As Rural Docs Age, Will There Be Enough Left?

By John Palmer

A new study of the physician workforce in rural parts of the U.S. shows that as aging doctors retire in those areas, there will continue to be an uneven distribution and perhaps even a shortage of physicians there.

The report, “Implications of an Aging Rural Physician Workforce,” was published in the July 25 issue of the New England Journal of Medicine (NEJM) and claims that 66% of primary care shortages in the U.S. and 62% of those for mental health were located in rural or partially rural areas of the country.

“Although there is disagreement about the adequacy of the overall physician supply, there is little disagreement that the uneven distribution of physicians presents serious access problems in many rural areas,” wrote lead author Lucy Skinner of Geisel School of Medicine and the Department of Economics at Dartmouth College. “Limited access to physicians can reduce access to preventive care and exacerbate unmet health needs, leading to costly hospitalizations and poor health status.”

The report stopped short of predicting what implications such shortages might have on the future physician workforce in these areas, and whether new physicians are taking up practices there. But the researchers pointed out that rural areas tend to have older and poorer populations than cities—populations with less comprehensive health insurance and shorter life expectancies. Therefore, the importance of maintaining a physician supply in these areas is paramount.

The authors of the study used information from the U.S. Census to figure out the age distribution of rural physicians. From there, they were able to predict workforce growth through the year 2030.

“Despite decades of private- and public-sector initiatives aimed at increasing physician supply in rural areas, these projections of the rural physician supply are troubling,” the report said. “In 2030, residents of rural areas will have access to one third as many physicians per capita as their suburban and urban counterparts will. Yet rural residents are likely to be older, poorer, and in worse health than city dwellers, with a lower life expectancy, and they are more likely to be uninsured.”

The data show that from 2000 to 2017, the age distribution of rural physicians shifted dramatically, reflecting a pattern of many younger physicians choosing to go into practice in urban areas, coupled with older physicians retiring out of practice.

According to the study, the total number of rural physicians grew only 3% (from about 61,000 in 2000 to 62,700 in 2017), while the number of physicians under age 50 living in rural areas decreased by 25% (from 39,200 in 2000 to 29,600 in 2017).

“As the number of younger physicians entering rural practice has declined, the rural physician workforce has grayed,” the report said. “By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60. In contrast, the number of urban physicians under 50 grew 12% from 2000 to 2017, and in 2017 only 39% of urban physicians were 50 years of age or older and only 18% were at least 60.”

What does this mean, exactly? While the number of rural physicians held steady during the 17-year period of study at about 12 physicians per 10,000 people, the report said, that number is expected to dip 23% by 2030, to an average of about 9.4 physicians per 10,000 people. This takes into account that rural physicians over 45 will start to retire by that year. The study did forecast a stable supply of physicians under 45 in 2030, but made no prediction about where they would go into practice.

“The supply of nonrural physicians is projected to remain steady at 29.6 per 10,000 population by 2030, just below the rate of 30.7 in 2017,” the report said. “Thus, we project that the large existing disparities in physician supply between rural and nonrural areas will widen through 2030.”

The NEJM report comes on the heels of a 2017 study published by the Journal of the American Medical Association (JAMA), claiming that it may be time for the healthcare industry to start instituting a mandatory retirement age for some physicians.

According to the JAMA study, the number of practicing physicians older than 65 in the United States has increased by more than 374% since 1975. In addition, in 2015, 23% of practicing physicians were 65 or older.

While some professions such as airline pilots, judges, and air traffic controllers carry a mandatory retirement age, the healthcare industry does not, and some physicians and surgeons practice well into their 80s.

Many hospitals are hesitant to institute a retirement age for fear of lawsuits alleging discrimination; plus, there is something to be said for the expertise that older physicians can pass on to younger staff members.

In most cases, despite outside evaluations that might point to a decline in cognitive skills, most hospitals seem willing to side with surgeons until they make a mistake and cause the hospital to be sued.

Some hospitals have programs that allow aging physicians to go into mentoring or teaching roles, or to adopt less hands-on supervisory roles in the field, supervising medical students or heading up academic departments.

Meanwhile, the JAMA article cited statistics showing that between the ages of 40 and 75, the mean cognitive ability of most people declines by more than 20%. While there is significant cognitive variability from one person to another, and while some older physicians are visibly impaired by their age, the article maintained that others retain their ability and skills well into their elder years.

Suggestions for improvement

The NEJM report recommends beginning to look for interventions now that could increase the number of physicians going into practice in rural areas.

In addition, the report claims that while current incentive programs—such as loan repayment, expansion of the national health service corps, medical school recruiting grants, and providing focused training and experiences to students who are likely to practice in underserved rural communities—are helpful, they are not likely to attract enough physicians to fill in the gaps.

“Though these initiatives may have resulted in a slower decline in rural physician supply than would otherwise have occurred, they do not appear to have yielded even a stabilization of that supply,” the authors wrote. “Furthermore, the greater the shortfall in the rural physician workforce, the harder it may be to attract new physicians to assume the greater patient workload.”

To attract more younger people into rural practice and keep them there, the report says the healthcare industry will need to strategize and invest much more aggressively.

For one, the report suggests that medical schools should expand graduate programs into rural hospitals and offer higher salaries for physicians to offset the higher average costs of care in low-volume areas, which might influence some physicians who might otherwise avoid these areas to practice in them. In addition, the authors suggest deploying mobile facilities, such as vans equipped to diagnose and treat patients, to areas of high need.

Lastly, the authors say that rural areas in higher need of physicians should look into alternatives such as hiring nurse practitioners (NP), who in many cases have the same training as physicians—and are more likely to choose to practice in rural areas.

“Not only are the percentages of NPs training in primary care and practicing in rural areas higher than those of physicians, but a growing body of studies confirms the high quality and cost-effectiveness of care provided by NPs and their greater propensity to serve vulnerable populations,” the report suggested. “Medical schools, graduate medical education programs, teaching hospitals, clinics, and other sites training primary care clinicians, particularly those located near rural populations, could work with NP education programs to explicitly capitalize on the greater likelihood of NPs practicing in rural areas, to create NP residency programs in rural health, and to develop programs that make it easy for rural NPs to consult with physicians and rural health specialists.”

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.