TWO HARBORS, Minn. — It’s a national trend: Medical students, lured by more lucrative careers in specialized medicine, have been shunning primary-care positions. Some of the biggest losers are clinics in rural areas.
It’s a trend that one study says is coming to a crisis: Only 2 percent of medical students say they are going into primary-care practice, according to a study published this fall in the Journal of the American Medical Association. In addition to the issue of comparatively lower prospective pay, paperwork and dealing with chronic patients were factors in medical students’ decisions, the study found.
In Minnesota, “It is a crisis,” said state Sen. Yvonne Prettner Solon, DFL-Duluth. Prettner Solon serves on the Health, Housing and Human Services Committee and recently became a member of the state’s Rural Health Care Initiative.
“It really is hard for people to get in to see physicians, because there aren’t enough of them. There aren’t a lot of the incentives that pull physicians into family practice; the pay is low and conditions aren’t always the best.”
An aging rural population, with many living alone
The Minnesota Department of Health last year released a report on rural health that found several factors contributing to the need for primary-care doctors. Among them: an aging population — and the fact that residents in rural areas tend to live alone at a higher rate than in urban areas. Of the most rural counties, 46 percent have 13 percent of the state’s population but only 5 percent of the state’s practicing physicians.
“When you’re saddled with tens of thousands — or hundreds of thousands — of dollars in graduate- and medical-school loans, and you make $129,000 a year [as a family practitioner], it’s difficult to pay off,” Prettner Solon said. “And when you can go into specialties, you can make $450,000 to over a million dollars a year.”
And it’s not just doctors. Rural areas are experiencing shortages of registered nurses, pharmacists, dentists and other health-care workers. And on top of that, the workers themselves are aging and not being replaced quickly enough.
Replacements are hard to find
Sue Nordman is the chief operating officer of the Sawtooth Mountain Clinic in Grand Marais. It provides health-care services for all of Cook County and part of Lake County, a total of 1,451 square miles.
“I know for our case, we’ve been in search of replacing two of our [primary care] physicians for a couple of years,” Nordman said. “It’s just been hard for rural clinics. With four or five providers on staff, it’s hard when someone wants days off. We just can’t provide that availability.
“Our nearest major medical center is in Duluth, 110 miles away,” she said. “We are isolated.”
Michelle Juntunen, director of medical advancement at the University of Minnesota Medical School — Duluth Campus, said the school’s mission has always been to provide doctors who are willing to serve in rural areas. As part of its mission, it requires its students to spend time in rural areas as part of their training.
“When this branch was funded by the state Legislature in 1969, when the first funding money was approved, it was recognizing that there would be a shortage,” Juntunen said. “We send the students out to get a taste of what it’s like to work in Moose Lake and Cloquet — we send them out to find out what it means to be a rural care physician.”
Students spend three days in the communities, working in the hospitals and clinics and living with host families.
UMD medical school seeks applicants from rural areas
Juntunen said the school tries to find applicants who come from rural areas who will know what life in smaller towns is like.
“They don’t look only for good grades and desire, but if they come from rural communities,” she said. “There’s a better chance that you know what it’s like to live there and you really will go back. Maybe not to your own hometown, but you’ll stick with it.”
Juntunen said travel to clinics is one of the biggest challenges facing patients trying to get care in rural areas.
“If you need a doctor, you might not see one for quite some time,” she said.
Because of this, the health-care crisis can also be seen as an economic crisis. Poor preventive health care because of a lack of family practitioners — a situation where “you’re following families in every aspect, minor surgery to a baby coming to newborn care,” Juntunen said — can lead to more expensive medical problems down the road, resulting in higher medical bills, more lost work time, and so on.
Nordman, at Sawtooth Mountain Clinic, said recruiting for rural areas is difficult.
Advertising with creativity can pay off
“I tried to advertise in places you wouldn’t necessarily expect,” she said. “We’re a big tourist area, so I put an ad in the Boundary Waters Journal. We have a larger dog-mushing community, so I put an ad in a dog-mushing magazine.”
She said a family-practice physician who was on vacation in the area was a dog musher and applied for and got one of the jobs.
“But to have long periods of no inquiries, it’s difficult,” she said.
Juntunen agreed, and added that it’s not only the doctor who needs recruiting.
“Nowadays, you’re not only recruiting students in rural areas, but you’re recruiting the spouse. New doctors might say, ‘I’d love to work there,’ and then the spouse says, ‘Oh my God, what is there for me to do?’ I’ve seen situations where communities think they’ve got one, but it doesn’t work out because of the spouse.”
Prettner Solon said, “Being in rural areas for some … is an incentive, but it isn’t for a lot of people, unless they’ve been trained in rural areas or grew up in rural areas.”
The state, as part of its Rural Health Care Initiative, has put together loan-forgiveness programs of up to $64,000 over four years for medical students who end up practicing in rural areas. Participants make a three-year commitment and do not receive the money if they don’t complete the time requirement.
Tele-medicine helps avert travel
UMD is working on a mental-health program that pioneers “tele-mental” health equipment and is working out of some small towns such as Cook, Mora and Little Falls. Patients can set up a video conference with a psychologist.
“You can go right into the clinic, you don’t have to travel — travel often means waiting,” she said. “We’re expanding the pilot program to put laptops into the homes of elderly people who won’t have to leave their homes and can access the program through laptops.”
Juntunen said a family doctor who works in a rural area isn’t seen just as a doctor.
“What does it mean to embrace and work in rural communities?” she said. “Obviously, in most young people’s minds, there’s a lot less to do in a rural community. The other thing is, young people need to know what it means to become a leader. If you graduate and live in a rural community, you are seen as a leader. What are the expectations, not only as the doctor but as the leader?”
Catherine Conlan covers rural economics, business and other issues in northeastern Minnesota, writing from Two Harbors.