Physician Shortage Persists in Many Rural Areas

The eight family practitioners, the three surgeons, the two internists, the obstetrician, the pediatrician, the radiologist and the urologist who work in this remote little town all bear out an underappreciated theory of medicine: Doctors go where the patients are.

During the 1980s, when the nation’s supply of doctors rose by more than one-quarter, bigger places grew saturated and physicians dispersed into the hinterlands.

Rural settlements such as Houlton, population 6,400, became home to all manner of generalists and specialists. Kinds of care that not long ago would have required a two-hour drive to Bangor can be had at the town’s 49-bed hospital.

But not all towns have fared so well. And even Houlton would like more doctors, especially front-line primary care physicians. In Maine, 22 areas are considered to have shortages because people outnumber doctors by more than 3,500 to one.

Bringing medical care to places simply too poor or sparsely settled to keep doctors busy and paid has been the goal of the National Health Service Corps for the last 20 years.

In all, about a quarter of the nation’s population lives beyond the cities and suburbs, most in places that are neither terribly impoverished nor very far from a town. A variety of statistics and other evidence suggests the scarcity of physician care that was common for many of them a generation ago has greatly eased.

“It’s improved tremendously,” said Bradley Bean, administrator of Houlton Regional Hospital. During the 1980s, he said, “We’ve made major strides.”

Houlton is the last exit on the northern end of Interstate 95, a border town supported mostly by potato farming and lumbering. Trout and deer are plentiful, but the closest shopping mall is 120 miles away, and winters are cold, snowy and long.

An unlikely place for expensively trained specialists to settle? Actually, no. For Houlton and out-of-the-way towns like it have something that cities with more than enough doctors do not. Houlton has patients.

Incomes are more than comfortable, and living is relatively cheap. A family physician fresh out of training easily can make $100,000, which also is the price of a very nice house here. That helps explain why the 17 doctors in the town represent a 50% increase from a decade ago.

Many, such as Dr. Hassan Abouleish, who came here three years ago, say they prefer the hands-on, personal style of medicine they can practice in little places.

“This allows me to get to know my patients better,” said Abouleish, 31. “They don’t get lost in a maze of doctors and big hospitals.”

Despite the gains in numbers, many rural health advocates and some academics and government officials are reluctant to concede that market forces are relieving the doctor shortage. Many still refer to “the rural health crisis.”

“Through the ‘80s, we did not see trickle-down occur,” said Dena Puskin, acting director of the federal Office of Rural Health Policy. “We continue to see a profound shortage in communities of less than 10,000.”

A recent report from the University of Washington labeled the rural physician shortage “one of the most persistent problems to confront American health care policy-makers in this century.”

Others say that’s nonsense.

“It’s clear that the number of physicians in rural areas has increased very rapidly,” said Paul Frenzen, a sociologist at the U.S. Department of Agriculture. “Even the most rural areas have gained physicians.”

Dr. William Schwartz of USC is even more emphatic: “There is no shortage.”

Both sides argue their cases with statistics. Frenzen, for instance, has analyzed where physicians are locating. He concludes that primary care doctors became more evenly dispersed across the country throughout the 1980s.

Among other statistics cited by those who think the situation is not so bad and getting better:

* Throughout the 1980s, the number of primary-care doctors per 100,000 people increased 21% in rural areas and 16% in cities.

* Even by the late 1970s, every town of 2,500 people had at least one doctor.

* At the start of the 1980s, people living in rural areas visited doctors slightly less than city residents. But by the end of the decade, this difference had disappeared. People everywhere average five trips to the doctor annually, suggesting access to care is the same.

* On average, rural people have to travel just five minutes more than city residents to see their doctors.

But statistics also can paint a different picture:

* Cities have 225 doctors per 100,000 residents, compared with 97 per 100,000, or less than half as many, in rural areas.

* More than 100 sparsely settled counties, mostly in the Plains states and Texas, have no doctors at all.

* Country people complain of more chronic illnesses than city dwellers, although their death rate is lower.

* A total of 237 rural hospitals shut down during the decade. In 1989, they accounted for two-thirds of all community hospital closings.

Where doctors choose to set up shop is in large part a matter of economics--and where the patients are.

This idea, called standard location theory, is typically used to predict where supermarket chains will put new stores. When applied to doctors, it suggests they will bypass doctor-filled cities and go to smaller towns with less competition. As the total number of doctors increases, it follows, they will filter into ever-smaller towns in search of patients.

Certainly, the supply has soared. From the mid-1960s to the late 1980s, the total number of U.S. physicians more than doubled, while the population increased by less than one-third.

When researchers from the RAND Corp. in Santa Monica proposed in the early 1980s that economic forces largely would take care of physician distribution problems, they were widely scorned. Now, Dr. David Kindig of the University of Wisconsin, among others, says the RAND predictions have proven to be “technically correct.”

“There is some truth that a rising tide carries all boats,” Kindig said. “This is not true in all communities, but the physician population in all kinds of rural areas is rising.”

But even the most avid believers in location theory doubt economic forces will assure equally good and convenient medical care to everyone.

One fact of medical life is centralization. CT scanners, catheterization labs and other glitzy gear attract both doctors and patients. Tiny hospitals simply cannot afford them, so the weakest close.

Dr. Thomas C. Ricketts III of the University of North Carolina drew a line down the center of a map from North Dakota to West Texas. Here are the scattered little towns with one, two or three doctors that cannot attract a new one when someone leaves or retires.

“You can find 300 or 400 places that have lost physicians in the last 10 years and have changed from adequately served to underserved,” he said. “That’s the crisis.”