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Posted by on Dec 5, 2009 in At TMV, Economy, Health | 20 comments

Die Slowly Or Move To The Big City

Rural America is not served well by the medical profession because there is a lack of family practice doctors, a problem that could be addressed somewhat in the health reform bills now before Congress. That’s the good news. The bad news is that the reform package, if passed, would extend insurance coverage to millions more in areas where there are a lack of doctors to attend their illnesses.

I have experienced the dilemma up front and personal having lived in rural Oregon for 13 years. What reminded me of that ordeal was a splendid article in today’s Washington Post about Dr. Ben Edwards, a family practitioner in Post, a tiny town in West Texas. I strongly recommend reading the article for it precisely outlines the Catch-22 dilemma in Washington because it won’t solve the doctor shortage nor improve care.

Several years before I moved to Oregon I was diagnosed with diabetes. The condition worsened as the years rolled by. I could afford the oral medication prescribed by a San Diego physician at the time but I could not afford insurance premiums or copay visits to a doctor. My teeth fell out. My vision deterioated. I developed numbness in all my extremities as nueropathy set in. Bad circulation in my legs made it painful to walk. These were symptoms I figured out on my own. What I didn’t realize that at the same time I developed kidney problems and congestive heart disease. More on that later.

In 1994, my third year living in Gold Beach, the Oregon state legislature enacted a universal health care plan (OHP) with coverage extended to some 700 types of illnesses. Premiums were based on a person’s income. My reported income was 0 for which the monthly premium was $7. I confess I was part of the shadow, underground earners who lived off of cash tips for cleaning fish and pumping propane gas for visiting fishermen and tourists at the RV park where I worked rent-free.

OHP saved my life.

The first thing I did was see a dentist. He was the only dentist participating in the state health plan beween Brookings and Coos Bay about 90 miles apart and serving about 7,000 residents. The waiting list was nine weeks for the first visit. He worked on four patients at the same time, each in separate rooms. His wife, who was his secretary, told me her husband attended to 90 patients a day, seven days a week. He did not have a dental hygenist. He pulled my six remaining teeth. By the end of the fourth visit I received complete upper and lower dentures I still wear today, some 15 years later.

There were two family practice doctors in Gold Beach, three if you count an old man who no longer took on new patients and specialized in herbal treatments for whatever causes. One of the doctors suffered from a personality disorder and insulted all of his patients for failing to follow his instructions.

I was fortunate to become a patient of Dr. Michael O’Gara who himself was a diabetic. He put me on a special diet, told me to get a diabetes monitor to test my blood sugars and changed my medication from oral to direct insulin injections. All that was new to me.

But, Dr. O’Gara was equipped to do little more to treat diabetes. The closest specialists were 100 miles inland in Medford. I had no car at that time.

Gold Beach had a public hospital supported by a district tax. It had no trauma unit and eight beds. As a result, most people in the Gold Beach area subscribed to a life flight service for $72 a year that would airlift patients to Medford. The number of flights per subscriber was limited to three per year, as I recall.

I moved to Nehalem, about 250 miles up the Oregon coast, in 2001. There, the nearest doctor was in Tillamook, about 30 miles to the south. Same situation. Specialists dealing with diabetes were non-existent. By then, I owned a 1982 Ford Ranger and had to drive 90 miles to Portland to see specialists dealing with my circulatory problems.

It wasn’t until I returned to San Diego in 2003 that the heart and kidney conditions were diagnosed. And, that discovery came accidentally. A hospital-run senior health clinic prescribed diuretics to battle a water-retention condition. Eventually, I became dehydrated, lowering my natural potassium level to nil. I was taken to the hospital where a battery of tests and an MRI finally determined my heart, kidney and lung malfunctions.

The point of my story and the one about Dr. Edwards of Texas illustrates how difficult it is for patients receiving adequate health care in rural areas of America. It is not a question of public options or stringent rules on health insurers denying coverage for pre-exiting conditions.

It is a system that makes it economically awkward to entice family doctors to practice medicine in rural America. The rural hospitals can treat broken limbs but rarely can afford the expensive diagnoses equipment to treat respiratory, heart, kidney and other diseases.

There was much amusement of the sardonic sign the Democratic congressman from Florida displayed when fighting the Republicans on the health care legislation. “Die Quickly,” it said, referring to the Republican plan.

By the same logic, the sign for rural America might be “Die Slowly Or Move To The City.”

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  • superdestroyer

    A few aspects of the article that are not mentioned.

    First, Medical school are almost 50% women these days. For all of the problems of finding men who would move to a town such as Post, Texas, it is much harder to get women to move to the same places.

    Second, physicians are increasingly marrying other physicians or other professional. The idea that a physician marries a nurse or the home coming queen are long over. What is the second physician suppose to do in such a town and especially if they are a specialist, lawyers, CPA, MBA, etc.

    Third, physicians going to tier one colleges, medical school, and residencies makes them academic oriented. When you look at the quality of the schools in a town like Post, the economic status of the other students, and opportunities of graduates, anyone with a graduate degree is probably not going to be interested.

    Fourth, the growing number of Asians and immigrants in medicine means that there are fewer people who will ever live in a place like Post.

    I doubt if any government program is going to find enough white or Hispanic men who have stay at home wives and who do not care about the education of the children to fill of the need for rural physicians.

    • jkremmers

      I agree 100%. I now live in semi-rural Temecula, Calif., about 90 miles southeast of LA. The vast majority of physicians are Asian and Middle Easterners. The health care they provide is good, but not superior to San Diego, LA or Portland. But you are spot on about the rural areas, where local male whites and Hispanics dominate and women practitioners are surprisingly rare.

      All in all, I think the paucity issue is primarily driven by economics. The desire to quickly pay off thousands of dollars in education bills is paramount. — Jer

  • superdestroyer

    How would single payer or a national health service help a town like Post. If all physicians make the same money, then why not work in a large city where the spouse can also work and the children can go to prep schools? True socialized medicine would take away the ability of places like Garza County to deal locally with the problem.

  • dduck12

    I’m speaking out of ignorance, but shouldn’t we encourage more nurse practitioners for these areas. Mobile medical units would also help. The Army has always innovated in bringing medical care to remote areas and the government, if they are serious, should look at this opportunity to tap into their expertise. I know, simplistic, stating the obvious, etc., but this is a type of wa, if we suddenly bring on millions of new patients. 2,074 HCR bill pages, how many are devoted to this problem?

    • $199537

      I’m speaking out of ignorance, but shouldn’t we encourage more nurse practitioners for these areas

      There are the same problems recruiting nurse practitioners and physician’s assistants to rural areas as there are for doctors. Most PAs and NPs like to live near urban areas too.

      SD is absolutely right that socialized medicine will do nothing to help rural medicine.

      • dduck12

        I meant they should be incentivized (bribed, if you prefer), which would be easier than for Docs. Have they really thought out the consequences of all those extra bodies hitting the system described, above? It’s a war, baby.

  • ProfElwood

    I grew up in a rural area in Missouri, but as a farming community, everyone either had a car, or could get a ride from someone who did. We also had a local, retired doctor of osteopathic medicine (a competing group to the AMA, at least in some states) who ran an office out of his home.

    The article highlights two needs. The one is more local doctors. As I’ve stated many times, educating these people does not have to cost hundreds of thousands of dollars, nor does medicine require the best and brainiest of our scholars. The costs and requirements are both set by the AMA. The other is transportation, which should be a much easier problem to address.

  • ksb43

    I can’t believe I’m saying this, but Superdestroyer is right. Women do represent about 50% of medical school graduates, but they tend to be clustered in female friendly specialties, such as obstretics, gynecology, pediatrics, neurology, and the like. I still see astonishingly few female surgeons–far less than 50%, in the more testosterone laden specialities.

    Physicians also do tend to marry one another these days. One of the most infuriating stereotypes of nurses is that they are out to marry a doctor (patently untrue, in my experience). But, even if a nurse (male or female) was trying to, the physicians form very strong bonds with one another, and tend to socialize only amongst themselves, and pair up with each other.

    Finally, these young doctors are so laden with debt by the time they graduate, hundreds of thousands of dollars in most cases, that the repayment of that debt is the deciding factor in where they set up shop to practice medicine. The days of the young man with a medical degree and an unworking wife to manage the rest of his life, are gone forever.

  • vey9

    Yet, Ft. Lauderdale and Miami, FL are lousy with doctors. One can call an office to schedule a routine physical at !0AM and be seen by 1.

    That area, coincidentally I am sure, also bills Medicare at double the per capita rate for the rest of the US.

  • EEllis

    At the very beginning of this debate I posted on TMV that I believed more people would be helped by working on the people under served by heath care rather than those uninsured. Right now if there is health care then you can find help insurance or no. When there are no doctors or hospitals all the free insurance in the world wont help.

  • DLS

    It’s not as bad as you think, Jerry, but a relative dearth of doctors has long been known.

    What to do? At least at first, obviously we shouldn’t rush to demand anything totalitarian, such as requiring all residencies to be done in rural areas (and in decrepit central cities, something you neglect but which remain a problem other than being excellent battlefield medical training sites for military doctors), or imposing limits or quotas on more attractive locations and suburban enclaves. A better method might be to exchange tuition costs, or forgive medical-education debt, in exchange for four years’ commitment to practice in an underserved location. At least one person in the private sector (not using a government program) did this in Maine, if I recall, by having residents throughout the area to be served pay for his education; in exhange, after licensure he practiced there several years (he was there, if I also recall corerctly, when he was the subject of a news story about this service-disparity and -shortage issue). This is certainly — a carrot, not a stick — something state governments right away could try, or counties could pool their resources, or it might even be considered a federal program (payment for education or payment of debt in exchange for a reasonable service commitment), and incentives to motivate people to seek to serve underserved localities is better than some command-and-control direction by czars and apparatchiki who would treat doctors little better than they would distributing and rationing water or natural gas or gasoline nation-wide from refineries, for example.

  • DLS

    “requiring all residencies to be done in rural areas […]and in decrepit central cities […] or imposing limits or quotas on more attractive locations and suburban enclaves”

    Even lower on the moral scale, and not worth mentioning earlier, would be the even-more-totalitarian example of ordering a certain number of “excess” doctors in “overserved” areas (this goes for MRI machines and such, too, of course) to be redistributed in underserved areas. (“Eliminating costly duplication…”)

    * * *

    Related to this issue is a revisitation (it, too, is an old problem) of not enough primary care doctors and “too many” specialists. How to solve it? Education limits or quotas? For residencies, too? Or even on how many doctors may have what kinds of practices, where? This could become “fun”…

  • DLS

    “Mobile medical units would also help. The Army has always innovated in bringing medical care to remote areas and the government, if they are serious, should look at this opportunity to tap into their expertise.”

    Shoving aside the politics and the motives typically behind the idea, it has occurred to many before to use the military not in truly military roles but for disaster relief. Here is an example where relief could be provided. It is being provided already, in some cases (and making news) by volunteer organizations, who have provided these services in rural areas and in inner-city zones (an area I’ve already said has been neglected, but which also has inferior services). (One group’s leader or spokesperson-doctor said that normally he takes his group to Haiti or Zambia, but this year he was staying in the USA because there was a need, possibly more, need here for his group’s services.) The military has been and is involved in other nations, as well, delivering relief supplies and assistance, including medical assistance. Leaving political issues aside for the moment, if there’s thought of the military acting as relief workers elsewhere, why not here, and why not have military doctors assume or join in the role played by these volunteers?

  • Great post Jerry! And the thread is thought-provoking as well.

    Speaking as a small-town kinda person who’s currently living in an urban environment (and DYING to get back out to the small town), I think there’s another aspect here that’s not getting enough discussion: quality of life.

    Superdestroyer touched on it with the “prep schools” reference, though that’s kind of a stereotype. It is true, though, that many people will choose urban over rural because they simply do not want the lifestyle that comes with rural living. Although the article doesn’t discuss the town of Post much, many towns like Post do not have movie theaters, or offerings of the Arts (other than high school plays), or museums, or interesting dining options.

    Instead, rural living centers up on family and neighbors, and (very often) church-related activities.

    Even if we (the body politic “we”) were to arrange loan-free general practitioners, those areas would still be hard to serve. It isn’t all about the outstanding debts.

    For the record: I find the quality of life in small towns to be vastly superior to that of the big cities. The pace is slower, the people are more family and community focused, and outdoor activities tend to abound. But it’s important to recognize that such a life doesn’t appeal to everyone — especially folks who aren’t familiar with it.

  • EEllis

    I think the situation is more complicated than portrayed. Is not that doctors wouldn’t want to work in the country as much as they have no place to work. Established docs aren’t going to move, I mean they are established and comfortable, and a new doc is going to pick up and move somewhere he doesn’t know? With no idea what kind of business or money he could make? If there is a job it’s a good chance it is filled. Even tiny hospitals find staff, but doctor are not the ones to create the facilities. Personally I don’t think it’s the feds business but I would much rather have my tax money spent on Hospitals and clinics than this ill conceived health-care bill we have going now.

  • jkremmers

    A couple of more thoughts. The lure of doctors to small towns by paying for their education was glamorized by a movie — Doc Hollywood — and a TV series — Northern Exposure.Not a bad PR gesture in the real world.

    What about Doctors Without Borders? Their service could provide real relief to local medics and people living in rural America. A network of targeted areas would be a boon appreciated more in our own backyards than in the jungles of some foreign outpost. — Jer

    • superdestroyer

      In looking around the internet about this story, there have been several comments about how even the debt forgiveness does not amke up for the loss of income from living in small towns. Most of the patients in Post will be either Medicare or Medicaid and will have the lowest reimbursement rates. Also, since it is a single physician, all of the overhead is paid by one physician.

  • Living in Brookings, just South of Gold Beach, I agree. I have had a doctor tell me that the game plan for any serious condition or accident, pack the patient in the car and head for Medford; which is a 2.5 hour trip over a two lane narrow road twisting over mountain passes part of the way.

  • merkin

    My son is in his second year of medical school. He graduated with highest honors with a Chemical & Biometric Engineering degree, the engineers who work in the pharmaceutical industry. . It took him two years of applying to be accepted to medical school.

    I can confirm much of what has been said. He is married to another professional, a lawyer. They live in Atlanta, where his medical school and her law firm are. He is very fortunate that he was accepted to three schools the second year he applied and one was in Atlanta.

    He also was lucky he had a father who could pay his tuition and fees of about $40K a year. But if he hadn’t he would have gotten grants and loans to pay for his tuition. There are programs available now to do what you have suggested, trade a fixed term in an under served area (or the military) for tuition money up front. But my son wouldn’t have, and most med school students don’t participate in these programs. They want the flexibility of choosing whatever path interests them later, whether it is to going go into practice, into a specialty, do research, teach or practice overseas for awhile. The up front commitment limits them too much. Besides most employment opportunities after they are licensed offer to pay off all or a portion of their loans after a certain number of years.

    The most effective way to get doctors who want to live in rural areas is to give a preference in the admission process to students from rural areas. They are more likely to practice there when they graduate. However, it shouldn’t surprise you to learn that preferential admission policies like these are under increasing political attack as part of the affirmative action debate. There are no admission policies that are as subject to affirmative action as the medical schools’ policies are.

    My has said that he would go through medical school three more times than to have to go through chemical engineering again. The medical work is primarily memorization and a lot of it is by rote. Yes, the work could be learned and done by a broader range of intellect than is currently the case.

    Most of these kids are not motivated by money. These are very bright people. They can expect to do well and be paid appropriately whatever they decided to do. In fact their top earning potential is probably more limited as doctors than if they went into corporate management or finance.

    My son and his wife have started looking for their first house. Their number one priority is good schools, whether public or private, as was mentioned in the thread.

    I think there is zero chance my son would practice in a rural area. He was raised in the city, went to the best private schools and he will do the same for his children. With his background he is an odds on bet to go into research.

    Thank you for the attention. There is nothing that beats being able to brag about my kids. I love the kids.

  • superdestroyer

    Merkin, The difference between medicine and other professions such as law or finance is that the mean pay is higher in medicine but finance and law are log-normally distributed where a few people get rich and many people do not get to make much.

    Physicians are guaranteed a higher mean income but have to give up the chance of make millions. I would wait until you son finishes his rotations, his intership, his residency,and his boards before you take his bragging seriously. A surgery residency is a thing that no one would want to go through twice.

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