tennessee can “.”

Hughey, the Tennessee pharmacist, said Sibley had prescribing agreements ready to go when the law was enacted. He credited her with advancing ivermectin sales throughout the state.

“Had Dr. Sibley not stepped in and really pushed forward, there’s no telling how hard it would have been,” Hughey said. “It would have been a lot less widespread.”

Sibley also works with Children’s Health Defense, the Kennedy-founded group that has become one of the nation’s most influential anti-vaccine organizations. In podcasts, Sibley has referred to the covid vaccine as a “” and “ that’s ever been produced.”

Separately, before Tennessee legislators in 2024 about an alleged plot to change the weather and block sunlight. The New York Times then included her .

Sibley has said in podcast interviews that she was told by God to treat covid patients. She said she has advocated for ivermectin ever since.

“God agrees with what I’m doing,” Sibley said in 2023 on the podcast , which is recorded in Nashville. “I wake up every day and I say: ‘Yes, sir. I’m reporting to duty.’”

In legislative and government hearings throughout 2022, Sibley testified that she had treated around 4,400 people with ivermectin, including some Tennessee lawmakers, all without taking payment. Sibley described ivermectin as “a wonder drug” and said making it more available “.”

“I’ve taken bucketloads of this stuff myself,” Sibley said . “I feel like I’ve been a good test subject.”

Sibley has said she dispenses ivermectin using treatment guidelines developed by Paul Marik, who in 2020 co-founded the Independent Medical Alliance, a medical group that has promoted ivermectin as an effective treatment for , , , and .

Some Tennessee pharmacies now follow those protocols, too. The protocols recommend patients take 1.5 to five times as much ivermectin as is normally prescribed to treat parasites, with the dose taken for days or weeks instead of just once.

Marik and other ivermectin proponents sued the FDA in 2022 after it discouraged the use of the drug for covid by tweeting: “You are not a horse. You are not a cow. Seriously, y’all. Stop it.” The agency settled the lawsuit with no admission of wrongdoing and deleted the viral tweet in 2024.

The American Board of Internal Medicine has revoked Sibley’s and Marik’s board certifications but declined to explain why. Sibley still holds a Tennessee medical license; Marik is based in Virginia and is not licensed. Sibley and Marik the internal medicine board’s actions.

In response to questions from ºÚÁϳԹÏÍø News, Marik, through an Independent Medical Alliance spokesperson, said medical science benefits from “open discussion of ideas and treatments.”

“Many independent doctors have reported that treatments like Ivermectin, in conjunction with traditional treatments, are showing promise. These ideas should be explored,” alliance spokesperson Lynne Kristensen said in an emailed statement.

Marik testified in favor of Tennessee’s ivermectin legislation in 2022, telling lawmakers that it is necessary because people would otherwise buy animal-grade ivermectin in stronger dosages meant for livestock.

“They’re buying ivermectin from farm stores. We don’t know the quality,” Marik said at a March 2022 legislative hearing on the Tennessee bill. “So this would prevent that from happening.”

Tennessee Does Not Track Its Ivermectin Market

Arkansas, Idaho, Louisiana, and Texas enacted similar laws in 2025, and legislation that makes ivermectin available without the need for a doctor visit has been introduced or debated in at least 24 other states, according to a ºÚÁϳԹÏÍø News analysis. That means half the country could be following Tennessee down an unlit path, because no one knows the full scope of its ivermectin market.

Tennessee does not effectively track which pharmacies offer ivermectin this way, and the state government has been unable to produce some foundational documents that pharmacies are legally required to file before they sell the drug, according to a ºÚÁϳԹÏÍø News investigation.

Doctors and pharmacies are the Tennessee Department of Health when they sign agreements that allow ivermectin to be dispensed without patient-specific prescriptions, although it is not clear whether this consistently occurs.

In response to a ºÚÁϳԹÏÍø News public records request for those ivermectin notifications filed by pharmacies, the agency over three months produced records from only 12 pharmacies, half of which have agreements with Sibley. The agency said it did not locate records related to at least 13 others that ºÚÁϳԹÏÍø News has identified as selling ivermectin without requiring individual prescriptions.

Department of Health spokesperson Dean Flener said the agency would not answer questions about whether or how it regulates ivermectin or the pharmacies that distribute it.

Tennessee has said it does not track how much of the drug is sold in the state, and the amount is not well captured by federal or insurance data sources. That’s because the drug is often sold at compounding pharmacies, which make customized medications that are not FDA-approved and rarely covered by insurance. Drugmakers and wholesalers did not respond to questions about how much ivermectin they supply to pharmacies in the state.

Even the Independent Medical Alliance, one of ivermectin’s , says it doesn’t know how much is flowing through Tennessee.

States are getting pressure from clinicians ”who have had success with the use of ivermectin,” said IMA President Joseph Varon, a physician based in Houston. “That’s what happened in Texas, and that’s what happened in Tennessee.”

‘An Unproven, Potentially Unsafe Drug’

Once signed by Tennessee Gov. Bill Lee, the state’s ivermectin law took effect immediately — even before the state’s physician and pharmacy licensing boards created rules to guide the process, which Tennessee law also requires. 

Some board members were shocked.

“We’re talking about an unproven, potentially unsafe drug,” Shant Garabedian, a doctor on the state’s Board of Osteopathic Examination, said of off-label ivermectin use during a . “It’s already law. Somehow it passes without our sort of input.”

In meetings that followed, at least five members of Tennessee’s medical boards voiced concerns about the law beyond safety and efficacy. Some said pharmacists could overcharge for a drug that normally costs pennies per pill. Some worried that a loosely regulated, cash-based ivermectin market might attract shady characters, especially because the law also shields prescribers from ivermectin-related civil lawsuits.

“This involves no clinical engagement,” Melanie Blake, then-president of the Board of Medical Examiners, said during a . “If they’re exempt from liability as well, I hate to think of things that individuals could do just to make money, but this would be one.” 

The boards eventually enacted regulations affirming that ivermectin could be dispensed without any diagnosis. Board members said the law left them no choice.

“This is more of a situation where, legally, the legislature has decided for us,” John McGraw, another board member, said in a . “This has sort of tied our hands in a lot of ways.”

The first known sale under the new law occurred in Sibley’s home of Johnson City, a city of about 74,000 people in northeastern Tennessee. According to a , Sibley entered into a collaborative agreement with pharmacist Josh Harrison at The Compounding Lab, which dispenses drugs for people and animals. 

The first customer was Bernadette Pajer, an anti-vaccine activist who has worked with Children’s Health Defense. In a of the Nashville podcast Rebunked With Scott Armstrong, Pajer said Sibley was a medical adviser for the group and described the first ivermectin sale.

“On that day, she was the doctor, he was the pharmacist making the sale, and I was the first customer,” Pajer said. “So that was pretty cool.”

Ivermectin pharmacies have spread across the state. In the suburbs of Nashville, Roman Pharmacy advertises ivermectin on at least four billboards along Interstate 65, and is mostly focused on the drug. Outside Knoxville, allows customers to order ivermectin for multiple sclerosis and Parkinson’s disease, or “to use it to detoxify.”

Roman Pharmacy did not respond to interview requests. Fresh Pharmacy declined an interview.

In Chattanooga, the Medicine Counter pharmacy says on its website that ivermectin should be taken “only as prescribed by your healthcare provider.” And yet the pharmacy sells some of Tennessee’s available without a prescription from a doctor — up to 21 times as strong as a standard tablet, for nearly $19 per pill — according to the ºÚÁϳԹÏÍø News analysis.

Himanshu Patel, Medicine Counter’s head pharmacist, declined to be interviewed. He said in an email that the pharmacy operates in a “very competitive market” and that its strongest pills were below the maximum dose for humans evaluated by the FDA for safety purposes.

And then there is Compound Rx, which, in addition to selling ivermectin in its store, has built a website in preparation to ship nationwide. The site, which is in “test mode,” cannot currently make any sales. It also asks customers how they heard about the pharmacy, with a dropdown menu of answers that features right-wing figures such as Donald Trump Jr., Steve Bannon, Laura Ingraham, and Kevin Sorbo.

Who is not listed as an option? Your doctor.

Hughey, the Compound Rx pharmacist, said he wasn’t involved with the website, which he said may never launch.

The highly concentrated pills are a concern for Tennessee state Sen. Richard Briggs, who worries lawmakers have created a “dangerous” ivermectin market rife with “misleading advertising” about what the drug can actually do.

Briggs, who is a surgeon and the only Republican who voted against the ivermectin bill in 2022, said he planned to introduce legislation to rein in the sale of ivermectin when lawmakers reconvene in 2027.

“But it may be a hard sell, because with the anti-vaxxers and some of these other folks,” Briggs said. “We don’t base a lot of things that we do on science, data, or facts. To a lot of folks in the legislature, the facts are just an inconvenience.”

‘Enough Trouble With Ivermectin’

Lawmakers in at least seven states have considered ivermectin legislation this year, including Alabama, Florida, Oklahoma, and South Carolina. If enacted, these bills would allow people to obtain ivermectin without an individual prescription, like in Tennessee, or make it available over the counter.

Kennedy praised such legislation at an event in Texas last August.

“I think it’s a really good bill,” he said of Texas’ ivermectin legislation, according to . “I think Americans should have the choice.”

But proponents have hit roadblocks. A Utah bill failed to advance out of the state House this year. In Oklahoma, some lawmakers have put up a fight.

“I’m a scientific person. I need to see some research and some data that shows what we’re treating,” Oklahoma state Rep. Cynthia Roe, a Republican and nurse practitioner who opposes the state’s ivermectin bill, said in an interview. “And God forbid somebody start giving it to their kid.”

Back in Tennessee, one of the medical boards that was alarmed when the law was enacted in 2022 started to distance itself from ivermectin altogether.

In January, the Board of Medical Examiners grappled with how to punish Ricky Lee Jackson, a doctor who was licensed in Tennessee and had been sanctioned and fined by Washington state’s medical commission. The Tennessee board normally mirrors punishments from other states without hesitation. But the Washington case centered on Jackson prescribing ivermectin for covid, which in Tennessee no longer required a patient to see a doctor.

After a debate, the board voted to reprimand Jackson — but told its staff to ensure the public record made .

“This board has been in enough trouble with ivermectin,” member Keith Anderson said, according to a . “Maybe we ought to just leave that out.”

journalist Blake Farmer and reporter Adam Friedman contributed to this report.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The health giant has rolled out a new suite of note-taking software, made by healthcare AI pioneer Abridge, intended to summarize a patient’s visit at supersonic speed. For many clinicians, the technology soothes one of the persistent headaches of their lives — administration and paperwork.

But the AI scribe caused another headache for Boyer and his colleagues: It is “not super useful.” They end up correcting the computer-written notes.

Abridge is “not good at picking up on clinical nuance, at picking up on the emotional tone” that can be critical in the mental health field, Boyer said. For example, for manic patients, what’s said is less important than how it’s said, Boyer said, and the software struggles with picking up on those cues.

Note-taking software isn’t the wave of the future; it’s the wave of the present. Hospitals nationwide are implementing it. And researchers are finding some benefits. A year after installation, doctors who used these products the most saved more than half an hour of work daily, according to published in April in the Journal of the American Medical Association.

Many doctors love the products where they’re deployed — several to the scribes.

Nevertheless, as Boyer’s example shows, there are persistent questions about the systems’ quality. While Boyer and his colleagues spend time correcting notes, safety researchers worry clinicians might not be diligent about catching errors. That might mean future doctors rely on bad information.

Abridge says it evaluates its scribes at every stage of deployment, including with head-to-head tests against previous versions of the software.

“Following deployment of a model, we monitor clinician edits, star ratings, and free-text feedback from clinician users about note quality,” the company’s director of applied science, Davis Liang, told ºÚÁϳԹÏÍø News in a statement.

Artificially intelligent scribe software is part of a swarm of AI-powered tools coming to healthcare. Clinicians and patient-safety advocates say government regulations are not well constructed to guard against the threat that the new technology will miss or obscure important details of patients’ conditions, potentially harming them.

“There is currently no safeguard in place” to vet scribe software at the federal level, said Raj Ratwani, a researcher specializing in human factors — that is, how people interact with technology — at MedStar Health, a large hospital system based in Columbia, Maryland.

Ratwani worries that safeguards on health software will relax even further. from the Office of the National Coordinator for Health IT — the body that regulates electronic health records, the central chronicle of care for patients — could weaken requirements to make medical records understandable, easy to use, and transparent about the use of AI, Ratwani said. And an incomprehensible record could confuse clinicians and lead to errors.

Beginning in the Obama administration, the Health and Human Services Department’s IT office , in which developers try their products on doctors and nurses. Regulators also sought to require more transparency from companies in the surging market in AI tools.

Both of those requirements are axed in the proposed rules from HHS Secretary Robert F. Kennedy Jr.’s health IT office.

Doctors and other health practitioners consult records for clinical information, such as scribe notes summarizing the history of patient care and lists of drugs and therapies their patients have used. Doctors also input orders for care.

Poor or cluttered design of a records system “might make the list of medications so complicated and confusing that the ordering provider selects the wrong medication,” Ratwani said.

Abridge’s general counsel, Tim Hwang, said the company “broadly supports” the government’s rules as a “necessary modernization” that “accommodates the speed at which AI is evolving.”

The old rules “put way too much burden” on electronic health record systems, said Ryan Howells, a principal at Leavitt Partners, which consults for digital health companies. Leavitt supports the proposals.

Dropping requirements, the administration argues, will result in more innovation and competition. The electronic health record market has steadily consolidated, with hospitals and other clinicians choosing from fewer vendors.

A 2022 study found the top two vendors, Epic and Oracle Health, of the hospital market. And Howells argued too many rules burdened providers looking for good record systems. Federal regulations, Howells said, are “the single biggest inhibitor to true clinical innovation.”

The Trump administration proposal to remove requirements governing records is overbroad, some critics say. It removes regulations intended to keep records secure. It also eliminates privacy protections for sensitive medical data they safeguard, overhauls standards governing the formats data is sent in, and more. The rule may give clinicians “more health IT choices to meet their needs through increased competition,” the government wrote in its proposal.

HHS’ health IT office declined comment, noting the proposal is still winding through the regulatory process. Public comment closed in February.

But most concerning to some — even in the hospital and developer sectors — are proposals to scotch prerequisites to ensure new products are tested on actual users, and to ensure AI tech’s decisions are transparent to doctors and nurses.

“Historically, hospitals and health systems have been challenged by the black box nature of certain AI tools and how the algorithms are developed,” the American Hospital Association’s Jennifer Holloman said. And with more AI tools flooding the market, the association , transparency is even more critical.

Complaints about the safety of electronic health records are long-standing, even for seemingly straightforward tasks. Ratwani likes the example of ordering medication for a given condition.

“The physician is trying to order Tylenol, and the medication list can be so confusing that there’s 30 different versions of Tylenol all at a different dose and for different purposes, when in reality that could be designed much more simply and make it easier for the physician to actually pick the right type of Tylenol that they’re ordering,” he said.

Real-world user testing was intended to simplify record design for doctors. But the administration is ending that requirement in a confusing way, said Leigh Burchell, vice president for policy and public affairs at Altera Digital Health, an EHR developer.

In Burchell’s interpretation of the rules, which refer to “enforcement discretion,” a principle in which the government can opt not to enforce certain rules, companies are still required to do the testing — the part that takes work — but are not mandated to report their results to the feds.

The administration is also ending a Biden-era idea to create AI transparency “model cards.” The concept was that clinicians could explore the data used to train AI tools that advise clinicians with a simple mouse click. But few took advantage of the year-old tool, Trump’s regulators say.

Still, hospitals and doctors are wary of removing it. The tool “provides information on how a predictive or generative AI application was designed, developed, tested, evaluated and should be used. These data are critical to foster trust in AI tools and ensure patient safety,” the AHA wrote in a comment letter to the HHS IT office. The American College of Physicians , saying a “lack of clarity could undermine clinician trust, increase liability expense, and erode the patient-physician relationship.”

Even developers aren’t totally sure about the idea. Burchell said the electronic health records trade group she’s part of had “a lot of different perspectives” on the issue. “Normally, we tend to be a bit more aligned on our responses.”

Still, Burchell’s group thought companies should be transparent about the data AI relies on to make decisions and how it comes up with recommendations.

Evidence for AI tools’ effectiveness or contradictory.

A comparing 11 AI scribes for potential use as a pilot in the Veterans Health Administration found the software performed worse than humans across five simulated scenarios. “Although ambient AI scribes can generate complete notes, the overall quality remains broadly below that of human-authored documentation,” the authors noted, with the omission of information being particularly concerning, given the potential to affect follow-up care.

The vendors in the VA study weren’t identified, for what the authors called “contractual reasons.”

And that’s just one type of AI tool. A wave of them is coming, each needing its own evaluation, to say nothing of tools that have already been installed.

Boyer said he can mostly ignore his AI scribe, for the moment. But he worries that management will design his job around the expected time savings and schedule more patients — meaning he’d need to spend more time both with patients and correcting the software’s errors.

A KP spokesperson, Vincent Staupe, said the company does not require its clinicians to use AI.

“When I am correcting that note, I feel like this is too much work,” Boyer said. “This is definitely making this worse, and this is taking up time that I need to not be spending on correcting an AI tool.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The waiver program, run by the Department of Health and Human Services, allows physicians who aren’t U.S. citizens to stay in the country while transitioning from the visa they used during their training to temporary worker status. In exchange, the doctors agree to work in underserved areas for at least three years.

“It will be the patients that suffer the most because in about three months, there’s going to be hundreds of places that are not going to have a physician that should have,” said a psychiatrist caught in the delay.

The doctor — whom ºÚÁϳԹÏÍø News agreed not to identify because they fear government reprisal — was among hundreds who applied this year for a J-1 visa waiver through the HHS Exchange Visitor Program.

If they receive one, the psychiatrist — who attended medical school in their home country in Europe before coming to the U.S. for their residency and fellowship — would work with vulnerable and disadvantaged patients in New York.

In recent years, the HHS program reviewed waiver applications in one to three weeks, according to two immigration attorneys.

But it currently has a backlog of hundreds of applications, which still need to be reviewed by the State Department and approved by U.S. Citizenship and Immigration Services, according to four attorneys interviewed by ºÚÁϳԹÏÍø News.

They said the foreign physicians will likely have to return to their home countries if their applications don’t advance to USCIS by July 30.

For them to reenter the U.S., their employers would have to pay a new $100,000 fee associated with the H-1B work visa. It’s a cost that many hospitals and clinics in rural and underserved areas say they can’t afford. “That’s the cliff that this train is headed for,” said Charles Wintersteen, a Chicago-based attorney who specializes in health workforce-related immigration.

HHS spokesperson Emily Hilliard didn’t answer questions about the number of pending applications or explain what caused the delays. But she said the Exchange Visitor Program has reviewed all fiscal year 2025 clinical J-1 waiver applications, as well as some from fiscal 2026.

The department is “implementing key process improvements to prevent future delays” and “working diligently” to evaluate remaining applications ahead of the July 30 deadline, she said.

The psychiatrist in limbo said employers hiring J-1 waiver physicians have to show they were unable to fill positions with American workers. If the doctors they planned to hire can’t arrive on time — or at all — patients will have to wait even longer for those vacancies to be filled, they said.

Wintersteen said postgraduate medical education positions are largely funded through Medicare and that “the taxpayers who pay for that training will not get the benefit of it.”

Physicians and immigration attorneys said HHS hasn’t explained the delays or let them know what to expect from their applications.

“Why would HHS want to take a program that is working — a program that places hundreds of U.S. trained international physicians in highly underserved parts of the country every year — and slow-walk it into non-existence,” Jennifer Minear, a Virginia-based health workforce immigration lawyer, said in an email. “How does that serve the public health? It is baffling.”

Waylaid Waivers

The U.S. healthcare system depends on foreign-born professionals to fill its ranks of doctors, nurses, technicians, and other health providers, particularly in chronically understaffed facilities in rural and low-income urban communities.

Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to .

Once noncitizens complete postgraduate education in the U.S., which typically ends on June 30, they must return to their home country and wait two years before applying for an H-1B work visa. Or, they can seek , which lets them remain in the U.S. on H-1B status in exchange for working for three years in a provider shortage area.

The attorneys said they’re seeing delays only in the Exchange Visitor Program, not in the other federal or state J-1 waiver programs.

The HHS clinical care program received 750 waiver applications last year, Minear and Wintersteen said, and is reserved for doctors working in pediatrics, psychiatry, family and internal medicine, or obstetrics and gynecology.

The program typically needs to forward recommendations to the State Department by mid-March, from John Whyte, CEO of the American Medical Association.

Minear said HHS stopped processing applications in late September or early October before it started forwarding them again a few months ago.

“But the pace is dramatically slower” than usual, she said.

Minear said the State Department usually takes two or three months to review HHS recommendations and must send them to USCIS before July 30 for most of the doctors to stay in the country.

If they don’t make that deadline, Wintersteen said, doctors will have to leave the country unless they obtain another kind of visa, get a J-1 waiver through another program, or extend their current visa by taking board exams or doing additional training.

The psychiatrist, who is supposed to start work on July 1, said they applied for a waiver in order to stay in the U.S with their partner, and because it would let them help the most vulnerable mental health patients. They said their future clients would likely include trafficking survivors, homeless people, and prison or jail inmates. “That’s the population I want to work with,” they said.

Waiver Delay Meets H-1B Dilemma

President Donald Trump issued a that railed against the tech industry’s use of H-1B work visas. The order created the $100,000 fee that applies to workers in all fields — not only tech — living outside the U.S. The payment doesn’t apply to those already in the country.

As of Feb. 15, employers had paid the fee for 85 workers, from USCIS. It’s unclear if any of those payments were for physicians or other medical providers.

The psychiatrist said officials at the hospital that plans to hire them said they can’t afford to pay to bring them back to the U.S. if they must go home.

“A lot of hospitals who hire J-1 waiver physicians are in underserved areas, and so they treat Medicare and Medicaid patients,” they said. “By definition, for the most part, they’re not rich hospitals.”

Barry Walker, an attorney in Tupelo, Mississippi, focused on health workforce-related immigration, said employers have already spent money on recruiters and attorneys like him to help with the waiver process.

Adding the H-1B fee is “just a deal killer, especially for the small, rural hospitals,” he said.

Attorneys said most employers will sponsor physicians in need of an H-1B visa only if they’re in lucrative specialties, such as cardiology or orthopedics, in which they can recover the cost of the fee.

They said healthcare facilities are much less likely to pay the fee to hire foreign nurses, lab technicians, and other healthcare professionals who are more likely than physicians to complete their training outside the U.S.

Employers , but attorneys said they haven’t heard of a hospital or clinic being granted one.

Fighting on Two Fronts

Physicians, hospital leaders, lawmakers, and immigration experts are trying to draw attention to the J-1 waiver delays at HHS while hoping to overturn or limit the new H-1B fee.

The Trump administration hasn’t acted on letters from , , and that requested an exception to the $100,000 fee for physicians or all healthcare workers.

In March, a bipartisan group of lawmakers that would create a healthcare exemption. It has not yet had a hearing.

At least three lawsuits — from the , a , and a that includes a company that recruits foreign nurses and a union that represents medical graduates — are seeking to end the fee entirely.

As for the J-1 waiver delays, the American Medical Association CEO asked the Exchange Visitor Program to use “emergency batch processing” for physicians with contracts to start work this summer.

Efrén Manjarrez, president of the Society of Hospital Medicine, which represents doctors who work in inpatient units, also called for emergency measures.

“Every day this backlog persists is a day that hospitalized patients in these communities face greater risk,” to the program.

Meanwhile, Canadian hospitals have been recruiting foreign physicians completing their training in the U.S, the psychiatrist said. They said one of their friends accepted an offer, withdrawing their HHS waiver application to head north.

The psychiatrist said if they must leave the U.S., they’ll be separated from their partner and out of a job for months as they work to get licensed in their home country.

Even if their employer were able to afford the H-1B fee, they’re not sure they’d want to return.

“This entire process has been so incredibly painful and just soul-crushing,” they said. “I would rather go to a country that would appreciate my motivation to work with patients.”

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One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.

Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.

It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.

Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician . Rates are outlined in the group’s contracts with insurance providers.

“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many are banding together to form or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.

Threats to Physician Autonomy

Primary care practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges of up to 86,000 primary care doctors by 2036, as more primary care doctors retire and fewer enter the field.

The number of people who can’t find a primary care doctor has grown by 20% in the past decade, according to a .

Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.

The released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”

By contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group announced it would be . Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of , an independent health care consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”

The , a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said , a vice president at AAFP.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.

“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said , a vice president with .

A Different Payment Model

When those independent practices band together, Glenn said, Blue Cross can offer . Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.

Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.

If there is money left at the end of the year, it’s split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.

IPAs Can Help, Depending on Who’s in Charge

But IPAs are not a panacea for primary care’s problems, according to some health care leaders.

There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.

The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.

“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.

Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.

“It doesn’t happen overnight, and it does take an investment,” she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.

This article is from a partnership with and .

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ºÚÁϳԹÏÍø News senior correspondent Renuka Rayasam discussed excited delirium on Vox Media Podcast Network’s Criminal on March 6.

• Read Rayasam’s “As More States Target Disavowed ‘Excited Delirium’ Diagnosis, Police Groups Push Back.“

On CBS News’ CBS Mornings on March 5, Céline Gounder, ºÚÁϳԹÏÍø News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

ºÚÁϳԹÏÍø News California correspondent Christine Mai-Duc discussed Affordable Care Act premium increases on CapRadio’s Insight With Vicki Gonzalez on March 2.

• Read Mai-Duc’s “‘Kind of Morbid’: Health Premiums Threaten Their Nest Egg. A Terminal Diagnosis May Spare It.“

ºÚÁϳԹÏÍø News rural health reporter Andrew Jones discussed how younger doctors are struggling to diagnose measles on KMOX’s Total Information AM on Feb. 27.

• Read Jones’ “Hospitals Fighting Measles Confront a Challenge: Few Doctors Have Seen It Before.”

ºÚÁϳԹÏÍø News South Dakota correspondent Arielle Zionts discussed the $50 billion Rural Health Transformation Program on Marketplace’s Make Me Smart podcast on Feb. 19.

• Read Zionts’ “States Race To Launch Rural Health Transformation Plans,” co-reported with Sarah Jane Tribble and Maia Rosenfeld.

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Listen: More than 2 million Americans could benefit from PrEP, but only about a quarter of them are getting the HIV prevention medication. On Feb. 4, during WAMU’s “Health Hub,” ºÚÁϳԹÏÍø News reporter Zach Dyer shared tips for overcoming common hurdles to care.

Billing mistakes. Stigma. Doctors who aren’t keeping up with the latest research. Those are just some of the hurdles that for many Americans.

The Centers for Disease Control and Prevention estimates more than 2 million Americans could benefit from a treatment known as PrEP, but only a quarter of them are getting a form of the drug. Zach Dyer appeared on WAMU’s “Health Hub” on Feb. 4 to share tips patients can use to avoid those pitfalls and find a doctor who knows more about PrEP.

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During procedures, he seemed “hesitant, not sure of how to go on to the next step without being prompted” by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.

The chief of surgery, concerned about the doctor’s cognition, “would not sign off on his credentials to practice surgery unless he went through an evaluation,” Katlic said.

Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon “did not come of his own accord,” Katlic recalled.

But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist’s report advised that the surgeon’s difficulties were “likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.”

That didn’t mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. “He retained a lifetime of knowledge that had not been impacted by cognitive changes,” Katlic said. The hospital “took him out of the OR, but he continued to see patients in the clinic.”

Such incidents are likely to become more common as America’s physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.

Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.

Yet researchers have documented “a starting in their mid-60s,” said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.

At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. “Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,” Gallagher said.

A few health organizations have responded by establishing mandating that older doctors be screened for cognitive and physical deficits.

UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor’s practice or privileges.

Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.

Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute “a vast minority,” he said.

The number may actually have shrunk. A federal lawsuit, along with the profession’s lingering reluctance, appears to have put the effort to regularly assess older doctors’ abilities in limbo.

Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.

It’s fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that “‘I’ll know when it’s time to stand down,’” said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. “It turns out not to be true.”

When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, .

That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, that were likely to impair their ability to practice medicine independently,” a study reported.

Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.

“I thought as we got the word out nationally, this would be something we could encourage across the country,” Orlando said, noting that Hartford’s program cost only $50,000 to $60,000 a year.

Instead, he has seen “zero progress” in recent years. “Probably we’ve gone backward,” he said.

A key reason: In 2020, the federal over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital’s late-career program.

But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children’s Hospital in Corpus Christi, Texas, while few new ones have emerged.

“It made lots of organizations uncomfortable about sticking their necks out,” Gallagher said.

Instituting later-career programs has always been an uphill effort. “Doctors don’t like to be regulated,” Katlic acknowledged. Late-career programs have “in some cases been very controversial, and they’ve been blocked by influential physicians,” he said.

As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.

“Neither works very well at all,” Gallagher said. “Physicians are hesitant to share their concerns about their colleagues,” which can involve “challenging power dynamics.”

As for voluntary evaluation, since cognitive decline can affect doctors’ (or anyone’s) self-awareness, “they’re the last to know that they’re not themselves,” he added.

In a recent , Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.

“How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?” he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.

“There are all sorts of accommodations” for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.

Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.

The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.

Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending “the people who have the courage to speak up.”

“If you see something, say something,” he continued, referring to health care professionals who witness doctors (of any age) faltering. “We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’”

The New Old Age is produced through a partnership with .

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MacDonald wanted to find a new doctor right away. She needed refills for her blood pressure medications and wanted to book a follow-up appointment after a breast cancer scare. 

She called 10 primary care practices near her home in Westwood, Massachusetts. None of the doctors, nurse practitioners, or physician assistants was taking new patients. A few offices told her that a doctor could see her in a year and a half or two years.

“I was just shocked by that, because we live in Boston and we’re supposed to have this great medical care,” said MacDonald, who is in her late 40s and has private health insurance. “I couldn’t get my mind around the fact that we didn’t have any doctors.”

The shortage of primary care providers is a , but it’s particularly acute in Massachusetts. The state’s primary care workforce is shrinking faster than in most states, according to a .

Some health networks, including the state’s largest hospital chain, , are turning to artificial intelligence for solutions.

In September, right when MacDonald was running out of blood pressure medications, MGB launched a new AI-supported program, . MacDonald had received a letter from MGB, telling her no primary care providers in the network were taking new patients for in-person care. At the bottom of the letter was a link to Care Connect.

MacDonald downloaded the app and requested a telehealth appointment with a doctor. She then spent about 10 minutes chatting with an AI agent about why she wanted to see a physician. Afterward, the AI tool sent a summary of the chat to a primary care doctor who could see MacDonald by video.

“I think I got an appointment the next day or two days later,” she said. “It was just such a difference from being told I had to wait two years.”

Round-the-Clock Convenience

MGB says the AI tool can handle patients seeking care for colds, nausea, rashes, sprains, and other common urgent care requests, as well as mild to moderate mental health concerns and issues related to chronic diseases. After the patient types in a description of the symptoms or problem, the AI tool sends a doctor a suggested diagnosis and treatment plan.

Care Connect employs 12 physicians to work with the AI. They log in remotely from around the U.S., and patients can get help round-the-clock, seven days a week.

Care Connect is one of many AI-based tools that hospitals, doctors, and administrative staff are testing for a range of routine medical tasks, including note-taking, reviewing diagnostic results, billing, and ordering supplies.

Proponents argue that these AI programs can help relieve staff burnout and worker shortages by reducing time spent on medical records, referrals, and other administrative tasks. But there’s debate about and to use AI to improve diagnoses. Critics worry that AI agents miss important details about overlapping medical conditions.

Critics also point out that AI tools can’t assess whether patients can afford follow-up care or get to that appointment. They have no insight into family dynamics or caretaking needs, things that primary physicians come to understand through long-term personal relationships.

Since her first foray on the app in September, MacDonald has used Care Connect at least three more times. Two of those interactions led to an eventual conversation with a remote doctor, but when she went online to book an appointment for travel-related shots, she interacted only with the AI chatbot before visiting the travel clinic.

MacDonald likes the convenience.

“I don’t have to leave work,” she said. “And I gained some peace of mind, knowing that I have a plan between now and me finding another in-person doctor.”

So while she hunted for that person, MacDonald planned to stay with Care Connect.

“This is a logical solution in the short term,” MacDonald said. “At the end of the day, it’s the patient who’s feeling the aftermath of all of the bigger things going on in health care.”

Scarcity and Burnout

Many factors contribute to the shortage of providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay. They earn about , on average, than specialists such as surgeons, cardiologists, and anesthesiologists. 

At the same time, their workload has been increasing. Primary care doctors days packed with complex patient visits, followed by evenings spent updating medical records and responding to patient messages.

When MacDonald signed onto Care Connect, she was one of 15,000 patients in the Mass General Brigham system without a primary care provider. That number has grown as primary care doctors have left MGB for rival hospital networks.

, a primary care physician at an MGB health center in Chelsea, Massachusetts, said she’s staying at MGB for now, but she’s grown frustrated with the system’s leaders.

“They don’t make any effort to ease the shortage,” said Rao, who is also part of an MBG’s primary care doctors. “They put their money into specialties. Primary care feels like a peripheral part of the system, when it really should be a central part.”

Last year, MGB pledged to spend $400 million over five years on primary care services — though that includes the multiyear contract with Care Connect.

“Care Connect is just one solution among many in this broader strategy to alleviate the primary care capacity crisis,” , MGB’s chief operating officer, said in an emailed statement. “Our investment supports retaining our current physicians as well as recruiting new ones.”

Walls said MGB has increased staffing support for primary care physicians, implemented other AI tools, and hired a new executive for primary care. Some of these changes are based on recommendations from their own primary care doctors.

But some of those doctors say they would like other changes, and salary increases in particular.

Walls would not disclose the exact amount MGB is spending on Care Connect.

Bridge to Better Care or a ‘Band-Aid’?

MGB has rolled out other AI tools, including one that can transcribe a doctor’s in-person conversations with patients. Rao isn’t using that tool. She worries that patient information could be leaked and medical privacy violated, and she doesn’t want her conversations with patients to be used to help develop the next generation of AI medical tools.

“What if they’re just using my interactions with patients to train their AI and boot me out of my job?” she said.

That’s not the goal, said , a primary care physician who manages the program for MGB. All decisions about patient care are still made by real doctors, she said.

“We are not replacing our in-person primary care,” she said. “It’s still important, and the majority of patients still have in-person primary care.”

But the fear among some primary care doctors at MGB is that Care Connect will gradually erode access to in-person primary care visits. Of the $400 million pledged by MGB for primary care, they want less spent on AI and more used to attract and increase pay for primary care staffers.

, an MGB internist who is also involved in the unionizing effort, said the use of Care Connect can only fill a gap. “That sounds like a band-aid for a broken system to me,” he said.

Expanding AI Tools

As of mid-December, the Care Connect doctors were each seeing 40 to 50 patients a day. By February, the MGB network plans to make Care Connect available to all Massachusetts and New Hampshire residents who have health insurance, and to hire more doctors to staff the program as needed. 

Patients can use the program like an urgent care service, Ireland said. They can also decide to make one of the remote doctors their permanent primary care provider.

“Some patients want in-person care,” Ireland said. “But I do believe there’s a subset of patients who will appreciate the 24-hour, seven-day-a-week model and choose to be a part of this.”

Care Connect isn’t for patients who need emergency care or a physical exam, she said. And patients who need tests or imaging are referred to the network’s clinics or labs.

But the remote doctors can manage some of the same routine issues that all primary care doctors do, Ireland said, including moderate respiratory infections, allergies, and chronic conditions such as diabetes, high cholesterol, and depression. 

says only immediate, not ongoing, health problems should be on that list. Lin is chief of primary care at the Stanford University School of Medicine and founded Stanford’s Healthcare AI Applied Research Team.

“In its current state, the safest use of this tool is for more urgent care issues,” Lin said. “Your upper respiratory tract infections. Your urinary tract infections. Your musculoskeletal injuries. Your rashes.”

For patients with multiple chronic conditions such as high blood pressure and diabetes — or for patients with especially serious conditions like heart disease or cancer — Lin said nothing beats a human who sees you regularly.

Still, Lin agrees that the chat summary generated after an AI encounter can help a physician be more efficient. For patients, Lin understands the practical appeal of a virtual option.

“I would rather these patients get care, if that care can be safe,” he said, “than not get care at all.”

The company that developed the AI platform for Care Connect, , contends the program is delivering safe, effective care to patients with complex, chronic ailments — many of whom have no other option besides a hospital emergency room.

“America’s got a big problem with health care, issues with cost, quality, and access,” said , the company’s CEO. “To solve it, you need to start with primary care, and you have to use technology and AI.”

In addition to Mass General Brigham, K Health partners with five other health networks, including the highly ranked and Los Angeles-based .

In a funded by K Health, Cedars-Sinai researchers compared several hundred diagnosis and treatment recommendations made by AI with those made by physicians.

The researchers found the AI to be slightly better at identifying “critical red flags” and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient.

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Instead of typing on her computer keyboard during the exam, Urban’s primary care physician at the practice in Media, Pennsylvania, had an ambient artificial intelligence scribe take notes. At the end of the 30-minute visit, Urban’s doctor showed her the AI summary of the appointment, neatly organized into sections for her medical history, the physical exam findings, and an assessment and treatment plan for her rheumatoid arthritis and hot flashes, among other details.

The clinical note, which Urban could also review on the patient portal at home, was incredibly thorough, she said. It summarized all of her questions and concerns and the doctor’s responses. The scribe “made sure we didn’t miss anything,” Urban said.

Ambient AI scribes are being hailed by physicians as a game changer that helps free them to focus on their patients rather than their computer keyboard. By releasing doctors from the onerous and time-consuming task of documenting what happens during every patient encounter, , AI scribes may help reduce physician burnout and after-hours “pajama time” catching up on work in the evening.

The potential of AI to transform every aspect of the health care system — from patient care to clinical efficiency to medical innovation — is an area of intense focus, including by the Trump administration.

Last January, President Donald Trump issued an to remove barriers to American leadership in AI. Later in the year, a from the federal Department of Health and Human Services invited stakeholders to weigh in on how the department can accelerate the adoption of AI in health care.

Several startup vendors in recent years have introduced ambient AI scribe products that can be integrated into electronic health records. EHR market leader Epic is technology, which it expects to release widely early this year, according to , a family medicine physician who is chief medical officer and vice president of clinical informatics at Epic.

Health tech experts estimate that a third of providers have access to ambient AI scribe technology. As adoption looks likely to grow rapidly over the next few years, many expect it to become more of a recruiting tool, a minimum requirement for incoming clinicians, who are increasingly prioritizing work-life balance.

“It’s part of keeping doctors happy,” said , a professor and the chair of the Department of Medicine at the University of California-San Francisco, whose forthcoming book, , explores how AI is transforming health care. “Health systems that initially might have done a hard-nosed return-on-investment calculation — many are softening on that and realizing that the cost of recruiting and retaining doctors is pretty high.”

But many questions remain. Does the use of ambient AI scribes improve patient care and health outcomes? Will doctors use time they gain by employing an AI scribe to improve the quality of the time they spend with their patients or just boost the number of patients they see? To what extent will expanding the amount of detail available from a patient visit lead to bigger bills if the AI scribe is integrated with a coding app that optimizes provider charges?

For now, these questions remain mostly unanswered.

Urban said that the AI scribe didn’t change her experience as a patient very much. Typically, after a patient gives verbal permission, the AI scribe records the visit on a phone and organizes the conversation into the structure of a clinical note, filtering out small talk that isn’t pertinent to the medical visit but incorporating relevant details about a family member’s recent cancer diagnosis, for example. The scribe’s note is often then integrated into the provider’s EHR. The doctor later reviews the note and signs off on it.

Even though the visit may not feel very different to patients, some clinicians report that ambient AI scribes are changing patient encounters in unanticipated ways.

“Now, when I’m doing a physical exam, I have to say what I’m doing and what I’m finding out loud in order for the AI scribe to document it,” said , Urban’s primary care doctor. “People find that very interesting,” she said.

When Capalongo places her stethoscope over the carotid artery under a patient’s jaw, for example, she might say that she doesn’t hear a “bruit,” or vascular murmur, whose presence could indicate atherosclerosis. Patients have told her, “I never knew why a doctor would listen there,” she said.

Saying things out loud for the AI scribe that would typically appear only in a clinical note can create its own set of challenges, particularly during sensitive physical exams. Doctors may feel it’s important to adjust their conversation accordingly.

“Sometimes patients are anxious and scared and my saying things that they don’t understand or they may worry about during an uncomfortable examination does not help the situation and honestly is insensitive to what the patient is going through,” said , a professor in the Division of Colon and Rectal Surgery at the University of Minnesota, who is also chief health informatics and AI officer at Fairview Health Services in Minneapolis. “I’ll keep that top of mind and make sure I record it” after the visit.

“How we have conversations with patients about these tools is really important, in particular for maintaining trust and ensuring accurate information,” Melton-Meaux said.

Studies have found that, across a range of measures such as completeness, timeliness, and coherence, the notes created by ambient AI scribes are generally at least as good as, and sometimes better than, traditional documentation, said , a pediatrician who is vice president for applied informatics at the University of Pennsylvania Health System.

An ongoing concern is around AI “hallucinations,” in which false, sometimes fabricated information appears in an AI output.

Kaiser Permanente, an of ambient AI scribe technology, provides it to more than 25,000 doctors, advanced practice providers, and pharmacists systemwide. It has found hallucinations to be “quite rare,” said , an internist who is vice president of AI and emerging technologies at KP.

But they happen. An AI-scribe-generated note, for instance, might say that the doctor planned to refer someone to a neurologist or to follow up in two weeks. The problem? The doctor might not have said that.

“The technology is not perfect, and that’s why physicians are reviewing it,” Yang said. It’s learning from regular physician visits as it goes, he said. That’s why having a person check the work product is critical.

Still, even such a “human-in-the loop” system is fraught, Wachter said. “Humans stink at maintaining vigilance over time,” he said.

As the use of ambient AI scribes becomes routine, some clinicians worry that the technology will widen the divide between health care haves and have-nots.

Large health systems are able to move forward with the technology, Melton-Meaux said. But what about critical access hospitals or small private practices? “There need to be more resources,” she said.

Physicians’ enthusiasm for ambient AI scribes stands in sharp contrast to their negative reaction to electronic health record systems that have become widely adopted in recent years to replace paper charts.

“During the last 10 years, when EHRs became a thing, we all became very grumpy, overworked data scribes,” Wachter said.

The introduction of AI scribes makes physicians feel like technology is working for them rather than the other way around, health care AI experts said.

And AI scribes are “training wheels” for more consequential adoption of AI in health care, Wachter said.

To improve health care value and save costs, Wachter said, we need a system that makes it more likely that physicians will practice evidence-based medicine to order the right tests and prescribe the right medications.

“It’s a few years away, but it’s all AI-dependent,” he said.

Epic has introduced roughly 60 AI use cases for patients, clinicians, and administration, with over 100 more in the works.

“It’s so much bigger than a scribe,” said Epic’s Gerhart. “It’s literally listening and acting in a way that tees things up for me so that I can take action.”

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