Moundview Memorial Hospital in Friendship lined up four recruiters last year to replace a doctor who is leaving in May.
Resumes have come from only three doctors — one who didn’t return the hospital’s calls, and two who can’t work until next year. It’s so hard to attract doctors, Moundview has kept its medical director even though he is a felon who is not allowed to treat Medicare patients.
“There aren’t many doctors willing to consider my little hospital, and when they do, there always seems to be a reason,” said Jeremy Normington, chief executive officer.
One of the biggest challenges in rural health care, experts say, is a shortage of doctors willing to give up the convenience, technology, prestige and typically higher salaries of metropolitan areas to practice in rural settings. That means rural patients can have trouble getting health care — waiting longer for primary care and traveling to large cities for specialty care.
But medical student Clay Dean is a pioneer in a new program to increase the number of rural doctors in Wisconsin.
Raised on a beef farm near Blue River, a town of 400 people about 65 miles west of Madison, Dean is in the first class of the Wisconsin Academy for Rural Medicine at the UW School of Medicine and Public Health. The students are getting much of their training in northern Wisconsin.
Just 5 percent of medical school graduates want to practice in rural areas, according to a national survey last year. But Dean says being a rural physician will allow him to also be a community leader — like his father, a veterinarian and school board president.
“I probably could have the biggest impact on a smaller community,” said the 26-year-old, who, during training in Rice Lake, gave his first injection, learned to deliver anesthesia and helped treat farmers who rarely go to doctors.
“Here, you’re a jack of all trades,” he said.
Rural shortage acute
A growing national doctor shortage is particularly severe in rural areas.
About 16,000 more primary care doctors are needed nationwide today, according to the U.S. Department of Health and Human Services. The shortage of all kinds of doctors is expected to reach 124,000 by 2025, the Association of American Medical Colleges says.
Rural areas have one-fourth fewer doctors per person than urban areas, and 68 percent of the communities with federally designated doctor shortages are rural.
Wisconsin’s doctor shortage is most acute in Milwaukee and rural parts of the state, a 2008 report said. Today, of 174 primary care doctor job openings listed on a statewide database, nearly two-thirds are in rural places, according to the Wisconsin Office of Rural Health.
St. Joseph’s Community Health Services in Hillsboro, about 80 miles northwest of Madison, recently hired a physician assistant and a nurse practitioner to replace two doctors who left, largely because doctors were difficult to find, said Sue Zimmerman, community relations director.
It took Stoughton Hospital two years to fill a recent doctor job, and another has been open since October.
“The candidates we interview have many options open to them,” said Terry Brenny, the hospital’s chief executive officer. “We really have to compete.”
Debt and salaries
A major obstacle for rural areas: Medical students graduate with an average debt of $156,000, according to the American Medical Association.
Starting salaries for family medicine doctors, the type rural areas need the most, are about $170,000 a year, according to the physician recruiting firm Merritt Hawkins and Associates. Specialists, such as cardiologists and radiologists, make $390,000 or more. They usually work in large cities.
In part because of financial considerations, the number of medical school students going into family practice has dropped 54 percent since 1997, according to the American Academy of Family Physicians.
“You get paid a lot less for working just as hard,” said Dr. Chris Frank, a family medicine resident, or doctor in training, in Baraboo.
The National Health Service Corps offers up to $120,000 to pay off medical school debt to doctors willing to work for four years in underserved rural areas. Wisconsin provides $50,000 in debt forgiveness for a three-year commitment to certain rural areas, including some the federal program may not cover. A bill before the Legislature would increase the amount to $100,000.
Foreign doctors help fill the gap by getting visas to stay in the United States if they work for three years in rural areas. Since 2002, when the foreign doctor program expanded nationally, 80 of the doctors have worked in rural Wisconsin, including 34 now, according to the state Department of Health Services.
But many foreign doctors leave after their duty is over, forcing rural communities to keep searching for physicians, said Dr. Martin Janssen, who is semi-retired in Friendship. Five of the eight physicians who have left there since 2002 had the visas, called J-1s.
“There’s not a lot of permanency with the J-1s,” Janssen said.
Struggles in Friendship
The upcoming vacancy in Friendship is a case in point. Dr. Sheryl Sulangi-Lorenc, a J-1 visa doctor from the Philippines, is moving to New York now that her three-year commitment is over.
She likes Friendship, about 85 miles northwest of Madison, even though it’s far from major stores and ethnic restaurants, she said. But she and her husband, who are expecting their second child, want to move closer to his family.
Normington, the hospital administrator, said it’s hard to get doctors to consider Friendship and its neighboring city, Adams, which have a total of about 2,500 people.
He tries to sell doctors on the lakes and golf courses north of town and the Wisconsin Dells to the south. But he can’t afford the $20,000 signing bonuses many competitors offer.
“For us, that money goes to recruiters,” Normington said.
But they don’t always help. After the last search turned up only one doctor candidate, who wasn’t board certified, the hospital hired a physician assistant.
With just three doctors on staff now, including the departing Sulangi-Lorenc, the hospital must hire a physician to replace her, Normington said. If none is found, he might use a temporary doctor service.
WARM a solution?
The Wisconsin Academy for Rural Medicine, or WARM, could give rural areas more doctors to choose from.
Dean and two of the program’s other inaugural students, now in their third year of medical school at UW-Madison, are training in Rice Lake and Marshfield. WARM has expanded each year, with 20 first-year students expected this fall. Training sites are being added in Green Bay, La Crosse and small towns near those cities.
The medical school has offered some rural training for years. But WARM greatly expands the exposure and selects students from rural areas, with the hope that they’ll return to similar places when they graduate.
While many doctors consider high-tech specialties in big cities to be more prestigious, rural doctors must learn to handle almost everything, which requires a broader set of skills, said Dr. Byron Crouse, WARM director.
That includes knowing about rural culture, he said.
When chatting about the price of milk with patients who are dairy farmers, for example, “you talk about the price per 100 pound weight, not the price per gallon in the store,” Crouse said. “Those things translate into trust.”
‘Bread and butter’ training
Dean understands people from small towns. After graduating from Riverdale High School in Muscoda in 2001, he went to UW-Superior and graduated from UW-Platteville.
Two years ago, he married his high school sweetheart, Cortney, a speech therapist. They want to settle down in a rural part of Wisconsin — “wherever someone will take me,” he said.
His training in Rice Lake and Marshfield has been a whirlwind of weeks-long rotations, similar to what students in Madison receive: internal medicine, surgery, primary care, psychiatry, anesthesiology, pediatrics, neurosciences.
But some opportunities have been different. While students in Madison typically compete for doctors’ attention in the operating room with other students, residents and fellows, Dean is usually the only one up north. He’s been able to deliver spinal blocks to several patients by himself. And he’s getting extra training in sports medicine, nutrition, ophthalmology and techniques such as doing biopsies and sewing sutures.
“If you’re going to practice in a rural setting, it’s going to be bread and butter,” said Dr. John Olson, of Marshfield Clinic, who oversees the WARM training in Rice Lake and Marshfield. “So we give them an extra dose of the bread and butter stuff.”
Learning to care
During Dean’s pediatrics training one day this month, he helped evaluate children with coughs, sore throats, diarrhea, ear infections and allergies.
He also honed his bedside manner and shot-giving skills.
While placing a stethoscope on the chest of Britta Hogan, a spunky 6-year-old, he asked, “Is your heart still in there?”
“Yes!” she exclaimed with a big grin.
Before looking in her ears: “You didn’t put any candy in there, did ya?”
“No!” Britta responded with a giggle.
Then it was time to give an injection to Britta’s 19-month-old sister, Kinsey. Dean and a nurse tried to comfort her, but there was no escaping some screaming.
Dean had given shots to cattle on his family farm, but this was his first human.
“It doesn’t hurt my feelings as much to give it to a cow as it does a kid,” he said.