Doctor shortages distress rural America, where few residency programs exist

Anger, devastation, and concern for her patients washed over Dr. Bridget Martinez as she learned that her residency training program in rural northeastern Nevada would be shuttered.

The doctor in training remembered telling one of her patients that, come July of this year, she would no longer be her physician. Martinez had been treating the patient for months at a local health care center for a variety of physical and psychiatric health issues.

"She was like, 'I don't know what I'm going to do,'" Martinez said. "It almost set her back, I would say, to square one. That's so distressing to a patient."

Martinez and three other resident physicians make up more than a third of the family practice providers at a health clinic in Elko, a city of about 20,000 people in the largely rural 500-mile stretch between Reno, Nevada, and Salt Lake City. Another patient cried and said she was unsure who her provider would be once Martinez returned to Reno to finish training.

Established in 2017, the rural family medicine training program in Elko is shutting down for a variety of reasons, including financial struggles, lack of a united support system, and a historical lack of health care investment in the area. Experts say systemic factors are common barriers to establishing and sustaining training programs for doctors throughout rural America.

More than 100 million people, or nearly one-third of the nation, have trouble accessing primary care, according to a recent study published by the National Association of Community Health Centers. This number has nearly doubled since 2014. The pandemic worsened provider shortages nationwide, but the problem is more acute in rural areas, which have long struggled to recruit and retain doctors and other medical professionals. Researchers say the relative lack of providers is one reason people living in rural areas experience worse health outcomes than people who live in urban areas.

Experts say expanding the number of medical residency training programs in rural areas is key to filling gaps in care because many doctors — including more than half of family medicine physicians — settle within 100 miles of where they train. And while the number of training programs has increased in rural areas during the past few years, research shows 98% of residencies nationwide are in urban areas.

Members of Congress have introduced several bills to address the health provider shortage, but they have not yet advanced.

Meanwhile, rural medical training programs need more state and federal investment to grow and remain sustainable, said Dr. Emily Hawes, associate professor at the University of North Carolina-Chapel Hill School of Medicine and deputy director with the federal Rural Residency Planning and Development Program.

There have been positive milestones, she said, including provisions in the Consolidated Appropriations Act of 2021 that created more flexibility in funding and accreditation for rural hospitals that want to establish residency programs.

Congress also created the Rural Residency Planning and Development Program, which Hawes helps lead. The initiative funded its first cohort in 2019. Since then, the program's parent agency, the Health Resources and Services Administration, has given more than $43 million to 58 organizations in 32 states to launch rural medical residency programs. As of last fall, the recipients had created 32 accredited training programs in family medicine, internal medicine, psychiatry, and general surgery, and received approval for more than 400 new residency positions in rural areas.

But it's still not enough, Hawes said.

For starters, the Centers for Medicare & Medicaid Services don't reimburse rural hospitals for medical residency programs at the same rate they do urban hospitals, despite rural hospitals facing similar or higher costs. Rural hospitals' lower patient volumes and higher rates of underinsured or uninsured patients affect how much the government pays to fund graduate medical education, or GME.

Hawes and other doctors argued in a research paper that rural hospitals participating in resident physician training should be paid the full cost of hosting residents, which amounts to at least $160,000 each annually.

The challenge of paying residents' salaries proved to be part of the problem for the program in Elko.

Officials at Northeastern Nevada Regional Hospital decided, when they launched their residency program six years ago, not to use CMS funds to pay salaries and instead to pay those costs out-of-pocket. That amounted to about $500,000 a year, said Dr. Daniel Spogen, a professor in the Family and Community Medicine Department at the University of Nevada-Reno School of Medicine and director of the medical residency training program in Elko.

In retrospect, Spogen said, he wishes he and other faculty had pushed the hospital to pursue CMS funding, because it would have given the program a stronger financial foundation.

In a February press release, hospital officials said the decision to close the medical training program was difficult but necessary, because of rising costs and increased requirements.

In the end, the community and residents suffer the consequences, Spogen said.

Hawes said rural communities and their resident physicians often benefit mutually: Residents experience a more diverse and involved training than they would in a larger hospital, because having fewer residents and doctors means they can take on bigger tasks. Martinez recalled treating a gunshot wound in the emergency room, something she said she probably would not have gotten to do in a Reno hospital.

Closing any rural medical residency program ends a key opportunity to locate physicians in the areas where they're most needed, said Hawes. Martinez and her husband, who is also finishing his medical training, had planned to stay in Elko. While that's not off the table, she said, they're keeping their options open now.

Spogen said people living in Elko will go back to relying on urgent care, which is not a substitute for primary care.

The nearest city with more health care resources, 230 miles away by car, is Salt Lake City. Spogen said the patients he treats through the program don't have the financial resources to go elsewhere.

Rural medical training programs don't have to end in struggle, Hawes said. Part of her job with the Rural Residency Planning and Development Program is to ensure faculty, residents, and hospital leaders have the resources, support, and knowledge they need to sustain their programs.

Spogen estimates that a resident physician brings in about $600 a day for the hospital where they train, resulting in roughly $190,000 in revenue per year.

Experts say when programs succeed, they grow quickly, like the Wisconsin Collaborative for Rural Graduate Medical Education, part of the Rural Wisconsin Health Cooperative. When the collaborative was established in 2012, there were 25 rural medical residency training positions in Wisconsin, said Lori Rodefeld, the group's director of rural GME development and support. Last year, the collaborative supported 51 positions — more than double the number from 11 years ago.

In addition, 65% of residents have remained in rural medical practice, Rodefeld said, which is higher than the national average for physicians who did their residencies in rural areas.

"We're very, very lucky," Rodefeld said. "I don't know of many other states that have this kind of model where they have technical assistance available to multiple existing programs and for those who want to get started."

Martinez and her husband chose Elko to complete their medical residencies because they knew they could help fill a need.

"It's almost intoxicating," Martinez said. "You don't want to walk away from something like that, especially when you feel so valued."