Dr. Dan Larson has been recruiting primary care doctors to Hudson Headwaters Health Network, a nonprofit system of community health centers that serves 3,700 square miles in the Adirondacks, Lake George and Glens Falls, for two decades.
But in the past year, his job has become more difficult.
A big problem, Larson said, is that more doctors are going into more lucrative subspecialties, leading to a shortage in primary care physicians, particularly in rural areas. Larson doesn’t blame the doctors for making this choice; he said young doctors finish their residencies with so much debt that it’s difficult for them to take a lower-paying job when there are better offers. That debt is growing, Larson said; today it’s not uncommon for doctors to graduate $300,000 in the hole.
“Primary care doctors make half, a third, one fifth of what a subspecialist makes,” Larson said. “To get a qualified primary care doctor to serve in an underserved area is difficult.” He said he’s currently recruiting a primary care physician who is completing his residency; this young physician is committed to service, and likes the idea of working upstate. But he is also $275,000 in debt. “If a lucrative, for-profit, high-volume practice in suburbia can pay him more than we can, you can’t blame him for going,” Larson said.
This trend has an impact, Larson said. “We get legitimate complaints that it’s hard to get in for an appointment,” he said. “Doctors may be pressed for time.”
In his State of the State address last week, Gov. Eliot Spitzer proposed creating a program called “Doctors Across New York” that would offer grants to help repay education loans to make it easier for doctors to move to the state’s medically underserved areas. “There are huge regions of New York where doctors are scarce,” Spitzer said. “From our inner cities to the North Country, our medically underserved New Yorkers deserve better. There should be a family doctor, and there will be, for every family in New York.”
increase called for
In a study that will be released this week, the University at Albany’s Center for Health Workforce Studies found that while New York experienced an overall increase in the supply of full-time equivalent physicians between 2002 and 2006, several upstate regions saw little growth, and, in some cases, declines. The Capital Region and North Country experienced physician growth of 2 percent or less, while the Mohawk Valley saw a 4 percent decline. In the Mohawk Valley, there are 167 physicians per 100,000 persons, compared to 332 physicians per 100,000 persons in New York City.
Of the 79,415 licensed physicians in New York, 72 percent are located in downstate New York, and 91 percent are in urban counties, according to the study. According to the state, over one-quarter of the state’s population live in areas designated underserved; the state Department of Health estimates that over 300 primary care physicians are needed in those areas.
“Many upstate providers are reporting increasing difficulty,” said Jean Moore, director of The Center for Health Workforce Studies. “There are some parts of the state that have chronically had trouble attracting and retaining physicians. Urban, rural areas present less attractive opportunities for physicians. The economic opportunities are not as strong. … We don’t have physicians where we need them.”
The problem exists throughout the country. The American Association of Medical Colleges has called for a 30 percent increase in the number of medical students in the next decade.
“We have had no increased production of physicians for years and years,” Moore said. “There may be pretty big gaps between supply and demand.”
med school project
Hospitals and health networks are already working to address the physician shortage.
In 2006, Cooperstown-based Bassett Healthcare, a system of physicians, providers, hospitals and community health centers in eight counties, including Fulton, Montgomery and Schoharie, joined a new group, the Upstate New York Physician Recruiter Network, that aims to draw physicians to upstate New York. Members include Glens Falls Hospital, Saratoga Hospital and Rochester General Hospital; one of the things they do is attend career fairs in New York City to talk to young doctors about practicing in upstate New York.
Bassett is also in the process of creating a regional medical school campus in Cooperstown where medical students would spend their final two years. This project, said Bassett CEO William Streck, will introduce young physicians to the advantages of practicing in a more rural region. He said that people who spend time in the area often find that they like it. “Rural life is, to those who partake in it, quite acceptable,” he said. Right now, Bassett takes students from Columbia-Presbyterian Medical Center in New York City for clinical rotations lasting about six weeks; it also takes students from Albany Medical College, Dartmouth College and the University of Rochester Medical Center. Bassett also offers the Shadow-A-Surgeon program, where students can spend the summer working with faculty, surgical residents and nurses in a teaching hospital in a rural community.
“We have a very sophisticated recruiting system,” Streck said. “We have a very attractive practice. Yet even with our great practice model, even with our very talented recruiting group, [it’s difficult]. . Our experience is that the majority of physicians tend to go to urban areas. You can only forgive the loans of people who are willing to [go to an underserved area].”
All of the physicians in the Bassett system are employed by Bassett, making them part of a larger group even if they work at a smaller clinic within the system; in many areas, smaller practices are independent and not connected to a bigger entity. Bassett’s way of doing things is something doctors find attractive, Streck said.
Like Larson, Denise Harter, the medical staff affairs manager at Bassett, has noticed a change. When she started working at Bassett 11 years ago, staffing shortages were limited to a few speciality areas. Now, she said, there are shortages in almost every area.
Larson and others who work in rural areas praised Spitzer’s proposal. “I’m delighted by the concept,” Larson said. “Obviously, the devil is in the details.” He added that the proposal doesn’t address all of the factors contributing to the physician shortage: The pay gap between primary care physicians and subspecialists must be narrowed, even if it can never be closed.
Spitzer’s proposal “is an idea whose time has come,” said Joe Riccio, communications manager for the Saranac Lake-based Adirondack Medical Center.
Riccio expressed confidence that once doctors spend some time at the Adirondack Medical Center they’ll want to stay. The trick, he said, is getting them to come in the first place. “Once you get physicians in here they’ll find that it’s an excellent facility, an excellent staff,” he said. “They’ll find that it’s a great place to make a life.”
There are about 10 positions Adirondack Medical Center would like to fill, Riccio said. “We have a medical staff that is aging,” he said. “We’re planning five to 10 years down the road.” In October, the hospital hired a physician recruiter to focus on attracting and retaining talent; the recruiter visits residency programs and has developed a manual for prospective doctors.
Only recently has recruiting primary care physicians to Hudson Headwaters become more difficult, Larson said. In the past, the staff at Hudson Headwaters was confident young physicians would be drawn to the area for perks such as nice scenery and access to the outdoors, as well as cultural areas such as Saratoga Springs and Glens Falls.
“We were always privileged,” Larson said. “We thought we were so good at what we did. We thought there was a nice quality of life here. That’s why I think we were previously successful [at recruiting].” Right now, the physician shortage in Ticonderoga and Moriah is severe, he said. “You have to be the right person to live there. It’s beautiful, but isolated.”
He pegged the starting salary for a primary care physician at Hudson Headwaters at “under $150,000.”
Hudson Headwaters wants to add four primary care physicians by this summer. “We could add two of those tomorrow, and two by summer,” Larson said.
The Center for Health Workforce Studies conducts an annual survey of all physicians completing a residency or fellowship training in New York. About half of these people, Moore said, stay in New York to practice. “It’s a tremendous resource,” Moore said. “How do we tap this important source of new physicians and create pathways to the parts of the state where we need them?”
In 2007, the center added two questions to the survey to better understand why physicians leave the state and how they approach their job searches. Researchers found that the two most common reasons for leaving the state are proximity to family and inadequate salary.
What this shows, Moore said, is that many physicians come to New York to train and never have any intention of staying in the state to practice.
“Maybe we need to get smarter about who we recruit,” Moore said. “This is a complicated problem, and we’re going to need a variety of strategies. There’s no way we produce enough physicians if things don’t change dramatically.”
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