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The American doctor deserts

The doctor shortage is already here, but there’s a way to fix it.

A group of doctors all wearing one giant coat walks togther on a path. One doctor is separating from the group to move in the opposite direction, toward a rural area in the distance. Julianna Brion for Vox
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Joslyn Conchas grew up with a single mom in Fresno, slipping in and out of poverty. She became interested in medicine while helping her grandfather pick ticks off their dogs and started dreaming of becoming a vet.

Then her grandpa got sick, afflicted by high cholesterol and heart disease, and she began thinking about taking care of people instead. She saw how hard it was for her grandfather, who spoke only Spanish, to communicate with her doctor, who did not speak any.

Not long ago, Conchas’s ambitions might have led her far away from the San Joaquin Valley — to college, to medical school, and to a residency at a teaching hospital in a big city, with no guarantee she would return to the place she came from.

But this fall, the 17-year-old will start her pre-med undergraduate education at University of California Merced with a guarantee that, if she graduates, she will have a spot at UC San Francisco’s medical school, the first step toward keeping her closer to home when she’s ready to practice as a full-time physician.

Fears of a looming doctor shortage in the United States have been around for a long time and have only heightened since the pandemic. But in hundreds of communities, the doctor shortage isn’t a distant concern; it’s happening. America doesn’t have enough physicians practicing in certain parts of the country and in critical specialties. There are not enough primary care doctors in small towns and poor city neighborhoods alike. There are not enough obstetricians in rural practices. There are not enough psychiatrists almost anywhere.

The vast majority of rural America, 80 percent, is considered by the federal government to be medically underserved. About 20 percent of the US population lives in rural communities, but only 10 percent of doctors practice there.

These localized shortages — call them doctor deserts — are not inevitable. They are, in part, the result of policy choices. Doctors tend to spend their careers near the place they spent their residencies, several additional years of training they undergo after medical school. These residencies are paid for by the federal government, through Medicare, and virtually all are at big, academic medical centers, rather than in the places where people most need care right now.

If the US wants more doctors practicing in small towns, then it needs to put residencies there. Given the mechanics of the Medicare program and the paucity of resources in rural hospitals, that has been a challenge — and some leading scholars now consider the program so entrenched that it’s not worth trying to change, an 800-pound gorilla that may never be tamed.

Instead, state and local governments are setting up new residency programs outside of the traditional Medicare pipeline.

Getting doctors to the places that need them most, many experts have come to believe, will result not from reforming the traditional residency system but from working around it — a pipeline that could eventually begin right out of high school, as it is for Conchas. The efforts might seem small: a doctor here, a doctor there. But for the places that need more health care providers, even a handful of new doctors can make a huge difference.

In the end, the search for a solution is ending up where it began: in the communities where these doctors are needed, with a new generation of practitioners like Conchas.

“I’ve seen how prevalent health disparities in my community are,” Conchas said the day before her high school graduation ceremony. “I want to be part of the solution. I want to make my community as strong as I can.”

What the doctor shortage is — and isn’t

The answer to “does America have enough doctors overall” is complicated and arguably somewhat unclear. The US has significantly fewer doctors per capita than some other wealthy nations, such as Germany and Sweden. But US numbers are actually about the same as a number of other developed countries — Canada, the United Kingdom, Japan, France — that still generally rank better on measures of health care quality than the US does.

Groups like the Association of American Medical Colleges continue to project long-term workforce shortages. Demographic trends, including an aging patient population and boomer-generation doctors reaching retirement age, may lead to more overall pressure on the US health system’s capacity.

But the more acute shortages are already happening in individual communities and specialties.

Even if the United States may need more doctors overall in the future, right now, “the misallocation problem is bigger,” Janet Coffman, a professor at UCSF’s Institute for Health Policy Studies, told me.

The problem is getting worse. Last year, scholars from Harvard and the London School of Economics found that the number of primary care doctors in rural counties, adjusted for population, dropped between 2010 and 2017, while remaining steady in small and large metro areas. More than half of America’s rural counties lost primary care doctors; most metropolitan counties saw an increase.

Rural Americans die at higher rates from heart disease, cancer, chronic lower respiratory disease, and stroke than their urban peers, and those poor outcomes are at least in part a result of having fewer doctors. The study authors wrote that the findings demonstrated the need “to redistribute physician resources to match the unequal health burden experienced by rural and urban populations in the US.”

How did the US doctor workforce end up so badly misallocated? The economic opportunities available in rural areas versus cities are an important factor, experts say. Working in a large hospital system can be more lucrative than operating a one-doctor practice in a small town. Surgeons, who typically practice in the major hospital systems, earn better money than doctors practicing internal medicine. And human factors play a role too. Many people prefer city living for family, social, or cultural reasons.

But one reason doctors are in the wrong places is that the US has built a pipeline to put them there.

After medical school, doctors in training move on to residencies at teaching hospitals, where they continue their education. Medicare currently spends about $16 billion every year on supporting residency programs, including the direct and indirect costs of running a teaching hospital, equivalent to about 90,000 medical school grads working full time. Large academic medical centers in urban areas dominate that program: 98 percent of all the residencies funded by Medicare are in urban hospitals. Some major hospital systems even fund additional residency slots beyond what Medicare covers.

There are legitimate reasons that so many residencies are hosted at large hospitals in big cities. Residents see a high volume of patients and a diverse set of cases, which is useful for developing broad real-world experience. The quality of care at many of these facilities is high. For some specialties, teaching hospitals are the only place to perform their chosen branch of medicine. And in general, even experts critical of the Medicare residency program credit its long-term investment in the country’s medical workforce.

Still, many experts argue the current program is overly weighted toward those big academic medical systems. The formulas that dictate Medicare’s residency funding have mostly been left unchanged since they were created in the mid-90s, meaning the medical training pipeline has not been meaningfully remade to address the maldistribution of the country’s physician workforce. Analysts for the Congressional Research Service wrote last year that Medicare’s general medical education payments “generally do not address changing health care workforce needs.”

But the existing Medicare medical education infrastructure is well entrenched. Powerful hospital groups and physician trade organizations are invested in the program as it exists today. There have been some modest improvements. Congress has added primary care spots in recent years and authorized new funding to seed residencies in places like rural Alabama, where John Waits and his team at the University of Alabama-Birmingham have set up training programs at clinics in underserved rural and urban communities.

But some of that funding, established by the Affordable Care Act for the teaching health center program, has to be reauthorized by Congress every couple of years, leaving clinics in constant doubt about future finances, which compromises recruitment. Students ask themselves, “Is the funding going to run out? Am I going to be able to finish?” Waits said. “It hurts our recruiting.”

The permanent Medicare funding, meanwhile, is akin to a third rail in medical education politics.

“Folks have been criticizing Medicare for decades and it’s not changed. Nobody wants to lose the residency programs they have. Nobody wants to lose the advantages they have,” Coffman said. “We should continue to chip away on Medicare — but at the same time we need to be working at the local and state level to do what we can.”

Some experts are asking themselves: Should we try to overhaul it — or would it actually be easier to work around it?

A new path to getting doctors where they’re needed

It is not exactly news that America’s rural communities don’t have enough doctors. It’s a problem policymakers have been working on for a long time — with limited success.

Ideas like repaying the student loans of doctors who practice in rural areas have been around for a long time, but the evidence suggests they have a limited effect. They fail to solve the fundamental problem: People tend to settle down near where they train after school.

Putting residencies in rural health care facilities is the most direct path to more doctors practicing in those areas. Medicare funds most residencies in the US, but it is not required that doctors train in a Medicare-funded residency, only an accredited one. States and local groups are making more concerted — and successful — efforts to set up and fund alternatives as the doctor deserts continue to grow.

But that is a challenge. For one, rural hospitals are floundering. It’s hard to start up a residency program at a hospital that may be a few years away from closing entirely.

“I have partners that are worried about their own existence,” said Kenny Banh, who runs a rural medical training program in Fresno County, California. “We’re constantly putting out the fire today while trying to plant the seeds for tomorrow.”

Prior efforts failed because they lacked sustained funding and political support. That is a hard lesson learned. Wisconsin, for example, attempted to seed a number of rural training programs in the 1990s, but they sputtered out in the 2000s. It took another decade until a renewed effort to launch rural residency programs got going.

That program, started in 2014, has proved more stable, helping to launch 75 residency positions across the state while being supported by a tax on rural hospitals in underserved areas that helps draw matching funding from the state Medicaid program. (It is similar to the funding mechanism used in some states for Medicaid expansion: taxing hospitals because the matching funding from the government ultimately brings more money to those hospitals.)

The program receives $750,000 annually right now; its leaders are trying to sell the state legislature on doubling that investment as part of the state budget currently under consideration.

“If you don’t have the funding, it’s harder to sustain a program,” said Lori Rodefeld, who provides technical assistance through her role at the Wisconsin Collaborative for Rural Graduate Medical Education. “That’s a lesson learned.”

Recently, additional federal funding has supported setting up rural residency programs in states like North Carolina. Policymakers are also becoming more imaginative about where residencies can be hosted; a West Virginia program has been focused on setting up residencies at federally qualified health centers, clinics that receive a special pot of federal funding for operating in medically underserved areas.

It all follows from the same principle: Train new doctors where you want them to practice. And states have had to get creative because Medicare’s general medical education funding appears almost impossible to change.

California in particular has had to be creative about alternative paths for developing and training a medical workforce. It is now putting $75 million annually into state residency programs, partly supported by a cigarette tax, approved by the voters in 2016, a tenfold increase in the state’s investment.

It has also launched a series of smaller programs at individual medical schools, which are offering supplemental classes and on-the-job training to get new practitioners accustomed to working in medically underserved communities. They have now even begun recruiting pre-med students directly out of high school from the communities where they want new doctors to practice.

That is the next evolution in this crusade: Pull the next generation of doctors from the cities and towns where more doctors are needed, rather than hoping doctors will relocate there.

“Our students are put back in the clinics they are from, the rural clinics they went to as students. They are invested in that clinic’s success,” Banh, who runs one of these programs in the San Joaquin Valley, told me. “That’s how you actually fix these physician shortages.”

The future of medical training is in California’s San Joaquin Valley

Sidra Suess now practices in Stockton, about 30 minutes from where she grew up in Modesto, in the heart of the San Joaquin Valley. This region, directly to the east of the Bay Area, is fertile agricultural land that stretches from Sacramento in the north nearly all the way to Los Angeles in the south. More than half the population is Latino.

But while it is rich in soil, it is poor in more ways than one, including health care access.

The San Joaquin Valley is home to 1.8 million people, 20 percent of whom are living in poverty, twice the rate of the entire state. Half the valley’s population is either covered by Medicaid or uninsured. Doctor shortages persist across the area; there are not enough primary care docs or enough psychiatrists, among others. Obesity and asthma are common.

Suess’s dad worked at a gas station while her mom took care of her and her siblings. They went to a dentist regularly, she remembers, but otherwise, visiting a doctor was rare.

“If you think you have strep, you sit and wait it out until it gets better or you go to the ER,” Suess recalls. “That model hasn’t changed much.”

After college, while she took the exams needed to get into medical school, she wasn’t sure she wanted to pursue it. Then she learned UCSF was launching a program to support medical training focused on the San Joaquin Valley. The first class was set to start in 2012. Suess applied to med school and the PRIME program — Programs in Medical Education — and got in as part of that first class.

Through her four years at med school, Suess attended special lectures and workshops meant to educate the doctors-in-training on the San Joaquin Valley. They visited different hospitals, clinics, and doctors’ offices throughout the area and even spent days shadowing physicians at work, a sort of pre-residency. Community leaders spoke about the area’s history and its people. A number of her classmates were also from the area and considering a career practicing there.

Upon graduation, Suess decided to take a residency in Oakland, but she says she always saw herself coming back to the San Joaquin Valley. In her third year of residency, she started spending one day a week back in the valley, in Stockton, where she would ultimately settle down. After finishing her residency in 2018, she got a job practicing internal medicine at the Kaiser Permanente clinic there, where she still works.

She feels the strain that doctors in the region are still under, given the continued limitations of the medical workforce there.

“The day-to-day of it, in reality, what it ends up being is a harder workday, a longer workday, and more overbooked patients,” she said. “That’s what you have when you’re working in a community that doesn’t have enough doctors.”

More reinforcements are coming. The San Joaquin Valley PRIME program has continued to expand under the leadership of Banh, a trained emergency medicine doctor who came to the US as a child from Vietnam and helped launched the program in 2012.

The program is now recruiting students directly from the community, after seeing promising early returns for their support during medical school with about 70 percent of their graduates still practicing in the area. The idea is that those students will be motivated to come back and practice in the communities they came from, while addressing a lack of diversity in the valley’s medical workforce that can make it hard for doctors to relate to or communicate with their patients.

“I joke to the admissions office: If you went to the soup kitchen, that counts way more than you volunteering at the soup kitchen,” Banh said.

In high school, Joslyn Conchas signed up for a doctors academy program that brought in guest lecturers and even set up hospital visits for students who thought they might want to pursue a career in medicine. Early in her senior year, the teacher who ran that program told the students about the San Joaquin Valley PRIME program.

When Conchas heard that she’d be guaranteed medical school admission upon graduating with her bachelor’s, she was sold on it.

“Sign me up,” she said. The PRIME program would give her “a shot at becoming a doctor as soon as I can.”

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