How states are keeping doctors from moving out

Widespread concerns about physician shortages have many states working to keep doctors trained in medical schools and residency programs there from crossing state lines to practice medicine.

Nationwide, there were 258.7 active physicians per 100,000 people in 2010, according to new statistics from the Assn. of American Medical Colleges. In individual states, ratios range from a high of 415.5 physicians per 100,000 people in Massachusetts to a low of 176.4 per 100,000 in Mississippi.

On average, only 39% of U.S. physicians practice in the same state where they went to medical school. Forty-eight percent practice in the state where they completed graduate medical education, said the report, released Dec. 2 by the AAMC Center for Workforce Studies.

As a result, medical schools, hospitals, medical societies and state legislatures increasingly are taking a practical approach to retain the physicians and doctors-in-training they already have, said Christiane Mitchell, AAMC director of federal affairs.

"We see states becoming more and more sensitive to the physician shortage issue," she said. "People are beginning to recognize the need."

Physician shortages nationwide are projected to reach 62,900 doctors by 2015 and 91,500 by 2020, according to 2010 AAMC projections. Many states have responded by opening new medical schools or expanding existing ones. Several offer incentives such as bonuses, scholarships or loan repayment programs to keep physicians from leaving.

Communities also are developing new residency programs in hopes that physicians will develop long-term professional and personal relationships during GME training that will tie them to the area, Mitchell said.

Recruitment and retention often go hand in hand. For example, many medical schools recruit students from the states in which they are located, with the idea that students are more likely to practice in their home state. But such efforts can be thwarted if there aren't enough GME positions for those students after graduation, Mitchell said.

"There are certain schools that their entire mission is to train physicians from their states to practice in their states," she said. "But if there are not enough [GME] training positions there, they are going to go somewhere else."

Enticing doctors to stay

Several recent efforts in Iowa are designed to attract physicians most likely to stay in the state. Iowa is below national averages, retaining 22% of its medical school graduates and 37% of physicians who complete GME training there, the AAMC report says.

"We train people and then we send them all over the country," said Lawrence Hutchison, MD, president of the Iowa Medical Society and a family physician in Dubuque, Iowa. "We need to keep the best and brightest in Iowa."

To help stem the outflow, the medical society three years ago developed a database of doctors in residency programs nationwide who have some connection to Iowa. The database is used in physician recruitment, and includes doctors who were born in Iowa, went to medical school there or are doing residency training in the state.

"We decided to really focus on people with ties to Iowa," Dr. Hutchison said. "It just doesn't do us a lot of good to recruit from Idaho, Minnesota or Texas, because those people just end up going back home."

The medical society has a mentor program that matches medical students with practicing Iowa physicians. There also are opportunities for residents or medical students to spend a month or more working in a community medical practice.

"We want to give students exposure to what real medical practice is like out in Iowa," Dr. Hutchison said.

Several states -- including Kansas, Mississippi and Alabama -- offer loan repayment programs for doctors to practice locally, said Glen Stream, MD, president of the American Academy of Family Physicians and a family physician in Spokane, Wash.

Some programs have been in place for decades. In Oklahoma, the Physician Manpower Training Commission began in 1975. The state-funded commission offers scholarships and loans to medical students and residents who agree to practice in rural Oklahoma for a set amount of time, said Rick Ernest, commission executive director. For example, a medical student may accept four years of tuition assistance in exchange for practicing in an Oklahoma community for four years.

The program has had positive results, Ernest said. Unlike many rural states, Oklahoma is above national averages, retaining 48% of its medical school graduates and 52% of physicians who complete residency training there, according to the AAMC. Retention is even higher -- 74% -- for physicians who completed both medical school and GME training in the state.

"Our program has helped keep more physicians in the state," he said.

Training locally

New residency programs are a proven way for states to train and keep physicians, but starting them is a challenge, said Mitchell, of the AAMC. Medicare funding for existing residency programs has been frozen since the Balanced Budget Act of 1997, but new residency programs at institutions that have never had them before can qualify for federal funding.

Such institutions have three years to develop their programs before funding is capped. Meanwhile, the federal Health Resources and Services Administration is providing funding for new residency programs at community health centers.

One example of a school seeking to retain more physicians by offering GME is Florida Atlantic University's Charles E. Schmidt College of Medicine. In November, the school announced it was partnering with five southeast Florida hospitals in a GME consortium projected to create as many as 350 residency positions there within the next few years. School officials said the program will help alleviate physician shortages in the state.

Many osteopathic medical schools -- such as new schools in Harrogate, Tenn., and Yakima, Wash. -- have a core mission to train primary care physicians for the states and communities where they are located, said Stephen Shannon, DO, MPH, president of the American Assn. of Colleges of Osteopathic Medicine.

The University of Kentucky College of Medicine in Lexington has pipeline programs designed to attract students from the state, and offers debt relief primarily through the state Office of Rural Health, said Emery Wilson, MD, dean emeritus of the medical college.

"It's very important for us to raise our own physicians here and keep them here, because we are probably not going to get many physicians coming in from other states," he said.

The school also opened a satellite campus in Morehead, Ky., and is considering a second elsewhere in the state to give third- and fourth-year students the opportunity to experience rural medicine first-hand.

"That is the latest in what we hope to be a successful way to not only get doctors to practice in Kentucky, but to get primary care physicians to stay," Dr. Wilson said.