Heather Stock is part of a dying breed.

Dr. Stock, a first-year internal medicine resident at Harrisburg Hospital, grew up in Pennsylvania, went to medical school at Penn State University, and wants to stay right where she is, doing urban under-served care.

	Darrell Sapp, Post-Gazette
	Medical school interns, from left, Alik Widge, Gabriel Cisneros, Bryan Ward and Jeanna Goo in front of the UPMC Montefiore, where they have patients. Click photo for larger image.

State Rep. Josh Shapiro, D-Montgomery, wishes there were more doctors like her. Instead, he said, only 8 percent of doctors who train at Pennsylvania medical schools stay in the state to practice.

The growing scarcity of physicians, combined with the state's aging population and rising demand for health care, is creating a crisis in Pennsylvania, he contends.

"It's like having a baseball team with no farm team," said Mr. Shapiro. "Forty-one percent of current Pennsylvania physicians are going to retire within the next decade, and no one is coming to take their place."

In hopes of changing that, he has introduced a bill in the House that attempts to increase the number of primary care generalists and stem the flow of young physicians out of Pennsylvania by repaying their student loans. To entice young physicians to stay, the bill would repay a doctor's medical school loans at a rate of 10 percent a year for 10 years.

With the mean debt of graduates hovering around $150,000, loan "forgiveness" would be a step in the right direction, Dr. Stock said.

"Pennsylvania is going to be in a crisis very shortly," she said. "Hardly anybody is staying in the state to practice -- let alone primary care, and let alone primary care in a health shortage area."

The crisis is in part the result of high medical-school tuition costs. To pay off their debts, more and more medical students are choosing to enter specialties, which pay more than primary care.

"It has been found that in states where there are a higher proportion of specialists, overall health spending is higher, while quality of care is lower," said Gabriel Silverman, a student at the University of Pittsburgh School of Medicine. "It's a vicious cycle of higher tuition costs begetting higher health system costs leading to even higher tuition."

John Derrickson, executive director of the American College of Physicians, Pennsylvania Chapter, also supports the bill: "Residents who finish their training are being recruited nationwide, and though Pennsylvania has wonderful training programs and world-renowned teaching hospitals, it has not made an attractive environment for people to open their practices."

The flight of physicians is due in part to the high cost of overhead to start a practice in Pennsylvania. The state requires all doctors to have medical malpractice insurance, at higher rates than almost any other state in the country.

"Pennsylvania has a bit of a bad reputation nationally when it comes to physician recruitment, due to high insurance costs," said Chuck Moran, of the Pennsylvania Medical Society. "In states with lower overhead costs, physicians can have a better salary."

Health care providers in Pennsylvania are required to purchase at least $1 million in malpractice liability coverage. To help defray these costs, Gov. Ed Rendell introduced an abatement program in 2002.

Still, Mr. Derrickson said, "Even with abatement, malpractice fees are still considerably higher than almost anywhere in the country."

Amy Kelchner, of the Governor's Office of Health Care Reform, disagreed: "Compared to other states of our type, size and demographic, we're probably in the ballpark of what other states are paying."

And, she said, the numbers can be misleading.

"Numbers do not show that we have doctors leaving Pennsylvania. The total number of doctors has in fact increased a little over the last couple of years."

Data from the American Medical Society show that in 2003, 31 percent of residents planned to remain in Pennsylvania after completing a residency or fellowship program. In 2005, that number increased to 34 percent.

Though these numbers are higher than the 8 percent cited by both Mr. Shapiro and Mr. Moran, Ms. Kelchner attributed the still-low percentages to Pennsylvania's high number of medical schools.

"A lot of out-of-state people go to school here and train here, then go home to practice," she said. "We have a large number of schools, so students are in and out. That skews the numbers."

Still, she said, "that's not the point. The point is that we'd like to keep everyone who trains in Pennsylvania in Pennsylvania."

While the need for Mr. Shapiro's bill and for changes in the health care system in general are acknowledged by many, the proposed legislation's influence remains to be seen.

Gabriel Cisneros, a fourth-year medical student at UPMC, still plans to return to California after graduation. "Everybody's going to be in debt after graduation," he said. "But I'd like to be closer to my family. My mind is set on leaving Pennsylvania."

A provision of the bill that might further deter participants says that if doctors move out of state before 10 years, they must reimburse the state for the amount received up to the time they leave, plus interest.

"I'm strongly in support of the concept of this bill, which is that something needs to be done to keep doctors in Pennsylvania," said Dr. Stock. "But with the field of health care changing the way it is, I don't think a lot of people will go for a 10-year commitment."

Mr. Shapiro believes the commitment was fair. "Ten years is a reasonable amount of time in exchange for the commonwealth paying for their medical school training," he said.

But Dr. Stock pointed to federal loan-reimbursement programs that require a shorter commitment from participants, and might thus be more attractive to students.

"I'm from Pennsylvania, so it's easier for me to look at a 10-year commitment," she said. "But even I would have to research my alternatives before I would commit to that."