By Robert Davis, USA TODAY
NASSAWADOX, Va. — In the modest building that houses Shore Memorial Hospital in this town of about 600 people between the Chesapeake and Hog Island bays, a health care crisis is brewing.
It's a problem rooted in the 1980s and 1990s, when U.S. medical schools put a cap on enrollments, believing that managed health care, among other factors, would create a glut of doctors.
They were wrong. And now the impact of a national shortage of surgeons and family practice doctors is echoing across the country.
The shortage of surgeons is a particular threat to the health care of 54 million rural Americans, medical specialists say, including the "watermen" who catch crabs, scoop clams and grow oysters here.
Shore Memorial, which on average has 61 patient admissions a day, was built 70 years ago to save lives being lost to simple ills such as appendicitis. Having a surgeon is vital to keeping open the doors of Shore Memorial and thousands of other small hospitals like it.
But as local doctors have moved away from this community or retired during the past 10 years, the ranks have fallen from seven full-time surgeons to two. There also are only two anesthesiologists; one is nearing retirement.
Medical schools were "woefully wrong" in their calculations, says Josef Fischer, who as chairman of surgery at Beth Israel Deaconess Medical Center in Boston trains new surgeons every year. "It's going to be tough in this situation to make it better."
From the late 1970s to the mid-1990s, several national advisory groups, including the Institute of Medicine and the Council on Graduate Medical Education, issued reports forecasting a surplus of physicians. As a result, medical schools voluntarily held enrollment relatively constant at about 16,000 new students a year. From 1980 to 2005, enrollment was flat while the U.S. population grew by more than 70 million, according to the Association of American Medical Colleges (AAMC).
After educators realized the forecasting mistake, medical schools began accepting more applicants. Last year nearly 17,800 students entered U.S. medical schools, the largest entering class ever.
However, Fischer says there's "a perfect storm" forming for a shortage of doctors and surgeons because of the time it takes to train doctors — typically three to seven years — and the fact that the number of senior citizens in the USA is growing rapidly.
As the 79 million baby boomers begin entering retirement age, so are their doctors. From 1985 to 2006, the percentage of doctors 55 and older rose from 27% to 34%, and the AAMC predicted in a 2006 report that members of this group — roughly 250,000 active physicians — will retire by 2020.
The impact often is most severe in rural America, where only 9,334 of 211,908 physicians are general surgeons, according to AMA data. The Census Bureau defines "rural" as open country or small towns with fewer than 2,500 residents.
David Lingle, 43, chief of surgery at Shore Memorial, says he is happy doing the work of several doctors. He answers calls for help when he's in his yard playing with his children or chopping wood. He can venture farther to fish for flounder or speckled trout only when he is not on call.
Because Lingle is a general surgeon in a small town, the alarm from his hospital pager could mean that a stranger needs help following a crash on the highway that connects North Carolina's Outer Banks to the New Jersey shore, or a friend from church might be having an aneurysm.
"I like the variety," says Lingle, who grew up in Arnold, Mo., a suburb of St. Louis. "We've figured out a way to make this work, but access to surgery in the periphery is in jeopardy." He says that he is worried that "nobody will want to sign up for this job anymore."
Thomas Russell, executive director of the American College of Surgeons, says there are not enough new doctors going into general surgery. Surgeons such as Lingle "have no one to sign off to, they are on call all the time," Russell says. "They can burn out after doing this year after year after year."
'They want balance in their life'
The shortage of surgeons is part of a larger shortage of medical professionals that has been recognized as a threat for more than five years. Medical schools have been enrolling more and more students annually to achieve a 30% increase in enrollment over 2002 levels by 2015.
But even a growing corps of young doctors may not help those who need general medical care, particularly if they live in rural areas, because of the career paths physicians are choosing.
Many of today's young doctors start their careers $150,000 to $250,000 in debt in education costs, so they often go where they can make the most money, Fischer says. And critical areas such as general surgery and family practice medicine are less lucrative than some specialties, such as bariatric or orthopedic surgery.
A typical new surgeon makes about $165,000 in his or her first year, Fischer says. After five years, he or she will earn $220,000 to $300,000 or more a year, depending on whether the practice is private or in an academic setting.
In rural areas, however, surgeons generally make less, Fischer says, especially if their hospitals don't supplement their salaries.
The number of physicians in specialties such as thoracic surgery and emergency medicine has more than doubled since 1990, according to the AMA.
However, "fewer and fewer are going into family medicine and primary care," says James King, president of the American Academy of Family Physicians. And "many are not willing to go" to rural areas.
After an industry-wide review of allegations that surgeons were charging too much, Medicare lowered the amounts that the U.S. government pays doctors during the 1990s. For some common procedures, general surgeons now get about half the money they received 20 years ago, Fischer says.
"Are the best and the brightest going into medicine like they once did? The answer is no," Fischer says. "They are becoming investment bankers, attorneys and captains of industry because the American way — how prestigious things are — depends on money."
During the past three years, Fischer says, none of his surgical students has opted to become a general surgeon like Lingle.
Besides wanting to pay off their debt by earning more money quickly, today's new doctors also put a higher value on their free time. "My generation neglected our families. We neglected our children. We were always operating," says Fischer, 70. "This current generation, much to their credit, says, 'We're not going to do that.' "
Russell says new doctors "want to know when they are on and when they are off. It's no longer a calling for younger people. They want balance in their life."
King says some of his physician friends are telling their children to avoid medical school.
"They tell their kids not to go because of all of the hassles," says the family physician from Selmer, Tenn. "They say it's not worth the headaches anymore."
A call for new priorities
Various physician groups are trying to drive changes that will offset the impact of the doctor shortage.
The American College of Emergency Physicians wants liability and reimbursement changes so that specialists will agree to come to the emergency room to see patients in the middle of the night.
The college of surgeons is promoting rural medicine among its members by focusing on effective rural practices at meetings and pairing country doctors to look for innovative solutions.
Meanwhile, the largest nationwide expansion of medical schools in 40 years has some schools facing challenges ranging from how to pay for new buildings to how to recruit more faculty members, according to the AAMC.
"It will take more than somebody waving a magic wand" to increase the number of surgeons, Fischer says, adding that there still are only about 1,000 spots a year in surgical training programs, he says.
And King says medical schools need to hunt for a slightly different type of student — those who want to practice medicine in rural areas — and focus less on attributes such as an applicant's previous clinical research.
"Just increasing the number of slots for medical schools is not going to solve the problems of supplying health care to the citizens," King says.
Reimbursement an issue
He and others say physician reimbursement has to change in a way that will compensate for treating rural patients "where they live." Many patients have to travel or be transported long distances to get the care they need, the doctors say, especially trauma and critically ill patients. That will only get worse as the shortage grows, they say.
King says doctors should be compensated for helping patients manage chronic conditions. A follow-up phone call, e-mail, or a visit with a dietitian or a nurse on a physician-led team might help eliminate the need for surgery. "If we do this right," he says, "the prognosis for medicine is excellent."
Ben Murphy agrees. A 2003 graduate of Nandua High School here on the Eastern Shore, he met Lingle through his grandmother, one of the surgeon's patients.
While attending the University of Virginia, Murphy began to seriously consider medicine, so he called Lingle, who invited the college student to spend 40 hours a week with him over the summer.
For two months, when the biting flies the locals call "greenheads" are most vicious, Murphy worked in the little white house across the street from the hospital where Lingle and his partner, Charles Goldstein, 48, see patients. He followed Lingle into the operating room to observe surgery.
"I fell in love with all parts of medicine," says Murphy, 22, who begins his training at Johns Hopkins Medical School in Baltimore in August. "The more medicine I saw, the more I loved it."
He's concerned about the direction medicine is heading, he says, but he's excited to become a doctor and thinks he will choose surgery, "though there are still a lot of decisions to be made."
Another uncertainty is whether he will return to Shore Memorial someday. The small local hospital might look different after he has treated patients in a big-city facility.
"I like rural areas," Murphy says in a telephone interview. "I may eventually want to go back there. At first, I'll probably go somewhere else, but I could see myself going back there later in life."
Sitting in a hot, dark conference room near the operating room, Lingle takes a short break as the staff prepares a room and a patient for another procedure. "We joke that in 10 years, Ben will be back," he says. His smile fades as he considers the odds of that happening. "At least he will be a doctor."
By Robert Davis, USA TODAY
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