Oklahoma falls short in its doctor-to-patient ratio.
Oklahoma has one of the most severe shortages of doctors anywhere in the nation, and the numbers will make you queasy.
Various rankings put the state between 45th and 47th for doctor-patient ratio, with roughly 200 physicians per 100,000 residents, according to the Association of American Medical Colleges. Compare that to the top state on the list, Massachusetts, which has more than 400 doctors per 100,000 residents.
That means patients sometimes have to wait weeks or even months to see some kinds of specialists. It means some doctors might close their practices to new patients, and it means patients might go the much more expensive route of seeking care through an emergency room.
“That takes away from continuity of care and is harmful to quality of care and preventative services,” says Dr. Kayse Shrum, president of the Oklahoma State University Center for Health Sciences.
Ultimately it means more expensive, less efficient health care.
“Why?” is the most obvious question regarding the doctor shortage. But even the experts haven’t fully determined that.
“It’s a good question, and I don’t know that we know the answer, but there are many factors that contribute to it,” says Dr. John Schumann, president of the University of Oklahoma-Tulsa.
S.O.S.: Save our (medical) students
Part of the problem, Schumann says, is simply a numbers game. For medical schools, Oklahoma only has the OU College of Medicine in Oklahoma City (and the new OU-TU School of Community Medicine) and the OSU Center for Health Sciences College of Osteopathic Medicine in Tulsa.
But even with a relatively small number of medical schools, doctors say Oklahoma does fairly well in terms of the number of local students who want to become doctors and the number who graduate.
Oklahoma graduated 255 doctors from these schools in 2015. That number is relatively strong, according to Dr. John Zubialde, professor of family medicine at the OU College of Medicine.
“If you look at Oklahoma, we are about right at the national average in terms of the number of graduating medical students that we have,” he says.
And Oklahoma actually does better than the national average of retaining students once they graduate medical school, ranking 11th in the U.S., although schools are always working to do better.
Where we really come up short is finding places for students to do their residencies in Oklahoma.
Oklahoma has relatively few Graduate Medical Education (GME) positions — informally referred to as residency slots — compared to other states. Many are sponsored and administered by OU and OSU and take place in their hospitals and affiliates. OU has roughly 600 slots in the Oklahoma City area and around 180 slots in the Tulsa area. OSU has around 165 GME slots at OSU Medical Center in Tulsa.
Unfortunately the slots don’t always match up to the residencies graduates want.
“There are actually more slots than there are students, but it’s a sorting game,” Schumann says. “That is, there’s enough internal medicine and family medicine and pediatric slots — primary care specialties. But there aren’t enough urology, ophthalmology, dermatology slots for the number of people who want them.”
Though the numbers might seem appropriate, the ratio of medical graduates to GME positions in Oklahoma differs considerably from other states. According to 2014 data from the Association of American Medical Colleges (AAMC), Oklahoma had 280 first-year residency slots available, compared to 1,644 slots in Illinois — nearly six times more. Considering Illinois’ population is roughly three times Oklahoma’s, that’s quite a disparity.
Since a government regulation was added in the late 1990s, institutions can no longer grow their residency programs unless other, non-federal funding is secured.
“Believe it or not, in the year 1997, Congress passed the Balanced Budget Act of 1997, which caps the number of Medicare-approved residency slots in the United States,” Schumann says. “We see some growth in the number of residency slots, but that’s typically through different funding mechanisms.”
That fateful moment in 1997 became a critical turning point in the saga of America’s doctor shortage. At the time, experts believed we were headed toward a surplus of doctors.
But even though it’s now painfully evident those experts were wrong, lawmakers on Capitol Hill say there’s nothing they can do about it.
Lawmakers recognize the problem, but there is little political will to increase federal spending given the national debt. Dr. Bruce Koeppen, dean of the new Frank H. Netter M.D. School of Medicine at Quinnipiac University in Connecticut, says he lobbied his state’s congressional delegation for many years.
“They basically said, ‘We think you’re doing a great thing there at Quinnipiac, we applaud what you’re doing, but we don’t have any money for you,’” Koeppen says.
Given Oklahoma’s current budget woes, doctors agree the money seems even less likely to be found at the state level than at the federal level.
It is possible to create medical schools and residency slots without the help of the federal government, but it is by no means easy. Quinnipiac is a private school that has invested $100 million in the Netter School.
Closer to home, OU’s new collaboration with the University of Tulsa to create their school of medicine in Tulsa was seeded with a $50 million donation from the George Kaiser Family Foundation. Subsequent gifts from the Oxley and Warren Foundations to OU-Tulsa and TU jointly provide funds for hiring faculty and offering student scholarships.
OU pays for about 25 percent of its residency slots in Oklahoma City from its operational fund. OSU does the same for about 36 percent of its slots. But admirable as that may be, doctors at both schools say it won’t keep pace with the number of additional slots that are needed.
One solution would be to create more medical schools and more residency slots. But those, of course, take money. In the case of residency slots, the bulk of the money comes from Medicare.
Additionally, once Oklahoma graduates leave for a residency elsewhere, they are less likely to return.
“You wind up getting married, buying a house, kids get attached to schools, then there has to be a real draw to kind of pull you out of that,” says Dr. Daniel Duffy, former dean of the OU School of Community Medicine, who adds a graduate’s hometown or family base can be a draw, too.
Hospitalism side effects
Further aggravating the doctor shortage, Schumann says, is the ongoing phenomenon of what many call “hospitalism,” where doctors are no longer in private practice and are simply employees of a hospital or large health system, also known as hospitalists.
“Over the last decade we’ve gone from two-thirds of doctors who are privately employed, meaning they own their own business or their own practice,” Schumann says. “Now, two-thirds or more of doctors are employees.”
Sources say the days of family doctors doing a one-year internship and setting up a small private practice are history, not to mention the fact that it’s so expensive.
“If I go to an employee position, I’m paid a salary,” Schumann says. “Malpractice, rent, overhead, billing … all of that is taken care of … they like the safety and the security of being an employee rather than the risk associated with running an office, which is an inherently risky thing.”
But, more hospital-based physicians create a bottleneck because they don’t see outpatients.
“If they’re only working in the hospital,” Schumann says, “patients only see them when hospitalized. You won’t see hospital doctors with a
garden-variety complaint like back pain or when you need your thyroid medication or your cholesterol medication looked at or adjusted,” Schumann says.
The hospitalism phenomenon and the demise of private practice have taken an even bigger toll on rural areas, for the simple fact that there aren’t many rural hospitals. And with limited resources, they are less able to employ physicians directly.
“I’m in my 70s, and when I started, banks were fighting over each other to loan a doctor money to set up a practice at incredibly low interest rates,” Duffy says. “That hasn’t happened for 20 years.
“Quite frankly, given the huge debt that doctors have when they’re starting to practice and the lack of private capitalization, it’s virtually impossible for the ‘Marcus Welby’ single doctor to open a practice.”
Duffy says realistically, a doctor has to have a team of three to five colleagues to keep up with the workload, along with innovations in medicine.
“You can’t be on call 24/7 and not burn out and leave practice after about three or four years,” he says.
In private practice a doctor has more control and the ability to call the shots, but in general, Schumann says younger doctors prefer the job security of a hospital setting to the control of a private practice.
And if you think a place like Tulsa has trouble luring 20- and 30-somethings away from the glitz and excitement of big-city life in Chicago — with its prestigious medical schools — now imagine how tough it is for a small town of 8,000 people. Zubialde says survey data shows medical graduates value geographic location and lifestyle even more than salary.
Doctor shortages exist across the board, but the shortage is most severe for primary care medicine. Since hospitals are now having to find ways to fund their own slots, they’re going where the money is. And that’s in specialties that do expensive procedures.
“The way our reimbursement system is set up, you get paid more if you do a procedure, than if you sit down and talk to a patient and help make sure that they’re eating properly, not smoking, etcetera,” Koeppen says.
He says that’s created an increase in the number of sub-specialty residency slots because those residents are making money for the hospitals that pay their salaries.
“So primary care residency programs are at a disadvantage,” Koeppen says, adding that another factor is that career-long earning potential is less for primary care physicians than those in many specialties.
“You can’t be on call 24/7 and not burn out and leave practice after about three or four years.”
There have been efforts to make primary care programs more feasible for hospitals, including funding for the divisive Affordable Care Act, but supporters are fighting an uphill financial battle.
“The ACA has provisions to address the primary care shortage, but the ‘Teaching Health Center’ provision, which was designed to create new primary care residencies, has time-limited finding,” Koeppen says. “In my testimony before the Senate subcommittee on the issue, I advocated for making this funding more durable.”
PAs pick up the slack
The production of new doctors has gotten a much-needed shot in the arm from the rise of physician assistants. (Note: don’t call them physician’s assistants. They hate that.) The PA position was created in 1965. The first class of PAs in Oklahoma was at OU College of Medicine Physician Associate Program in Oklahoma City a few years after that, and the first class graduated from the OU-Tulsa Physician Assistant program in 2010. The state now has 1,400 PAs, according to OU.
“The PA phenomenon has really taken off within the last 10 years,” Zubialde says. “And that’s exactly because we recognize that we’re not going to be able to train enough doctors.”
PAs can do many more physician duties than they can’t.
“It is amazing that so many times people might have a PA in a hospital setting and they don’t even realize they are a PA and not a physician,” says Shannon Ijams, program director for OU’s physician assistant program in Tulsa, “because we can diagnose and order lab tests, interpret lab tests or order imaging, write prescriptions, make referrals … it’s so broad.”
That frees up doctors for tasks that require more training. Also, schools get PAs into the pipeline quickly, with 30 months of intense training, as opposed to four years of medical school plus three to seven years of graduate medical training, or even longer, for doctors. So, it’s a fast and efficient tourniquet for the doctor shortage. And unlike doctors, PAs can move more easily from specialty to specialty where they’re needed and where they want to go.
“I could work in a family practice clinic for five years and then go work with just a pulmonologist or just a cardiologist,” Ijams says. Were she a physician, Ijams would have to do another residency if she entered a new field.
PAs also are ideally suited to fill in the gaps in rural care, because they can do virtually all of the primary care duties that are needed most often in a rural setting.
“Although we have fewer physicians than we think we need in rural Oklahoma, we may not have too little primary care,” Duffy says. “We have really done a magnificent job of training physician assistants and nurse practitioners, who are in some ways better suited to deliver care in very small areas than our physicians.”
Ijams says Oklahoma law has been less restrictive than some states in allowing PAs certain privileges, giving them the freedom to work in small towns where doctors are not available.
“PAs can communicate with their supervising physician via phone or through the EMR (electronic medical records) or via Skype or other telemedicine capabilities,” Ijams says. “So, it’s allowing these providers to meet these needs. They really would not have providers in that community if it were not for the PA or nurse practitioner working in there.”
A puzzling prognosis
Just as they do when patients face a difficult disease, doctors caution people that the outlook is uncertain when it comes to the doctor shortage.
“It’s not a simple fix,” Zubialde says. “I think that’s the one thing that I would like to make sure people understand.”
Additional factors complicate the issue, such as an aging population that grows larger every day and requires the most expensive kind of care.
“Eighty percent of our resources is spent on chronic illness care,” Zubialde says. “These are older patients and more disabled patients with high illness burdens such as heart failures, COPD, diabetes. You know, all of those kinds of things that really drive a lot of the use of health services.”
Doctors themselves are getting older, too, and Oklahoma has more doctors over the age of 60 than the national average, according to Becker’s Hospital Review. Data is sketchy on the exact number of doctors who retire each year, but with such a large number of baby-boomer physicians nearing retirement age, it will only exacerbate the shortage.
Besides that, some doctors like Koeppen say their younger counterparts, in general, don’t want to work as many hours as they did. So in a sense, it will take more than one new doctor to replace one outgoing physician.
“That’s why the ER specialty is so popular,” Koeppen says. “It’s not because of the TV series ‘ER’, it’s because it’s shift work,” Koeppen says. “You do a number of shifts in the ER, and you get days off, where they can then go and do what they want to do.”
If all that’s not dire enough, the Affordable Care Act means that millions of additional people are now insured and are trying to get in to see the same number of doctors.
Oklahoma is a few years behind other states in creating a comprehensive plan to address the doctor shortage problem, Zubialde says. But he says the good news is that a group of health leaders and representatives from business, labor, tribes, academia, nonprofit organizations, state and local governments, professional organizations and private citizens are working on the Oklahoma Health Improvement plan. Once that’s done, he says implementing solutions will be a matter of political will, and even more importantly, resources to make them happen.
“It’s bringing the business community, the provider communities, the hospital associations and all the folks that need to be partnering and talking about these things together,” he says. “You’ve got to get the legislators and everybody else on board with this plan to say, ‘Yeah, this makes sense. Let’s work on it. Let’s make it happen.’”
If you want a sense of just how much catching up Oklahoma has to do with some other states, and if you can handle a bit of medical envy, just take a look at the charts from the Accreditation Council for Graduate Medical Education (ACGME) that show the number of medical residents in each state.
Oklahoma has a total of 831 residents, according to the latest ACGME data. By comparison, New York has 1,326 residents who entered residence programs last year — in internal medicine alone.
That’s an extreme example, but no matter how you slice the numbers, it’s plain to see how Oklahoma has earned its various rankings at the bottom of the doctor supply barrel.
There are a few bright spots here and there. Take family medicine for example, one of the specialties where the shortage is most severe nationwide. The ACGME says Oklahoma has 1.32 residents in family medicine per 100,000 population compared to .73 for Massachusetts and 1.02 for New York, states that typically have an embarrassment of riches when it comes to the number of residents and practicing doctors.
For more information, visit the ACGME’s data book at www.acgme.org.