Dr. David Lingle, one of the two remaining surgeons at Shore Memorial Hospital in rural Virginia
Photo: H. Darr Beiser, for USA Today
USA Today focused on Nassawadox, in rural eastern Virginia [1]: there, the number of surgeons at Shore Memorial Hospital has plummeted from seven to only two, and one of those two is "nearing retirement."
This story and several other recent reports, from states far flung as Mississippi, New York [2], Nevada, Wisconsin [3], and Hawaii, suggest that the shortage of doctors in the rural US is a bona fide epidemic.
Robert Davis's report focusses on a major miscalculation by national medical school authorities. From the late 1970s until the mid '90s, experts in medical education urged medical schools to hold enrollments steady, forseeing a surplus of doctors (as if too many would somehow be perilous). With hindsight it's hard to understand the reasoning behind their forecast. Now baby boomers are aging -- becoming more doctor-needy. Boomer-cohort physicians are retiring by the tens of thousands, and there have not been enough new physicians trained to fill their shoes.
Medical schools made an about face last year, accepting a record 17,800 students, but it takes many years to train a doctor. Davis writes of the doctor shortage, "The impact often is most severe in rural America (towns with populations less than 2500), where only 9,334 of 211,908 physicians (less than 5%) are general surgeons."
Last summer, Chris Talbott wrote about the severity of shortages in the Mississippi Delta [4]. Citing statistics from Mississippi State University's Social Science Research Center, Talbott wrote that nationwide there are 280 doctors for every 100,000 people; but in Mississippi's 18 Delta counties, the rate is less than half that (103, per 100,000 residents). "And the Delta has some of the nation's highest rates of infant mortality, heart disease and other serious illnesses."
Map: RUPRI, via American Academy of Family Physicians [5]
The rural doctor shortage isn't limited to poor regions in the South, though. Sen. Kent Conrad of North Dakota told Talbott: "We're facing a real crisis." And Eloise Aguiar writes for the Honolulu Advertiser [6] that in Windward O'ahu, the island's rural north side, eight doctors "have closed their practices or left for the Mainland" just in the past two years. Agular's sources said that high costs of malpractice insurance in Hawaii, heavy workloads and low rates of reimbursement from insurance companies were driving many of O'ahu's rural physicians away. And as they leave, the patient loads of the doctors who remain only become heavier.
Jason Hidalgo reports that Nevada has too few family practicioners [7], as most physicians-in-training opt for more lucrative specialties. "The impact is especially being felt in rural areas, where doctor recruitment and retention is always a challenge, said Gerald Ackerman." Ackerman is a board member of Nevada Health Centers Inc., which operates several rural clinics in Nevada. "We've had positions in two to three rural communities that have been open for well over a year or two," he said. Ackerman noted that it's especially difficult to recruit doctors with families to rural communities. "The physician may have a wife (or husband) who has a degree, but she may not have an opportunity to work in a small rural town. You also have to consider if they have children in school.""¨
Economic and quality of life questions are shaping the medical profession like never before. "Are the best and the brightest going into medicine like they once did? The answer is no," Josef Fischer, surgical chief at Beth Israel Deaconess Medical Center in Boston, told USA Today. Dr. Fischer went on: "They are becoming investment bankers, attorneys and captains of industry because the American way — how prestigious things are — depends on money."
And in rural areas, doctors tend to make considerably less of that. Valerie Bauman, reporting on the dwindling number of doctors in rural New York, writes that one physician who was earning $150,000 a year at the rural Adirondack Medical Center, "was lost to a Seattle practice that paid him $450,000 - plus a $50,000 signing bonus."
Thomas Russell, who directs the American College of Surgeons, stressed that there's more behind the dearth of physicians than just differentials in pay. Most young people today, he said, "want to know when they are on and when they are off." Mediocine, he said, "is no longer a calling for younger people. They want balance in their life."
Dr. Iracema Arevalo, a pedicatrician and native of Peru, greets 6-month-old Cynthia Rocha. Arevalo works at Community Health Services in Fremont, Ohio.
Photo: Tracy Boulian, for The Plain Dealer
The rural doctor shortage has been exacerbated since September 11, 2001. At that time, foreign-born medical students were permited to remain in the U.S. upon completion of their training if they agreed to work 3-5 years in a community that was medically "underserved." The program granting J-1 Visa Waivers, initially administered by the USDA, sent many foreign-born doctors to rural communities. After 9/11, national sentiment toward immigrants changed and federal agencies clamped down. A climate of suspicion and increased regulation convinced many foreign-born doctors who had once hoped to stay in the U.S. to return to their home countries.
It appeared the J-1 Visa Waiver program might end. However, it was extended and moved under the Department of Health and Human Services. Now most foreign-born medical students seeking to stay on and work in the U.S. apply to do so under the Conrad State 30 Program [8], which "allows state health agencies to annually hire up to 30 foreign physicians to practice in rural and inner-city communities that often have difficulty recruiting physicians."
But a startling story this week by Joan Mazzolini for the Cleveland Plain Dealer finds that in Ohio, many of the foreign-born physicians who have been granted visa waivers are not working in rural areas [9] at all but on staff of some of the most established urban medical centers in the nation. "The Ohio J-1 program has evolved from getting family doctors willing to move into areas with few doctors to providing big hospitals with a way to keep foreign-born residents whom they trained on their full-time staffs," Mazzolini writes.
Ohio's new state health director Dr. Alvin Jackson, who formerly led a health clinic in rural Fremont [10], Ohio, says, "Reviewing the program is one of the top things on my radar." At most, that could mean thirty newly graduated doctors working in rural Ohio. And considering the current epidemic, that would be a good thing.