Doctor shortages continue to be an issue in Iowa’s most rural areas. But momentum is picking up with hopes of reversing the trend.
Iowa ranks 43rd nationwide in the ratio of doctors to residents, and ranks last in the number of emergency medicine and OB-GYN physicians, according to the Iowa Medical Society. Neighboring states such as Nebraska, South Dakota and Missouri all rank higher.
In addition, the U.S. Department of Health and Human Services has identified 41 Iowa counties, most of them rural, with shortages in primary care physicians.
The problem is expected to get worse before it gets better, with an additional 32 million Americans anticipated to have access to health care through the Patient Protection and Affordable Care Act.
Gov. Terry Branstad has proposed spending $4 million on two programs to address the issue in his budget for the 2014 fiscal year, which starts July 1:
- He wants to put $2 million annually toward a program that would pay off the student loans for up to 20 students who agree to work five years in a rural part of Iowa.
- Another $2 million would fund a program created under former Gov. Tom Vilsack that provides matching grants to hospitals for more medical residencies.
Branstad also wants to change how medical lawsuits are reviewed, saying in his Condition of the State address that “frivolous lawsuits are harming our ability to recruit and retain doctors.”
Michael Bousselot, the governor’s health care policy adviser, said both appropriations are a priority of the governor, and he's confident both will be included in the final budget.
“To break those rankings, we need a lot of doctors, but we’ll see immediate effects because there will be 20 doctors in the first year of the Rural Physician Loan Repayment Program,” Bousselot said. “There will be 20 doctors getting their loans paid back that will be in small communities.
"The same thing with residencies. That’s more doctors in hospitals in Iowa, right away, and that’s a good thing.”
The Iowa Academy of Family Physicians initially came up with the idea for the Rural Physician Loan Repayment Program, Bousselot said. He added that Branstad wants to expand the program to include emergency care and OB-GYN physicians.
In one small town in northwest Iowa, with a population under 5,000, the town’s lone doctor is retiring, and residents are worried they will lose that convenient access to health care. Bousselot suspects similar scenarios are happening in other communities.
“The thing that’s scary about these numbers is, maybe now the conversation shouldn’t just be about small and rural communities,” he said. “Maybe it should be more about mid-sized communities that we’ve traditionally thought would be there forever.
"If you don’t have doctors, people aren’t going to want to be there. It’s a quality of life issue.”
Dr. Jamie Wallace, who grew up in Mount Vernon, said it was important for her to practice in similar-sized community. She was twice the recipient of a scholarship for students planning to pursue medical careers in communities with a population of fewer than 10,000.
“One of the best things is being able to see people that I know,” Wallace said. “You know their background story, and you know their family and their history.
"It just makes it so much easier to care for them as a whole person.”
Wallace, who started at Mount Vernon Family Medicine in September, said a variety of factors make it less likely for doctors to practice in a rural area. She said the majority of medical students come from more populated areas and therefore are more likely to start their careers in a similar-sized community.
Also, she noted fewer rural students have doctors in their families who might otherwise steer the student into the medical profession.
Student loan debt is a big factor, too. Medical school graduates now face an average of $162,000 in debt, according to the Association of American Medical Colleges. According to a report released in July 2012, a graduate with that much debt would face monthly payments of $1,500 to $2,100 after residency training.
“It’s like they’re buying a house,” Bousselot said. “Most people would graduate college, but they’re buying a house as their education that they need to start paying back. That’s monumental, to start, and, because it’s not a house, it impacts their decisions.”
Family medicine doctors, also known as primary care physicians, generally make less money than doctors trained in specialty areas, such as surgery or internal medicine. Small towns sometimes don’t have enough residents to support in a practice in specialty areas, and that means students concerned about paying off their debt quicker often end up in larger cities.
Wallace said it seems as if some medical schools steer students toward specialty practices, rather than general practice.
“If we don’t encourage students to go into the primary care specialties, then we’re training physicians that will, because of the job, inherently go elsewhere, to larger cities,” Wallace said.
A new program at the University of Iowa is designed to support medical students from small to medium-sized towns in Iowa, with the goal of having them return to practice in a similar-sized community in the state.
Students who go through the Rural Iowa Scholars Program are expected to practice for at least five years in an a city with fewer than 26,000 residents that is at least 20 miles from a population center of 50,000 people. Those students who meet the requirements are eligible for a loan repayment program worth $100,000.
Dr. Victoria Sharp, director of the program, said four students will be in the program each year. Curriculum is designed to enhance their connection to rural Iowa.
“We set them up with mentors in small towns,” Sharp said.
“Before they start medical school, they go meet their mentor and shadow them for a few days. Then they start medical school and interact with those mentors.”
State leaders hope increasing the number of rural doctors in Iowa will improve the quality of life in Iowa and help the state’s economy. Wallace said the UI program and other initiatives make sense.“The awareness is the first step to it getting better,” she said.