Rural Arizona wrestles with serious doctor shortage: ‘It’s a pipeline issue’

Published Sept. 2, 2019 in The Arizona Republic.

By Jeannette Hinkle, The Arizona Republic.

BENSON — The people of Benson didn’t know it, but their hospital was on the brink of closure. 

The management team at Benson Hospital kept the increasingly dire financial position from patients — even from staff members — as they searched for ways to bring the budget back into the black. But when the hospital couldn’t meet payroll, management decided it was time to send out an SOS.

Benson Hospital’s board reached out to Tucson Medical Center. Without a significant donation, the 22-bed “frontier” critical access hospital, open since 1970, would have to shut its doors.

Tucson Medical Center agreed to take Benson Hospital under its tent last year, a move welcomed by most everyone at Benson Hospital. Staff members, who maintained a high quality care rating throughout the turmoil, say they’ve since seen improvements they’d waited years for. 

A one-time state appropriation of $900,000 for the current fiscal year gave Benson Hospital an added financial boost. 

Earlier this summer, the halls of Benson Hospital, which are decorated with dozens of paintings by local artists, shuddered with the sound of drills and hammers. Workers were renovating the lobby, painting the walls and replacing the carpet, a color described as “just old,” with clean-looking synthetic wood planks. 

Benson Hospital’s new CEO, Julia Strange, also vice president of community benefit at Tucson Medical Center, pointed to peeling, outdated wallpaper borders ringing the hospital’s hallways. 

Those are next, she said.

The aesthetic improvements at Benson Hospital are perhaps as important as giving staff long-overdue pay bumps.

Like most rural hospitals in the state, which provide medical care to vast areas that otherwise would be uncovered, Benson is facing a physician shortage. Talented new doctors want to work in hospitals with resources, and a tired lobby offers a bad first impression.

A glaring shortage

Arizona is just beginning to quantify its rural doctor shortage.

In 2019, the state Legislature passed a bill that will give researchers studying the shortage access to granular, standardized data that paints a more complete picture of health-care personnel needs than the dated county-level estimates being used now.

But even with imprecise data, the current shortage of doctors in rural Arizona is glaring. Several rural hospitals in the state either currently are experiencing a shortage or expect to experience one in coming years.

In 2018, an outside consultant evaluated Benson Hospital’s professional needs. According to that consultant, Benson currently has a deficit of doctors in family medicine, internal medicine and pediatrics. 

Looking ahead to 2023, that deficit will worsen as a wave of current doctors retires. In Cochise County, where Benson is located, the consultant predicted a deficit of 51 full-time equivalent doctors, with a moderate deficit of doctors in family practice and a high deficit of doctors in internal medicine and primary care.

In Yuma County, 100% of residents live in a primary-care shortage area, according to the Arizona Hospital and Healthcare Association.

“In the winter, if you want to get an appointment with a primary doctor in town, it is possible that you will wait six weeks for something urgent, three months for something not urgent,” said Dr. Kristina Diaz, a family medicine practitioner at Yuma Regional Medical Center.

Without action, that wait will only lengthen. Roughly 50% of Yuma County’s primary-care physicians likely will retire in the next five years, Diaz said.

A ‘vicious cycle’

The shortage of physicians is especially pronounced in primary care. Arizona ranks 44th out of 50 states in total active primary-care physicians, and that shortage is worse in rural areas, according to the Arizona Hospital and Healthcare Association.

Doctors say the shortage can be dangerous.

With a dearth of primary-care physicians, patients discharged from rural hospitals who need follow-up appointments often can’t get them. Sometimes, that means patients end up back in the hospital; other times, it means patients elect to go without needed medical treatment or advice for weeks.

Recently, one of Diaz’s patients was discharged from the hospital with congestive heart failure. When the patient left the hospital, he had been prescribed a specific kind of medication, one he couldn’t afford.

For two weeks, until his appointment with Diaz, the patient went without the medicine he needed. By then, he was having trouble breathing. 

“I had to admit him again,” Diaz said, “hoping that somebody will listen to him when he leaves the hospital and says, ‘I can’t afford that expensive medicine.’ This is this vicious cycle, and I worry that it’s going to get worse as more people start retiring, if we don’t start replacing the workforce.”

Benson Hospital’s Dr. David Brower is one of only a few primary-care physicians serving patients in the area. Benson itself has a population of just under 5,000.

Since Brower began working for Benson Hospital in 2018, he’s been inundated with patients who have let health problems fester because of a lack of access to primary care.

“There’s like four doctors here and they’re booked,” Brower said. “Patients come to you and they’re like, ‘I have high blood pressure. That’s all I know.’ Then you start kind of peeling back the layers and they have this condition and this condition and this condition and this condition.”

‘A special type of physician’

Springerville is a trading-post-turned-town nestled in the White Mountains. Incorporated in 1948, Springerville is home to about 1,900 residents, more than one-third of whom live below the poverty line.

On Main Street, across from the town’s post office, stands a reddish stone statue of a stern-looking woman in a bonnet. She holds a baby in her arms, and a small boy tugs at her flowing skirt. She is Madonna of the Trail, a tribute to “the pioneer mothers of the covered wagon days.”

Springerville was remote when pioneer mothers ferried their broods through the ponderosa pines that green the air in nearby Apache-Sitgreaves National Forest, and it’s remote now.

It’s not for everyone, said Greg Was, CEO of White Mountain Regional Medical Center.

After a protracted search that involved blanketing websites with hiring advertisements, the hospital turned to a costly outside agency to recruit a primary-care doctor, an expense that many rural hospitals can’t afford. 

At Benson, rising costs associated with recruiting doctors, exacerbated by the high demand, contributed to the financial emergency that led Tucson Medical Center to assume control. It’s not a unique situation. Since 2010, nearly 90 rural hospitals have shut their doors, and many more are at risk of closure.

Eventually, the agency that White Mountain Regional Medical Center hired found a former neurosurgeon looking to finish out his career at a slower pace. But the area still needs practitioners who specialize in family medicine, general surgery, women’s health, urology and psychiatry.

It’s just hard to convince doctors to practice in rural areas, Was said.

Some doctors want to work in hospitals with the latest medical equipment, some discount rural hospitals because they expect the pay to be lower, and others are uncomfortable shouldering so much responsibility for patients’ health. But for many hospitals, selling doctors on a rural lifestyle is the most difficult part of the hiring pitch.

“You need a special type of physician, one that wants to come in and settle here,” Was said. “We don’t have the shopping conveniences or the entertainment that would attract a physician and his family to a larger city, so it makes it a more difficult sell. We have hiking, fishing, a lot of outdoor activities, but to go to Walmart you have to drive an hour to Show Low.”

Benson Hospital has it a little easier than most rural hospitals. One of the biggest draws for potential employees is the small town’s proximity to Tucson. About half of Benson Hospital’s staff commutes.

The pipeline problem

Doctors raised in rural areas are far more likely to build a career in rural medicine, which is why health-care advocates in Arizona are working to convince people in towns experiencing a doctor shortage to study medicine, then go back home.

“It’s a pipeline issue,” said state Sen. Heather Carter, a Phoenix-area Republican and chairwoman of the state Legislature’s Health Committee.

Carter said the pipeline to rural medicine should start in elementary school with strong science programs and pitching kids from small towns on health care as a career. But until that infrastructure is strengthened, the state is betting that exposing new doctors to rural medicine will fill the growing gap.

Brower was raised in Phoenix, a decidedly urban setting, but his internal medicine residency in Sierra Vista, not far from Benson, gave him a window into what rural practice could look like. He was “enamored.”

When he was offered a job at Benson, Brower accepted enthusiastically.

“I tell my patients all the time, ‘I plan on being in Benson for a long time, so if you’re planning on being here a long time, we’ll get to know each other,’” Brower said. “I see very little that I can see someone else offering me that I don’t already have here. And I see a lot that Benson Hospital and this community offers me that I can’t get other places.”

Brower said that while his role as one of Benson’s few doctors has been stressful at times, it has also allowed him to practice a type of medicine that is deeply personal and fulfilling.

“I’ve had patients where it’s been the case that they haven’t seen the doctor for 20 years,” he said. “Now, six, nine months later, them being like, ‘Doc, you changed my life. You absolutely changed my life. I didn’t think I was going to live five years and now I’m hopeful for the future.’ That’s not something you can get from city practice.”

Doctors aren’t choosing rural medicine because, unlike Brower, they haven’t been exposed to it, Carter says. They go to medical school, then they go to residency, and that residency is usually at an urban hospital, too often in another state. 

Only 42% of Arizona’s medical students remain in the state after graduation, according to a report by the Association of American Medical Colleges. When doctors do complete a residency in Arizona, they stay to practice in the state 48% of the time, the report found.

“Typically where a student completes his or her residency is where they will set up practice, because during their residency they’re building those professional and community relationships,” Carter said. “That is typically where they will remain in their professional career.”

Carter argues that the state offers too few opportunities for medical students to find a residency in Arizona, let alone in rural Arizona. 

In the 1990s, the federal government froze funding dedicated to helping hospitals subsidize the cost of resident placements, and after the Great Recession, Arizona cut all state spending on residencies, Carter said.

In years since, health-care advocates have worked to marshal private dollars to make up for the lack of state funding for residencies, called graduate medical education in budgetary terms, but it wasn’t enough. According to the Arizona Hospital and Healthcare Association, the average cost to train a physician resident is about $165,000 per year.

State finds money to help grow doctors

In May, partly because of Carter’s advocacy, the Legislature passed a budget that included residency funding for the first time in roughly a decade. 

In fiscal year 2020, a total of about $5.6 million in combined state and federal dollars will go toward funding graduate medical education in rural areas. That number will rise to about $11.1 million in fiscal year 2021, then to $16.7 million in fiscal year 2022. The funding is expected to result in hundreds of new residency slots.

The budget also included funding for telemedicine and broadband improvements in rural areas, money aimed at helping hospitals like Benson fill patient health needs for specialists without having to hire or contract with doctors to take patients at rural hospitals in person.

“This is a very big deal,” Carter said.

There’s also been movement to address the pipeline problem on the federal level. In July, U.S. Sen. Kyrsten Sinema, D-Ariz., joined other lawmakers in signing a letter supporting a policy that reimburses medical students for their residencies at critical access hospitals like Benson Hospital. 

Sinema also supports the Resident Physician Shortage Reduction Act of 2019, which would increase the number of residency positions eligible for graduate medical education funding through Medicare.

Staff at Yuma Regional Medical Center are already planning to use the funds to reinvest in the hospital’s residency program, which has been successful in keeping doctors in Yuma after they finish residency there.

“For the class that starts in July of 2020, we will go from 18 residents to 24 residents,” Diaz said. 

The newly appropriated state funds, bolstered by a federal match, mean the hospital can fund a sports medicine fellowship, and it’s now considering starting two new residency programs, one of which would be for psychiatry. 

Currently, Yuma County, with a population of about 208,000, has only one psychiatrist.

The new state funds are “huge” for Yuma, Diaz said.

“We’ve been sitting at the starting line to be able to move so many things and meet the needs of our community, but we haven’t had the funding for it, so we’ve had to stay at the starting line,” Diaz said. “Now we can run the race. And I’m really excited for that.”

Diaz, who graduated from Yuma High School, said she’s confident that when residents come to Yuma, they’ll choose to stay.

This summer, Diaz attended a conference to speak with potential residents. She brought a banner that read “Experience the warmth of Yuma.”

“We’re not talking just about the heat,” Diaz said. “We’re also talking about the people. There is a strength in our community, and that has been our recruiting tool.”