Oklahoma is short on physicians and long on health care need. It is no shock to find the state listed at the top of negative lists and bottom of the favorable lists ranking health and health care among the states.
Medical students are increasingly choosing the larger salaried specialty fields of medicine over primary care practice. Those who do go into primary care tend to opt for the lifestyle practicing in an urban or suburban community affords them; the current pool of physicians is rapidly reaching retirement.
“The average age of a primary care physician in Oklahoma is 54,” says Michael Woods, program director for the University of Oklahoma’s rural residency program.
We have the oldest average age of physicians per capita in the nation, says Rick Ernest, executive director of Oklahoma Physician Manpower and Training Commission a state agency charged with building rural health care.
Some estimates predict that Oklahoma will need as many as 2,000 additional primary care physicians by 2015, Woods says.
Oklahoma already ranks near the bottom of the Association of American Medical Colleges list of doctors per capita at 43rd in the nation and 41st in primary care physicians per capita. There are 76 physicians per 100,000 residents in the state, while the rest of that nation averages 220 physicians for every 100,000.
“We are in trouble, and it’s getting worse,” Woods says.
We have a perfect storm on our hands, says Kayse Shrum, president-designate of the OSU Center for Health Sciences.
In addition to all this, she says, “A federal cap was placed on residency funding in 1994. All hospitals with residency programs were ‘capped,’ or not allowed to expand residency programs with federal money,” she says.
Running The Numbers
If you look at the problem just from the aspect of getting more people educated as physicians and funneling them to the areas of need, there are already issues.
“It takes 10 years to mint a new doctor,” says David Kendrick, CEO of MyHealth Access Network and associate professor of internal medicine at the University of Oklahoma School of Community Medicine.
The state has two medical schools. Each year these highly competitive programs whittle large application pools down to incoming classes of about 165 at the University Oklahoma and about 115 at Oklahoma State University. Woods says the average debt for these students four years later at graduation is $162,000.
The total bill can climb to $300,000 as interest accrues during a student’s residency program while payments are deferred.
“That impacts the choice of the student into the type of medicine to practice,” says Woods.
When faced with this debt, the economics do not favor primary care fields like family medicine, pediatrics, internal medicine or obstetrics and gynecology, which offer an income average of $58 an hour or less, says Woods. In a specialty field, physicians are able to earn $100 or more an hour.
The choice of doing a four-year residency and earning $400,000 or a three-year residency and earning $100,000 becomes an easy one, says James Prise, a family practice physician.
The income of a primary care doctor is definitely nothing to scoff at. But when given the option to train for one or two additional years for up to quadruple the income each year, it is easy to see why a student would make that choice.
After selecting a field to continue in, landing a spot in a residency program is another highly competitive hoop to clear. This further decreases the number of students from a class continuing their medical training in the state.
“Highly educated, highly trained smart people can live pretty much wherever they want,” says Kendrick. “And when they go away for residency, it is hard to get them back.”
Those entering a primary care practice as new doctors most often choose urban and suburban clinics.
“The need for family docs gets sucked up by urban and suburban needs,” says Prise.
This makes the shortage of physicians especially hard on rural areas.
Add to this expanded access to health care through the Affordable Care Act’s expansion of Medicaid, and Oklahoma’s ability to provide primary care looks pretty overwhelming.
A February 2011 New England Journal of Medicine article evaluated the capacity for states to provide primary care in the event of Medicaid expansion, based on the increase in Medicaid in the states in relation to the number of primary care doctors available.
“Oklahoma was far and away the most dramatic physician shortage in that survey,” says Kendrick.
The state was predicted to have the largest rise in Medicaid with the smallest growth of primary care physicians.
The fallacy, though, says Kendrick, is that these people already live in our state. They just do not have access to health care when they need it. An expansion of Medicaid does not change that. It only makes the care more affordable.
Accessibility seems to be an entirely different story for a state already suffering a doctor shortage before any expansion to health programs. So the question remains: How do we fill this physician gap?
Additional physician assistants and nurse practitioners can be of some help, but even these medical professionals are opting for urban and suburban practices.
“There has always been a disparity between urban areas and rural areas,” says Ernest.
PMTC was created in 1975 to incentivize physicians to practice rural areas. In Oklahoma 25 percent of the population lives in rural areas. However, only 10 percent of the physicians practice there.
OU and OSU medical schools are both working to produce more primary care physicians ready to practice community and rural medicine. Fourth-year students generally do a month-long rotation in a rural clinic. OU even has a school of community medicine option, which allows students to spend the third and fourth year of medical school in Tulsa learning about primary care. Students can continue on to a rural medicine residency.
Part of the battle rural medicine faces is lifestyle.
“You are out in a community where there are two or three doctors, and every third night you are on call. It is a major problem for all of rural America,” says Ernest.
He says the most effective way to overcome this, thus far, is to throw money at it.
PMTC’s core program offers scholarship money to students in exchange for service in a rural area defined by populations of 7,500 or less. This is helpful but tops out at $60,000 for four years of service.
A new program funded by a grant from the Oklahoma Tobacco Settlement Endowment Trust and matched by the Oklahoma Healthcare Authority will offer physicians an even more attractive reason to leave the city – $160,000 for four years of rural service.
“When you owe four years in a community, you get your family established. You have relationships in the community. We are hoping that will make people stay. In a lot of cases it does,” he says.
National Health Service Corps is a program run by the U.S. Department of Health and Human Services that incentivizes physicians to practice in underserved areas in much the same way. For each year of service a student commits to practicing in an underserved area, money is rewarded based on a need score given to the community. Communities with higher need scores garner greater reward. However, no matter which community a physician selects, if he or she stays with NHSC for six years, their remaining school debt is paid off, says Woods.
Prise moved to Oklahoma from Canada where he practiced in a rural clinic. After 15 years of 80-90 hour weeks, he wanted the ability spend more quality time with his family and a more fixed schedule.
He has practiced in Canada, New Zealand and the U.S. He says the rural shortage is a worldwide problem
“There is a [misconception] among our urban counterparts that if people in rural areas need medicine they will drive to the city,” Woods says.
When he started his practice in Ramona, Okla., there had not been a physician there in more than 50 years.
“In the first six months of practice, I saw more cancer than I did in three years of residency,” he says.
People just were not getting health care. “You need to get physicians in communities to provide health care,” he says.
Woods says that rural physicians often take on a leadership role in the community and have an impact on the overall health of the community. When he starts seeing flu cases in his clinic, he contacts the superintendent of the school district to notify the school to take precautions. Also, he spends his Friday evenings on the sidelines of the football game to care for players.
“That’s part of what you do in small communities,” he says.
Small communities also risk losing their hospitals as they lose doctors. Ernest says there are about 25 to 30 rural hospitals in Oklahoma. If these hospitals are lost, people are 60 to 70 miles from medical help.
A community needs resources to deal with the day-to-day fever or the grandfather that falls, says Prise.
Some physicians want this lifestyle. They like the open space of the country and all the activities it offers, says Woods.
Students with rural backgrounds are among these. However, Woods says the students most likely to go into rural medicine tend to be applicants pursuing a second or even third career. They tend to have lower MCAT scores and grade point averages.
“The only thing that tells you is how well a medical student is going to do in the first two years of basic science work,” he says.
These students may excel in the clinical setting; however, an unintended consequence of medical school admission being focused on scores is a selection biased against them.
Woods says some states like Alabama have rural pipeline programs that are very effective in working to recruit and train the students most likely to succeed in rural practice.
Woods himself does a lot of work with the local high school. When he began practice in Ramona, he said there would be three or four years between students coming to him interested in pursuing medicine. Now he has three to five a year in a school that graduates classes of 50-60 students.
“You can make an impact working with your school system,” he says.
An App For That
Technology can also have a major impact on optimizing scarce resources.
While a medical student at OU, Kendrick first developed Doc2Doc as a tool to coordinate medical care of prison inmates. Use of the tool resulted in a 70 percent reduction in specialty care.
The solution worked so well, the system was rolled out in Tulsa where wait times to get into specialists decreased. Primary care doctors were then able to use the tool to consult and coordinate with specialists about patients’ needs.
Wait times dropped as specialists were able to triage patients online. One dermatologist who had typical wait times of six to nine months for availability found that half of the cases could be consulted with by phone or referred back to the primary care doctor for further instruction.
MyHealth Access Network is another tool Kendrick has built to optimize a patient’s data and defragment care.
The Journal of the American Medical Association reports that 18 percent of medical errors that lead to adverse drug reaction are due to missing patient information.
Additionally, when you visit the emergency room or dermatologist, your primary care doctor does not necessarily know and thus does not have the ability to add this to your patient file or treatment plan.
Kendrick says technology in medicine is much like technology in airplane flight. In the early days of flight, in order for the pilot to know how high and which way he was flying, the only tool he had was looking out the window.
Gauges were introduced to the dashboard of the plane in order to help aggregate and process all of this information.
“It’s not taking away the pilot’s decision-making. It is giving the information to make those decisions,” he says.
Medical informatics is a field popping up to help provide these gauges to physicians. Kendrick says Oklahoma is a leader in this field.
“There is so much data coming at us. I’m still required to look at every piece of data and put it into a story in my head,” Kendrick says.
With the proper information, though, when a patient came to him, he could look at those gauges and determine if the patient is at risk for certain health issues in the future and what interventions might be most effective in heading them off.
He can also proactively look at his patient load in aggregate and understand and make room for patients who are most in need of care.
“Everybody should practice at the top of their license,” he says he tell students.
If you can keep each doctor practicing what they are experts in, it unclogs the entire system. Data and technology can help us distribute that load.