Quincy -- A doctor shortage is looming in America, and rural medical centers are bracing themselves to take the hardest hit.
Sitting at the laptop computer in his office, during a rare moment of downtime, Scotland County Hospital's Dr. Randy Tobler picked apart every aspect of the shortage, as he sees it. Cultural factors, the lack of resources in rural areas, goverment red tape, doctor burnout -- all have melded to fuel what the Association of American Medical Colleges believes could be a shortage of up to 100,000 physicians by 2025.
Tobler said the doctor shortage is "the issue" in health care right now.
It's becoming increasingly difficult to attract young physicians to Scotland County Hospital, where Tobler not only is a doctor but also the organization's CEO. He has come to rely heavily on those from Memphis, Mo., and the surrounding communities who study medicine in urban areas and return home with a degree. He acknowledges, while a nice safety net to have, such physicians are in limited supply.
Like most other medical centers in small towns across the country, supply and demand has taken its toll on Scotland County Hospital. Deeper pockets in cities like Chicago and St. Louis draw away the already limited number of medical students entering the field as primary care physicians. The AAMC report, released in 2016, estimates that of the expected 100,000 doctor shortage, a gap of up to 35,600 primary care physicians is expected to form.
"A lot of these residents are coming out of their training with 2-, 3-, $400,000 in debt," he said.
Tobler estimates half of all critical access hospitals -- a category Scotland County Hospital falls into -- operate in a deficit and are closing with increasing frequency. They can't match the highly competitive salaries and benefits packages afforded to new doctors in major metropolitan hubs.
"A lot of it has to do with cultural factors and desires of where people want to live and practice," he said. "That's always been an issue in rural America."
Tobler is the opposite of the trend. He began his career in St. Louis and, in his late 40s, he tired of the city, bought a farm and moved his family near Memphis. While the move has been tranquil, it also means Tobler is essentially always on call. On any given day, he arrives at the hospital between 6:30 and 7:30 a.m. and tends to stay until at least 7 p.m., often spending the rest of the evening away from the hospital yet still on call.
"A lot of doctors that have a lot of good years left are retiring prematurely," he said, "or they're jumping off the grid and doing cash-only practices."
Doctor burnout, often fueled by excessive red-tape measures that have increasingly intertwined governmental regulations with the health care field, is becoming more prominent. Tobler is beginning to see it in younger doctors.
"I'm not saying those measures aren't good things to do," Tobler said, "but they're distractions from seeing patients."
Tobler believes the one-size-fits-all approach that has equated smaller rural clinics with more innovative metropolitan facilities cannot be successful. The solution, he said, lies in allowing smaller facilities such as Scotland County Hospital to be "late adapters of the health care transformation."
A changing lifestyle
Chris Waggoner is also an exception to the rule. He entered the medical field with the intention of practicing in a small community. While enrolled at the University of Illinois in a rural medicine program, he was drawn by the notion of treating all aspects of a patient's health, from birth to death, and decided to become a primary care physician.
"I think it has something to do with how you view your role as a doctor," Waggoner said. "My philosophy is that I want to take care of as much as I can and only reach out for help whenever I need someone more specialized or a procedure done that I can't do."
Waggoner is the only primary care physician on staff at Illini Community Hospital in Pittsfield and one of the few doctors around that makes house calls. He attributes the shortage, in part, to a change in the physician's lifestyle. Doctors are becoming increasingly more inclined to seek out jobs considered to be 8-5, rather than to being on call at all times, as is typically demanded in a rural setting. Waggoner is always on call. He has missed his children's games and often doesn't make it home before dark.
"If I'm looking at $250,000 in debt, yeah, I can take that job as a primary care doctor," he said, "or I can go into something more specialized, make a lot more money, get it paid off a lot quicker and have a nicer lifestyle."
As a one-man show, he constantly tests the limits of his education and experience. Whereas larger cities have more resources -- technology, specialists, collaboration -- bringing such luxuries to Pittsfield is not always an easy feat.
"This is a tough sell," he said. "You have to have that person that is interested in working in a small area. Especially when you're primary care, the person has to want to be a little bit more on their own and has to be confident enough in their education and their abilities."
Several rural clinics have come to rely on a cycle of medical students who complete their residency in smaller, medically underserved areas, or work there immediately after medical school to help repay their loans, before seeking employment in larger cities. Such programs fill a need, but they don't solve the long-term issue of finding permanent physicians.
"A lot of times, part of the visas for foreign medical students is that they have to work in a rural setting for so long," he said. "Smaller towns are desperate to get a doctor. We would rather have someone who says they want to be here for three years than someone who isn't here at all."
He has seen some students cycle through that become attracted to the independence of rural America and the close personal relationships with patients that develop in small towns.
"It starts in medical school, I think, getting students exposed early to what rural America looks like," Waggoner said, "It's incredibly rewarding, being a primary care doctor. You get to connect with patients so much more."
Finding the solution
Demand for doctors has increased significantly as baby boomers have reached retirement age and beyond.
"You basically have this perfect storm," said Scott Koelliker, executive vice president of Blessing Physician Services. "As we get older, our health care needs increase. You have more people trying to get in and fewer doctors to see them."
Nurse practitioners across the country have risen to the occasion to fill in the gaps left by the shortage of doctors. Blessing has been trying to grow its nurse practitioner ranks in recent years.
"I think you'll see more and more organizations using nurse practitioners to help extend their organizations out into the reach, extend their practices to make them more accessible," Koelliker said. "Using them to treat some of the minor conditions in various specialties allows the physicians to focus on the more complex diagnoses."
Koelliker said Blessing has fewer issues than the smaller practices in the areas surrounding Quincy when attracting physicians, because he is able to use Quincy as a selling point.
"Quincy offers 99 percent of the amenities a professional would need," he said. "Some of the small towns are really struggling to find and recruit physician talent."
Even with its selling points, Quincy still meets some of the guidelines to qualify as a medically underserved area, which brings in significantly more doctors. Blessing Physician Services also works with several colleges and universities, opening up its doors to students in need of on-the-job experience.
"They come here as an obligation to repay some of those student loans," he said, "but they stay here to raise a family."
The issue can be resolved, Koelliker said, by reaching students even before they graduate high school by promoting and encouraging them to pursue their interests in medicine.
"More and more programs are trying to be more flexible with students," he said. "They know there's a lot of folks that have to work and go to school and that it's very expensive to go."
A focus on wellness and prevention may also be able to right the sinking ship.
"How do we keep people from becoming chronically ill?" he asked. "If we can teach adults at younger ages to take care of themselves today, we can prevent some of that demand we see in later years. The healthier the population, the less demand there is on physicians."
In its report, the AAMC offered a multi-pronged solution that includes innovations in care delivery, better use of technology and increased federal support for an additional 3,000 new residency positions annually during the next five years.
AAMC President and CEO Darrell G. Kirch said medical schools have been increasing their class sizes to grow the number of physicians, and urged Congress to approve an increase in federal spending.
"We believe this is a measured approach to deal with a problem that has the potential to affect every American," Kirch said. "Because it can take up to 10 years to train a doctor, our nation needs to act now."