As far as Barbara Kuhl is concerned, there’s no doctor shortage in Marienville, Forest County. People mistakenly think her town is in the middle of nowhere.
“We’re the middle of everywhere,” she said, noting the Jenks Township village is 25 miles from hospitals in Brookville and Kane with more distant ones in Clarion, Franklin, Oil City, Warren and Dubois in northwestern Pennsylvania. “I don’t think there really is a doctor shortage, given the fact we have a physician assistant here. We do have an ambulance service and it’s not inconvenient to go 25 miles to the Kane or Brookville hospitals because there’s no traffic on our highway, and there is no waiting time at the hospital.”
Former residents of Sheraden, Mrs. Kuhl, 76, and her husband George, 81, own and operate Bucktail Hotel Restaurant and Bar in Marienville. Driving to a hospital in Jefferson County, she said, compares in time with driving from suburban communities to hospitals in Oakland or elsewhere in Allegheny County.
“I think our health care is good,” she said. “We just don’t require a lot of health care but those that do seem to get by. I think it is available but everyone shops out of town, so they plan their doctors’ appointments along with their shopping trips.”
Trees vs. treatments
In truth, physicians in Forest County are rare as ospreys in a county of 7,716 people — but more accurately 5,500 people given the 2,200 inmates at the Forest State Correctional Institution with their own doctors.
Paul Harvey, 72, who actually lives in Coolspring, Jefferson County, is the only physician practicing medicine in the county and just on Tuesdays at the Marienville Rural Health Clinic. There he sees patients and supervises Shannon Daubenspeck, a physician assistant who sees patients five days week. The arrangement meets Medicare requirements for rural health centers, he said.
Even Dr. Harvey agrees there’s no pent-up demand for more physicians.
“I know them, and they know me,” he said of his patients, with the usual problems of hypertension, diabetes and high cholesterol. “We get patients from as far south as Brookville and all the way from Warren,” 45 miles north.
What the area lacks, he said, is a psychiatrist or psychologist. He does concede that doctors aren’t eager to move to Forest County so “getting someone to Marienville is hard.”
That’s why he was coaxed out of retirement.
Doctor deserts
Despite those opinions, rural America and low-economic areas of the country have too few primary care physicians and certain medical specialists, including most rural counties in southwestern Pennsylvania.
Forest County’s ratio of population per family physician is the highest in the state — one per 7,716 people, based on the Robert Graham Center’s Primary Care Physician Mapper program that uses Medicare and Medicaid records. The map starts reflecting shortages when the ratio rises above 1,137 people per primary-care physician, with that category including family and general practice doctors and general internists.
For example, Fayette County has 54 primary care physicians for 136,600 people, or one doctor per 2,355 people. In northern West Virginia, a six-county region encompassing Ritchie, Pleasants, Doddridge, Calhoun, Gilmer and Wirt counties, there are 48,400 people but only 10 doctors — one for every 4,840 people.
The wife of a rural doctor in that area said her husband in his 60s works 12 to 14 hours each weekday at two health centers and makes rounds at a local hospital, with all the paperwork being done each evening. On weekends, he does rounds at two nursing homes.
She said he’d likely be too busy to call back but she’d give him the message. He never called.
Shortage reportage
While the Association of American Medical Colleges said the nation has an ongoing shortage of family physicians, others said medical colleges are unwilling to change their philosophy to train a higher percentage of family doctors. Meanwhile, most medical students have an enormous educational debt-load and don’t want to earn low wages in America’s hinterlands.
In its most recent report, the AAMC said demand for physicians will continue growing faster than supply, even with a modest annual increase in newly trained primary-care physicians. The nation, it said, will fall short of 61,700 to 94,700 total physicians by 2025.
That’s a shortage of 35,600 primary care physicians,10,200 medical specialists, 33,200 surgical specialists and 32,600 other positions, all while aging baby boomers, 65 and older and needing the most health care, soon will top 40 percent of the nation’s population.
“The total projected physician shortage persists under every likely scenario, including increased use of nurse practitioners and physician assistants, greater use of alternative settings such as retail clinics, delayed physician retirement and rapid changes in payment and delivery,” the AAMC report stated.
Wrong ratio
Other analysts said the actual problem is doctor distribution, with fewer than 25 percent of doctors in family medicine and more than 75 percent involved with medical specialties.
Medical schools tend to admit students from upper-crust society who become doctors and return to upper-crust communities or university health centers to complete their medical residencies and launch careers.
Too few students from rural, low-income areas lead to too few physicians returning home to practice medicine. The family doctor shortage especially affecting rural and low-income communities nationwide could be corrected simply by improving reimbursements for primary care and recruiting and encouraging more students from deficit areas to become doctors.
“About 80 percent of all medical school students come from the top 40 percent of income and only about 5 percent of all med students come from the lower 20 percent of income,” said Erik Porfeli, associate dean for community engagement and admissions in the College of Medicine in Northeast Ohio Medical University, that offers such a recruitment program.
Normal, day-to-day human behavior, he said, has people gravitating home or to communities similar to those where they grew up. “When you compose a medical school and when your students are not from medically under-served areas, what do you expect?” Mr. Porfeli said.
Quarterbacks needed
The ideal family physicians-to-specialists ratio of 40-60 or 50-50 would lower health costs and lead to better, more continuous care, said Laurence Bauer of the Family Medicine Education Consortium. He and Mr. Porfeli attended the Family Medicine Education Consortium conference Oct. 28 in Pittsburgh when the issue was discussed.
“From our organization’s point of view, more primary care is better. We just created a system that’s out of balance and continues to be out of balance,” Mr. Bauer said. “Family physicians, general internists and psychiatrists all are low on the pecking order and that creates an issue. We’ve created medical schools that, in my opinion, select people not generally wanting to go into general medicine and much more likely to go into sub-specialties.
“If you have a primary care physician serving as quarterback and allow him or her to make referrals, fewer people will be referred. But when they are, they don’t get lost in the system,” he said.
Only 75 percent of Americans currently have a primary care physician, with the remaining 25 percent using specialists or emergency rooms for basic treatment at high cost. A 50-50 split of family doctors and specialists would resolve that problem.
“Whether it’s a general internist or family physician, they understand the complexities of the health care system and that’s extremely valuable to patients,” Mr. Bauer said. “If would be great if everyone had a family physician and a system to reinforce it.”
Even more shortages
The national physician shortage is compounded by 20 million more people with health insurance under the Affordable Care Act and a scarcity of medical residency programs for new doctors to complete their training. Each year about 500 new doctors fail to get into residency programs, the AAMC said.
The association and the Council on Graduate Medical Education also have pinpointed physician shortages in geriatrics, internal medicine, general surgery and certain pediatric sub-specialties. In addition, the Endocrine Society reports the need for 1,500 more endocrinologists and 100 more pediatric endocrinologists, considering the diabetes epidemic and a higher incidence of hormonal disorders.
The American Geriatrics Society placed the national need for geriatricians in 2013 at 17,000 with only 7,500 available.
Meanwhile, there are only 28,250 psychiatrists in the United States (about 9 per 100,000 people), with 1,309 in Pennsylvania (about 10 per 100,000 people), and 6.5 psychiatrists per 100,000 people in West Virginia. Yet, one in five Americans has a mental disorder, according to the National Institution of Mental Health.
The AAMC said the shortage could soar as medically under-served communities begin seeking higher levels of medical care with insurance through the ACA.
“What we are seeing is that United States medical schools have increased their admissions by 26 percent, from 2001 to 2015, and we’re beginning to see an increase in medical students, and that came about as a result of our call [for more physicians] a decade ago,” said Janis Orlowski, AAMC’s chief health care officer. “It takes 10 years to train a physician. And while there are increases in admissions to medical school, the number of residency slots have not increased at the same proportion.”
Deploying physicians
In a survey last summer, area medical schools said they were training more rural physicians.
The Lake Erie College of Osteopathic Medicine in Erie, which trains doctors of osteopathic medicine or DO’s, has opened new campuses over the past eight years and is the nation’s largest medical school with an annual class size of about 535 students.
It also has a $500,000 scholarship program through Highmark to place graduates in rural areas. “Our commitment is putting physicians where they are needed and that’s what we want of our students — to go to areas that are under-served and where they are needed most,” said Eric Nicastro, assistant institutional director of communications and marketing.
West Virginia University Medical School and the Penn State University College of Medicine have increased enrollment gradually while placing medical school campuses in areas with physician shortages. The idea is that doctors tend to stay where they are trained. That’s especially true for residency programs.
“The national physician shortage is something we’ve been aware of for quite some time and have, in part, driven us as well, and many other medical schools, to increase enrollment. We currently are up to 110, which is an increase from 87 back in the 1980s,” said K.C. Nau, WVU associate vice president for health sciences.
Penn State College of Medicine in Hershey has launched a new program at University Park designed to train students in rural settings that have “remarkable needs.” In recent years, Penn State has increased its class size by 10 to 150, said Terry Wolpaw, the medical school’s vice dean for educational affairs.
“So much of this is about moving education into the community practice and get our learners to see how they practice medicine in that setting and perform as a community-based caregiver,” Dr. Wolpaw said. “That increases the chances that that is where the physician will end up.”
Pitt isn’t rural
The University of Pittsburgh School of Medicine has a different philosophy, given its ranking as one of the nation’s top medical schools.
John Mahoney, Pitt’s associate dean of medical education, said some med schools work to generate a larger quantity of doctors, “but here at Pitt, our research emphasis is a big deal — teaching students about research, critical thinking, leadership and solving big problems.”
Based on that philosophy, he said, Pitt has maintained an average class size of 148 students.
“One of our emphases is generating the next generation of leaders in primary care fields — those with big ideas to solve problem A or B,” he said. “Pitt graduates are going to some of the top programs and residencies, leading to careers where they are leaders in the field.”
That’s to say, the average Pitt grad, like many new physicians, has different ideas about the center of everywhere.
David Templeton: dtempleton@post-gazette.com or 412-263-1578.
First Published: November 27, 2016, 5:00 a.m.
