Rural hospitals facing worst of doctor shortage

PHOTOGRAPHER: Bethany Bump

A few nights a week, Sue Kiernan hears the whipping blades of a helicopter from her home, about a mile from Nathan Littauer Hospital.

Choppers fly out of the Gloversville hospital on a regular basis, usually heading east to transfer a car crash victim to Albany Medical Center or a heart attack patient to Ellis Hospital in Schenectady.

“We’re a rural hospital,” said Kiernan, vice president for development at Littauer. “We can’t do everything, but we can stabilize. But if a surgical patient comes in one weekend and one of our surgeons is not immediately available and the problem can’t wait until Monday, then we would have to ship that patient out.”

It’s not unusual for a small, rural hospital to have to transfer patients to bigger hospitals with more specialists, nicer medical equipment or better facilities, health care officials say. But when a transfer is needed because there simply aren’t enough physicians on staff, a community can suffer.

The Mohawk Valley has the worst ratio of physicians to population in the state, making it one of several problem areas for New York’s worsening physician shortage, according to a 2011 survey by the Healthcare Association of New York State.

The shortage has prompted hospital officials to look for new recruitment and retention strategies, as the medical field grapples with new doctors increasingly choosing specializations over primary care to help pay off massive debt. At the same time, rural hospitals are struggling with the burden of enticing physicians and their spouses to live in communities that can be isolated or economically challenged — or both.

New York state hospitals outside of New York City needed 763 new physicians in 2010, according to HANYS. Of this, rural hospitals were short 280 physicians.

In 2010, nearly 2,300 physicians retired or left the staff of hospitals that responded to HANYS’ 2011 Physician Advocacy Survey, compared to 1,600 the year before.

Health care officials emphasized that the doctor shortage is not just a New York problem, but a national one. The Association of American Medical Colleges predicts there will be a shortage of 91,500 physicians nationwide by 2020, evenly divided between primary and specialty care.

Fulton, Schenectady and Albany counties were among 19 counties that noted a decline in the number of surgical subspecialists they employ. Meanwhile, the 22 counties that make up the state’s Mohawk Valley, North Country and Southern Tier reported a decline in general surgeons.

Littauer employs 34 physicians: 19 in primary care and 15 specialists in the areas of anesthesia, neurology, urology, pediatrics, obstetrics and gynecology.

Currently, the hospital is looking for only one specialist, said Kiernan. “But we will be in a position within five years where we will be looking at a number of our primary-care physicians thinking about retirement,” she said. “And then we have to replace them. So we’re just going to have to be vigilant and aggressive when we go out there to recruit.”

Kiernan is in charge of recruitment, and she said it’s become tougher and tougher to do so in the region. It’s not that the opportunity is a bad one, but employing a physician often means enticing the spouse to the region, as well, she said.

“We are a good hour away from Albany, so sometimes it depends on how far somebody would be interested in commuting,” she said. “Not all doctors can live within 20 minutes of the hospital, which being on call requires.”

For the population Littauer serves, the hospital only needs two general surgeons who are on call every other night. It’s a work demand not every young doctor is willing to meet.

“I don’t care what their specialty is, they are looking for a quality of life,” she said. “And that quality of life is not being on call every other day.”

The changing demographics of today’s physicians intrigue Dr. Tim Shoen, vice president of Medical Affairs at St. Mary’s Healthcare in Amsterdam.

He went to medical school in the 1970s; since that time, he said, doctors are less willing to face the 60- or 80-hour work weeks that their predecessors often did. Fewer physicians go into private practice, as well.

Part of the reason for that is the massive debt medical students take on. The HANYS report found the lower income of a primary-care physician has prompted an increasing number of new doctors to choose a specialty.

The increase in demand for primary-care services is expected to dramatically outpace the increase in supply, according to the report.

“That indebtedness is what’s driving people to overpopulate specialties,” said Shoen. “And I think it’s taking its toll on primary-care practices. It’s going to be very problematic when we have a world of chest surgeons but no one who will take out an appendix.”

While St. Mary’s has enough specialists, he said, it’s undergoing an assessment of its primary-care needs.

But recruitment in rural areas is challenging. And geography, weather and professional isolation all contribute. When rural counties make up 16 percent of the state population but only have 9 percent of the physicians, that’s a problem, according to HANYS.

Like Shoen, Kiernan has seen how important external factors are in recruiting young doctors. Married physicians want to know there is a good school system in the area, as well as economic vibrancy and job opportunities for a spouse.

“Where it becomes so frustrating is when you get the doctor who really wants to be here. They see a need here. They know that there is a need here,” she said. “And we have patients who just absolutely adore their doctors, so it’s a wonderful professional experience. But if you can’t get them to live in the community, therein lies the problem.

“Rarely do we have a physician who comes in and then leaves. But if they do leave, it’s generally because their spouse is unhappy in this area.”

Although the state-funded initiative Doctors Across New York helps to train and place physicians in underserved communities with student loan repayment incentives, it has only put a dent in the problem. The program began in 2008 and two years later had placed approximately 100 new physicians in rural and urban underserved areas.

For St. Mary’s Healthcare, the program is bureaucratically difficult. The hospital was founded in 1903 by the sisters of St. Joseph of Carondelet with a mission to help the poor and underserved in the community. The state identified the community as a physician “shortage area” several years ago, the kind of community that could use Doctors Across New York.

In 2009, St. Mary’s recruited a general surgeon and obstetrician through the program, but later recruitment efforts through DANY required the hospital have the doctor already signed to a contract before money would be granted, said Shoen, and those negotiations didn’t always fall within the allotted DANY time frame.

“We tried, but the rules kept shifting,” he said. “Part of me thinks that a really motivated hospital would be willing to put a competitive compensation package on the table, with or without the grant.”

Hospitals have begun to hire more physician’s assistants and nurse practitioners where physician shortages are severe. Nevertheless, 69 percent of rural hospitals who responded to the HANYS survey said there were times when their emergency department was not covered for certain specialties, requiring patient transfers to outside hospitals.

With 340 physicians — many of them specialists — Albany Medical Center is often where these patients end up.

Its specialist services are growing, too, said Dr. Ferdinand Venditti, president of Albany Med’s Faculty Physician Group and vice dean of clinical affairs. About 20 to 30 new specialists are added each year.

“With that in mind, what’s happened over the last couple of years is the transfer from other hospitals to us has grown dramatically,” he said.

In 2003, the hospital received 1,700 patients who started at another institution. In 2011, Albany Med received more than 7,000 transfers.

“It’s unbelievable,” he said. “There are days where we have 35 patients sent to us by transfer from other hospitals.”

It could be for a variety of reasons: The transferring hospital can’t provide coverage for a particular treatment; they don’t have the right specialist or don’t have enough physicians on staff; there’s no one on call; or they just don’t have the facilities to provide the care.

From 2009 to 2010, 34 percent of hospitals that responded to HANYS had to reduce or eliminate services because of physician shortages, while 66 percent said there were times when a physician shortage left their emergency department without coverage for certain specialties.

So patients are shipped out and transferred to other hospitals, sometimes by helicopter.

Albany Medical Center takes in transfer patients for such reason as trauma, pre-term labor, complex neurosurgery and heart attacks, said Venditti.

“It’s all of that, and frankly it’s getting worse,” he said. “It’s becoming a much more common phenomena that institutions around us don’t have the capability for caring for the patients that show up in their ER.”

Albany Med has many of the qualities that smaller, rural hospitals can’t offer their doctors. It’s surrounded by multiple higher education opportunities and academic and institutional networks and is located in a growing urban center.

It has what Venditti calls the “bells and whistles” of good, high-quality care that’s attractive to high-quality physicians.

The economics of health care need to change before hospitals in underserved areas can catch up, he said.

“Take a small community hospital, maybe it’s Adirondack Medical Center, Champlain Valley Hospital or Nathan Littauer,” he said. “The pressures that they’re dealing with — between Medicare reimbursement cuts and declining revenue — make it difficult for them, I think, to stay as current as they might like to with equipment and staffing and the type of things that attract physicians. It’s an extraordinary task.”