Doctor shortage acute in rural South Dakota

In small towns in South Dakota and across the country, a health care crisis is brewing.

As the baby boomers age, U.S. medical schools are working to prevent a looming shortage of surgeons and family practice doctors, particularly in rural areas. The shortage is rooted in the 1980s and '90s when U.S. medical schools capped enrollment, with the idea that managed health care, among other factors, would create a glut of doctors.

But as 79 million baby boomers begin entering retirement age, so are their doctors. From 1985 to 2006, the percentage of doctors 55 and older rose from 27 percent to 34 percent. The ramifications often are most severe in rural America, where only 4 percent of doctors are general surgeons, according to American Medical Association data.

In South Dakota:

There were 236 family physicians in 2006.

67 more physicians are needed by 2020 to meet the ratio of 41.6 per 100,000 people recommended by the American Academy of Family Physicians. 18 of 66 counties have no doctors living there.

The average doctor is 50 years old.

Considering the state's aging doctor work force, the ratio goal will be difficult for the state to achieve, said Dan Heinemann, senior vice president of Sanford Clinic and family medicine doctor. "I think we're going to have to get creative in how we're going to do things," Heinemann said.

"As those small towns shrink, the age of those small towns is getting older. And as the small towns get smaller and the population of patients to support a practice shrinks, it might be very difficult to replace some of the practices."

Physician surplus forecast led to caps

Nationally, a number of factors have led to the coming physician shortage.

From the late 1970s to the mid-90s, several national advisory groups, including the Institute of Medicine, 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 mistake, medical schools began accepting more applicants. Last year, almost 17,800 students entered U.S. medical schools - the largest class ever.

USD's medical school followed national trends in pulling back enrollment, said Dr. Rodney Parry, dean of the Sanford School of Medicine at the University of South Dakota. In the late '70s and '80s, the medical school graduated 65 students per class, but reduced to 50 per class 20 years ago and that's where it has remained, Parry said.

Before the medical school can increase class sizes, it must be approved by the Legislature, Parry said. And it's more than just class sizes - there needs to be an increase in slots for hospital residencies where doctors do their crucial on-the-job training, he said. Where a doctor does his or her residency is a main factor in where they eventually will practice.

Family medicine, surgery aren't draws

The medical school has five residency programs, including internal medicine, pathology, psychiatry and child and adolescent psychiatry. The school also has a transitional year residency program, and a pediatric residency program is in the works. The residency programs are paid for partly by federal Medicare dollars, which are essentially frozen at 1990 levels, Parry said. The hospitals and health systems pick up the rest of the cost.

"South Dakota has the second fewest residency slots of any state in the nation that has a medical school," Parry said.

Many of today's young doctors start their careers $150,000 to $250,000 in debt in education costs, so they often go where they can make the most money. And critically important areas such as general surgery and family medicine are less lucrative than some specialties, such as orthopedic or plastic surgery.

"If we don't value those positions more in terms of income and payment, especially by the federal government, we're not going to have the kind of work force that we need for the boomers," Heinemann said.

Some physician groups are trying to drive changes that will offset the effect of the doctor shortage.

Pursuing incentives for rural care

Medical schools need to hunt for a slightly different type of student - those who want to practice medicine in rural areas - and focus less on attributes such as an applicant's previous clinical research, said James King, president of the American Academy of Family Physicians.

"Just increasing the number of slots for medical schools is not going to solve the problems of supplying health care to the citizens," he says.

He and others say physician reimbursement has to change in a way that will compensate for treating rural patients "where they live." Many patients have to travel or be transported long distances to get the care they need, the doctors say, especially trauma and critically ill patients. That will only get worse as the shortage grows.

King says doctors should be compensated for helping patients manage chronic conditions. A follow-up phone call, e-mail, or a visit with a dietician or a nurse on a physician-lead team might help eliminate the need for surgery.

New technology to close distances

Avera McKennan, which is working to expand into rural areas, is looking at technologies that can expand doctors' capabilities, including telemedicine, said Dr. David Kapaska, Avera McKennan's senior vice president and chief medical officer.

That includes Avera's eICU project, in which doctors and nurses can remotely monitor critically ill patients at rural hospitals from a central location in Sioux Falls. The eICU technology is in 15 locations now.

"It allows us to cross the miles without making the patient or the physician travel long distances," Kapaska said.