Like many states, Missouri is facing a doctor shortage.
The supply of doctors isn't keeping up, even as the population ages and more people have health insurance to pay for medical care. The American Association of Medical Colleges estimates that the country will have a void of about 90,000 physicians by 2020—half of them in primary care.
It’s not for a lack of interest in the profession. Despite the rising cost of tuition, a record number of students are graduating from medical schools. Analysts say the problem is that there are a fixed number of residency positions available — the three to five year-long internships where newly graduated medical students learn how to become doctors.
Residency stipends are funded by the federal government, hospitals and endowments. Some fear that federal funding for residencies could take a hit this year as legislators try to make more cuts to Medicare spending.
As the supply of medical school graduates increases, so does the competition for each residency position. Students typically apply to several programs throughout the country, rank their choices, and then receive a "match" from the National Resident Matching Program.
St. Louis Public Radio sat down with a group of fourth-year medical students at Washington University, who are just a few weeks away from learning where they’ll live and work for the next three years.
The nine students had selected nine different specialties, ranging from orthopedic surgery to ophthalmology and child psychiatry. That’s in line with trends from the AAMC’s 2014 Physician Specialty Data Book, which reported that primary care fields, like family medicine and preventive care, actually saw declines in the numbers of new doctors entering the workforce over the past five years.
Kathy Smith, who has applied to OB/GYN programs, said she would consider having a joint obstetrics and primary care practice. But even then, her plans are anything but conventional.
“I’m really interested in research, so I want to be in an academic institution,” Smith said. “I took a year off of medical school to get a master’s degree in biology.”
St. Louis may have a pretty high concentration of specialized doctors and hospitals, but one in five Missourians live in an area with limited access to primary care, according to the Missouri Foundation for Health.
For medical students, taking a residency in a large city seems to be more popular.
“Case volume is important to me, because you want to be able to do everything during your training. So that if you encounter it beyond your training, you can deal with it,” said Bhuvic Patel, who hopes to go into neurosurgery.
Missouri's Lesser-Known Missouri Export: Physicians
Even though Missouri supplies more than its share of the nation’s medical school graduates, it has one of the lowest retention rates in the country. Only one in five doctors practicing in Missouri went to medical school here.
Thomas McAuliffe is the director of health policy for the Missouri Foundation for Health. He said keeping medical students in the state for their residency is important.
”That’s the biggest predictor of when you stay in state or out of state,” McAuliffe said. “Especially for rural and family practice, people get embedded in the community.”
The U.S. medical system is set up to push graduates towards high-paying specializations, McAuliffe said. there aren’t many incentives for students to go into primary care fields. For starters, they don’t pay as well.
“You get bigger payouts from insurance companies for specialty care. Hospital systems and providers are pushing in the direction of specialty care because that’s where the need and money is. And medical students follow the stream,” McAuliffe said.
Of the nine fourth-year students at Washington University, just three expressed a strong desire to stay in St. Louis for their residency.
The Careful Economics of Medical Education
Take the average medical school graduate. At 26 years old, that individual has $100,000 to $150,000 in student debt.
“That’s a lot of money,” said Kathy Diemer, the assistant dean of career counseling for Washington University’s School of Medicine. After medical school, students must complete three to five year-long residencies, which usually pay between $50,000 and $60,000 a year.
“I think that is an interesting question that needs to be addressed now: Is there a way, especially if you want to encourage more physicians to go into primary care, of minimizing that burden?” Diemer said.
After medical school, the demand for doctors is high enough that residents can be relatively assured of finding a job in their specialty, and a high paying one at that. But a 2013 survey showed family medicine doctors made about half as much ($174,000) as their colleagues in specialties such as cardiology ($351,000) and orthopedics ($413,000).
Efforts to recruit students into primary care
One recent, snowy morning at Saint Louis University, a group of first and second year medical students filed into an auditorium to hear from primary care doctors like Dr. Matt Broom. He reminded them that even if they do have a lot of student debt, there are incentive programs for physicians who work in rural areas.
“You really can establish a practice, and it’s different now than it was 20 years ago, but at the same time there can be great relationships with families, and I think those are things to consider too,” Broom said.
This year, SLU will hire five additional primary care and internal medicine residents, thanks to a major donation from a private donor. But analysts say that without significantly increasing how much primary care doctors are paid, it will be a long road ahead to close the gap.
The Missouri Foundation for Health is a donor to St. Louis Public Radio.
For more health news, follow Durrie Bouscaren on Twitter: @durrieB