Recently the Shasta Health Assessment and Redesign Collaborative (SHARC), representing a wide spectrum of members from the private health sector and public health and social services sectors in Shasta County, completed an extensive study on Physician workforce in our community. Its findings are sobering, concerning to anyone who looks to the local health delivery system for care. It is also a wake-up call for our rural community if we want to get a handle on this. Some of the more critical issues identified was the verification of the gaps in available primary care doctors (i.e. Family Medicine, Pediatrics, General Internal Medicine, etc.) in our community and the clouds ahead with the knowledge over 50% of the existing ones are over 55 years old. Furthermore, 20% of primary care physicians are looking to retirement over the next five years. On the specialty care front, the situation is somewhat worse, particularly in certain specialties like neurology, general surgery, etc. where nearly 35% indicated either retiring in five years or leaving the area for other prospects. This should be no surprise to our community, particularly to those who recently had their primary care or even their specialty are physician retire and/or leave town for presumably a “better” opportunity elsewhere. For those of us who work in this healthcare “space”, it is not like we are not working hard to fill that void and trying to get ahead of it. However, many of the forces at play are beyond our control. Some are marketplace forces with respect to the volume of new doctors being trained. It may come as a surprise to many but 80% of our Medical Schools in the United States are private schools, charging $60,000 or more per year, not including living expenses, with the Federal Government more than willing to pony up the debt for those students. It is pretty typical for us to see a new primary care physician having $300,000-$400,000 or more of educational debt at the end of their training. This debt also becomes a major factor in medical students choosing better paying specialties than primary care. That said, with the growth of Medical Schools and their graduates why have we not seen that play out better in our communities? Well, graduation from Medical School does not guarantee or prepare you for being a licensed physician. In almost all cases, you need to finish a post-graduate residency. For primary care, it is typically three years of further training after medical school. For some specialties, it can go up to five years with a few more years of a Fellowship added in some cases. The road to being a physician is long, difficult and expensive. It does not help that the Federal Government, since 1997 (The Balance Budget Act) has effectively frozen publically funded medical residencies in this country. One exception has been the Teaching Health Center program that allows Community Health Centers like ours to train Family Physicians. But even this program is on its own “fiscal cliff” as Congress has not been able to find a long term solution to the funding for this training.
However, not is all lost. Redding does have some advantages. For example, we do have two excellent Family Practice Residency Training programs. One large one based at Mercy Medical Center (Dignity Health) in Redding with the other smaller program based at Shasta Community Health Center. These programs combined graduate around 8-9 physicians a year. If you consider that each Family Physician can care for around 1,500 patients, keeping our graduates here becomes a critical issue. Our success in this way has been variable. This past academic year over 50% of the graduates stayed in our community. We would love to drive that rate higher but that requires that our graduates (who come from all over the United States) are able to sink roots into our community. This is where our community can play a role in helping, where possible, through schools, churches, community groups, businesses, do what they can to make them want to stay. In short, there are plenty of jobs for physicians in our community, but it is the quality of life, work-life balance, the happiness of their spouses/significant others that make it happen for these young physicians.
In addition, there are many other strategies to fill in some of the gaps, particularly in primary care, like through the effective use of Nurse Practitioners and Physician Assistants. These programs also have grown in numbers, but they also suffer from the lack of financial support in the area of training during their education, and for newer practitioners, post-graduate residencies/fellowships that can help them be more competent and confident working in this very complex field of medicine. In our organization, we have started a post-graduate Fellowship for recently graduated NP/PAs but we need more of these opportunities throughout California and the U.S. but again opportunities are limited because of the lack of stable public funding. Not to make this political more than one can, but we have had this rural physician workforce conversation with Congressman LaMalfa who has gone to bat with his colleagues to find solutions to the Teaching Health Center funding issue and for that we are very appreciative. We think, in this area of federal policy, there is hope for more bi-partisan support to help close the gaps however all of this is further complicated by the debate over the Affordable Care Act and the issue of “repeal and replace”.
In truth, rural areas have always had an uphill climb when it comes to recruitment and retention of physicians. This climb has been made even more challenging with the various shocks to the system like adding millions of Americans through the Affordable Care Act to the ranks of the insured (providing a truer picture of the real gaps). That said, one could say that the repeal without replace of the Affordable Care Act could lessen the stress on the physician/clinician shortages but at what human cost? On an economic front, if you drop coverage of roughly 20,000 people from the Medi-Cal program and another 7,000 from the Exchanges (Covered California) in Shasta County, and the consequential $125 million reduction in local dollars running through our economy you got to think this is going to hurt our local economy as well. So in the end you have two linked issues of healthcare provider shortages and insurance coverage. On the training front Redding/Shasta County has the ability to find some solutions, particularly around primary care but we have no equivalent answers on the insurance coverage front. In both cases we need Congress to think beyond what is politically expedient and think more about what is in the long term interest of all Americans. Rural America in particular is most vulnerable to these decisions in Washington D.C.
Shasta Community Health Center