Despite efforts to increase the number of doctors in rural areas, many Oklahoma counties are still sorely lacking physicians to provide sufficient care to their residents, according to health experts.
Seventy-two of the state's 77 counties are designated as primary health-professional shortage areas by the federal government: 30 of them have 10 or fewer doctors of any type. The five counties not considered shortage areas are Oklahoma, Johnston, Canadian, Rogers and Wagoner, according to the U.S. Health Resources and Services Administration.
Oklahoma has 76 doctors per 100,000 residents, far fewer than the 220 doctors per capita nationally, according to the Association of American Medical Colleges. The state ranks 43rd in doctors per capita and 41st in primary-care physicians.
The shortage of primary-care doctors plays a large role in the poorer health outcomes of rural residents, health experts say. Rural counties have a significantly higher residents-to-doctor ratio than urban ones, according to data obtained by Oklahoma Watch from the Oklahoma Board of Medical Licensure and Supervision and the State Board of Osteopathic Examiners.
Since the 1970s, Oklahoma has been creating incentives for doctors to set up shop in rural areas and in recent years has tried some new methods, but shortages remain a significant problem.
Many large urban hospitals and medical groups have different sets of doctors for emergency rooms, clinics, and inpatient and outpatient care.
That is a luxury physicians in small rural communities do not have, said Dr. Maha Sultan, who practices in Frederick in southwest Oklahoma.
Sultan said her duties consist of working in a clinic; the hospital, including the emergency room; home health care, and nursing homes.
“Most new graduates want to get a job where it is 9-to-5, no responsibility after hours, nobody to call them and nobody to bother them, so they are not interested,” Sultan said.
“In a small town, you have to do everything. Some new doctors, they just don't want that life.”
Sultan came to Frederick about 20 years ago after emigrating from Syria and receiving medical training in Canada.
A friend referred her to Frederick.
“After four months, I was going to leave like everybody else,” Sultan said.
But the hospital, which was having difficulty with finances and a lack of doctors, pleaded with her to stay.
“I have been here for 20 years,” she said. “You don't see too many people like me.”
According to licensure records, Sultan is one of only three licensed physicians — two MDs and one osteopathic doctor — in Tillman County.
Sultan said she often misses the amenities that urban areas offer, but she has enjoyed working in a tight-knit community.
“I love the patients. I care for them; they care for me,” Sultan said. “They're very loyal, and I'm loyal to them.”
Lure of the city
It is the big-city amenities and educational and professional resources that draw many physicians away from rural areas, said Rick Ernest, executive director of the Oklahoma Physician Manpower Training Commission, a state agency responsible for encouraging physicians to locate in underserved areas.
“When you're in a rural community with one or two doctors, you spend every other night or every third night on call. That get's pretty old,” Ernest said.
More new physicians are choosing specialty practice, Ernest said, because they can earn more and pay off their sizable debt from medical school more quickly. Most of the specialty practices are located in urban areas, he said.
To encourage doctors to practice in rural areas, Ernest's commission has worked with the Oklahoma Tobacco Settlement Endowment Trust and the Oklahoma Health Care Authority to fund a $5 million, five-year program to help pay off doctors' student debts in exchange for them agreeing to practice in a rural area, Ernest said.
Ernest estimated the commission has helped send around 25 to 30 new doctors to rural areas each year.
One problem is that although medical-school class sizes at state universities have increased, residency programs have not kept pace. That means graduates must go out of state for residency requirements, Ernest said.
In 2012, a bill was passed by the Legislature that established a fund to create residency programs in rural areas, said William Pettit, associate dean for rural health at Oklahoma State University's Center for Health Sciences. The program has residencies in Enid, Tahlequah, McAlester, Lawton, Durant and Talihina.
OSU also has begun to offer a medical track that focuses on providing health care in rural areas. Students from rural areas are recruited to join.
“We think this is the way to go — start encouraging young men and women in high school (to believe) that a rural practice back in their hometown or a neighboring community is not only possible but can be rewarding from a professional point of view and financially,” Pettit said.
Work to be done
Cindy Duncan, interim CEO for Memorial Hospital and Physician Group in Frederick, said that the hospital has interviewed six doctors for a position since January.
All declined offers, either because they or their families did not want to live in a rural community or because of the range of duties required.
The hospital has not had a full staff of physicians since 2004, Duncan said.
“We're optimistic and want to say, ‘Yes, things will get better,' but based on historical experience, I would say no,” Duncan said. “You want to be positive, but going on 11 years, it's kind of hard to be positive about it.”
Physician shortages are a national problem, as well.
Small communities can expect to see more doctors retire, a reflection of the aging workforce and the fact that doctors in rural areas tend to be older, Pettit said.
“The handwriting is on the wall, with the aging workforce, that we're going to need to do something,” said Lou Carmichael, CEO of Variety Care, a community health center that also operates clinics in four rural areas.
“The communities that support those providers really understand that and usually they do just about anything they can to keep their doctor in town or their nurse practitioner or whoever,” Carmichael said. “It's an economic problem, as well as an access problem.”
About half of Oklahoma's population lives in the Oklahoma City, Tulsa and Lawton areas, but two-thirds of its doctors practice there, Pettit said.
Telemedicine, in which specialists videoconference with patients long distance, has helped compensate a bit for rural doctor shortages, but overall the state still is in need of more physicians, said Lyle Kelsey, executive director of the Oklahoma Medical Licensure Board.
The shortage has a disproportionate effect on the poor because poverty rates often are higher in rural areas, Carmichael said.
Each of the rural Variety Care clinics was opened after its respective community, faced with a lack of health resources, approached Variety Care.
Carmichael said to improve the health of Oklahomans, efforts cannot be focused only on urban counties.
“It's easy sometimes to focus on the big urban areas, but really the rural communities are where an awful lot of Oklahomans live and so it's really important for us to keep that at the forefront,” he said.