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Mon September 2, 2013
For Many Oklahomans, The Doctor Is Not In
Despite efforts to increase the number of doctors in rural areas, many Oklahoma counties are still sorely lacking physicians to provide sufficient care to their residents.
Seventy-two of the state’s 77 counties, or 94 percent, are designated by the federal government as shortage areas for primary health professionals; 30 have 10 or fewer doctors of any kind. The five counties not considered shortage areas are Oklahoma, Johnston, Canadian, Rogers and Wagoner, according to the U.S. Health Resources and Services Administration.
Oklahoma has 76 doctors per 100,000 residents, far fewer than the 220 doctors per capita nationally, according to the Association of American Medical Colleges. The state ranks 43rd in doctors per capita and 41st in primary-care physicians.
The shortage is especially severe in rural areas. Rural counties have a significantly lower rate of doctors per residents than urban ones, according to data obtained byOklahoma Watch from the Oklahoma Board of Medical Licensure and Supervision and the State Board of Osteopathic Examiners.
The shortage of primary-care doctors plays a large role in the poorer health outcomes of rural residents, health experts say.
Since the 1970s, Oklahoma has been creating incentives for doctors to set up shop in rural areas and in recent years has tried some new methods, but shortages remain a significant problem.
Many large urban hospitals and medical groups have different sets of doctors for emergency rooms, clinics, and inpatient and outpatient care.
That is a luxury physicians in small rural communities do not have, said Dr. Maha Sultan, who practices in Frederick in southwest Oklahoma.
Sultan said her duties consist of working in a clinic; the hospital, including the emergency room; home health care, and nursing homes.
“Most new graduates want to get a job where it is nine-to-five, no responsibility after hours, nobody to call them and nobody to bother them, so they are not interested,” Sultan said. “In a small town, you have to do everything. Some new doctors, they just don’t want that life.”
Sultan came to Frederick about 20 years ago after emigrating from Syria and receiving medical training in Canada. A friend referred her to Frederick.
“After four months, I was going to leave like everybody else,” Sultan said. But the hospital, which was having difficulty with finances and a lack of doctors, pleaded with her to stay.
“I have been here for 20 years,” she said. “You don’t see too many people like me.”
According to licensure records, Sultan is one of only three licensed physicians – two M.D.s and one osteopath – in Tillman County.
Sultan said she often misses the amenities that urban areas offer, but she has enjoyed working in a tight-knit community.
“I love the patients. I care for them, they care for me,” Sultan said. “They’re very loyal, and I’m loyal to them.”
Lure of the City
It is the big-city amenities and educational and professional resources that draw many physicians away from rural areas, said Rick Ernest, executive director of the Oklahoma Physician Manpower Training Commission, a state agency responsible for encouraging physicians to locate in underserved areas.
“When you’re in a rural community with one or two doctors, you spend every other night or every third night on call. That gets pretty old,” Ernest said.
More new physicians are choosing specialty practice, Ernest said, because they can earn more and pay off their sizable debt from medical school more quickly. Most of the specialty practices are located in urban areas, he said.
To encourage doctors to practice in rural areas, Ernest’s commission has worked with the Oklahoma Tobacco Settlement Endowment Trust and the Oklahoma Health Care Authority to fund a $5 million, five-year program to help pay off doctors’ student debts in exchange for the doctor practicing in a rural area, Ernest said.
Ernest estimated the commission has helped send around 25 to 30 new doctors to rural areas each year.
One problem is that although medical-school class sizes at state universities have increased, residency programs have not kept pace. That means graduates must go out of state for residency requirements, Ernest said.
In 2012, a bill was passed that established a fund to create residency programs in rural areas, said William Pettit, associate dean for rural health at Oklahoma State University’s Center for Health Sciences. The program has residencies in Enid, Tahlequah, McAlester, Lawton, Durant and Talihina.
OSU also has begun to offer a medical track that focuses on providing health care in rural areas; students from rural areas are recruited to join.
“We think this is the way to go – start encouraging young men and women in high school (to believe) that a rural practice back in their hometown or a neighboring community is not only possible but can be rewarding from a professional point of view and financially,” Pettit said.
Work to be Done
Cindy Duncan, interim CEO for Memorial Hospital and Physician Group in Frederick, said that the hospital has interviewed six doctors for a job for a position since January.
All declined offers, either because they or their families did not want to live in a rural community or because of the mix of duties required.
The hospital has not had a full staff of physicians since 2004, Duncan said.
“We’re optimistic and want to say, ‘Yes, things will get better,’ but based on historical experience, I would say no,” Duncan said. “You want to be positive, but going on 11 years, it’s kind of hard to be positive about it.”
Physician shortages are a national problem as well.
Small communities can expect to see more doctors retire, a reflection of the aging workforce and the fact that doctors in rural areas tend to be older, Pettit said.
“The handwriting is on the wall, with the aging workforce, that we’re going to need to do something,” he said.
About half the state’s population, but two-thirds of its doctors, live in the Oklahoma City, Tulsa and Lawton areas, Pettit said.
Telemedicine, in which specialists video-conference with patients long distance, has helped compensate a bit for rural doctor shortages, but overall the state still is in need of more physicians, said Lyle Kelsey, executive director of the Oklahoma Medical Licensure Board.
The shortage has a disproportionate effect on the poor because poverty rates often are higher in rural areas, said Lou Carmichael, CEO of Variety Care, a community health center that also operates clinics in four rural areas.
Each of those clinics was opened after its community, faced with a lack of health resources, approached Variety Care.
Oklahoma Watch is a non-profit organization that produces in-depth and investigative journalism on important public-policy issues facing the state.