In St. Cloud, pediatricians are flown in on a regular basis to help staff the local PICU. In Mankato, about one quarter of hospitalists are residents of Wisconsin or communities outside the city. Locum tenens are plugged in at hospitals and clinics all over the state.
Recruiting and retaining full-time primary care providers at various stages of their careers isn’t easy, especially in rural Minnesota. And the problem could get worse in the coming years.
Recently AAP’s Committee on Pediatric Workforce said it expects increased demand for general pediatricians in the near future and confirms there is a shortage of pediatric subspecialists and surgical specialists across the country. At the same time, the prevalence of chronic diseases in children is one the rise. About 27 percent of children have a chronic health condition, such as asthma, obesity, diabetes or a mental health disorder, that needs to be managed by a primary care team.
A variety of factors contribute to the shortage, irrespective of geographic area, such as higher rates of health insurance, fewer residency program vacancies available to medical students, and an increasing number of physicians seeking part-time work.
The biggest factor, however, may be physician age. More than one-third of the state’s 15,000 primary care doctors are over 55, and roughly 20 percent intend to work less than five years more, according to a 2013 report from the Minnesota Department of Health (MDH).
MDH estimates Minnesota will have a shortage of between 1,000 and 2,000 primary care providers by the early 2020s, according to Mark Schoenbaum, director of the Office of Rural Health and Primary Care at the Minnesota Department of Health, who was quoted in a 2013 article by the Associated Press.
Currently there are about 1,200 board-certified pediatricians in Minnesota. Assuming 20 percent intend to stop working in the next 5 years, 240 will need to replaced by 2019. However, Minnesota’s residency programs have been graduating between 33 and 37 pediatricians per year since 2006. At this pace, they will produce at most 185 pediatricians to fill the gap, forcing Minnesota to hire pediatricians from other states.
The majority of Minnesota’s pediatricians are located in the metro area and there is unequal distribution in rural areas. In fact, only 10 percent of Minnesota’s pediatricians are located in rural areas though it’s home to 30 percent of the state’s population. Additionally, the ratio of children per every 1 pediatrician is much higher in rural areas. There are 5,173 children for every 1 pediatrician in Northwest Minnesota, for example, compared to 898 children per pediatrician in the Twin Cities.
One of the ways Minnesota clinics and hospitals have been trying to address provider shortages is to rearrange how health care is delivered. The medical home approach is growing, EMR systems are being implemented, telemedicine is being explored, and non-physician clinical providers are stepping up.
The pediatricians at ACMC clinic in Willmar have managed to replace retirees and career-changers over the past few years, but it’s been a challenge, according to Michael Hodapp, MD, a general pediatrician at the multi-specialty clinic. In November, the clinic added a fifth pediatrician to replace one who left to become a hospitalist in the cities. Now the clinic needs to hire at least two more before Hodapp and a colleague retire in the next couple of years.
“There’s a definite need for more pediatricians here,” Hodapp said. “We get a lot of referrals from Southwest Minnesota. There’s just one pediatrician in Marshall. Otherwise there’s no pediatricians west of the border and no pediatricians south of the border until you get to Mankato.”
Aside from working and living in a rural setting, the 24/7 call responsibility is one of the reasons recruitment is more difficult. There are just five pediatricians to cover deliveries, newborn nurseries, ER and urgent care. They rely on locum tenens to cover one out of five weekends as well as some holidays.
Hodapp estimates he sees about 5,000 patients per year.
“We keep in contact with residency program directors,” Hodapp said. “And we keep close tabs on the local med students who come through. But we don’t rely on PAs and APNs in pediatrics like the rest of the clinic is doing.”
In 2013, the number of pediatric and med-peds residents who graduated from Mayo and the U of M was 46. Most stayed in the state, but only one chose to practice in rural Minnesota despite a generous federal loan forgiveness program.
The graduating classes from each school were comprised of more women than men, a strong desire to pursue subspecialties, and increasing interest in hospital medicine.
Large hospitals aren’t immune from hiring difficulties either. Children’s Hospitals and Clinics attempted to fill 20 positions for pediatricians and pediatric specialists between January 1 and October 1 of 2014. It only filled 8.
“We have had high-quality applicants for most of our positions,” said Ryan Berreth, DASPR. “The quantity varies on position; we have some very hard to fill sub-specialties, where we have limited amount of applicants. We also have other positions that receive a fair amount of applicants.”
Trends in recruitment and retention, he said, include providing an adequate CME budget, pairing new hires with individual physician mentors, and encouraging involvement with administration. Work life balance is important, too.
“Physicians are wanting a stronger work life balance with a fair/flexible schedule, including call,” Berreth said.
A large-scale survey conducted by Merrit Hawkins between March and June 2014 revealed that 81 percent of physicians described themselves as “over-extended” or “at full-capacity.”
Still, 71 percent said they would choose to be a physician if they had to do it all over again.
