‘This is where I belong’

Nine months of hands-on clinical training, seeing patients and working with physician mentors at Affiliated Community Medical Centers reinforced the desire of Sarah Eisenschenk, now a fourth-year medical student at the University of Minnesota, to become a rural primary care doctor.

“I guess I found out that this is where I belong!” she concludes in an essay posted this past summer on the Discover ACMC blog.

When you get right down to it, all health care ultimately is local – and you can’t have a good local health system when the right people aren’t in place.

Much has been written about the supply of physicians in the U.S.: how there aren’t enough of them, how specialties such as primary care and geriatrics are in short supply, and the geographic imbalances that leave some urban areas with a surfeit of physicians while rural and/or remote communities go begging.

As someone who lives in rural Minnesota, I’m keenly aware of how much it takes for local providers to attract and retain qualified doctors. They’ve notched up several successes in the past couple of years, but they can’t ever really stop recruiting because they know that a departure or a retirement, or a decision to expand a service – cardiology, for instance – could change the whole situation.

We don’t seem to be alone. The Association of American Medical Colleges projected last year that the national shortage of physicians could reach 62,900 doctors by 2015 (that’s just three years away) and 91,500 by 2020.

I was therefore taken aback when I recently came across some reports suggesting the doctor shortage isn’t as bad as it’s made out to be. According to data released by the Association of American Medical Colleges, there were 258.7 active physicians for every 100,000 Americans last year. More than six in 10 physicians settle in the state where they received their medical education, the report found.

This month the Colorado Health Institute issued a report on the state’s health care workforce and the impact of adding the uninsured to the health insurance rolls when this provision of the Affordable Care Act takes effect in 2014. The report’s conclusion: There’ll be a need for more health care providers but it won’t be as dramatic as many anticipated.

Here’s a final piece of data: First-time applications to medical school reached an all-time high this year, according to the Association of American Medical Colleges. Medical students are increasingly diverse, and the majority start their training with some previous exposure to clinical experiences.

While all of this sounds positive, the picture becomes more complex when you start studying the details.

The Colorado Health Institute report, for instance, is careful to point out that rural areas are, and will continue to be, short of doctors. Nor did the report take into account the impact of an aging population or the increasing trend among physicians to specialize rather than go into primary care.

The situation also varies considerably from state to state (click here to see an interactive map put together by American Medical News). Some states do very well at retaining physicians after they complete their training at one of the state’s medical schools. Alaska, California and Montana manage to keep 60 percent or more of their medical school graduates in the state. New Hampshire is the worst, exporting all but 28.3 percent of its graduates. The Upper Midwest is somewhere in the middle; of the 17,516 medical graduates whose training was in Minnesota, 7,735 – or 44.2 percent – remained in Minnesota to practice medicine.

Dig deeper and you’ll find that although Minnesota has 269.6 active physicians for every 100,000 residents, a figure that puts it among the best 15 states in the U.S., the number of active primary care physicians is 103.8 per 100,000. Moreover, 22 percent of all physicians in Minnesota are over the age of 60 and presumably beginning to think about retiring.

It’s not a time to get complacent, which is why I’ve found it encouraging to read the many physician stories posted at the ACMC blog. One of the most recent comes from Dr. Michelle Cilek of ACMC-Redwood Falls, who describes the rewards of being a family doctor in a smaller town where she can practice quality medicine yet still have time to garden, sew and attend her children’s soccer games. “Redwood Falls is a great community; my practice is busy and I am able to get to know my patients on a more personal level because I see them at church, my children’s activities and more,” she writes.

Dr. Merlin Nelson, a neurologist, likes the challenge of the variety of patients he sees. Being a five-minute drive away from the clinic or hospital when he’s on call is a pretty good deal too. ACMC physicians in Granite Falls, Litchfield, Marshall and Willmar share their stories here, here, here and here.

To the average patient, what matters most is having a doctor quickly available when the need arises. Issues of supply and demand, of geographic distribution, specialty distribution, availability of training slots and even the increasing burden of medical training costs can seem rather remote and academic. But making all the pieces come together is much harder than it looks, and it’s all the more rewarding to see when this happens in your own backyard.

Illustration: “Doctor and doll,” Norman Rockwell, 1929

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