Too many patients, not enough white coats

Virginia hospitals ramp up programs to recruit doctors and nurses

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by Marjolijn Bijlefeld

At 58, Dr. David Ellington isn’t ready for retirement yet. That’s a good thing, because finding a replacement in Lexington for a family physician will be tough. Ellington and his partner, Dr. Robert Pickral, also 58, have been vaccinating babies, diagnosing ailments and providing overall medical care since the early 1980s.

They got lucky five years ago when Dr. Laura Lanier moved to town to follow her husband who had taken a job there. She’s now an associate with the practice — and one of only a few doctors in town under age 40.

A picturesque city near the Blue Ridge Mountains, Lexington “is a great place to work and practice medicine,” says Ellington. But recruiting for doctors pits this practice against every other community in the state — and the nation, for that matter. That’s because the supply of new doctors and other health professionals is not keeping pace with the country’s growing and aging population. In response, communities and hospitals across Virginia are offering a plethora of incentives to attract doctors, nurses and the faculty to train the next generation of health-care workers.

In Fairfax County, for instance, nurses willing to sign on for two years at Inova Health Care System can apply to live in reduced rental housing in Alexandria where rates are about half the going rate for similar housing in Northern Virginia. Nurses pay $950 a month for a three-bedroom town house or $1,000 for a four-bedroom unit, excluding utilities. The affordable housing project, a partnership between Inova Health System and the Fairfax County Redevelopment and Housing Authority, is one of the more dramatic examples of a hospital and locality joining forces to provide a meaningful carrot for recruiting.

As a multitude of factors converge, shortages are expected. For more than 20 years, medical experts were predicting a glut of physicians with managed health care expected to reduce patient demand. As a result, medical schools tightened enrollments, even as the country’s population surged. Now many physicians are preparing for retirement at a time when Americans are living longer and need more medical care. Factor in the retirement of 79 million baby boomers, and it’s easy to understand the growing pressure on a strained health-care system.

Meanwhile, not as many bright young students are choosing medicine. Wary of the bureaucracy, long hours and stress associated with health care, many are going with more lucrative careers. Those who do opt for the long grind of medical school plus a residency (about seven to 10 years) are graduating with large debts. The average debt is $119,000 for public medical schools and $150,000 for private schools, according to the American Medical School Association. To pay off debt, many students focus on specialties that pay better than primary care. The American Academy of Family Physicians reports that the number of medical school graduates going into primary care declined 25 percent nationally from 2001 to 2006.

In Virginia, medical school entering-class enrollments have dropped by 7.2 percent over the past 11 years. In 1995, 470 Virginia residents were enrolled as first-year students, compared with 436 students in 2006, according to figures from the Association of American Medical Colleges (AAMC). During that period, the state’s population ticked up by about 14 percent to 7.5 million.

Today, there are about 2,000 students enrolled — including every level of postgraduate medical education — in the state’s three traditional medical schools: Virginia Commonwealth University School of Medicine, University of Virginia School of Medicine and Eastern Virginia Medical School.

But that doesn’t mean Virginia can expect 500 new doctors every year for the near future. In fact, Virginia medical schools are exporters of new doctors. Stephen S. Mick, a professor at VCU who has studied physician supply for the state, says about 64 percent of Virginia’s graduates move out of state to practice. “That raises questions about the wisdom of building any new medical schools. If graduates don’t stay here, who is going to bear the costs?”

Mathematically speaking, Virginia doesn’t face a physician-shortage crisis, yet. In fact, Virginia’s supply places it 21st in the nation in comparison with other states, according to the AAMC. In 2005 (the most recent year data is available) the state had 16,191 active licensed physicians, or about 2.14 doctors for every 1,000 residents. Mississippi is last, at about 1.6; Massachusetts is first at about 3.7.

Mick says a modest increase in physicians should keep Virginia in line with current doctor-to-patient ratios. However, access remains an issue with fewer doctors typically available in inner cities and rural areas. A growing number of older and female doctors also affects how easy it is to see a doctor. More than one-third of Virginia’s physicians are over age 50. “Older physicians tend to take on a smaller work load than younger physicians,” says Mick.

Overall, 28 percent of the physicians are women. That spikes to 49 percent among doctors under 30 and 41 percent of doctors between the ages of 31 and 40. Since these are women in childbearing and child-raising years, some of them may take career paths and reduced schedules that allow them to spend more time with family.

So how do hospitals, physician groups and communities compete for doctors? With intensity. Dr. Barry Gross, chief medical officer at Riverside Health System in Newport News, says finding family physicians is the biggest challenge.

Today’s young physicians want more balance in their lives. “I’m not saying they’re wrong,” he says, noting that the rigorous schedule physicians keep has contributed to countless divorces and cases of drug dependency. So matching a doctor to the existing health system has to be done right. On average, it takes about six months to fill a physician vacancy. “For each slot, we have phone interviews with about 10 people. Of those, we bring about half of them to interview here. To narrow it down to one person is costly and time consuming,” he says.

Plus, recruiting never stops. In Roanoke, Carilion Health System recently changed to a multi-specialty physician clinic, a model similar to the Mayo Clinic. The move paid off in recruiting, says Carilion Clinic Chief Operating Officer Nancy Agee. “We learned that physicians and staff like working in that collegial manner in which clinics form themselves.” In fact, the clinic has recruited 85 physicians in the past year — compared with the previous average of about 40 a year. Most of them came from outside the area, she says. Another 226 nurses came on board. Nurses may be attracted particularly to the clinic model, says Agee, because there is greater room for job movement within a clinic.

Carilion Clinic also trains some of its own health-care workers. The nearly 1,000-student Jefferson College of Health Sciences, on the campus of Carilion Roanoke Community Hospital, graduates nurses, physician assistants and paramedics among others.

Educating the next generation of health-care workers is important across the board, but it’s especially critical with nurses — a profession that faces a well-publicized shortage. This spring Virginia Commonwealth University’s School of Nursing in Richmond dedicated a new $17 million, four-story facility. Yet as nursing schools expand capacity to accommodate more students, the shortage of nurse faculty becomes more apparent, says Nancy F. Langston, dean of VCU’s college of nursing.

That’s because nursing students don’t go to school to become faculty. They want to be nurses, and they are being heavily recruited almost everywhere on the planet. Incentives include bonuses, sometimes as large as 30 percent of the salary, one-year bonuses and financial incentives for referrals to others who sign on.

In 1991, VCU en­­rolled 444 students in the nursing program. This fall, the number was 1,023. Some of those are students who received their associate’s degree in nursing at a community college and now want a bachelor’s or advanced degree.

Finding new nurse faculty is tough. Teaching doesn’t pay as well as other nursing jobs — although Gov. Timothy M. Kaine in February announced a 10 percent increase in nursing faculty salaries. In June, he unveiled a scholarship program designed to encourage master’s and doctoral students to teach at state schools after graduation. The program is small — $20,000 in annual grants to 10 students over two years — but a stab nonetheless addressing the faculty shortage.

VCU is actively recruiting, says Langston, by identifying students who they hope will return to teach. “I tell our undergraduate students, ‘Go to work full time, but come back and take a graduate course with us next year.’” To teach nursing, faculty members need at least a master’s degree. Preparing younger nurses with the credentials to teach is one way to ease the faculty crunch.

Still, Ellington worries about the future, and not just for his own practice. “As a patient moving into that older patient demographic, I have to wonder, ‘Who’s going to be there to take care of me?’”

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