Doctor shortage on horizon
By Michelle Rupe Eubanks
A beautiful view and low cost of living – that’s what the Shoals has to offer young doctors looking for a place to set up practice.
Compared to the heavy patient loads and poor reimbursement rates they’ll face once they relocate, the trade-off appears to be more than many care to make. As a result, the Shoals is on track to face a serious shortage of primary care physicians as many doctors retire.
It’s a problem medical care providers in northwest Alabama understand, but not one easily conquered.
The median age of doctors in the Shoals is 52, three years older than doctors elsewhere in the U.S. Alone, that might not be an insurmountable problem, but studies by the American Association of Medical Colleges reveal that doctors are choosing to retire earlier, citing a variety of reasons, from a desire for an improved quality of life to frustration with declining reimbursements from Medicare and Medicaid.
In many specialties, including obstetrics and gynecology, the problem is even more dramatic.
“When you look at it like that, there will be a shortage (of obstetricians) in this area in five years,” said Dr. Martha Aldridge, 57, who is in a position to consider downsizing her practice or retiring. “This is not a problem we can wait to solve. We have to think and act now because it takes years to train someone in this field.”
The best-case scenario for training someone in the field is 12 years – four for an undergraduate degree, four spent in medical school and four more training for a specialty.
The two medical schools in the state – the University of Alabama at Birmingham and the University of South Alabama – have grown their enrollments in the past year in an effort to alleviate the shortage of physicians – not just in the Shoals but in Alabama and even nationwide.
Even with schools to train young doctors, however, Alabama has not proved immune to shortages. Nationally, there are 281 physicians per 100,000 people. Statewide, there are 216 doctors for every 100,000, ranking it 44th among the 50 states.
The American Medical Education Conference has identified a need of 520 primary care physicians for the state’s aging population.
Crunch the numbers a little more, and the 39 physicians in Colbert County will see an average of more than 1,400 patients each, while the 66 doctors in Lauderdale will see more than 1,300 each. Those totals are well above the average of 885 patients per physician nationwide.
Largely rural states, including Mississippi, Utah and Iowa, have identified the shortages and developed plans to handle the crises. Texas, likewise, has taken the initiative to fund a new medical school campus through its state Legislature.
Alabama has yet to take similar measures.
Dr. Patrick Daugherty, a local oncologist, said the actions by other states have put Alabama and the Shoals even farther behind the curve when it comes to competing for doctors to fill the gaps left by those who retire.
At 60, Daugherty partners with two other physicians at the Northwest Alabama Cancer Center in Muscle Shoals. He said he’s committed to continuing his work as an oncologist, “but I do plan to cut back on my hours and develop my other interests,” which include two books and mission work through his church.
Daugherty suggests partnering with other local entities, including the Shoals Chamber of Commerce and the Shoals Economic Development Authority, to approach the issue in a similar manner to recruiting a new manufacturing facility.
It’s a plan he presented to the SEDA board when he was a member in 2004. Although he said the recommendation was largely ignored at the time, Daugherty said the time is now to begin recruiting for one of the few industries that’s growing in a weak economy – medical care.
Steve Holt, chamber president, said he’d be happy to help with a more concerted effort, if he knew what was needed.
“I guess we haven’t been as aggressive as we could have been, but physicians have always been in charge of the effort,” he said. “If (the chamber) had the money, I’d hire a recruiter tomorrow.”
The chamber was responsible for the “There’s No Place Like Home” campaign to inform retirees who moved to the Shoals about the types of medical care available locally.
The information will be of little help if the doctors who are here in the future are not high quality, said Dr. Gerard Haggstrom, a gastroenterologist in Florence.
“I’d like to stay (in the Shoals) to retire, too, but I can’t if there won’t be anyone to care for me,” he said.
Cultivating potential medical students while they’re still in high school would help relieve some of the burden, Haggstrom said.
“As a community, we could offer scholarships that would take care of all or part of the cost of medical school, and, in return, we could ask them to come back to practice,” he said. “It’s the only way we’d be able to compete with bigger markets like Atlanta.”
SEDA Executive Director Forrest Wright said his focus has been on recruiting new manufacturing jobs to the area. Those efforts have paid off in recent years with the addition to the Shoals of SCA Tissue, a Walgreens call center, North American Lighting and, more recently, National Alabama.
“If we find the area needs something else, though, we’re open to helping recruit that, too,” Wright said.
Statistics from the U.S. Department of Labor project the health-care industry as the fastest-growing job market in the economy, adding an estimated 4 million jobs by 2016. In the Shoals, the health-care industry is the largest single employer, and Daugherty contends it’s directly tied to supporting the local economy, from the doctors who live in the area to the people who staff the offices and hospitals to the patients who take their prescriptions to local drugstores.
“Besides, poor health care will not attract new businesses to the area,” he said.
Outside of recruiting, there appears to be few answers to the problem.
Carl Bailey is chief executive officer of Coffee Health Group, which operates ECM as well as ECM East and Shoals Hospital in Muscle Shoals. He said the addition of hospitalists to his facility, doctors who provide care to patients admitted to hospitals, has been one stopgap to the problem, but it’s no long-term solution.
“SEDA ought to be challenged to do an analysis of the industry and what it will take to keep this industry viable locally,” Bailey said. “There is no choice at this point but to take some drastic measures.”
Already, hospitals are limited on the amount of recruiting they can do. Often, however, they offer monetary incentives to help young doctors burdened with student loan debt from medical school. The deal, however, often requires them to commit to stay at the medical care facility for a certain period of time.
“In essence, it’s a loan,” said Bill Anderson, chief executive officer of Keller Hospital. “If we stipulate they stay five years in the community as part of the contract, and they don’t and they leave after one year, the time remaining would convert to a loan that would have to be paid back.”
For young doctors such as Dan Haggstrom, 31, growing up in the Shoals is not enough to lure him back to practice.
Instead, Haggstrom said he’s looking for a more metropolitan area, Atlanta, perhaps, and a hematology and oncology group large enough to keep weekends spent on-call at a minimum.
“Unfortunately, there is a need for doctors all over the place, so Florence doesn’t have a monopoly on that market,” he said. “There will be a lot of gaps to be filled as the (baby) boomers age.”
Other doctors, including Thomas Rosenstiel, spent a portion of their career in the Shoals before moving on to a market that better suited their needs. Now in Northport, Rosenstiel said economics played a role in his decision, as did quality-of-life issues.
“Usually, there has to be that tie for people to come to an area and stay,” he said. “My parents are (in Northport), and we’re able to be with them, but I’m also not on-call as often.”
Recent medical school graduates are posing a new model for physicians, and many of the older doctors, having come of age in the industry when 120-hour weeks were the norm for residency programs, are having some trouble embracing that new model.
“It’s hard for older physicians to adapt to this because it requires a difference in the division in workload and differences in pay scales,” said Dr. Hughes Evans, senior associate dean for medical education at the University of Alabama at Birmingham. “There are lots of implications.”
Dr. Foster Eich, who practiced pediatric medicine in the Shoals for 35 years, said the younger doctors simply don’t remember “the good old days when doctors weren’t bothered with all these other issues but were free to practice medicine.”
Eich spent four years cutting back his practice at Infants’ and Childrens’ Clinic in Florence, finally leaving for good in 2006. It was an advantage of being part of a group that his patients’ care was covered by people he knew to be qualified.
“You have to be able to balance your priorities,” he said. “I would have never practiced by myself. Being in a group, we took turns being on call, and it meant you got a day of the week off. I had a good bit of family time, but we had to plan to make it happen.”
The medical marketplace is rapidly shifting, and doctors now find themselves struggling to keep up with demands of the job as well as making ends meet financially.
When Dr. Steven Keith came to the Shoals a decade ago, he had just turned 30 and was one of seven doctors in a group. On-call time was manageable as a result, and family time with his wife and young children wasn’t cramped by serving hospitals in both Colbert and Lauderdale counties.
All that’s changed, and he now shares a practice with Dr. Aldridge as well as a part-time obstetrician and gynecologist and a nurse practitioner.
How does he feel about the future of his practice?
“Absolutely daunted,” Keith said. “I’ve been tempted to leave, but my wife and I have prayed about it, and decided to stay for now. We have a strong support system, and we’re involved in church.”
But he’s keenly aware of his partner’s decision to retire in the future, certain it will mean the end to his time in the Shoals.
“How can I stay and take on the 4,000-patient load we carry?” Keith said. “How can I recruit another doctor and tell him things that aren’t true? The reimbursements are low, liability is high and it’s tough. All we want as doctors is to be free to do what we got into this business to do, and that’s treat patients.”
Michelle Rupe Eubanks can be reached at 740-5745 or firstname.lastname@example.org.