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No relief: Shortage keeps older docs on the job

EVERSON, Wash. - At age 81, Dr. Kenneth H. Spady admits he’s finally ready to retire. Almost.

After nearly 53 years in practice, at least 1,500 babies and more than 260,000 office visits, the sole medical doctor in this town of 2,100 figures it’s time to plan for the future.

“I realize that sooner or later, something may happen,” said the soft-spoken physician who still rises at 5 a.m. and puts in 10-hour days in his Main Street exam rooms.

But Spady can’t hang up his stethoscope just yet.

After more than two years of trying, and several close recruiting calls, there’s still no one to take his place in this rural community 100 miles north of Seattle, where the nation’s shortage of primary care doctors has landed squarely at Spady’s office door.

“We’ve probably trotted eight or nine people through here,” said Dr. David A. Lynch, president of the Whatcom County Medical Society, which is helping conduct the search. “At this point, we have not been able to get a doctor to commit.”

As the nation’s debate about overhauling health care heats up, one truth remains undisputed: There are not enough general care doctors to meet current needs, let alone the demands of some 46 million uninsured, who threaten to swamp the system.

It’s a problem growing worse in Everson and across the country, where more aging doctors are finding they can’t retire. In the U.S., there are at least 4,500 primary care doctors older than 75, according to figures from the Physicians Masterfile database maintained by the American Medical Association. Overall, there are about 270,000 doctors practicing primary care, which includes family, general medicine and internal medicine.

Younger doctors opt for specialties

As younger doctors increasingly choose the better pay and balanced lifestyle promised by specialty practice, older doctors, especially in poor and rural areas, are working longer, reluctant to abandon their clients — but unable to find new care for them.

“Most of them would like to fade out, but they have an obligation,” said Dr. Joseph W. Stubbs, president of the American College of Physicians. “The issue is that there is not enough primary care because there are not enough medical students going into primary care.”

For patients, that translates into long waits, long drives, or, in worst cases, postponed care that eventually lands them in the emergency room.

Nearly 50 years ago, half of the doctors in the U.S. were general practitioners. Now, they make up less than a third of the physician workforce, according to studies by the American Academy of Family Physicians. Between 1997 and 2005, the number of medical graduates going into primary care fell by half, and fewer than one in five new graduates now say they intend to pursue the practice, the AAFP notes.

If current trends continue, the U.S. will be short by about 125,000 family care doctors by 2020, according to Dr. Ted Epperly, president of the AAFP board. He estimated that the U.S. needs between 40 percent and 50 percent more family practice doctors than the nearly 100,000 working now.

“The pipeline of family physicians has dried up,” said Epperly, who’s hopeful that health care reform will help correct the problem.

He's particularly optimistic that conversations now occurring are focusing on two key issues: incentives for new primary care doctors and adjustment of payment rates.

"We want to see primary care made whole again," said Epperly, who figures it will take seven to 10 years for improvements to be seen.

In the meantime, it's no secret why young doctors are shunning front-line medicine, said Amy McIntyre, 26, who graduated last month from the Alpert Medical School of Brown University in Providence, R.I. Compared to lucrative specialties that focus on cutting-edge interventions, primary care has been tagged as obvious and dull.

“The classic phrase is, ‘You’re too smart to go into family medicine,’” said McIntyre, who has had to defend her choice to pursue primary medicine. “Our culture worships high-tech, high-cost care. It’s not as exciting to say ‘I treated high blood pressure today.’”

Compensation disparities drive choices

And then there’s the compensation question. The median annual wage for a family physician last year was about $190,000, according to a survey by the American Medical Group Association, a physician search firm. In contrast, a dermatologist earned nearly $345,000 and an orthopedic surgeon earned about $450,000.

The difference is driven largely by Medicare-related reimbursement rates, which pay more to doctors who perform specific procedures than to doctors who diagnose and treat general illness. Under so-called fee-for-service Medicare rates, a Boston primary care doctor received $103.42 for a half-hour office visit, but Medicare paid $449.44 for a diagnostic colonoscopy, a procedure that takes about the same time, according to a 2008 Government Accountability Office report.

Compensation becomes key at a time when the average graduate leaves medical school with student loan debts that top $141,000 and can approach $200,000, according to the Association of American Medical Colleges. Many new doctors worry it'll take decades to repay loans, experts said. rightfalse


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On top of that, a specialist is more likely to have more control over his or her time, compared with a primary care doctor who agrees to shoulder the round-the-clock demands of community care, experts said.

“Today’s graduates are looking more toward family time and they believe a profession shouldn’t encompass their entire life,” said Stubbs, of the ACP. “We as a society have not managed to change the job description — and they’ve voted with their feet.”

‘I'm a dinosaur’

It’s a perplexing situation to primary care doctors who started practicing in another era. Dr. Thomas Alexander, 72, has operated a family care practice in Okmulgee, Okla., a town of 13,000 outside Tulsa, for 40 years. He’d like to retire, but, as in Spady’s case, he can’t recruit a replacement.

“They’re not willing to be on call 24 hours a day,” Alexander said of the new generation of doctors. “I’m a dinosaur. There’s not people willing to do that anymore.”

The problem is especially acute in places like Oklahoma and Idaho, where there are barely 80 primary care doctors per 100,000 people, compared to the U.S. average of 120 per 100,000, according to a report last year by the United Health Foundation. Washington state fares better, at 124 per 100,000, though the numbers fall in rural areas like Whatcom County, which has 105 primary care doctors in a region of just under 200,000.

Addressing the shortage of primary care doctors is receiving attention at the highest levels. In a speech to the AMA this month, President Barack Obama called for a change in fee-for-service payment arrangements that encourage more tests and procedures. And he specifically urged efforts to lure new doctors to general care.

“We need to rethink the cost of a medical education, and do more to reward medical students who choose a career as primary care physicians,” Obama said.

That could encourage young doctors to follow the path of Dr. Spady, who knew exactly what he was signing up for when he arrived in Everson, a small farming and canning town, in the summer of 1956.

“I was happy to come,” said Spady, a Seventh-day Adventist who regarded medicine as a calling. “It was almost a sacred mandate to avoid hurtful habits and practices.”

Spady was 27, with a young wife and the first of two children when he assumed sole responsibility for the health care of the small community. At the height of his practice, Spady would see three dozen patients in a day, then spent nights and weekends responding to calls or heading to the hospital in Bellingham, 17 miles away.

“There were many late nights,” recalls Esther Neyens, 82, who worked as Spady’s nurse from 1966 to 1989 and also was his neighbor. Spady delivered five of Neyens’ grandchildren and helped with a hernia operation for her husband, Anton.

Anton Neyens, 85, said he still can recall the sound of Spady’s diesel Mercedes pulling out of a nearby driveway.

“We could hear him leave in the middle of the night,” Anton Neyens recalled. “You’d always hear that Mercedes.”

We don't want him to retire, ever.’

Nearly every family in Everson includes a patient of Spady’s, either past or current. On a recent Thursday, Spady examined the ankle of Kimberly Scarpete, 46, who has lived in Maple Falls, near Everson, for 20 years.

“Last week, I dropped a huge can of stewed tomatoes on my toe,” Scarpete said. Her bigger trouble, though, is the combination of diabetes and other health problems, plus a lack of health insurance. Spady, she said, accommodates it all.

“I’m scared to death every day something’s going to happen and I am going to lose my house or something,” she said, noting that Spady often delays bills until she can pay them. “We don’t want him to retire, ever.”

But Spady will have to retire someday, of course, warns Lynch, the president of the medical society. When he does, he'll leave a hole in a region that already needs 18 new primary care doctors just to hold steady.

That worries Kerri Lenderman, executive director of the Whatcom Alliance for Healthcare Access. The nonprofit agency spent three years trying to recruit new doctors to the region.

“Frankly, after about a year and a half, we kept falling short,” she said.

Potential replacements were put off by the high cost of housing, by low student loan repayment help and by relatively low wages, perhaps $80,000 to $120,000 a year, according to the medical society.

Lenderman holds little hope of finding a replacement for Spady in the near future.

“I hate to say it, but, honestly, it will take a crisis for the community to realize we no longer have someone out in Everson,” she said.

Distance, delays — or no care at all

When that happens, patients in Everson and the surrounding area will be forced to travel for care — if they can get it at all. Many of the region’s residents are Medicare or Medicaid clients, and fewer doctors are taking new patients with government insurance.

“They will just go without or they will wait until it’s critical and then have the ambulance take them to the emergency room,” Lenderman said.

Spady says he’s done everything he can to make the practice attractive. He joined the Family Care Network, a coalition of family medicine providers in Bellingham, and he’s hired Teresa L. Regier, a nurse practitioner. He added electronic medical records five years ago as a way to make sure his practice was keeping up with technology.

Spady plans to work as long as his health allows. He knows his patients will miss him when he leaves, but he also knows it’s in their best interest for him to find a replacement.

“Some of them say they’re going to come to my house. Some say they don’t know what they’re going to do,” Spady said.

“I tell them, ‘There are many indispensable doctors in the cemetery.’”