Emergency departments in some rural areas don't have 24/7 on-site physician coverage

A hospital in Ekalaka, Mont., sits at the intersection of two dirt roads. 
(Photo by Arielle Zionts, KFF Health News) 

Many rural emergency rooms are no longer run by attending physicians, but instead depend on care by nurse practitioners and physician assistants. "A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7," reports Arielle Zionts for KFF Health News. "More than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals."

The 2022 report represents "82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government," Zionts writes. "The study is the first of its kind, so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School."

The idea of an emergency department without a doctor on staff remains controversial, and not all states allow it. "Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them," Zionts explains. Indiana, Virginia, and South Carolina have passed laws that require all their EDs to have a 24/7 physician on-site.

Even when states require their EDs to staff a round-the-clock doctor, that doesn't make finding one easy. "In the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing," Zionts reports. In response to the regional shortage, Sioux Falls-based Sanford Health launched an emergency medicine residency to help increase its ED physician numbers.

Some rural health advocates say lawmakers need to be sure that employing full-time ED physicians 24/7 is feasible for their region before passing legislation that requires it. Zionts adds, "Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it."

New doctors are avoiding abortion ban states, new analysis shows. Restrictions may add to mutiple-care shortages.

Fewer new doctors are applying for residency in
abortion ban states. (Hush Naidoo Jade photo, Unsplash)

States with significant restrictions or bans on  abortions may be inadvertently discouraging graduating medical students from applying for residency in their state, which could exacerbate regional physician shortages. Julie Rovner and Rachana Pradhan of KFF Health News report, "According to new statistics from the Association of American Medical Colleges, for the second year in a row, students graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions."

State battles over abortion aren't limited to uncertainties for doctors and pregnant patients; the tensions have "also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers," Rovner and Pradhan write. "Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. . . . A preliminary review of a new analysis by the AAMC found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal."

The AAMC's analysis shows that when new doctors start avoiding certain states, those states gain fewer doctors, which adds to regional physician shortages in many specialties. KFF Health News reports, "The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties."

The number of new doctors applying for OB-GYN and internal medicine residency slots in those states "dropped 6.7%, compared with a 0.4% increase in states where abortion remains legal," Rovner and Pradhan explain. "For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal."

Opinion: Recruiting physicians to rural areas needs to show what communities offer, which goes far beyond money

Rural medicine is often more about relationships than diagnoses,
which is a hard concept to incentivize. (UIC photo)

Student loan reductions and payoffs have not enticed enough graduating doctors to move into rural areas. But when medical providers experience working in less populated places, they often find smaller communities have so much more to offer, writes Arjun V.K. Sharma in his essay for Undark. "Strategies to attract doctors to rural areas can take many forms, but it is hard to imagine any being successful without the doctor seeing the benefits of the community in which they reside."

Government officials, public policy writers and community planners would do well to look at what it takes for a resident to opt to live in a rural location. Sharma explains: "Often, it is interminably fraught — already hard work is made harder, significant others are uprooted, and certain city comforts and sensibilities may be sacrificed. Physicians, then, must rely on forces internally summoned — autonomy, altruism, competence — to propel them forward. These qualities are harder to define and measure, which make them difficult to meaningfully pin to any reward."

"When I left the city for work in a rural hospital, I put those virtues to the test. I was unsettled, initially wading through the steady stream of 'hellos,' 'good mornings,' and 'good nights' from passersby in the corridor, and unsure of how to interact with psychiatric patients who ran a café near their small ward to ease their transition to the world outside," Sharma writes. "And I was uneasy, at times, with the care we provided — even if patients were appreciative of what they received. The same decisions we fashioned in the city — to get antibiotics delivered at home or to get a surgeon to clear out an abscess — came together with fewer resources, and with doctors stretched hundreds of miles apart."

Rural settings offer a space where all people intermingle and get to know each other. And the closeness of being together while all others are miles away "lent a power to something decidedly tangible. Interactions with patients had an unflinching honesty and tenderness about them," Sharma adds. "One morning, an older man with anxiety was referred from the emergency department to a senior physician. They ran into each other at the grocery store and at local hockey games; living down the street, the physician would often check in on him."

Sharma writes. "A connection to a rural identity could be bought with incentives, or it could be learned. . . . It could be lived through simple and heartfelt things: a teary 'thank you,' a firm handshake, or the question, over and again, from patients of your plans to stay. These gestures don’t absolve the system of its responsibility to make positive reforms. But they affirm value and purpose of work that, whittled down by staffing shortages and burnout, can still impact lives our society willfully neglects."

Rural doctors have to do it all, from snake bites to meat-stuck-in-throat; video looks at challenges of rural medicine

Amid a national physician shortage, getting a doctor to practice in a rural place has never been more challenging, and as rural hospitals close, the lack of providers is predicted to worsen, reports Hyacinth Empinado of STAT. "In 2023, 65% of rural areas had a shortage of primary care physicians, according to a report published by the Health Resources and Services Administration. More than 15% of Americans — about 46 million — live in rural areas, but only 10% of doctors practice in these communities, many of whom are primary care and family physicians."

Meeting the medical needs of 46 million Americans is a big undertaking. And because there are so few doctors, each has to work harder to tackle vastly different medical illnesses and accidents with limited resources. In this short documentary, STAT explores why the shortage exists and "shows what life is like for a doctor in Kansas who wears many hats and a physician in Illinois pondering retirement."

Friday's quick hits: All's quiet with rural reticence; celebrating Nina Simone; want your own Tiny Desk concert?

Nina Simone statue in Tryon, N.C. (Photo by Annie Chester)

Born in 1933, Eunice Kathleen Waymon was born in the quaint Appalachian town of Tryon, North Carolina. A rare musical talent, Eunice's first stage was the church before she became the Black nationalist known professionally as Nina Simone, Expatalachians recalls. Simone's sultry, distinct voice made her famous, and she used her music to fight against injustice, penning songs like “Mississippi Goddamn," which was her response to a 1963 white-supremacist terror attack in Birmingham, Alabama that killed four young Black girls. She died in 2003.

Rural America has a magic that spills into its music. From Bluegrass to folk to Appalachian roots to harmonica duos, you name it, there's a unique spirit to it. Consider sharing that spirit and enter to have your own "Tiny Desk" performance. Rural has a lot to share.

On Friday, it's good to take a breath. Maybe take a moment to read Maddy Butcher's piece on
rural reticence. . . In the rural West, quiet reserve is an essential skill and a fading art form, lost on people, like me, who rush to react and to be heard. Inevitably, it is rapidly losing ground to a louder, vainer way of being. 

A bachelor’s degree in automotive restoration has put a tiny Kansas school on the map. At a time when college enrollments are diving, McPherson College’s enrollment has been steadily increasing. Because its program is unique, it can cast a wider net than other colleges its size; it has 851 students — up 18 percent over the last five years. Check out that 1953 Mercedes-Benz 300S Cabriolet and status symbols by the likes of Clark Gable, Bing Crosby, Cary Grant and Gary Cooper.

The sign said, "Flowers are the Answer." What’s not to love? Floral foam, also known as "green fine-celled thermoset phenolic plastic foam" is particularly not lovable, writes Adrienne Mason for Hakai magazine. Flowers are beautiful, they’re natural, they lift our spirits and fill interior spaces. They let us say things without having to say too much. Mason says florists need to forget foam, embrace new—or re-embrace old—techniques, and educate their customers.

The English village of Lostwithiel is looking for a new general practitioner amid a national shortage of primary-care doctors. Residents hope a music video will do the trick. See what we did there: rural people know how to use music to create some magic. And maybe, just maybe, land a new doctor.

Do you have a friend who can do six degrees of Secretariat instead of six degrees of separation? Some people do not know a person like that, or anything about horse racing. Well, giddy up! Horse racing is set to join Netflix's stable of sports documentaries. Filming on what is understood to be a four-part series on the "Race to the Kentucky Derby" is set to start next month and the casting process has begun, with the series looking to tell the stories behind the owners, trainers, breeders, and jockeys involved.

Melanoma cases are more common in rural areas; one reason: lack of dermatologists, Michigan researchers say

Melanoma is the the third most-common cancer found in rural America. A new study from Cancer Reports on residents from rural Michigan that shows the frequency and deadliness of undiagnosed skin cancer among rural residents when compared to urban dwellers. "One reason for that dramatic disparity: lack of dermatologists in rural counties," reports Eric Freedman of Capital News Service in review of the report. "Michigan has almost twice the number of dermatologists per capita practicing in urban counties And 38 of the state’s 62 rural counties have no dermatologists at all."

Lead researcher Richard Shellenberger, an internal medicine specialist at Trinity Health Ann Arbor Hospital in Ypsilanti, told Freedman, “The lack of doctors in rural areas was a significant factor. It takes a special person to say, ‘I want to practice in the Upper Peninsula; I want to practice in rural Northern Lower Peninsula.’”

3D structure of a melanoma cell derived by ion abrasion
scanning electron microscopy. (Image from Unsplash)

If cancer is diagnosed late, it is more likely to be severe. Dearborn dermatologist Karen Chapel told Freedman, “The more deeply melanomas invade the skin, the higher their risk of metastasizing – spreading to internal organs – and being deadly."

Steven Daveluy, professor at the Wayne State University School of Medicine, told Freedman that rural residents are more than three times as likely to work outdoors than their urban counterparts, increasing their exposure to the sun,

While there is a national dermatologist shortage, the lack is more acutely felt in rural areas. Daveluy gave Freedman an example of a farmer he treated: "After years of sun exposure working outdoors, he found an open sore that wouldn’t heal on his scalp. He didn’t like to go to doctors, plus he was busy working his farm to keep everything running, so he delayed coming to get treatment. When he did come, the sore had grown significantly. Due to his delay in seeking care, his surgery was more extensive.”

Chapel and Shellenberger gave Freeman a short list of items that could help ease the medical care gap between rural and urban areas, which included telehealth, incentives for rural rotations by medical students, and government support for new physicians entering rural communities with a focus on specialty physicians.

Congress's auditing arm says states could keep more rural delivery rooms open by raising Medicaid reimbursements

Increasing state Medicaid reimbursement rates for rural hospitals could help them keep their obstetric units open, the Government Accountability Office said in a report Wednesday.

More than half of rural counties "did not have such services in 2018, according to the most recent data available," the report notes. "Studies showed that closures were focused in rural counties that were sparsely populated, had a majority of Black or African American residents, and were considered low income."

The GAO, the auditing arm of Congress, interviewed stakeholders, who said Medicaid reimbursement and physician recruitment and retention are the most important factors in keeping delivery rooms open. "Stakeholders said Medicaid reimbursement rates set by states do not cover the full cost of providing obstetric services. This may mean particular financial losses for hospitals providing these services in rural areas, where a higher proportion of births are covered by Medicaid. Medicaid covered 50 percent of rural births in 2018, compared to 43 percent of births for the United States as a whole."

"Recruiting and retaining providers is particularly challenging for rural areas, as they must compete with urban areas for a limited pool of providers to staff obstetric units that require a full range of maternal health providers, such as physicians and nurses, as well as anesthesiologists." The report said obstetric services would also benefit from more remote consultations, such as videoconferencing, to {ensure that rural patients who live longer distances from higher levels of obstetric care have access to such care through their own clinicians in their communities."

The report also suggests "establishing regional partnerships—such as a hub-and-spoke model where a larger hospital partners with smaller rural hospitals for care coordination and to provide training and other resources. . . . For example, a specialist from the hub hospital could help manage a rural patient's high-risk condition as needed and support the rural clinician for planning delivery at the local hospital."

Innovative program, with high-school grads conditionally accepted to medical school, aims at rural doctor shortage

Marshall University's BS-to-MD program's first graduates, this year.

Rural America has a growing shortage of doctors; Marshall University in Huntington, W.Va. aims to help mitigate that shortage in the state with an innovative seven-year "BS-to-MD" program that helps promising rural students become doctors, with the understanding that they will serve in rural areas after graduation, Dr. Kay Miller Temple reports for the Rural Health Information Hub.

Here's how it works: Promising high-school students are conditionally accepted to medical school, and in the meantime are given mentoring opportunities as they earn their undergraduate degree on an accelerated schedule. Once they get their bachelor of science degree, Marshall waives their medical-school tuition, Temple reports.

The program, which began in 2015, takes 10 students a year, and has nearly 30 undergraduates and around 35 medical students. Jennifer Plymale, the medical school dean and director of the Robert C. Byrd Center for Rural Health, told Temple that while the program seeks under-served students rather than specifically rural ones, about half come from rural areas because West Virginia is largely rural. 

"About 50% of our students matched in primary-care specialties," Plymale told Temple, and added that about 30% of students matched to in-state residencies. "Both of these statistics – in addition to community of origin — are important since specialty choice and training location have been proven by research to be strong indicators of final practice type and practice site. We have great faith that when our first cohort complete their residencies, they will either practice in rural West Virginia, in rural areas of nearby states, or, if choosing an urban setting, will be more mindful of the needs of rural patients."

Wisconsin starts nation's first rural residency program for obstetrician-gynecologists

The University of Wisconsin has started the nation's first rural residency program for obstetrician-gynecologists, Dr. John Torres reports for NBC News, after noting that 54 percent of rural counties lack obstetric services, up from 45 percent in 2014.

"This is a national crisis," Dr. Ellen Hartenbach, who designed the program, told Torres. "I want this program to be a blueprint for increasing training spots in the country." It tries to "recruit doctors who have already embraced rural life and who have some experience in small community hospitals," Torres reports.

Sperling's Best Places map

The first resident is Laura McDowell, practicing in Monroe, a town of 11,000 near the Illinois border. "Just because docs are leaving doesn't mean the need isn't still there," she told Torres. "Women shouldn't have to think twice about getting good, quality health care in their small, rural town."

The report aired on "NBC Nightly News" Saturday, Aug. 19, starting at 13:10 in this video.

Funding set to end for federal program that trains doctors for rural, medically under-served areas

MedicalCodingPro.com

A program that trains doctors to practice in rural and medically under-served areas is in danger of losing its funding. The Teaching Health Center Graduate Medical Education program, part of the Patient Protection and Affordable Care Act, "dispenses grants to community health centers to train medical residents," Michael Ollove reports for Stateline. "Under current law, the federal government will stop funding the program, which serves nearly 750 primary care residents in 27 states" on Sept. 30.

The American Association of Teaching Health Centers, a nonprofit advocacy group, said the ACA residency program has been successful, with 55 percent of graduates practicing in under-served areas, "compared to 26 percent of those who graduate from hospital-based residencies," Ollove reports.

"The teaching health centers have received bipartisan support in the past," Ollove notes. "But supporters worry that because the program is new, relatively small, and not as well-known as other federally funded doctor-training programs, it might fall through the federal budgetary cracks. Bipartisan support didn’t protect the program from earlier cuts. In 2010, Congress allocated $230 million over five years, or about $46 million a year. But when it approved a two-year extension in 2015, it reduced funding to about $43 million a year. That reduction was enough to cause some of the teaching health centers to train fewer residents. Some have closed."

Ollove writes, "Supporters also argue that of teaching health centers expose residents to the types of ailments and health disparities, such as higher rates of obesity, diabetes and heart disease, that they are likely to encounter if they practice primary care in under-served areas."

States addressing rural doctor shortages by creating opportunities for homegrown physicians

Many states are creating new medical opportunities close to home in an effort to train and retain homegrown doctors in rural areas, Michael Ollove reports for Stateline. Eighty-four percent of U.S. medical schools "have, or plan to establish, programs to recruit diverse students interested in working with underserved populations," Ellen Wexler reported in May for Inside Higher Ed. That includes a new medical school opening at Arkansas State University this fall that has an initial enrollment of 115.

Overall, medical-school enrollment in the U.S. has risen 25 percent—by nearly 87,000—since 2002, according to a report from the Association of American Medical Colleges (AAMC). The number of students in osteopathic medical school has more than doubled, to nearly 26,000, during that time. Doctor shortages are still a concern, especially in the rural South. By 2025, the U.S. will have a shortage of 94,700 physicians, reports AAMC. (AAMC map: Active physicians in 2014 per 100,000 population)

Some states, such as Georgia and Texas, are increasing their number of medical residencies, Ollove writes. Twenty-seven states "offer grants and stipends to medical students and residents willing to do clinical rotations in parts of their states where doctors are needed most. Some states have created branches of their medical schools in underserved areas to attract doctors and residents to the regions. The University of Kentucky College of Medicine, for instance, is creating satellite campuses in the southern and eastern part of the state."

"Arkansas, Kansas and Missouri passed measures in the last two years that enable medical school graduates to treat patients before completing their residencies," Ollove writes. "Almost all states have embraced telemedicine, in which doctors use audiovisual technology to treat patients in remote locations, notably rural areas, from afar. And several states, such as Arizona, Maine, Maryland, Nevada, Vermont and Washington, have liberalized laws to enable nurse practitioners and physician assistants to perform some treatment normally done by doctors." (Read more)

Rural Texas still badly short of doctors; budget cuts reversed boost in loan-repayment program

Doctor shortages in rural areas concern many states. Texas, which has the nation's largest rural population, more than 3 million, has largely failed to attract doctors to its rural areas, leaving many communities without doctors and forcing residents to travel long distances for services, reports Alex Wukman for FME News Service, a joint venture of the Killeen Daily Herald and the Temple Daily Telegram.

Of the state's 254 counties, 140 have at least one area considered medically under-served, but while the state's total number of doctors has grown, most of those doctors are going to urban areas, Wukman writes.  Rita Kelley, department head of Bell County Indigent Health Services, told Wukman, “Doctors go where the money is. We’re trying to keep doctors in Texas, but we have trouble getting them to go to rural areas.” (Texas Department of Rural Affairs graphic: Primary care physicians in rural Texas. The 23 red counties have none; dark pink have one; light pink are other rural counties)

In 2009, the Legislature souped up the physician-education loan-repayment program in an attempt to bring 900 doctors to underserved areas, Wukman writes. The more generous program has fallen well short of its goal of 900 doctors, with only 267 having taken advantage of the program, according to the Texas Higher Education Coordinating Board.

"In fiscal year 2010, the program attracted only 63 physicians, not the 225 advertised, but the cuts in 2011 is a historic record," Wukman writes. "In 2011, Texas faced a massive budget shortfall, estimated at more than $20 billion, which prompted spending cuts." Stephen Brotherton, president of the Texas Medical Association, told Wukman, “It’s a great program, but it’s only going to work as well as it’s funded, and the Legislature gutted the funding in 2011.” The Legislature did restore part of the funding in its last session. (Read more)

Roanoke Times looks at Appalachian Virginia's difficulties with federal health reform

The federal health reform law continues to put pressure on rural health care systems. We reported on doctors in rural Vermont who are already at capacity and unable to accommodate new patients. The same problem is occurring in rural Virginia, especially in its Appalachian region, and may increase if tehe state expends the Medicaid program.

As more patients become insured through the law, more people are seeking doctors, but there aren't enough doctors to treat the new patients. In Virginia "there’s a projected shortage of about 600 patient care physicians—a gap that is expected to grow to more than 2,500 full-time equivalent positions by 2030, according a 2010 forecast by the Lewin Group for the Virginia Department of Health Professions," Laurence Hammack reports for The Roanoke Times. 

Places like Highland County (Wikipedia map) have been especially hit hard, Hammack writes. The county of 2,200 people doesn't have a hospital or pharmacy and has been without a practicing physician since last December. The county does have a medical center that has 10,000 patient visits a year; nurse practitioners handle most of them. "In fact, the most frequent call to the Highland County Volunteer Rescue Squad is made from the medical center, where the most seriously ill or injured patients must be transported by ambulance or helicopter more than 50 miles to hospitals in Augusta, Bath and Rockingham counties, according to squad captain Chris Vernovai."

At least Highland County has a facility. In Lee County, at Virginia's western tip, the only hospital closed Oct. 1, Hammack notes. "Wellmont Health System, which ran the hospital, said the closure was partly the result of cuts in Medicare reimbursements under the Affordable Care Act." Beth O’Connor, executive director of the Virginia Rural Health Association, said "the hospital is the first in Virginia to close as a result of Medicare payment reductions, according to O’Connor."

Some local doctors aren't buying that the hospital closed because of the reform law, Hammack reports. Dr. Art Van Zee "said Wellmont’s blaming of the Affordable Care Act is 'an invented, if not spun, reason for the closure.' Van Zee said Wellmont shuttered the hospital with the expectation that patients would go to other hospitals it runs in neighboring counties, protecting its bottom line—if not the residents of Lee County." Van Zee told Hammack, “Many lives are at risk, and some lives without question are going to be lost.” (Read more)

Study confirms that placing new doctors' residency in rural areas is key to keeping them around

As many rural communities continue to struggle to attract new family physicians, a study by researchers at the Robert Graham Center says that where doctors practice their residency is the key to bringing more doctors to rural America. The study, which used information from the 2009 American Medical Association Physician Masterfile, found that 19 percent of family-medicine residency program graduates stay within five miles of their residency program site, and 39 percent locate within 25 miles. (Graham Center graphic)

"The distribution of physicians continues to compromise access to primary care, a problem compounded by limited volume of training outside of major metropolitan areas and large academic health centers," the study report says. "More research is needed to explore the influences of practice site other than training location, but these findings seem to support current efforts to decentralize graduate medical education training through models such as teaching health centers and rural training tracks." (Read more)

Rural Vermont lacks primary-care physicians to keep up with expected Obamacare demand

It's not groundbreaking news that rural areas are struggling to find young doctors willing to join practices, or set up their own practices. But Charlotte Albright of Vermont Public Radio highlights a new concern that concerns rural areas in the state, and could be one that affects rural areas across the nation. With health reform providing insurance to more people, more Americans could soon be seeking a primary-care physician. But in places like rural Vermont, there aren't enough such physicians to go around. In fact, many of the state's rural doctors no longer accept new patients, because they can't handle the extra workload, Albright reports. And with few younger doctors moving in, the average age of current doctors like Joe Hebert (above), who considers himself semi-retired, and spends part of each winter in Arizona, keeps getting older.

Paul Bengtson, CEO of Northern Vermont Regional Hospital in St. Johnsbury, population 6,300, told Albright: "There won’t be enough primary physicians and primary provides to fill the gap as quickly as it will need to be filled. . . . We haven’t taken any new patients in three years, just because we don’t have the manpower, as our patients are aging and getting more complicated and sicker to do the sort of medicine we want to do and bring keep bringing people into the fold.”

A 2012 survey by the Vermont Area Health Education Center found that "one half of  Vermont’s primary care physicians and two-thirds of internists either limited or closed their practices to new patients in 2012," Albright writes. Another survey, by the state Department of Health, "shows that in half of Vermont’s counties, about a quarter of primary care physicians are over the age of 60."

Vermont's plan to solve the problem is similar to what other states have tried, or are proposing: recruiting medical students to rural areas, and offering to help them repay school loans, Albright writes. David Reynolds, who recently retired as deputy director of health-care reform policy, told Albright, “It’s a simplified system, one payer, paying equitable rates, I think we’ll have something that will draw people here because they can practice medicine, not money." Albright adds, "But where the money will come from to create a universal health care system is still a big question. Meanwhile, the primary doctor shortage is getting worse not better, in rural Vermont." (Read more)

Longtime rural hospital boss urges doctors not to resist recruitment of more local colleagues

With the rural doctor shortage about to be exacerbated by federally subsidized health insurance and some states' expansion of Medicaid, there will be more competition than ever to recruit physicians, especially to rural communities. Some doctors resist such recruitment, but they are short-sighted, writes Stephen Meredith, former chief executive officer of Twin Lakes Regional Medical Center in Leitchfield, Ky.

Twin Lakes Regional Medical Center

"When I became CEO of TLRMC in 1983 our local hospital had seven doctors on its medical staff, so the first order of business was the recruitment of additional physicians, or so I thought. When this idea was presented to the collective medical staff it with was met with a resounding 'NO.' The medical staff’s concern was recruitment would hurt them financially by further 'dividing the pie' of a finite number of patients," Meredith writes for The Record in Leitchfield.

But many more doctors were recruited (now more than 30), and the old doctors realized it was a good thing, Meredith writes: "Two of the more vocal physicians against recruitment later acknowledged the addition of more physicians, especially specialists, made their own practices even busier than before. In defense of these men, they were so busy seeing patients in their practices, they had to believe they were seeing everyone who possibly needed medical care. However, they had no idea how many people were leaving our community for health care because of the shortage of physicians."

The phenomenon extends to other lines of work, Meredith notes: "What occurred within our medical community was recognized and theorized by John Nash as the theory of economic equilibrium for which he won the 1994 Nobel Prize in economics. His theory, in essence, is when we all work together for everyone’s mutual benefit rather than just our own, in the long-run, everyone benefits by expanding the 'size of the pie.' No one wins when it comes at the expense of others, but everyone wins when we take a broader view of our community and purposefully commit to pursuing initiatives which leave no one behind. After all, we are all in this together." (Read more)

Shortage of primary care doctors worst in rural areas

Despite a critical shortage of primary care physicians in the U.S., only 25 percent of newly educated doctors go into the field, and less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services. Rural Americans account for 16 percent of the U.S. population.

The report, online in Academic Medicine,  suggests that not only are we facing a primary care shortage, but also that the problem is not likely to be solved soon. In addition to finding that just 4.8 percent of the medical education system's graduates practiced in rural areas, 198 institutions (26 percent) produced no rural physicians and 283 institutions (37 percent) produced no Federally Qualified Health Center or Rural Health Clinic physicians, which were created to enhance the provision of primary care services in under-served communities.

“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said Dr. Candice Chen, lead author of the study. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

The U.S. is producing primary care physicians at rates that are “abysmally low” and unless changes are made to the system, the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act ramps up demand for these services, Chen said in a news release. In some states, the additional need for primary care doctors as a result of Medicaid expansion exacerbates the problem.

The study's authors said policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable graduate medical education system. It is critical to find a better balance in medical specialties and more primary care physicians to build an effective, affordable health system.

Osteopathic medical schools, becoming common in rural areas, steer graduates to practice there

Dr. Valerie Goodman, an osteopath,
examines Mary Elizabeth Gardner at
Goodman's office in Centreville, Md.

Many osteopathic medical schools are springing up in rural locations, usually to recruit applicants from rural areas and then hope those doctors practice in the region. Osteopathy emphasizes total body health through muscles and bones and de-emphasizes the use of drugs.

Since 2000, the number of U.S. osteopathic schools has increased from 19 to 34, offering about 1,900 new training slots, writes Ankita Rao of Kaiser Health News. In 2011, there were about 74,000 osteopathic physicians, compared with about 29,500 in 1990.

Osteopathic physicians constitute seven percent of all U.S. physicians, but are responsible for 16 percent of patient visits in communities with populations of fewer than 2,500, according to a report from the American Association of Colleges of Osteopathic Medicine. Eighteen percent of osteopathic medical school graduates, a toital 2,045 doctors, practice in rural areas, according to a 2010 study by the National Center for Biotechnology Information. America's population is only 16 percent rural, and only 9 percent of traditional doctors practice in rural areas.

The Edward Via College of Osteopathic Medicine in Blacksburg, Va., founded in 2003, has 1,100 students. James Wolfe, president of Edward Via, told Rao, "Our philosophy is 'Recruit from, educate in, return to.'"

Founded in 1997, the osteopathic college at the University of Pikeville in far Eastern Kentucky has graduated more than 700 physicians, 62 percent of whom practice in Appalachia, according to from the school. Part of its mission statement is to have a program that "produces graduates who are committed to serving the health care needs of communities in rural Kentucky and other Appalachian regions." The graphic below shows the osteopathic medical schools in the U.S.

A tale of the vanishing, independent country doctor

After years of training to become a doctor, a select and dwindling amount of physicians who are driven by passion and not money settle in rural towns to selflessly care for their neighbors, family and friends as primary care doctors. Jennifer Kahn of Parade magazine profiled Howard McMahan, M.D., practicing in Ocilla, Ga., where he is at the center of fighting host of health challenges: obesity, drug abuse, depression — and he is the only doctor for miles around.

Wydene Tomberlin,79, gets a hug from McMahan after
giving himan apple. (Parade photo by Melissa Golden)

A country doctor is on call every night, and needs a range of skills that no city doctor would dream of having: Your patients depend on you for everything from putting a cast on a broken bone to performing surgery, reports Kahn. Still, you like the idea of knowing your patients, knowing their families and serving your community.

McMahan's job has gotten harder over the past two decades in the midst of unemployment and economic hardship. Insurance companies have been chipping away at his earnings, and a growing number of his patients are now battling chronic diseases, reports Kahn. Colleagues have chosen an easier route and gone to work for larger medical centers and hospitals. But he likes knowing his patients by name, despite the financial struggles and pressures created by a changing health-care delivery system.

Over the past 15 years, the number of new general practitioners like McMahan has been significantly declining, as medical students drift away from the field in favor of more lucrative and less demanding specialties. By 2020, the Association of American Medical Colleges projects, the U.S. will have 45,000 fewer primary-care doctors than it needs, with demand expected to rise as more people gain health coverage from federal health reform.

The scarcity is really felt in rural America, home to nearly 20 percent of the nation's population but just 9 percent of its doctors. Doctors who want time with each patient, to listen intently and compassionately, must make an effort, McMahan acknowledges — especially now that computerized medical records have become so complicated, with dozens of menus that a physician must click through during each visit. Many physicians like McMahan begin their day early and often see their last patient at 7 p.m., reports Kahn. Then, it's time for them finish all of their notes and enter them into the electronic system; the challenges and demands of this type of practice take more of a toll with age.

Vacation is often not an option because as Kahn reports, McMahan is always on call; he last took a vacation seven years ago. "I remember running into one of my former med-school professors, and he asked me, 'Why are you not a surgeon?' " he laughs. "It's tough. For the first five or six years, I kept thinking that maybe I should go back and train to do otolaryngology or some other specialty."

Since starting out, he adds, cutbacks by insurance companies have eaten away at the modest profit margin he once relied on, reports Kahn. "For many family doctors, it's nearly impossible to make a living now," he says. "You have to make enough to pay the light bill, and to pay your employees — while still trying to be compassionate and not overcharge patients," Kahn writes. "That's why so many physicians these days are selling their practices." (Read more)

South Dakota starts program to get health workers, not just doctors, to work in rural areas

Mindy Jagerson, left and Julie Crick at
work at the Freeman Regional Health
Services Hospital (Argus-Leader photo)

Incentives to get doctors in rural areas, like this one in Missouri, are common. Now a program will put $10,000 bonuses into the hands of newly hired health-care employees if they promise to keep working in rural South Dakota for three years. The money comes from the state with a matching share from the worker's employer, reports Jon Walker of the Argus Leader in Sioux Falls. The South Dakota legislature approved the arrangement this year to protect towns where hospitals and nursing homes struggle to find employees.

The jobs include nurses, dietitians, nutritionists, lab technicians, pharmacists, paramedics, X-ray technologists and occupational, physical and respiratory therapists. "It's a no-brainer for the staff person," said Dan Gran, CEO at Freeman Regional Health Services. "They get their $10,000. All they've got to do is show up and maintain their employment. We benefit because we've retained them."  The program is limited to communities with less than 10,000 people.  If the town is smaller than 2,500, the state will pay 75 percent.

The new program bypasses federal involvement, notes Walker. It would use about $300,000 a year from the state general fund. A companion program sets up bonuses for rural health professionals with more training. They range from $35,000 for midlevel professionals to $100,000 for doctors starting new jobs and promising to stay three years in towns smaller than 10,000. The state again covers up to 75 percent of costs. Annual cost is $515,000 for the state. Deputy State Health Secretary Tom Martinec said it's reasonable to use public money to assist private business. "The fact of the matter is we need health care workers in rural areas. They're competing against larger towns. That's why we needed to step in."