University of North Dakota medical school works to add physicians in rural areas

MAYVILLE, N.D. — “See that needle? This is my favorite part,” said the woman whose job description includes sticking people with needles.

There was something about the light gleaming off the wicked point that drew gasps from a few of the high school students watching nurse Andrea Lee as she drew saline from a bottle with the syringe.

After the students followed her example — carefully — with their own syringes, she held up her ersatz patient, an orange she named “Orangelina.”

“Say ‘You’ll feel a little stick,’ and then you stick her!” she said in a dead-pan, jokey kind of way that you sometimes find in the “cool” high school teachers. “That’s the best way to put it, ‘stick her.’ If you go slow, she won’t appreciate it.”

With that, she stuck the patient, emptied the syringe and invited her curious charges to commence with the sticking. Hands-on exercises like that continued throughout the day at MeritCare’s Mayville Union Hospital the other week as part of an effort by UND’s school of medicine to increase the supply of doctors in the state’s chronically underserved rural areas.

The school is trying all kinds of things. There are programs meant to yield results in a few years, such as providing free tuition to students promising to serve in rural areas. And there are programs that won’t pay off for more than a decade, such as the “scrubs camp” that Lee and her colleagues participated in. The point was to introduce rural youngsters who have never thought of entering the medical profession to the opportunities that exist.

The premise is North Dakota, being the cold, isolated place that it is, has a hard time importing the doctors it needs from larger cities or foreign countries. The best solution is to grow its own.

COMMON PROBLEM

At UND, med school Dean Dr. Joshua Wynne has been warning of a dire shortage of doctors 15 years from now as more and more of the state’s Baby Boomers reach an advanced age where their needs for medical care exceed supply.

But he notes that the shortage is already here. Currently, to his knowledge, there are at least 50 openings for doctors statewide, which is a lot when you consider the university is producing only about 55 a year and a majority don’t stay. “It’s most severe in rural areas, but it applies to the entire state,” he said.

To grasp the extent of it, one need only look at a map of the state’s health professional shortage areas, or HPSAs. That’s a federal designation for areas that have too few doctors for the population served.

Of the state’s 53 counties, 34 are designated shortage areas, according to U.S. Department of Health and Human Services data. On top of this, there are 14 geographical areas made up of pieces of two or more counties. Together, they cover some three-quarters of the state mostly in areas away from the big population centers.

THE LONG WAIT

What it looks like on the ground is this: Family doctors who aren’t seeing new patients or requiring long waits because there are more patients than doctors. And surgeons who rotate through town once a week or less from larger cities.

Sometimes it’s the family doctors who rotate through and it’s nurse practitioners who fill the gap by providing some doctor’s services.

There’s a growing reliance on foreign doctors who often stay in areas short of doctors only for three years as a condition of their work visas.

In Devils Lake, for example, six of 11 doctors at Altru Health System’s clinic are older than 60 and within sight of retirement, according to administrator Elonda Nord. Because many of the older doctors have full patient loads, there can be a long wait for younger doctors that can accept new patients.

In Mayville, the hospital and clinic used to have three doctors and one nurse practitioner, but is now down to two doctors and two nurse practitioners, according to nursing director Doris Vigen, and they stay pretty busy in the clinic and the area’s nursing homes.

And those aren’t even the hardest hit communities.

THE SOLUTIONS

Wynne, the med school dean, sees three broad approaches to the problem: Retain the doctors the university is producing, import more from outside the state and produce more doctors.

Importation is the most expensive, he said, because competing nationally for doctors is expensive and turnover is high because doctors not from rural areas tend not to stay in rural areas long.

Still, that hasn’t stopped UND from assisting rural providers in recruitment efforts. It now has a full-time recruiter who makes referrals and advises providers statewide.

Aaron Ortiz, the recruiter, said he prefers to candidates that can fit into a rural area, but even those from abroad can work out if they develop ties within their new community. For example, he said, he encourages community members to invite new doctors to events and integrate them into the area’s social fabric.

Retention is the most cost-effective because it wouldn’t cost the state a whole lot more. UND already is pretty good at putting doctors in rural areas. A recent study in Academic Medicine found that 28 percent of its graduates practice in rural areas, making the university No. 7 among all U.S. medical schools. Unfortunately, the study found that such universities are very rare and a small number produce most of the nation’s rural doctors.

Wynne readily admits UND can do more and he plans to make it do so.

Studies and anecdotal observations indicate that there are several key predictors of whether a new doctor will practice in a rural area and stay there, according to Wynne and others the Herald interviewed.

n Those originally from rural areas tend to be comfortable going back, especially if they have family in the area.

A quarter of UND medical students already come from towns of 2,500 or less and Wynne said there’s been talk even of creating a kind of affirmative action program for rural students.

- Those who do internships or residencies — a kind of post-graduate apprenticeship — in rural hospitals and clinics are more willing to serve in similar areas. The Academic Medicine study found that doctors in rural residencies were three times as likely to practice there. It also found that rural residencies are often financially challenged, forcing many to close.

UND already has an internship program for third-year students that places them in places such as Devils Lake and Hettinger, N.D. Wynne pledged to work to reduce barriers to rural residencies.

- Those that have mentors who are favorable to rural practice.

The university has a family medicine interest group for students and introduces them to potential role models.

- Some that might be willing to serve in rural areas can’t do so because the pay isn’t sufficient to offset their debts.

The university, along with the state, has a solution to that too: Besides the free tuition program, there’s also a loan forgiveness program that reduce debts by as much as $90,000.

The last approach, producing more doctors, will also be more expensive, though Wynne believes it’s necessary because retention alone won’t be enough.

Earlier this year, he proposed a 68 percent increase in the med school’s budget to $68.8 million by 2015. This would allow the school to increase the number of students it can graduate each year.

Even then, Wynne said, there would still be some shortage. He projects that by 2025, if he gets the funding, the state would be short 43 doctors instead of 55. Without broadening the school’s pipeline, he said, the shortage would increase to 210.

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