Shortage of small-town doctors is getting worse -
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Shortage of small-town doctors is getting worse

Small-town doctors are older and scarcer in Nebraska, and the health of people living in rural places is at stake.

The graying of rural general practitioners will gradually exacerbate a shortage of primary care providers. As the shortage worsens, the demand for medical care in rural Nebraska may increase with the aging of the rural population and the federal health care law's requirement that Americans be insured and thus have better access to medical care.

Jim Stimpson, director of the Center for Health Policy at the University of Nebraska Medical Center, found the number of young rural primary care physicians has declined considerably in 10 years.

At the same time, the number of rural general practitioners middle-aged and older in Nebraska has gone up close to 20 percent over the same period.

Dr. Charles Korte, program director for the Mercy Family Medicine Residency Program in Des Moines, said young doctors who grow up in large communities generally won't move to small towns to practice medicine.

“It's unlikely that somebody who was born in a major city like Omaha and Des Moines ... (is) going to go to a smaller community,” Korte said.

Stimpson and others decry an overall shortage of general practitioners, particularly in rural areas. Eleven Nebraska counties don't have a primary care physician. Stimpson defines primary care doctors as family physicians, internal medicine doctors, pediatricians and obstetrician/gynecologists.

Stimpson's statistics showed the following trends:

ğIn 2011, 141 Nebraska primary care physicians ages 26 through 40 worked outside Douglas, Sarpy and Lancaster Counties, a 31 percent decline from 205 in 2001.

ğIn 2011, 257 young primary care doctors worked in those three urban counties, up 11 percent from 231 in 2001.

ğAmong primary care doctors 41 and older, 408 worked in rural Nebraska in 2011, up 19 percent from the 343 in that age group in 2001.

Nationwide, 30 percent of family physicians were 55 or older. That's up from 15 percent in 2000, according to the American Academy of Family Physicians.

Dr. Keith Shuey

Dr. Keith Shuey, 73, grew up near Tecumseh, Neb., and knew he would practice family medicine there.

“I've been here in the same office since 1966,” Shuey said. He's one of three physicians in the town of about 1,800. Two physician assistants and one nurse practitioner also work in Tecumseh.

Shuey, who still works full time, said he has missed his kids' basketball games, concerts and other activities because he was on duty.

Today's young doctors want regular hours and align with large practices and hospitals in cities, Shuey said. He and the other medical providers rotate emergency room service at Johnson County Hospital. It's not rare, he said, to be called at 3 a.m.

Emergency-room duty can be boredom or terror, he said. It can involve runny noses and earaches, and car-crash victims and cardiac cases. There's no cardiologist down the hall to refer patients to in Tecumseh.

Further, if a case goes bad, everyone in town knows about it and talks about it, he said. As a longtime doctor there, he said, he has been called to a fatal car accident on a Christmas morning. He then had to inform the parents, with whom he was acquainted, that their son was dead.

“And that was part of medicine,” he said. “And don't get me wrong. I have made a good living here.”

Many young doctors don't want to work in that kind of spotlight, under that stress, he said.

Dr. Donald Frey, vice president for health sciences at Creighton University, was a family physician for four years in rural Missouri. He said trauma victims there would be stabilized before they were rushed to a bigger medical center.

Rural doctors must handle “anything that comes through the door,” Frey said. “People cut out of that mold, so to speak, are disappearing very rapidly.”

In Iowa, no similarly clear trend is evident in the aging of rural physicians, according to statistics provided by the University of Iowa College of Medicine. What is clear is that far fewer family physicians practice in small Iowa communities — those with fewer than 5,000 population — than practiced in them 35 years ago.

The Iowa statistics show that 282 family doctors practiced in small Iowa towns last year, down from 418 in 1977.

Dr. Shelly Soltis

Korte, who oversees the residency program in Des Moines, said one or two out of eight residents in each year's class show interest in working in a rural area. Young doctors express concern about having enough free time, cultural outlets and job opportunities for spouses.

Dr. Shelly Soltis is one of Korte's residents who desires a rural practice. She grew up in a Minnesota town of 10,000, she said, and has no desire to live in the big city.

Soltis did a one-month family practice rotation in Blue Earth, Minn., and enjoyed it.

“It fits me,” she said. “I am sure there are days that I'll be overwhelmed.”

Efforts are being suggested or made to increase primary care in rural areas. Stimpson said state leaders should consider allowing nurse practitioners and physician assistants to function to the full extent of their training. In Iowa, for instance, nurse practitioners can practice with autonomy. In Nebraska, they must have a collaborative relationship with a doctor.

UNMC gives a loan for living expenses for med students in their final year that is forgiven if those doctors go on to practice in underserved areas.

Shuey said med schools need to emphasize recruitment of students from rural areas. Some advantage should be given to those students instead of focusing mainly on entrance exams and grade-point averages, he said.

A young doctor from Los Angeles, Shuey said, won't want to move to a town where the only businesses open past 8 p.m. are the tavern and the convenience mart.

Other answers, Shuey said, apply to both city and rural general practitioners. In many cases, they are paid one-third as much as specialists, he said. When a young doctor faces many thousands of dollars in student loan debt, he most likely will choose a specialty over primary care, Shuey said.

Shuey likened the small-town general practitioner to the family farmer. “He is fading out rapidly,” he said.

The paperwork required by insurance companies, hospitals, nursing homes and state and federal governments has increased considerably, he said. If he had it over again, he'd probably become a surgeon.

Still, he said, he knows he plays an important role in Tecumseh and shares profound moments with families. “And I like these people,” he said.

Through an email, Shuey described meeting with the mother of the first baby he delivered in 1966. The woman's husband is dying of cancer now.

“We both shed a few tears,” he wrote. “And we hugged — we will go from there.”

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