Loss of doctors leaves patients waiting

By Winston Ross
http://www.registerguard.com

FLORENCE — In a bigger city, the departure of two primary care physicians from a hospital network in a single month isn’t a big deal. Patients can be absorbed into other practices, and more doctors can be counted on to move in and fill the void.

In a town the size of Florence, however, losing two doctors at once is a much bigger problem. There are 1,113 people here for every primary care physician, or 200 more than the state average, according to research conducted by the Oregon Office of Rural Health.

The loss of two doctors in such a small area leaves administrators at Peace Harbor Hospital scrambling to find replacements, and patients such as Harvey Bjork on a waiting list looking for a new M.D.

“People are living longer and longer,� says Bjork, 76, guessing at one of the reasons for the problem. “I should have been dead by now.�

Florence has to compete with dozens of other rural areas with the same shortcomings and the same difficulty persuading doctors to relocate to a place where it’s getting harder and harder for them to make a living.

There’s a need for 200 to 250 new doctors a year in Oregon, the president of Oregon Health Sciences University in Portland said on a recent tour of the state, but a lack of state funds has limited enrollments at the medical school to fewer than 100 annually.

That means some stark differences between the number of available doctors in different parts of the state. Oakridge has 2,213 people per primary care physician, more than double the statewide average. Veneta is at 2,880 and Junction City 3,314.

The Bay Clinic in Coos Bay recently mailed out 700 letters to patients to notify them not only that their doctors had left the area but also that they wouldn’t be recruiting new physicians.

“It’s gotten tougher to recruit than it was five or six years ago,� said Pete Johnson, CEO of North Bend Medical Center. “The overall competition for people is increasing.�

The reasons for that vary widely, making it difficult to find solutions, experts say. Some doctors are reluctant to move to rural areas because there aren’t as many amenities, such as concerts and restaurants. Sometimes it’s a spouse who gets tired of living in a small Oregon town.

Beyond that, pay is an issue. Rural areas tend to have a greater percentage of older residents, insured by Medicare, the federal program that covers people 65 and older. A 2006 survey of Oregon physicians found that the Portland metropolitan area had the state’s highest proportion of patients with private supplementary health insurance, at 47 percent, and the Northwest region — which includes rural coastal areas — had the lowest at 28 percent.

Medicare accounted for 25 percent of the “payer mix� statewide but only 21 percent in Portland and 40 percent in Southwestern Oregon.

And Medicare’s reimbursement rates have declined steadily over the past several years, thanks to rising health care costs and government attempts to control them. That means doctors are getting paid less for the same amount of work, and they’re closing their practices to Medicare recipients more often.

The number of doctors who said their practice is completely closed to new Medicare patients jumped to 23.7 percent in 2006 from 11.8 percent in 2004.

Rural doctors also work more. They’re often required to cover shifts at the hospital as well as conduct their 9-to-5 practices because the hospitals don’t have enough physicians on staff to keep people there around the clock. Some doctors say they enjoy the continuity of care that that provides, but the end result is more hours on the job, especially with older residents who have numerous ailments.

Ron Shearer is a Florence physician who moved here 12 years ago from a busy practice in Bakersfield, Calif. He took an immediate 50 percent pay cut, he said, largely due to doubling the average age of his patients, to 70 from 35. His practice in Florence is 70 percent Medicare recipients, he said.

“There are a lot of people with multiple medications, more hospitalizations, more X-rays to review,� Shearer said. “The typical patient here requires about three times as much work as a younger patient.�

The list doesn’t end there. Last December, the Oregon Supreme Court threw out the state’s Tort Claims Act, which had put a $50,000 cap on damages payable by state-run hospitals for any single accident or occurrence. With no cap, doctors’ malpractice rates rose across the state and the risks of malpractice lawsuits are greater in rural areas, doctors say.

That’s because there are fewer specialists available for consultations and second opinions in rural areas, meaning a patient with a complicated condition may get only the care of a single internist. If they die or are irreparably harmed during transport from a rural to an urban area, the chances that they’ll sue the original doctor increase, physicians say.

“If you’re in a city, you know you can generally get a specialist to help out with a sick patient,â€? said Gary Young, president of the Lane County Medical Society. “If you’re out in other areas, you’re at a higher risk; more of it falls on you. … I’ve always worked in places where there’s plenty of help.â€?

Finally, state budget cutbacks have kept government-funded medical schools from increasing their enrollments, which means fewer doctors get added to the system despite there being plenty of interest among students and plenty of demand for their services. And those who do go to medical school are choosing internal medicine less and specialty training more. Rural areas often have only internists.

“When I went to medical school in Portland, I graduated in 1979 with 115 students in my class,� Young said. “Right now, despite the fact that Oregon’s population has doubled since then, we still only have about the same number graduating every year. The state didn’t want to pay for a bigger medical school with taxes being cut and other priorities, such as prisons.�

The array of challenges leaves patients such as Bjork frustrated. He lost his doctor this spring, which meant he either had to see whoever was on call at the hospital in a same-day appointment, go to the emergency room, or wait six weeks for the one doctor he found who was taking new patients.

“If you’ve got a medical problem, you don’t want to wait a month and a half,� he said.

Finding new recruits is tough, said Sheri Aasen, clinic manager at Dunes Family Health in Reedsport. Five years ago, two doctors left their practice. Their jobs were filled, but two more left in the past year.

“There’s a considerable difference now than five years ago,� Aasen said. “There seem to be fewer applicants, not as many family practice physicians.�

Some say the wages are too low or the workload too great, others don’t want to live in a small town, Aasen said.

In Florence, primary care manager Becky Ragan fields phone calls from “angry, upset� patients who want to know why their doctors left, patients she adds to a waiting list that now has 101 people on it — “the longest it’s been in a while.� “We let them know it’s a national problem,� Ragan said.

There are potential solutions to all this on the horizon, including new agreements with the University of Oregon and Portland State University to allow students to complete their first year of medical training during their fourth year of studies there, thus reducing medical school to seven years from eight years; a loan forgiveness program for recent graduates who practice in rural areas and priority scheduling of medical license exams for doctors willing to work in rural Oregon; and a rural residency program that allows students to complete residencies in rural hospitals and clinics, which often leads to them setting up their practices in rural areas.

In the meantime, patients like Bjork remain concerned. “I don’t see the crisis easing,� he said. “I think it’s going to keep getting worse.�

 

— The Associated Press contributed to this report

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