Arkansas ranks eighth in the nation for primary care physician need; state’s three medical schools hope to fill the gap.
by Dan McFadden
While the national conversation focuses on health care insurance, there is a related issue of equal concern at hand: a national shortage of physicians. What are the contributing factorws and can Arkansas keep pace with its growing demand for doctors?
According to the Association of American Medical Colleges (AAMC), the United States could see a shortage of up to 120,000 physicians by 2030. With the graying of America upon us, the U.S. Census Bureau reports by 2035 the number of older adults 65 and over will outnumber children 18 and under. In addition to an aging population taxing our already stretched too thin health care system, other factors contribute to the primary care physician shortage.
Increasing chronic diseases like diabetes, heart disease, obesity and smoking-related issues rates, along with an aging population, are creating a perfect storm and increasing demand for more primary care physicians and specialty physicians, according to Appathurai Balamurugan (Dr. Bala for short), the state’s chronic disease director and medical director for the Chronic Disease and Tobacco Branch at the Arkansas Department of Health (ADH) in Little Rock.
Bala points to America’s Health Rankings, reported yearly by the United Health Foundation.
“Arkansas has 120.9 primary care physicians per 100,000 population versus the U.S. average of 156.7, placing us eighth in the nation for primary care physician need,” Bala says.
Despite ominous national projections, there is a silver lining for Arkansas: the primary care workforce (family practice, general practice and internal medicine physicians, OB/GYNs and pediatricians) is growing even in the face of retiring physicians across the state.
The ADH Office of Health Statistics’ Health Professions Manpower Assessment report shows that over an eight-year period, the total count of Arkansas primary care physicians rose by 30 percent from 3,055 in 2010 to 3,966 in 2017. Although the increase is promising, the major challenge is primary care physician geographic distribution across all five Arkansas regions: central, northeast, northwest, southeast and southwest.
“The rural primary care shortage is real. Our main concerns are the southeast and southwest regions, each with six percent of our primary care physicians,” Bala says.
Two programs may offer long-term relief for underserved areas of Arkansas. According to Bala, the J-1 Visa waiver program is appealing to international graduates trained in primary care. It waives the requirement for those physicians to return to their home country for two years before applying for a new U.S. visa if the physician is willing to practice medicine full-time for three years in an underserved area of the United States. In addition, the National Health Service Corps (NHSC) Loan Repayment program provides repayment assistance to licensed primary care medical, dental and mental and behavioral health providers who serve in communities with limited access to healthcare.
HOPE ON THE HORIZON
While Arkansas is posting growth in the primary care field, will supply keep pace with demand? And are Arkansas’ medical students foregoing primary care for more lucrative specialties?
“A lot of medical students that move into internal medicine will later go on to specialize. They have to go through a primary care route to reach the end of their training,” says James Clardy, associate dean of Graduate Medical Education (GME), designated institutional official and professor of psychiatry at the University of Arkansas for Medical Sciences (UAMS). He is responsible for ensuring UAMS stays accredited to run the institution’s 61 programs from psychiatry to neurosurgery to pediatrics and ENT.
Clardy says there’s another way to look at the primary care puzzle through core residencies, the first place a student would go, such as family medicine, internal medicine and neurosurgery. Cardiology, for example, is a specialization because one must go through an internal medicine general residency first.
“Lots of people that go through the core residencies then go on into specialties, and that’s where it is hard to really keep up with more and more, as time has gone on,” Clardy says. “What I’ve tried to do practically in looking at our programs at UAMS is to try and determine what hospitals around the state say or think they need.”
Meeting those needs includes increasing Graduate Medical Education positions at UAMS, a dramatic shift from the past.
“When UAMS was the only medical school in the state, we had more GME spots than we had graduates from the medical school. When the new medical schools came in with all the new graduates, for the first time we were talking about pressure to have more GME spots.”
Does Arkansas offer enough positions for post-graduate medical students? Currently, there are approximately 275 Post Graduate Year One (PGY1), accredited positions in Arkansas, according to Clardy.
“PGY1 is the place where people go their first year out of medical school training.”
He adds when the NYIT College of Osteopathic Medicine at Jonesboro and the Arkansas College of Osteopathic Medicine at Fort Smith reach full enrollment, “there will be about 174 UAMS graduates and about 270 spots at the other two schools combined.”
All totaled, there will be 440 to 450 medical school graduates in Arkansas every year. For perspective, UAMS’ current total number of medical students averages approximately 160 per year.
Med Students’ Perspective
For perspective on the challenges ahead, some medical students provided their candid perspectives. What drives the decision behind residents’ choice of their life’s medical practice or specialty? Reaching beyond the data and needs of Arkansas, these UAMS residents are following their own paths.
“I did my family medicine rotating in Fort Smith and quite enjoyed it,” said Bryant Virden, a child and adolescent psychiatry resident. “There’s a big shortage in psychiatry, especially in the south here in Arkansas. I’ve done a fellowship in child and adolescent psychiatry, and there’s only about 50 or less of those folks in the state, which was one of the reasons I chose this field.”
Virden feels that psychiatry gives him the opportunity to spend more time with fewer patients daily with the added bonus of schedule flexibility.
According to Virden, approximately 50 percent or more in his 2014 class went into primary care, internal medicine, family practice or OB/GYN.
“I’m not sure what everyone’s motivation was, but I think it’s individualized. Some people go into the higher paying fields because it’s expensive in a lot of ways to be a physician.”
Among the financial challenges Virden lists are student loans, paying for medical board testing, licenses, malpractice insurance and more.
“If primary care is not making as much as some of the focus fields, then there might be less incentive to go into primary care,” he says.
Personal characteristics helped steer Signe Rebolledo’s decision for a career in diagnostic radiology.
“A lot of other specialties are very clinical based, and I just don’t get my energy from interacting with people in a clinical setting very well,” Rebolledo says. “I’m a very visual learner, and the field of radiology and pathology really were very interesting to me. You have very nice, limited, quality patient interactions, but then it’s a very visually-oriented field where you’re actually telling people what’s wrong so you can guide the care of more people than I ever would have seen in the clinic doing primary care type work.”
Rebolledo believes personality plays a major role in the field of practice.
“Whenever people are coming down on selecting what they want to do, it’s more of a personality thing and where they fit in within the field of medicine. Because if you work so long to get somewhere in your career, do you want to be settling for something that doesn’t make you happy every day?”
Paige Beck, a family medicine resident, says, “From the very first day of medical school, I promised myself I would go into whatever field I fell in love with. I wasn’t going to let salary play into what I chose to do.”
It was during Beck’s palliative care rotation that she found the work to be most rewarding.
“I was able to quickly and easily form a relationship with patients and their families and talk about difficult issues such as end-of-life care and death.”
Beck believes financial reward or lifestyle drives some people’s choices.
“Everybody has their different approach, but I do think people go into family medicine and primary care because they have a passion for it and found that they were good at it.”
Variety drove Brian Yuen to choose a practice in family medicine.
“I am in the Little Rock family medicine residency program at UAMS, which includes care in the clinic, hospital inpatient care, ER rotation, women’s health and delivering babies with our OB/GYN service,” Yuen says. “Going through family medicine rotation starting in the third year of medical school, I enjoyed doing a little bit of everything, developing long-term relationships with my patients and having that continuity of care.”
Although the primary care physician shortage is real, there’s no shortage of interest from students who want to do primary care, according to Yuen.
“I think we’re playing catch up (with the total volume of primary care physicians), but it’s improving, and I think eventually we will be able to meet that demand.”
UAMS RESIDENT SPECIALTIES
The University of Arkansas for Medical Sciences currently has 820 residents in 57 specialties. Residency is the first step of a doctor’s practice after medical school.
Family Medicine 174
Internal Medicine 64
Emergency Medicine 30
Internal Medicine – Northwest Ark 22
Orthopaedic Surgery 22
Obstetrics and Gynecology 20
Internal Medicine/Pediatrics 18
Pathology-Anatomic and Clinical 18
Physical Medicine & Rehabilitation 16
Cardiovascular Disease 12
Hematology and Oncology 12
Neurological Surgery 9
Pediatric Emergency Medicine 8
Pulmonary Disease & Critical Care 8
Child & Adolescent Psychiatry 6
Neonatal-Perinatal Medicine 6
Pediatric Cardiology 6
Transitional Internship 5
Vascular Surgery Residency 5
Pediatric Critical Care Medicine 5
Endocrinology, Diabetes & Metabolism 4
Geriatric Medicine 4
Infectious Disease 4
Child Neurology 3
Hospice & Palliative Medicine 3
Interventional Cardiology 3
Maternal-Fetal Medicine 3
Pediatric Hematology/Oncology 3
Pediatric Surgery 3
Interventional Radiology Direct Pathway 2
Cardiac Electrophysiology 2
Pediatric Pulmonary 2
Vascular & Interventional Radiology 2
Vascular Surgery Fellowship 2
Diagnostic Radiology & Nuclear Medicine 1
Radiation Oncology 1
Developmental-Behavioral Pediatrics 1
Forensic Psychiatry 1
Geriatric Psychiatry 1
Hematology Pathology 1
Sports Medicine 1
Surgery Critical Care 1