Rural areas feel doctor shortage

by Jason Hidalgo

The decision by U.S. medical schools to cap enrollment in the ’80s and ’90s is being cited by medical experts as a major factor in the ongoing shortage of surgeons and primary care physicians nationwide.

Medical schools implemented the caps because they expected managed care to create a glut of doctors. Nevada wasn’t an exemption.

“Medical schools responded by not really expanding class sizes and, of course, we’re faced with the situation we have now,” said Dr. Cheryl Hug-English, associate dean of admissions and student affairs for the University of Nevada School of Medicine.

From the late 1970s to the mid-1990s, several national advisory groups, including the Institute of Medicine and the Council on Graduate Medical Education, issued reports forecasting a surplus of physicians. As a result, medical schools voluntarily held enrollment relatively constant at about 16,000 new students a year. From 1980 to 2005, enrollment was flat while the U.S. population grew by more than 70 million, according to the Association of American Medical Colleges.

After educators realized the forecasting mistake, medical schools began accepting more applicants. Last year, nearly 17,800 students entered U.S. medical schools, the largest entering class ever.

“Anytime you try to predict that far ahead, other factors come into play that you didn’t anticipate. Some of those unforeseen factors include an expanding population, an aging population — because people are living longer — and physicians retiring younger.”

Although medical schools have since changed their forecasts, the impact of previous caps continues to resonate today. By 2020, there will be an expected shortage of 55,000 to 191,000 physicians, according to the U.S. Department of Health and Human Services’ Health Resources and Services Administration.

“The consensus has completely shifted from the 1970s and mid-1990s when medical advisory groups were saying there would be a lower demand for physicians,” said John Packham, director of the Nevada Rural Hospital Flexibility Program. “Almost everyone is on record that we’re looking at physician shortages within the next 10 to 20 years.”

In Nevada, shortages are being seen virtually across the entire medical spectrum. With the exception of anesthesiology and forensic medicine, Nevada’s physician rate per 100,000 people for all medical specialties is below the national average, Packham said.

The shortage also is being compounded by doctors retiring at younger ages, which is driving up the average age of doctors in the state. An estimated 38 percent of physicians in Nevada are older than 55, and about one in five licensed practicing physicians is older than 65, Packham said.

Confronting the numbers

Across the country, programs are having a difficult time recruiting family doctors as medical students opt for more lucrative specialties. The typical medical student graduates with an average debt of $115,000 to $116,000 — and that’s just for public schools, Hug-English said. Packham said only 80 percent of family medicine slots are being filled nationwide because not enough people are applying to become family physicians.

The impact especially is being felt in rural areas, where doctor recruitment and retention always is a challenge, said Gerald Ackerman, a member of the board of directors of Nevada Health Centers Inc., which operates several rural clinics across Nevada.

“We’ve had positions in two to three rural communities that have been open for well over a year or two,” said Ackerman, who is also the assistant director of the Center for Education, Health Services and Outreach.

“When you’re recruiting a rural physician, you also have to keep in mind that you’re recruiting the (physician’s) whole family. The physician may have a wife 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.”

Working on solutions

To help address the physician shortage, the AAMC recommends medical schools increase class sizes 30 percent by 2010. In the past two years, the University of Nevada School of Medicine has increased class sizes 10 percent to 20 percent, Hug-English said.

Increasing class sizes, however, is only part of the equation. To maintain quality of education, an increase in class size typically needs to be accompanied by a boost in other resources such as instruction areas, labs and faculty — and this requires a significant financial investment, Hug-English said.

An increase in class size also won’t be as effective unless the number of residencies in the state are also increased, experts agreed. According to Hug-English, doing a residency in a particular state is one of the highest predictors for getting a doctor to stay and practice in that state. Nevada has managed to increase its number of residencies but more work still needs to be done in this area to address the projected shortage, Hug-English said.

People also shouldn’t expect to see results right off the bat, Ackerman said. Given how long it takes for students to go through medical school, you likely won’t see an impact for eight to 10 years even if you increase class size and the number of residencies tomorrow, Ackerman said.

“The big thing with medicine is that it’s like steering an ocean liner,” Packham said. “You can attract people to the profession and get them jazzed up about specialty areas. But then you have needs popping up in another area 10 years later.”
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