Doctor Shortage Spreading in U.S. Presaged in Las Vegas

Mary Berg is paying the price for a shortage of U.S. doctors that by most accounts is about to get much worse.

After finding out in 2006 she had a rare and deadly gastrointestinal cancer, the 49-year-old mother of a teen-aged daughter found there were no doctors in Nevada who specialized in her type of tumor. Only one cancer center took her insurance. And because the tumor had spread, the need for a liver transplant was a distinct possibility, though no surgeons in the state were qualified to do the procedure.

Frustrated by years of not being able to get proper care, Berg and her husband decided this summer to walk away from their home near Las Vegas, which she says has since gone into foreclosure. They moved their family 300 miles away to Phoenix where she could be close to a specialist and a transplant center. Now, Berg has a team of doctors and nurses focused on her care.

“I get so emotional over it,” said Berg, her voice breaking and her eyes filling with tears as she sits in the living room of her new home, recalling the decision to leave Las Vegas. “We left a lot of friends. We left our house. We left our life.”

In the Las Vegas area, with about 2 million people, patients and doctors said it can take six months to see a primary-care doctor for a simple check-up. For more serious matters, the waits are far longer — more than a year, for example, to get an appointment with a neurologist who specializes in autism.

Waiting Weeks
Once a problem limited to rural areas, the doctor shortage is now hitting large population centers such as Las Vegas and Detroit where people are forced to wait weeks or months or travel hundreds of miles for care. Nationwide, there is a shortage of more than 13,000 doctors, according to the Association of American Medical Colleges, a Washington-based nonprofit that represents medical schools.

That shortfall is expected to grow 10-fold to 130,000 doctors within 12 years as the U.S. population ages and 30 million more people are added to insurance rolls under the 2010 health-care law, the medical college association said.

In a bid to address the shortage, the medical community has embraced the greater use of nurse practitioners and physician assistants, who can prescribe medicines and diagnose and treat many illnesses. The number of physician assistants is projected to increase 39 percent to 108,000 by 2020, according to the Bureau of Labor Statistics. Still, physician assistants can’t replace specialists as regional shortages of all categories of doctors persist.

Drying Pipeline
“This is a national problem across the board and it is going to get much worse,” said Christiane Mitchell, director of medical affairs for the AAMC. “We have an aging population and a whole lot of doctors retiring. We need to increase the pipeline of new doctors.”

It’s a problem that Mitchell Forman, a rheumatologist in Las Vegas and dean of Touro University Nevada College of Osteopathic Medicine, is all too familiar with.

On a recent Thursday, Forman darted from one room to another, juggling complex cases of patients with immune system disorders at Touro’s health center. One of his first appointments was with a woman who had waited more than three months to see him. In that time she lived with debilitating fatigue and muscle pain that she feared was lupus, an incurable disease in which the body’s immune system attacks healthy tissue causing damage to the heart, lungs and kidneys.

Finally Diagnosed
The woman, who asked that her name not be used to protect her medical privacy, described her pain and fears to Forman as a reporter looked on. Forman said he didn’t think she had lupus based on her blood work and his physical examination, instead he adjusted her pain medications and will see her again in several months.

The woman’s long wait for a diagnosis could have been worse. Forman said it takes most patients four months to get an appointment.

“God knows what happens in that four-month period,” he said. If you have a medical problem that requires special expertise, “you’re just going to have to wait.”

Multiple reasons are driving the shortages. As baby boomers age, their care has become more complex and time-consuming. At the same time, some of those baby boomers are also doctors who are expected to retire in the coming years, according to the medical colleges association. One in three doctors nationwide is older than 55, the group said.

Poor Distribution
Doctors tend to stay near where they train, creating a poor distribution of care in states like Nevada or Idaho that don’t have large medical schools or training hospitals.

Once more people are insured under the Affordable Care Act that emphasizes preventative care, “the wait times that are bad now will increase tremendously,” said Howard Baron, a former president of the Clark County Medical Society in Las Vegas.

“We are trading one issue, the lack of coverage, for another,” Baron, who is a pediatric gastroenterologist, said in an interview. “Everyone should be covered, but you have to understand what the consequences of this are.”

Baron is one of just six doctors in the state who specialize in children with digestive disorders, which can range from unexplained weight loss to organ failure.

There is generally a two-month wait to get an appointment with him during one of his 13-hour workdays, he said. That compares with about a week at the Cleveland Clinic in Ohio, which has 10 pediatric gastroenterologists on staff.

Nurse Practitioners
For years, hospitals and medical schools have been trying to find solutions to meet the growing demand from patients. Schools have increased the number of nurse practitioners and physician assistants they train to do some of the work currently done by doctors. Hospitals are using video conferencing systems to reach people in remote areas. The U.S. government has offered incentives, like loan repayments and scholarships, to get doctors to practice in under-served areas.

Many doctors could see more patients if they spent less time on paperwork and cut out unnecessary tests and procedures, said Uwe Reinhardt, a professor of economics at Princeton University.

Still, those solutions aren’t coming fast enough in places like Nevada. The state has the fifth-lowest ratio of doctors to patients in the country with 188 physicians per 100,000 people, according to 2007 data, the most recently available from the Census Bureau. Wyoming, Mississippi, Oklahoma, and Idaho are the only states with greater shortages, the Census figures show.

Follow-Up Care
The long wait times to see doctors can be particularly dangerous for those recently released from the hospital. In Las Vegas, some patients never receive critical follow-up care with their primary-care physicians and end up back in the hospital as a result, said Elissa Palmer, a family medicine doctor in Nevada and professor at the University of Nevada School of Medicine.

“They end up bouncing back to the emergency room because things get out of control,” Palmer said.

Collin Johnston, an urgent care doctor at a Las Vegas clinic, said he doesn’t always know where to send patients he sees who need a primary-care doctor.

One man he saw this month for a knee injury had high blood pressure and smoked. When the patient asked for a referral to a primary-care doctor, Johnston told him he didn’t know of one nearby who would take new patients or didn’t have a long wait.

Revolving Doctors
Annie Tomlin, a 35-year-old who was visiting Palmer for a checkup on a recent Friday morning at the Nevada School of Medicine Family Medicine Center, said she has shuffled among at least five primary-care doctors in the past 10 years.

Her past doctors have either stopped practicing, left Nevada or no longer take her insurance, she said. Each time she has to wait several months to sign up with a new doctor or wait hours at an urgent care center unfamiliar with her medical record.

Like Tomlin, more and more patients in Las Vegas are turning to urgent care centers, which can cost more than a doctor’s office visit depending on the services needed and what the insurer has agreed to pay. Many of these centers have popped up around Las Vegas, ranging from retail clinics, like those at Walgreen Co. (WAG) stores, to those run by University Medical Center, the largest public hospital in Las Vegas.

At one of UMCs Quick Care clinics in Las Vegas where Johnston works, up to 175 patients a day can show up seeking attention from one of two doctors at the center. On a recent Thursday afternoon, patients — including an infant with a cold and a man with a knee injury — waited more than two hours to be seen.

While these centers provide a valuable service, they can be slow, uncoordinated and more expensive than a primary-care doctor.

‘Fragmented Care’
“At a time when health-care costs need to be cut, when you need to provide quality services at a reasonable cost, we’re forcing patients to do the worst possible thing — get fragmented care.” said Forman, the rheumatologist.

One of the specialties in shortest supply in Nevada is transplant surgeons. No doctors in the state perform liver, lung or heart transplants, said John Ham, a transplant surgeon at University Medical Center who is part of the only team of doctors in the state that performs kidney transplants. He’s working to start the state’s first liver transplant program, though it is taking time to recruit the necessary doctors and nurses, he said.

Transplant Worries
The 200 Nevadans currently waiting for a liver transplant will have to travel out of state, Ham said.

Had Mary Berg stayed in Nevada, the time involved in getting to a transplant center in California or Arizona could have lowered her odds of success because a transplant needs to be done as soon as possible when an organ becomes available. At her new home near Phoenix she said she has a choice of hospitals, a doctor who specializes in her type of cancer, called a gastrointestinal stromal tumor, and is within an hour of a transplant center if her liver starts to fail.

Unlike Nevada, Arizona has two major nonprofit hospital systems. The Rochester, Minnesota-based Mayo Clinic has had a hospital in Scottsdale, Arizona, since 1987, with 464 doctors and 260 residents, fellows and medical students. Then, 30 miles away, there is the Banner Good Samaritan Medical Center in Phoenix, with 1,700 doctors who help train 250 physicians a year.

“I’ve got more options here without leaving Arizona than I ever had in Nevada,” Berg said. “Now, I have what I feel is an expert who looks at my care as a team approach where there is a team of doctors that can be called in. You aren’t going to feel out there in left field.”

This article originally appeared in the October 22, 2012 edition of Bloomberg.

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