Whitney Palmer

Healthcare. Politics. Family.

Pediatricians Becoming Scarce in Select Areas

Published in the November 2004 AAMC Reporter

When  Cheryl Pflueger’s contractions started four months before her due date, she traveled from her home in Brookings, S.D., to the Sioux Valley Children’s Hospital in Sioux Falls for preemptive steps that could halt early labor. The measures did not work, and Pflueger’s son Ben was born 16 weeks early, weighing 1 pound, 10 ounces.

Doctors immediately put Ben on a respirator designed specifically for the smallest infants, and Pfleuger and Sioux Falls special equipment for premature babies and pediatric specialists saved her son’s life.

“I have no doubt that if he’d been born in Brookings, he would not be here,” she said. “At the time he was born, we only had one pediatrician in Brookings.”

For the next three years, Pflueger, her 2-year-old daughter and Ben drove the one-hour trek between their hometown of 15,000 people and Sioux Falls many times for Ben’s follow-up appointments with eye doctors, hearing specialists and physical therapists. Pflueger’s husband often could not take time away from work, so the family was frequently separated. Traveling for medical treatment created a financial burden, as well.

“It would be great if we had these pediatricians within a short distance so all babies could get the best follow-up care,” Pflueger said. “It’s tough on some parents with the expense of driving, possibly staying overnight and then paying the bills for the doctors and specialists.”

Thousands of parents face similar problems each year when searching for healthcare for their children simply because they choose to live in less populated areas of the United States. The supply of general pediatricians is adequate and even growing in some parts of the country, according to several reports, but rural locations suffer from a scarcity of pediatric sub-specialists. And the problem is mounting.

Growing Without Spreading

From 1978 to 2000, the pediatrician population ballooned by 140 percent, according to a recent study by Gary Freed, M.D., a professor at the University of Michigan School of Public Health. This increase means the number of pediatricians per 100,000 children more than doubled from 49.8 to 106.2 during the period. These doctors, however, are not spread evenly nationwide.

“There is a significant difference in distribution of pediatricians across the country,” said Dr. Freed, who is also director of Michigan’s division of pediatrics. “This is not too say children don’t received healthcare from primary physicians, but this uneven distribution of pediatricians doesn’t provide parents with the choice of whether their kids can receive care from a pediatric sub-specialist.”

Family practitioners often step in to fill th void left by a less robust pediatrician population in smaller cities.

According to the study which was published in Pediatrics, pediatricians flock to more populated states, leading to high pediatrician-to-child ratios in select areas. For example, Massachusetts and New York have 165 and 154 pediatricians per 100,000 children, respectively. Inversely, South Dakota, Wyoming and Idaho have the fewest number of pediatricians per 100,000 children with 41, 35 and 28, respectively.

Visits to pediatric sub-specialists jumped substantially, as well. Children visit pediatricians for roughly 4.5 percent of their appointments, an increase of 2.9 percent since 1980.

Strategic Locations

The promise of higher income, more professional opportunities and increased social interactions drive pediatricians to settle in highly populated states. Dr. Freed said., leaving other states with a fraction of the physician workforce needed to effectively treat children. However, there is no data showing where pediatricians choose to locate.

The shortage is often a result of uneven geography of pediatric education in medical schools. Between 10 percent and 15 percent of medical school graduates each year pursue pediatric residencies, but not all states offer programs in the field. For example, the University of South Dakota School of Medicine does not have a pediatric residency, prompting, on aver, five to seven of its 50 students to leave the state each year, according to Lawrence Fenton, M.D., chair of South Dakota’s pediatrics department. Most graduates do not return after completing their residencies, but individuals who do are often general pediatricians.

“The challenge isn’t the general pediatrics, it’s the pediatric sub-specialties,” Dr. Fenton said. “Our sub-specialty care needs are huge. We’re the only tertiary care center for 250 miles, and it’s important that we serve the needs of all children in our patient area.”

Although South Dakota currently has 22 faculty members trained in various pediatric sub-specialty areas, between 15 percent and 20 percent will retire within the next decade. It will be difficult for South Dakota to entice younger specialists to come to a rural location when there is a desperate need for their services nationwide, Dr. Fenton said.

Michael Anderson, M.D., chairman of the American Academy of Pediatrics (AAP) workforce committee, agreed. Despite the growing pediatric sub-specialist population, such doctors are likely to remain within or close to academic medical centers because that is where they receive their core support. This concentration is a roadblock to easy healthcare access and only exacerbates the shortage problem in rural areas.

“For families who live in less populated areas, the fact that sub-specialties aren’t around can be devastating,” Dr. Anderson said. “Families in underserved areas are at a significant disadvantage because it is difficult to coordinate the amount of services some children need.”

Because of the shortages, some children go without medical attention, Dr. Fenton said, and this problem because visible when a sub-specialist finally moves into town and is immediately swamped with patients.

Recruiting Difficulties

Attracting new pediatricians, especially sub-specialists, to smaller areas could continue to be a struggle, though, said Richard Pan, M.D., MPH, associate residency director of pediatrics for the University of California, Davis. Pediatric students find residency positions mostly at larger medical schools in urban areas, and approximately 40 percent stay in the area to practice. Salary is also a factor, Dr. Pan said, noting that pediatricians’ already low compensation makes moving to rural, less affluent locations even more unappealing.

Other lifestyle factors contribute to the decision to stay in larger cities. Many residents consider their spouse’s career options, whether their children will receive a quality education in smaller city and the question of how a heavier workload due to fewer colleagues might affect their schedules.

“Residents view this decision as a serious  and significant issue with regard to lifestyle,” Dr. Pan said. “These are personal decisions that guide their career decisions.”

Marianne Felice, M.D., chair of pediatrics at the University of Massachusetts Medical School, echoed Dr. Pan’s thoughts, noting only a select few doctors can sustain the stress of being perpetually on-call because no other pediatricians are in town. Higher salaries and insurance reimbursement rates in large regions help to cover medical school debt, as well.

However, Dr. Felice pointed out that it is likely that not all pediatricians counted in Dr. Freed’s study are currently treating many patients. Although they are all licensed physicians, some could be faculty members or researchers, thereby lowering the actual pediatrician-to-child ratio in Massachusetts and other states with a large supply of pediatricians.

According to Scott Shipman, M.D., assistant professor of pediatrics at Oregon Health & Sciences University School of Medicine, budding pediatricians could have difficulty finding the job hey want in a larger city. The higher concentration means they may find themselves competing for a position they would not normally consider.

“There’s significant evidence in pediatrics to show there are fewer jobs available in populated areas,” Dr. Shipman said. “New graduates make sacrifices to stay where they are. They might be working weird hours or where they may not eventually settle down to practice.”

Offering Incentives

There are, however, measures the medical community can employ to i,prove the supply of general pediatricians and sub-specialists in rural locations. Even though it is unlikely that scores of these physicians will choose to relocate in the next few years, medial treatment can still reach children through telemedicine, said AAP expert Dr. Anderson. Not all services will be available through this method, but it could alleviate part of the problem.

Dr. Anderson said additional incentives are needed to entice new pediatricians to forgo a more affluent socially active lifestyle and practice in smaller locations. To draw more physicians in, hospitals could offer to pay off medical school debt if the pediatrician moves into the area.

Just as medical schools contribute to the uneven geographic distribution of pediatricians by virtue of their location, the schools can also help turn the tide to increase sub-specialist supply in the more rural areas across the country, according to Dr. Pan. Discussing the needs of underserved communities and encouraging students to practice there is not enough to improve rural medical care. Medical schools must consider this issue at the admissions phase.

“Medical schools need to look at who they are admitting overall,” Dr. Pan said. “It would be preferable to admit people from underserved or rural communities initially because they are more likely to go back there because they’ve lived there, know it and like it.”

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March 28, 2010 - Posted by | Family, Healthcare | , , , , ,

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