Skip to main content

Rural Healthcare Workforce Shortages Defy Easy Solutions

 |  By John Commins  
   February 27, 2013

With the clock ticking on sequestration and its cuts to healthcare funding, it seems callous to pile onto rural providers with more gray news.

And yet, lost this week amid the lead-story brouhaha over the self-inflicted wounds administered by our federal elected officials were two items that illustrate the challenges of bringing physicians to rural America.

First, the New York Times reported that a 15-member commission created more than two years under the Patient Protection and Affordable Care Act and charged with assessing the needs of nation's healthcare workforce has never met because funding hasn't been allocated.

Of course, nobody expected the National Health Care Workforce Commission would solve the problems of recruiting and retaining physicians and other clinicians into underserved areas. And the federal government is doing other things to encourage physicians to settle in underserved areas with debt-relief programs such as the National Health Service Corps.

However, a high-profile commission could have raised public awareness about these chronic, widespread and growing clinician shortages in rural areas.

Also this week, the Association of American Medical Colleges issued its annual report, Physician Education Debt and the Cost to Attend Medical School, and found that while the average debt load for medical school graduates in 2012 was $170,000—up 5% over 2011—those new doctors did not prioritize debt as the driving force in their decisions to seek a particular specialty.

In fact, "education debt" placed 11th—dead last—on the list of "influence of various factors on the specialty choice of 2012 graduating medical students."

Upon review, the low priority of debt obligation in making a lifelong career decision makes sense. Yes, $170,000 in student loans is nothing to sneeze at, especially if you've just acquired a doctorate in phrenology.

However, we're talking about highly compensated professionals. Although you wouldn't know it by listening to them, physicians are among the highest paid classes of workers in the United States. Primary care docs fresh out of residency can earn about $170,000. That's a much better debt-to-salary ratio than the typical law school graduate or new veterinarians

Atul Grover, MD, a general internist and AAMC's chief public policy officer, tells HealthLeaders Media that student loan debt concerns among medical school graduates have been overblown by policymakers and the media.

"That was the conventional wisdom, but I don't think it was informed by very good studies," Grover says. "As we have done better and better surveys over the years from our graduating classes and gotten better information about what is driving their specialty choices, we have noted for a couple of years now that there doesn't appear to be a clear relationship to debt."

The problem, however, is that many of the government programs that are designed to attract physicians to rural areas center on student debt deferment, reduction, or forgiveness, an incentive we now learn that these young docs don't prioritize.

"When it comes to the actual specialty choice, debt does not seem to be that much of a big driver. It has more to do with people's personality and how well that fits what they want to spend their day doing. What we don't know is whether it had an influence on people's willingness to serve underserved communities," Grover says.

"If you have a large amount of debt and you are worried about making your loan payments, while it may not affect your specialty choice it may affect your decision to serve an underserved population that has a high Medicaid population with lower reimbursements. We already have trouble getting physicians to see Medicaid patients now. And Medicare is always on the edge with the (Sustainable Growth Rate [formula])."

The results of the report also suggest that finding actionable and effective enticements to bring physicians into rural areas could be problematic. Many of the enticements the young doctors cited when they chose a particular specialty were based on personal opinions and preferences such as personality fit, lifestyle choices, work/life balance, and future family plans. It would be hard to develop a rural healthcare physician recruiting strategy around intangibles such as "role model influence."

The AAMC study is limited because it surveys medical school students who've already accepted the burden of amassing debts. The study cannot gauge the intimidating effect of these debts in chasing away would-be physicians from attending medical school in the first place—particularly students from minority groups or lower socio-economic backgrounds.

"Does it discourage them from going into medicine because they may not understand how it is possible to repay very large debts of $170,000 to $180,000?" Grover says. "From that standpoint, if you are scaring off potential physicians from rural and underserved areas because of that huge price tag and those are the very students more likely to go back and serve those communities, then debt is a much bigger issue."

Many observers, including Grover, believe that the best way to find physicians willing to serve in rural and underserved areas is to recruit medical school students from those same areas.

"If you look at a lot of public medical schools like the University of Mississippi and the University of Arkansas, where they specifically are taking students from the state, that is part of their mandate as a public university," Grover says. "They do a much better job of keeping those doctors in their states and also going back into their communities, because that is where families are."

That is not as easy as it sounds.

"The challenge there is we can't start that at medical school or even college. It's a K-12 issue," Grover says. "People have to understand that this is an opportunity to aspire to do this when they are going through middle school. When you get to college it is often too late."

"The other thing we find is if you want to get physicians in rural areas, it's not just helpful that they are from rural areas. Their spouse has to be from a rural area. So, we have to get rural physicians and then match make for them," Grover says with a laugh, although it's not clear if he's joking.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

Tagged Under:


Get the latest on healthcare leadership in your inbox.