Clifton Adcock writes this article in the September 2nd edition of The Oklahoman about the rural doctor shortage in Oklahoma. His article begins with a powerful sentence that reveals the failure of the state government and the expensive agency it has created to solve this problem. The Oklahoma Physician Manpower Training Commission, set up to encourage physicians to locate in underserved areas can now officially be declared a failure, I believe, as the article reports that 72 of Oklahoma’s 77 counties are considered and designated to have physician shortages.
This agency should, of course, be abolished, but will likely use its failure to garner a bigger budget as does every other failed government program. Indeed, the legislature in 2012 created a fund to establish residency training positions in rural areas and is now encouraging high school students in rural areas to pursue medicine thinking that this move will lure them back to their hometown. All of this combined with paying off student loan debts and other incentives.
There is no mention in the article about the impact of the big corporate hospitals setting up shop in rural areas. Many struggling rural physicians have become big city hospital employees, agreeing to funnel patients (seen, to be blunt, as revenue generators) to the mother ship. This arrangement, which devastates the business of the rural hospital, tends to repel a young physician from practicing in that small town as the hospital and practice environment exude instability and corporatism.
When I was a medical student, I went to a small town for 6 weeks as part of my training, something that was called an “externship.” Here, I worked with some of the best doctors I have ever been around. I had more responsibility in their small hospital than I did at the big medical center and was astounded that these small town doctors took on many specialized tasks and did it well. One of the doctors administered anesthesia when an appendectomy or an emergency C-section was needed. Another of the doctors had spent time learning a bit more about orthopedic injuries than the others. One doctor had trained for a year after his family medicine residency learning how to handle more complicated obstetrical patients and another had spent a year after his family medicine training doing surgical training.
You couldn’t drag these physicians to a big city where they would not be allowed to practice their special skills and take complete care of their patients. Another reason they loved their practices in this small town is that they had complete control of the hospital where they worked. The older doctors had started the hospital in this town and it was still seen as theirs, even though by the time I arrived they no longer had any ownership of the facility. They were still able to forgive bills for inpatient care, however, and did this regularly. Poor patients paid what they could without fear of a faceless hospital administrator bankrupting them. Many patients eligible for entitlement programs didn’t enroll because they did not financially fear their doctor or local hospital and with good reason.
I believe if rural physician shortages are to be effectively addressed, the physicians in these small communities should be allowed to own these hospitals and control them. This opportunity to more completely control patient care and the finances associated with it would not only draw the attention of young physicians finishing their training but would more than likely result in big city doctors relocating to these communities. Hospital ownership would provide a powerful anchor to those choosing to locate in these small towns, as well, making the doctors less likely to succumb to the seductive but duplicitous offers of the corporate hospitals.
I know that what I am suggesting will likely not happen, but rather new government “incentives” will be added to the ineffective ones currently recommended and tried. In addition, states expanding Medicaid will find it increasingly even more difficult to recruit doctors to the rural areas, something current legislators should give some thought to. The failure of government programs invariably results in bigger budgets for the failures. Maybe it’s time to give the free market and private sector a chance to solve problems like this, the cause of which is the ham-handed intervention by the very government that now proposes solutions.
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G. Keith Smith, M.D.