Rural health care mania

A few months ago, the City Beat was at UND to hear Dr. Ellen Cosgrove, one of the finalists for med school dean. I had the pleasure of meeting Dr. Richard Johnson, a radiologist from Devils Lake, who went to the same meeting to raise heck about the university not producing as many doctors for rural areas to address the growing shortage.

When I went to introduce myself to him after the meeting, he was chatting with a UND faculty member, whose name I didn’t write down. They were having a very animated discussion about the shortage, which is what eventually inspired me to write the story about the issue last week.

Dr. Johnson laid out a compelling scenario, which he has seen as a doctor in Devils Lake.

Many of the doctors are older and close to retirement while many are foreigners who will probably leave once their work visas allow it. It’s even worse in the smaller towns around where there aren’t even doctors. Nurse practitioners are doing the jobs of doctors and just getting doctors to sign off on their work. Some want to become doctors but it’s been hard to get into the state med school at UND.

If only there was a way to get young doctors who will stay, Dr. Johnson said.

The faculty member said it’s not just Devils Lake.

It’s hard to get young doctors in Grand Forks, too. His neighbor, a surgeon, was speaking to some sort of medical advisory board and decided to illustrate the problem actually existed. The neighbor called up Altru and asked for an appointment to get an insurance checkup. Three months, he was told. He said the insurance company will pay for everything and bargained it down to a month. A whole month!

The faculty member said Dr. Johnson that he’s heard some frank talk from students and it doesn’t involve going back home and serving their community at all. “Let’s talk (expletive). It’s about the shortest hours and the highest pay.”

What he means is the tendency of med school students to go into specialty fields, oncology, say, where the pay is higher and the hours are regular. Nobody needs an oncologist at 8 a.m. on a Sunday. North Dakota, however, doesn’t have a shortage of on oncologists. It has a shortage of what are known in the profession as “primary care physicians,” known to the layman as your pediatricians and family doctors.

That conversation really opened my eyes to the problem.

In fact, not long after that, I had to get a medical check up because I was in line to fly with the Thunderbirds — That didn’t work out, unfortunately. — and was given an estimated waiting period by Altru that would be way longer than the Air Force was willing to wait. Such a wait was not necessary the last time I called Altru for a check up, maybe six or seven years ago.

Fortunately, Altru referred me to its Family Medicine Residency at UND, which got me in the following week.

Writing the story took a lot of research and I ended up talking to quite a few people, including Dr. Johnson. Unfortunately, I didn’t have the space that would’ve done the story real justice. This was self-imposed because if I wrote as much as I wanted to, everyone would be bored.

On this blog, of course, I have a weird group of readers who are willing to put up with that sort of thing, so thank you and allow me to dump the content of my notebooks on you.

The problem from 20,000 feet

The shortage of doctors had been on my radar screen since at least January 2009, when Dr. Joshua Wynne, the then-interim dean and the now-med school dean, told the Legislature about the devastating demographic trends that threaten to turn North Dakota into the land of the super-elderly always in need of medical care, but unable to get enough of it from the available supply of doctors.

But, as Dr. Johnson’s tone suggested, the shortage as it exists is already pretty bad.

Before I get to my interview with him, let me give you the 20,000 feet view. I was clued in to something called Health Professional Shortage Area by Aaron Ortiz, a recruiter of doctors working at UND’s Center for Rural Health — which I failed to mention even once in my story because writing was such a struggle.

What makes an area an HPSA is pretty complex — You can read the center’s explanation here. — but suffice to say that one definition is a geographic area in which there are fewer than one doctor per 3,500 residents. It could be a whole county or a natural population made up of portions of many counties.

Below are some links that helped me visualize these HPSAs:

• You can see on this map, also from the center, all the HPSAs in North Dakota. I ignored the yellow areas that are HPSAs that apply only to health care that’s affordable to the poor. That’s a entirely different problem that affects only one population group and I didn’t have time to delve into it.
• For a comparison, see this map of health profession shortage areas for primary care physicians around the country (Check out the main map page for the Rural Assistance Center, run by the Center for Rural Health. These guys are all over this issue.). Again, I ignored the yellow areas. You’ll notice that the geographical HPSAs make up a very large proportion of North Dakota’s land area compared to many states. Mountain states appear to suffer the most.
• I looked for a map of population density to see if there are any correlations and, yes, sparsely populated areas — rural areas — tend to have shortages. Not an earth shattering conclusion, but I had to see because I was surprised there were so many HPSAs in California. Apparently that state’s an exception.
• What the maps don’t tell you is the extent of the shortage, which vary from HPSA to HPSA. The U.S. Department of Health and Human Services offer a more specific list of HPSAs and their scores from 0 to 25, with 25 being a really, really bad shortage.
• I even used that to make a rough, color-coded map of the HPSAs and their scores.

The problem at ground level

To understand what the situation looks like on the ground, I naturally called Dr. Johnson.

Now, there’s something I have to tell you about Dr. Johnson that you might not sense from the interview: He’s crazy passionate. He has the same zeal as a Tea Party activist, and he’s mad as heck, too, except his focus is on health care. He is like a thorn on the side of Dr. Wynne, whom he is pushing like mad to make rural health care the med school’s No. 1 issue. So I like him, but sometimes there’s a slight bit of rhetorical excess.

Dr. Johnson started out by talking about all these foreign-born doctors in Devils Lake and how he’s scared they won’t be able to feel at home there and, eventually, leave. “We spent this week interviewing lady from Pakistan. Her husband’s a banker. Is he going to find a job here? The weekend before was a fellow from Nigeria. The last doctor was a young single woman from Uganda. Do you think she’s going to make a life here in Devils Lake?”

He said they have temporary work visas that require them to serve in an underserved area for three years, but, after that, they can go wherever they want and they tend to. He called them the “best and the brightest” that their nations have to offer, but they wouldn’t want to stay here. “They’re great doctors. The problem is this is not their culture. The climate here is not for them.”

Of the native-born doctors in Devils Lake, many are on the verge of retiring, according to Dr. Johnson. There are 11 docs at Altru’s Lake Region clinic and six are older than 60.

The shortage has gotten so bad that Dr. Johnson, who’s a radiologist, has started playing primary care physician so patients can get the referrals to specialists they need.

He said I should talk to Elonda Nord who runs Altru’s Lake Region clinic.

So I did.

We talked first about recruitment and I was surprised to learn that the clinic is “continually recruiting,” as in all the time. There are 11 doctors, six that are 60 and older and four that are from overseas, she said (I know that only adds up to 10; obviously the remaining doctor doesn’t fit in those categories.). However, the four foreign-born doctors are all citizens and some have been in the area for a long time, at least 1980 in one case. 

Still, Elonda said, most of the foreign-born doctors that come are as Dr. Johnson described, staying only long enough to fulfill their visa requirements.

I asked her about the suggestion that doctors aren’t accepting new patients and she said that this is true of the older doctors, who have full loads. The younger doctors do take on new patients, she said, but it can take a while to get an appointment. The clinic tries to never turn people away, she said.

This is why the clinic is always recruiting. The goal, she said, is to increase staff to 15 or 16 doctors, including 2 to 3 more in family practice and 2 to 3 more in internal medicine.

Continous recruitment is apparently the norm among the state’s critical access hospitals, those in the HPSAs. According to recruiter Aaron Ortiz, 23 of the 36 hospitals he works with are always looking for new people.

Now Devils Lake is a pretty decent-sized town compared to a lot of other places in North Dakota. What’s it like in the smaller towns?

At MeritCare’s Mayville (N.D.) Union Hospital and Clinic they’re down to two doctors and two nurse practitioners from three doctors and two nurse practitioners. Nurse practitioners are experienced nurses who fill in for doctors, but, as Dr. Johnson mentioned to me, they have less training. So as good as they are, they’re not a real substitute.

Doris Vigen, the director of nursing, said all of them stay super busy at the clinic and in area nursing homes. This reminded me of Dr. Johnson’s lament that doctors are so busy in these small towns that it’s a challenge for them to find time for a vacation, which becomes a deterrent for anyone thinking about going into practice there.

The solutions

The remedy for this shortage isn’t exactly a mystery. As Dr. Johnson noted to me, “The literature is replete with solutions.” One example, he said is the University of Minnesota-Duluth, which sends 65 percent of its med school grads to the state’s small towns. How? The dean told him the school only takes students from towns of 20,000 or less. “What you put in is what you get out” is what Dr. Johnson said he was told.

So how about that Joshua Wynne?

I went to talk to the med school dean about that and other solutions. Let me summarize three basic approaches to solving the doctor shortage that Dr. Wynne ennumerated for me:

1. Retain the doctors you’re educating.
2. Import new ones.
3. Increase the number of doctors you can educate. You’ll hear terms like “broaden the pipeline” or “grow your own” related to this approach.

The first is most important because it’s the most cost effective. The state is already spending money to educate doctors, it just has to persuade them to stay. Not that UND’s been slacking. There’s a terrific and relatively recent study in Academic Medicine showing that it’s among the top in the nation in placing its grads in rural areas.

The second is helpful but very expensive. Turnover is higher whether you’re talking about doctors from Pakistan or from San Francisco. Those folks tend not to want to stay in North Dakota. And, for foreign-born doctors, there are legal fees associated with their visas. So this is a stop-gap measure at best.

The third is important but expensive. As you’ve read, Dr. Wynne wants a massive budget increase to hire more faculty and add a new building. On the other hand, a lot of universities around the nation are already doing this so there is a threat of a glut down the road. Of course, as the Academic Medicine story says, only a small number of med schools focus on rural health care.

So let’s talk specifics.

Retain the doctors you’re educating

UND’s approach in this regard is all encompassing.

• It starts all the way in middle school or even grade school. ”Scrubs camps,” one of which I visited in Mayville, introduce children and teens from rural areas to the medical profession in the hope that a few of them will be inspired to go into medicine.
• When the students are applying to med school, the fact that they’re from rural areas do help. One in four at the med school are from towns of less than 2,500 residents, which Dr. Wynne said isn’t bad.

Being the state’s only med school means it can’t take in only rural students the way Duluth does, he said, but it can do something like an affirmative action program. The school is evaluating the admission process, he said.

• Recently the med school, with state funding, started the RuralMed program to make it more affordable for rural students to attend med school. Basically, it’s the Northern Exposure plan where the state pays for the education and the students promise to practice medicine in rural areas. I’m not 100 percent sure how they pick who gets the money, but I think there has to be some reasonable certainty that the students will stick around, say if they’re from a rural area.
• In med school, students may join a family medicine interest group where they can meet with doctors that have already taken that route. Research shows that those in family medicine are more likely to serve in rural areas.
• They can get placement in rural areas as interns where they focus on specific patients and all the medical issues they face, just as family doctors do, rather than specialize in one disease or another. Again, research lights the way. Familiarity increases comfort.
• Once they graduate, the med school tries to remove barriers to serving in rural areas. I didn’t have time to get him to explain what he means by this, but I do know that some rural clinics can’t afford to keep residencies open.
• When the new doctors are done with their residency, the university is considering a program to provide substitute docs so the new docs can take vacations. Doctors serving in underserved areas, as I mentioned above, can be very, very busy because so many depend on them.

After hearing all this, I asked if he wasn’t taking a rather soft approach to the shortage. I mean if the problem is as dire as it sounds, why isn’t he talking about goals or quotas?

Dr. Wynne noted that RuralMed alone would put eight of 55 annual med school graduates in a rural setting.

Of course, that’s just 15 percent of the graduating class.

“This can’t be an all or none phenomenon,” Dr. Wynne said. The focus on primary care and family medicine is great, but the state is short on specialists as well, he said. Unlike Minnesota, North Dakota has but one med school, which can’t afford to play only one role, he said.

Another question I remember asking, but isn’t reflected in my notes is: Why not offer a program to help nurses get their medical degree?

Maybe it was Dr. Johnson that mentioned this or maybe I just made it up on my own, but it seemed reasonable because many of these nurses have been serving in rural communities for a very long time. The ones I met in Mayville have been there for years and years and are well-rooted in the community. Why not give them free tuition like the RuralMed students? They’ve already more than demonstrated their commitment to rural medicine.

I don’t think Dr. Wynne really had much to say about this to me, but Dr. Johnson said Dr. Wynne told him doing so would be a challenge because accreditation would be a nightmare.

Import new ones.

To talk about recruiting new doctors, I talked to Aaron Ortiz, who, as I mentioned before, is a UND employee who helps rural health care providers statewide with recruitment.

“One of the biggest issues we constantly hear is lifestyle,” he told me. Candidates often ask about big city amenities or jobs available for spouses, he said.

The most ideal candidates are from North Dakota who know the quality of life the state offers, he said, it’s even better if they have relatives in the community where they’re recruited to.

The next best candidates are from similarly rural places, such as Wyoming, he said.

The worst are those from the East or West coasts or from abroad who aren’t familiar with rural living, he said, and, typically, it’s better to just go for the ones that are doing their residencies in North Dakota.

“What we’re trying to do is not put square pegs into a round hole,” he said.

“Sometimes just hearing that we’re calling from North Dakota, they’re not interested,” said Elonda Nord, the Lake Region clinic administrator. “I never try to sugarcoat the weather. Yes it’s cold here, two to three months it’s really cold.”

Still, sometimes outsiders do fall in love with North Dakota, Aaron said, such as Dr. Rup Nagala (and also his wife, Dr. Vani Nagala) who moved to Oakes, N.D., in 1982 and never left.

One way to retain foreign-born doctors, Aaron said, is for the community to work hard at integrating into the social fabric, inviting them to events and making sure they’re not always going home alone after work.

Elonda said her experience with the foreign-born doctors that choose to stay in Devils Lake is they have very good friends in the community and go home to visit family fairly regularly.

Conscious of the desire of some to at least live in a city rather than in a small town, I asked Aaron if it wasn’t possible to recruit a doctor who would commute from a bigger city.

He said he’s seen that done, such as the case of two doctors commuting to Elgin, N.D., from Bismarck (which Google Maps says is an 87-mile drive each way.). But, he said, those doctors sometimes find it hard to attract patients put off by the fact that they don’t live in the community.

Increase the number of doctors you can educate

The problem with recruitment is the pool of labor that’s available, given the conditions stated above, is kind of small. The problem with retention is there aren’t that many to retain to begin with. UND graduates only 55 doctors a year.

In the longterm, in Dr. Wynne’s view, the best solution is increase the number of grads. If the the percentage of grads that go into family medicine and move into rural areas stay the same, an increase in the number of grads will increase the supply of doctors for rural areas.

I don’t think Dr. Johnson is satisfied with that sort of logic and he’s been talking about going to the Legislature when Dr. Wynne is there asking for money.

Since I have delved into exactly how Dr. Wynne plans to structure the added faculty — Will there be more focused on family medicine? — or the expanded residency program — Will more of them be in rural areas? — I couldn’t tell you much about how this effort to “broaden the pipeline” might work out.

I did, however, ask Dr. Wynne if it was important to tread cautiously here because, as he recognized, a lot of other universities are expanding their med schools, too. UND wouldn’t want to end up overinvesting.

Dr. Wynne said the university will be able to adjust as market trends emerge. “We’re not being closed-minded about this,” he said. If there are too many faculty members in a field that’s saturated, he said, their numbers could always be thinned through attrition.

For now, there’s not a lot of other trends on the horizon other than the rapid aging of the Baby Boomers and their increased need for medical care.

That tsunami will reach shore in about 10 to 15 years, Dr. Wynne said, so UND has to start now.