Tuesday, September 23, 2014

The shortage of doctors in rural areas and medical schools’ attempt to fill this gap

The United States has a serious shortage of doctors, and rural areas are hit harder than most places. According to the U.S. Department of Health and Human Services, there are 6,100 federally designated health professional shortage areas in the United States. Urban areas have approximately 84 primary care doctors per 100,000 people. However, rural areas have only 68 primary care doctors per 100,000 people. To put these numbers into perspective, approximately 20% of the population lives in rural areas, while only 9% of doctors practice there. The future looks even bleaker; the Association of American Medical Colleges warned that by 2020, the United States will have a shortfall of 45,000 primary care physicians and 46,000 surgeons and medical specialists.

If medical school applicants are increasing, then why is the severe shortage of doctors in rural areas? Dr. Howard Rabinowitz, professor of family and community medicine at Thomas Jefferson University's Medical College, has studied this issue for over 30 years and cites several reasons. For current doctors, commonly cited reasons for leaving rural areas include insufficient insurance payments, administrative hassles regarding insurance claims, and rising business and malpractice insurance expenses. Additionally, fewer people from rural areas are applying to medical schools, and approximately half of the students from rural areas want to practice in metropolitan areas instead of returning to their rural communities.
When a rural area loses a doctor, the consequences can be particularly problematic for the community because that doctor may be the only one around within an hour (or more!) drive. For a family, that means not only time spent driving to the doctor, but also the gas expense and lost wages if one must take time off of work to go to the doctor. 

Medicare and medical schools have taken steps to try to control the shortage. Medicare gives a 10% bonus to doctors who serve communities with physician shortages. From 2011-2015, these doctors are eligible for additional bonuses depending on the type of care they provide. Medical schools are thinking even more proactively by influencing students during the educational stages of becoming a doctor. For example, the University of Missouri School of Medicine’s Rural Track Pipeline Program targets students who want to practice in rural areas and offers repeat exposure to these areas. More than 450 medical students have participated in the program, and more than 57% of students practice in rural areas both inside and outside Missouri. The University of Colorado School of Medicine’s Rural Track program helps students understand the benefits of practicing medicine in a rural environment. Applicants are up from 62 in 2006 to 190 in 2010. Lastly, Kansas, a state that has five counties without any doctors, opened a medical school devoted to rural medicine. (See this blog post on the University of Kansas and this blog post describing other similar programs).

Medical schools’ rural track programs offer a better solution by developing students’ interest in rural areas early on. Research shows that only 3-4% of medical school graduates plan to practice in rural areas, while schools with rural track programs, such as University of Missouri School of Medicine, show more than 50% of matriculates work in rural areas. This outcome is quite promising.

Will legislative and medical school efforts be enough? For current doctors, especially those with families, the bonuses may not be enough to draw them to a rural area. Uprooting a family often means the spouse finding another job, children having to start new schools, and leaving family and friends – essentially leaving an established life. For many, moving to a rural area may not be worth the effort. Additionally, many of these doctors likely did their residency in metropolitan area hospitals and became accustomed to certain aspects of urban areas, such as more extensive cultural or educational opportunities. Arguably, medical schools' rural track programs offer a better solution by beginning students on a rural track before residency. Although the current number of rural track programs is limited, hopefully other medical schools begin to adopt this idea so we can begin solving a problem before it's too late.


Charlie said...

I grew up in Vancouver, and as such, I have family up there. My cousin used to date a girl who went to medical school at the University of British Columbia. The province of British Columbia has a population of about 4.61 million; half of which lives in the Greater Vancouver area, and the other half is scattered throughout over 364,000 square miles (about 2.2 times the size of California).

Because a significant portion of the population lives in rural areas, access to medical care is an issue, even in a jurisdiction where there is universal healthcare. However, as part of their curriculum, medical students are required to undertake their residency in a rural area for a period of time.

Enrique Fernandez said...

Very interesting topic. I spent some time in rural Iowa and when I arrived, one of the first things I was told by locals was, "Don't get hurt or sick while you're here, but if you do, don't go to the hospital here. You'll be worse off, if you do." Which made me think that the quality of doctors are not as great as they might be in Des Moines or a state like California. It would be interesting to know the percentage of successful malpractice claims filed against doctors in rural areas as compared to doctors practicing the same type of medicine in urban areas. I'm not sure if such information would provide much insight to the quality of medical care, but it would be interesting to know how they compare.

Desi Fairly said...

Two comments:

1. The H1B non-immigrant visa has a provision for foreign medical students to work in the US. The visa has the potential to provide rural areas with more doctors, however there is no requirement as to where the non-citizen must work. Furthermore, there is a 6 year time limit to work under the H1B. Helpful legislation might provide for an additional time extension on the 6 year limit for doctors who practice in designated rural areas. This would avoid the problem that most doctors do not want to uproot and more to rural areas; immigrating non-citizens are already uprooting to come to the country.

2. As a "tip my hat" to King Hall, I think it's great that the law school encourages its public interest students to practice in rural areas. Hopefully this will help alleviate the lack of lawyers in rural areas.

Juliana said...

Part of the problem this article references is that many doctors don't want to practice in rural areas. I think part of this has to do with less prestige, less room for specialization, and less technological resources available. This make's me think Enrique's comment might hold some truth -- the doctor's that do go to rural areas aren't always the best in their field. So I think the issue becomes not only attracting doctors, but quality healthcare in general. And doctor's might only be one part of the problem.

David Gomez said...

I was thinking of writing on this exact topic. In my wife's hometown, which is semi-rural, the only hospital and emergency care facility closed recently. There is still a large opposition in the community. Many homes still display placards that read "save our hospital." People in town are concerned for the elderly citizens because they have transportation issues and require medical services more frequently.

Ahva said...

I definitely agree that incentives like the ones mentioned in this blog post need to be provided in order to encourage medical students to practice medicine in rural areas. Another factor that may exacerbate the shortage of physicians in rural areas in the near future is the fact that many doctors nationwide are in their fifties, and doctors tend to retire earlier than the rest of the workforce. Once this older cohort of physicians retires, the physician shortage will become even worse, making it all the more important for states and medical schools to be proactive in incentivizing doctors to work in rural areas.