Rural areas have a doctor deficiency

By Lee Romney, LA Times Staff Writer
http://ktla.trb.com

The young man told the emergency room doctor at Sutter Coast Hospital that he had come to await the end of the world under the big trees. He realized he needed help.

But there are no psychiatric beds here, and not a single psychiatrist practices in Del Norte County.

A nurse got on the phone, to seven facilities as far south as San Francisco, more than 300 miles away. None had room. Stabilized on medication, the young man walked out of the ER alone the next afternoon.

He was just one patient whose care was affected by physician shortages during a recent, and typical, 24-hour stretch here.

There was the elderly man with the shattered shoulder, told he would have to see a specialist in Oregon. There was the intensive care patient flown by turboprop plane to Medford, Ore., because Del Norte County has no cardiologists.

And there were patients like 64-year-old Carolyn Dyer, disabled, on Medi-Cal, arriving at this emergency room sicker than they should have been because preventive care is so hard to come by in the area.

“A lot of times you can’t get in to see anyone,” Dyer, who felt pain in her chest, jaw and arms, said of the clinic that takes most government-insured patients.

Residents of this county (population 26,000) enjoy cutting-edge technology at their hospital. But the community suffers a rural plague: an inadequate and constantly churning supply of doctors.

In 2005 alone Crescent City lost a general surgeon, an orthopedic surgeon and 10 primary-care doctors, six from community and Native American clinics that treat the poor. The exodus cut the county’s capacity in half in key fields and exacerbated other shortages. (The number of obstetrician/gynecologists countywide: one.)

A more Spartan existence

Recruiting and keeping doctors is tough in towns with no cultural attractions, no high-end shopping, limited job opportunities for spouses and limited spousal opportunities for the single. Del Norte County has also suffered from the decline of logging and fishing, and Crescent City’s key economic stimulus is nearby Pelican Bay State Prison.

Physicians who set up practice in rural areas are confronted by both a higher proportion of old and poor patients on Medicare and Medi-Cal compared with urban areas, and lower reimbursements. They must treat complex cases without the help of specialists, and they often face brutal schedules with no backup.

Although the rural-urban doctor gap isn’t new, analysts say it is worsening even while the number of doctors and medical students surges.

As policymakers grapple with the big picture, rural communities struggle day by day.

Take the case of Dr. John Tynes. Recruited from Dallas seven years ago, the lanky OB/GYN arrived to share duties with a colleague. But that doctor left. Tynes took out a business loan to set a new partner up in practice. A year and a half ago, his recruit bailed too, leaving Tynes about $70,000 in the hole.

An amateur photographer, Tynes delights in the beauty this coastal community offers. But recreation is elusive for the only doctor in a 1,000-square-mile county who is capable of doing emergency C-sections. Hikes with his wife and daughter are timed: 10 minutes out from the car, 10 minutes back.

Dreams of travel have been redirected to home improvement on his 100-year-old Victorian. If he goes away, the hospital must import a backup. Leaving for good is an option, but, he said, “We have friends here. We don’t want to be the ones to walk away and say: ‘You can’t have babies here anymore.’ ”

In a recent survey, 50% of participating rural California hospitals said they had reduced services, cutting key specialties such as obstetrics, according to Peggy Broussard Wheeler, vice president of the California Health Assn.’s Rural Healthcare Center.

Other rural hospitals, in Fresno, Kern and Tulare counties, have closed over the last five years, undone partly by a heavy load of indigent patients.

In some ways, Crescent City is fortunate: Its 59-bed hospital is guaranteed paying patients from the prison. And the larger Sutter Health chain that the facility belongs to offers economies of scale. The medical center also benefits from technology rare for rural hospitals, such as an electronic intensive-care unit that allows “intensivists” in Sutter’s Sacramento control station to monitor patients and direct treatment via video.

“The problem isn’t having a hospital,” said Sutter Coast spokesman Grant Scholes. “It’s finding the doctors.”

There was no single cause for the recent exodus.

A doctor who had practiced here for half a century died, stranding 2,000 patients. The hospital’s general surgeon left town, forcing Sutter to bring in temporary replacements until scoring a permanent hire last April.

When one of two orthopedic surgeons retired, the other bowed out of emergency care. He otherwise would have had to fix every broken arm or hip, common in a community that attracts retirees.

Instead, patients are now loaded onto planes nearly daily, bound for other hospitals.

Particularly hard hit by turnover is the Del Norte Community Health Clinic, which handles the bulk of indigent care in the area.

A federal medical-school loan-repayment program for doctors who commit to underserved areas has enabled the clinic to steadily lure recruits. But few stay.

One husband-and-wife team left for Southern California because she yearned to play violin in an orchestra.

The clinic’s former medical director returned to Oregon, seeking more-elite schooling for his boys. Others bailed when spouses got restless.

The clinic stopped taking new patients; even now, with new recruits on board, the wait for an appointment can stretch to three months.

And they’re gone

“It’s a dirty shame,” said Dyer, who was airlifted to Medford for quadruple bypass surgery the day after her emergency room visit , and has been in the ER half a dozen times since. “This is a nice little town. But the doctors we do have, they come in, you get to know them, and they’re gone.”

The dearth of general practitioners has pushed rural residents, already less healthy than their urban counterparts, further outside the medical system.

“They don’t have a primary care physician,” said the hospital’s ER director, Dr. Sandy Saunders. “They run out of medicine. You see a lot of people who have basically been neglected.”

Across the street from the hospital, at Sutter Coast’s daytime urgent care facility, two nurses and a physician’s assistant ease the strain on the ER.

For the patients who need follow-up, physician’s assistant Kalani Baker reaches for fliers listing the nearest providers who accept Medi-Cal, 80 miles south in Eureka and Arcata.

For those who have no car or gas money, there’s a second handout: the bus schedule. The ones who can’t pull together the $24 bus fare get another sheet, about free transport.

Even those with some resources have trouble finding care. At a Crescent City Women’s Club luncheon recently, hospital spokesman Scholes discussed recruitment.

“Will Crescent City get a cardiologist?” one woman asked. “Not likely,” Scholes admitted.

“How about a dermatologist?”

“Would be nice,” he said, “but it’s not a priority.”

A recruiter hired by Sutter Coast lays it on thick in an online posting for a surgeon: “Amid an awe-inspiring cathedral of soaring ancient redwoods, along a rugged wave-swept Pacific shore, deep in the cool serpentine canyons of the untamed Smith River, Del Norte County is where you will find the real Northern California.”

Selling the lifestyle

Hawking the region’s high points has made Del Norte Community Health Clinic medical director Warren Reywaldt feel like “a Realtor.” He has taken candidates on 30 redwood tours in recent months (and feted most at the town’s one Thai restaurant).

We tell them, ‘We want you to understand that we don’t have malls. We don’t have theaters,’ “said clinic administrator Charlene Mazzei.

A community committee has been formed to address the doctor crisis, along with ways to keep physicians and their families from leaving. Assemblywoman Patty Berg (D-Eureka) has held forums on the problem and is urging legislative fixes.

Potential solutions: improved access to telemedicine, which in many areas would require expanding broadband service, and higher Medi-Cal and Medicare reimbursements.

Other goals include pressing medical schools to rotate residents through rural areas and expanding a state loan repayment program.

Sutter Coast has devised its own solution. To get around a state law that bans hospitals from hiring doctors directly, to insulate the doctor-patient relationship from the profit motive, Sutter created its own community clinic. OB/GYN Tynes recently moved his offices there, and the hospital is aggressively courting colleagues for him.

The clinic is projected to lose as much as $500,000 a year, Scholes said cheerfully. But it is offering an enticing package that most local practices can’t match: a salary in the 75th percentile for the region and no overhead or administrative duties.

The efforts have not yet borne fruit. Still, Tynes and his wife, Irene, are enthusiastic. To celebrate, they bought a gleaming Airstream trailer.

“We’re hoping we’ll get to use it,” Tynes said.