In rural Missouri, there are roughly half as many primary care doctors per person, compared to urban parts of the state. That's a problem, when you consider that rural residents are also older (about three years, on average) and poorer (about five percent more live in poverty). In this Health & Wealth report, small towns in Missouri are facing the shortage by "growing their own" doctors and nurses, starting as early as middle school.
The shortage is expected to get worse over the next ten years, as baby-boomers get older and need more care. Plus, starting in 2014, around 500,000 more Missourians will be insured under the Affordable Care Act.
The hospital in Albany, Missouri was constantly understaffed in the 1980s. Not just doctors, but primary care staff in general. "The problem was, there was a shortage of qualified registered nurses, physical therapists, lab technicians, x-ray technicians, just an overall shortage," said Donna Walter, an administrator at the Northwest Medical Center.
It wasn't for lack of trying. The hospital paid a recruiter to hunt down new employees, but Walter says that didn't always work out so well. "A lot of recruiters just do cold calls, and happen to find somebody who's disgruntled in their job and talk them in to going somewhere else. And they continue to be disgruntled people, and don't stay."
So about twenty years ago, administrators started "growing their own" staff. The idea was that people who grew up in the area would be more likely to want to stay. The first step was to get local kids interested in health care.
Katie Dias started at the hospital in middle school. "I started off in seventh grade as a candy-striper, just filing, taking papers back and forth, doing kind of less medical things."
Now, Katie goes by Dr. Dias. She started practice in Albany in August, the hospital's first home-grown physician. The hospital helped her out with $60,000 in school expenses, and in return, she agreed to work there for the 5 years.
But she doesn't have plans to leave. "I love being in a rural setting, I love serving this community, I love serving the people of this area."
Of course, there are a number of loan-repayment programs that help out young rural doctors, like the National Health Service Corps. Dias got help from Missouri's PRIMO forgivable loan program -- about $110,000.
But programs like that can sometimes have unintended consequences, said Jon Doolittle, CEO of the hospital in Albany. "The programs that are in place, like National Health Service Corps and PRIMO loans, are very important elements of the toolkit. But they probably lead to cases where people are seeking to fulfill a commitment and move on."
People like Katie Dias are surprisingly hard to find. According to one study, only three percent of students entering medical school say they want to go into a rural practice.
Kathleen Quinn, at the University of Missouri, has studied what makes young doctors go into rural practice. "It might be obvious, but the research shows that where you're from is the very most important thing that influences you to go back. You might have a rural identity, you grew up in a rural area, your values are tied back to rural. It's just who you are." Quinn says her research supports "grow your own" approaches like the one in Albany.
But you have to start young, says Michelle Mollick, executive director of the Northeast Missouri Area Health Education Center, a non-profit that's part of a state-wide network aimed at getting rural kids interested in health care careers.
"Kids in middle school start ruling out careers because they say I can't do math, I'm not good at this, I'm not good at that," said Mollick. "So they start dropping off their willingness to study math and science. So we start early because you have to inspire them first. You have to catch their interest. Then you have to show them that the coursework they're studying in high school is absolutely applicable to everyday."
Mollick spent a recent Saturday in the small town of Milan, Missouri. At a table in the school gym, she showed groups of students how to put on gloves without contaminating them. In the school library, students learned to take blood pressure. In the computer lab, they were taking each other's respiration and temperature. A local family doctor manned the blood pressure station, and mixed in career counseling too.
"Should I major in biology or chemistry? If I major in biology, should I minor in chemistry?" asked one student.
Michelle Mollick says this type of exposure is especially important for students in rural areas. "Students who are in very small schools don't have the accessibility to as many advanced placement classes, to as many extra-curricular activities. It is different to be in a school with a graduating class of 30, versus 400. I think those students really need to be coached and advised as they go off to college."
While these sorts of efforts are aimed at helping staff rural hospitals, as well as giving career opportunities to rural students, the results could also help small towns like Milan and Albany. Like many towns in northern Missouri, these two have remained about the same size over the past hundred years. The vast majority of high school graduates move on and don't look back -- roughly 95 percent, according to Milan High principal Mark Forster.
According to one study, every doctor practicing in a rural community generates $1.2 million in economic activity, and 23 additional jobs. That activity means more amenities like restaurants and shops, as well as better schools. That, in turn, attracts more professionals, like doctors and nurses.