Incentive programs implemented to address rural doctor shortage
When you think of small town America you imagine mom and pop shops, a few stop lights and a kindly country doctor. But the reality is often empty storefronts and even fewer doctors. Rural doctor numbers aren’t increasing.
By Lexi Churchill, Humera Lodhi, Jiayi Wang
As the country’s population grows, so does its need for doctors. There is no place where this is more apparent than in rural America. But a medical residency cap introduced in the Balanced Budget Act of 1997 makes it difficult for medical schools to meet this need.
In Missouri alone, 97 percent of rural counties are designated as Primary Medical Care Health Professional Shortage Areas by the U.S. Department of Health and Human Services.
There's been a massive expansion of medical schools but the main limiting factor is the amount of residency spots which have been pretty stagnant,” MU medical student Ryan Rader said. “That's kind of where there's a bottleneck. You've got all these people, all these spots opening up for medical schools but when it comes to training, there's a limited number of spots.”
The state legislature stepped in to help. Rep. Keith Frederick, R-Rolla, introduced the Assistant Physician Licensure bill to the Missouri House of Representatives. Medical students who were not accepted to a residency program could now apply for an assistant physician license. The license allows assistant physicians to practice medicine as long as they are within a 50-mile radius of a supervising doctor. Assistant physicians may only serve as primary care providers in underserved areas.
“It is a blessing in disguise that this slice, this program has been drafted,” MU nurse Ray Paguntalan said. “Everybody deserves health care, deserves to be treated, deserves to have proper health, and if we're able to provide for him, why not?”
The bill was passed in 2014 and Missouri became the first state to license assistant physicians. Paguntalan graduated from medical school in 2012 and works two part-time jobs as a psychiatric nurse. He became one of the first people to apply for an assistant physician license. This license allows Paguntalan and others to serve in the medical-field as they always wanted to.
“There's a lot of people that I know that are physicians that haven't gotten any residency, but they are also experienced in the health care. They’re nurse practitioners, they’re physician assistants,” Paguntalan said. “They planned to go to become physicians but they never got the chance to because they never got selected for residency.”
Another initiative is the Conrad 30 Waiver Program which began in 1994 and was reauthorized in 2003. The federal government waives J-1 visa requirements in exchange for foreign doctors serving in underserved areas. Twenty-five percent of American doctors are foreign medical graduates.
The department also implemented a student loan forgiveness program. A student’s medical school loans are forgiven if they work in an underserved area.
Other government agencies offer similar loan relief programs. Kaleem Syed is a psychiatrist living in Columbia who began working in rural Missouri under the National Health Service Corps Student to Service Loan Repayment Program.
“I'm one of the mentors of that program. They refer me people maybe seven, eight times a year,” Syed said. “My goal is to encourage them to use this program and to tell them how I feel about work in those areas.”
Many times these programs have difficulties attracting medical graduates despite the incentives. The assistant physician program began accepting applications in January 2017, but it has only received eight applications since then.
Other programs also experience low recruitment numbers. Most medical students graduate hundreds of thousands of dollars in debt, but few take advantage of the loan forgiveness program.
“There's a lot of uncertainty amongst my classmates about whether or not this program will be here in 10 years because the amount of loan write offs for physicians will be significant,” Rader said. “It's a great idea and it's a great program, but we're concerned that it might not be here in 10 years.”
Meanwhile, the shortage of doctors continues to climb. The National Association of American Medical Colleges estimates a shortage of up to 95,000 physicians across the country by 2025.
However, the physician shortage is not the only health care problem rural areas face. Syed Rashid is a doctor in Moberly and said patient-doctor relationships are sometimes difficult in small towns.
“Not all patients want to come get services in Moberly. A lot of them still come to Columbia,” Rashid said. “They have this perception that they will not get adequate care. I think historically they have had some experiences in the past.”
Lynette Sonka is one of those patients. She lived in small towns for decades and prefers to go to bigger towns for her health care. Sonka lives in Madison -- a town with no hospital or Walmart. She makes a quick drive to Moberly for her groceries, but prefers the hour-long trip to Columbia for her health care needs.
“I went to small town doctors, 20, 30 years ago when I lived in small towns. I just had one bad experience, maybe two,” Sonka said. “I have more faith and more trust in the doctors in Columbia.”
Sonka goes out of her way to seek medical care in Columbia because she is wary of the doctors in her small town. However, for other patients who need to leave town to get the health care service they need, driving long distances isn’t always an option.
According to the Missouri Department of Health and Senior Services, education and income have an impact on health. A report by the department found rural Missouri residents are at a significant disadvantage when it comes to these socioeconomic conditions when compared to urban Missouri residents.
“A lot of them are poor and they can’t afford a lot of things-- multiple visits to big cities they don’t want to do, sometimes vehicle is an issue, sometimes they don’t feel comfortable going to bigger towns,” Islam said. “So a lot of times we have to take on more than we would if we were in a bigger city.”
Incentive programs have been trying to attract physicians to underserved areas for years, but have not had an overwhelming turnout. Rural cities remain an unpopular destination for young doctors, leaving residents of these town with fewer and fewer options.