Area leaders upped the ante last fall with a report suggesting the shortage will be more acute in Kansas City than
in other Midwestern markets.

Members of the Metropolitan Medical Society of Kansas City, which produced the report, “Safeguarding the Quality of Health Care in Kansas City,” are working on several initiatives in conjunction with local businesses, chambers and economic development agencies to attract physicians to the region.

Several factors contribute to the national shortage: an aging Baby Boomer population that’s living longer, thus requiring more care; and medical schools that heeded several misguided national reports from the 1908s and ’90s that predicted the nation was headed for a surplus of physicians.

As a result of those predictions, class sizes at medical colleges across the country held steady at roughly 16,000 new students a year through the 1980s and into the mid-1990s, according to the Association of American Medical Colleges. During that same time, the U.S. population increased by 70 million.

Medical schools eventually recognized the forecasting mistake, says Karen Pletz, Kansas City University of Medicine
and Biosciences President and CEO, and began increasing their class sizes. But it takes about seven years to train
physicians, which builds in considerable lag time before the workforce starts to benefit from the increases in enrollment.

Even increased enrollments won’t be able to keep up—it’s an aging workforce, with the number of retirees expected
to outpace new physicians for years to come. All the while, the massive Baby Boomer population is reaching retirement
age, and living longer than ever before, meaning more people requiring more care than ever before.

While some experts forecast a shortage across many medical specialties, nearly all agree that the most severe shortages will be among primary care physicians. Dr. James Crane, Associate Vice Chancellor for Clinical Affairs at Washington University in St. Louis, says a root cause of the coming shortage can be seen in existing practices.

“Primary care physicians are facing growing demands on their time because of health literacy,” he said. “They’re the
ones responsible for educating patients about healthy lifestyles and wellness programs. That takes time. The other reason they’re feeling stressed is because of the growing number of patients with complex, multiple problems. The population is aging and we have a growing epidemic of obesity which leads to diabetes and heart disease.”

Seventy-hour weeks aren’t uncommon among internists, but they only get paid for about half of that time.

“Typically a primary care physician sees at least three patients an hour, which is a lot. That accounts for about 35 hours a week,” Crane said. “Then beyond directly seeing patients, the average internist spends about 42 hours a week in nonbillable functions such as dealing with insurance companies, and taking phone calls from patients. These demands on
time lead to primary care physicians being overworked and frustrated.”

In response, older family practitioners are choosing to retire early. Many who are in mid-career are choosing other career paths, going to work for medical-related companies in a non-physician position; or switching to a concierge service—also known as direct access care—in which physicians still provide service, but don’t accept insurance of any type. With that, a physician’s panel of patients drops from about 2,500 to about 500, allowing them to spend more time with patients, charge more billable hours, and avoid dealing with insurance companies.

“Young people in residency see this happening to established physician practices and they realize it isn’t an attractive
career path. It’s tough for people to balance family and work, especially so for women and more than half our students
are women now,” Crane said. The result is that an increasing number of graduates are choosing specialty fields, which pay nearly twice as much as what an internist makes.

“People who go to medical school are smart,” Crane said. “They look at their debt and realize they can make more
money as a specialist by about two-fold. We have 52 residents we graduate each year, and only five or six go into primary care,” Crane said. Compare that to 10 years ago when about a dozen would have been going into primary care.”

Perfect Storm

It is, simply, a perfect storm—one that could be especially turbulent in Kansas City. The primary culprit, according to the MetroMed report, is that Kansas City physicians receive lower reimbursement payments from insurance companies than what they would receive if they work in smaller communities like Topeka or Springfield. The report also says Kansas City has difficulty attracting physicians from other parts of the country because of an outdated negative perception about malpractice conditions in Missouri; and because we “don’t have mountains or water,” outsiders dismiss the great quality of life here without giving it a chance.

The local medical schools recognize the importance of keeping as many of their students as possible in the region after they graduate. Fortunately, says Pletz, KCUMB was quick to recognize that those national reports predicting a surplus of physicians were misguided.

“We looked at the Baby Boomer demographics, which has hugely impacted every segment of the market,” Pletz said, “and realized those reports didn’t add up. In 1998 we first changed our class size, gradually increasing it from 175 in 1997, to 220 students today.”

In his first budget, Missouri Gov. Jay Nixon is requesting $39.8 million for the “Caring for Missourians” initiative, which would increase class sizes throughout all health care fields in the state’s public universities.

Betty Drees, dean of the School of Medicine at the University of Missouri- Kansas City, says the initiative would pump nearly $12 million into UMKC health care programs, making it possible to increase class size by 91 students.

With plenty of quality applicants, why not increase class size more? Why isn’t every school increasing class size?

“We have a set class size, which is a decision the Board of Regents makes,” says Heidi Chumley, Senior Associate
Dean for Medical Education at Kansas University School of Medicine.

Increasing a class size too rapidly could, essentially, water down the education, unless the size of the staff and
faculty were to increase dramatically, too. That takes time and money. There is a fine balance to be maintained in
order to ensure institutions are able to keep important national accreditations.

Even if schools are able to properly fund growth in class sizes, they must still contend with yet another shortage—
a lack of residency positions available throughout Kansas City. Until hospitals can take on more residents—and they are limited by federal caps, Pletz says—there’s really no point in increasing class sizes.

Increasing the number of residency slots available is a driving force behind UMKC and KUMC efforts to forge partnership with area hospitals, and is vital to keeping doctors in the area after they are done with their education.

“The biggest bang for the buck is public medical education,” UMKC’s Drees said. “Students who go to public medical schools are more likely to stay in the region.”

That’s a problem KU has struggled with. Chumley said about 80 percent of KUMC students come from Kansas. The
number who remain in Kansas after they graduate is closer to 50 percent.

Dr. John Sheldon, MetroMed President Elect, and Medical Director of the Research Medical Center Radiation Oncology Department, said his organization has launched several initiatives geared toward keeping more of those locally educated and trained physicians in the region after they graduate.

“We are establishing a mentoring program where we help connect medical students with practicing physicians to serve as mentors,” he said, “which will help to create and sustain a relationship.” Ideally, upon graduation the student will have formed an attachment to Kansas City through the mentorship.

KCUMB’s Pletz contributes to a much broader initiative to recruit young professionals to Kansas City, and target those who are already here.

It is, quite simply, a tourism-style branding effort. Kansas City offers an excellent quality of life, it’s a great place to raise a family, Pletz points out. But young people today look for more than simply good schools for their kids.They’re looking for a more urban setting, with a more diverse, cosmopolitan lifestyle. The new and improved Kansas City offers that, but most young people outside of the area don’t know it.

To address that perception disconnect, the Area Development Council offers an multi-media campaign that its members can use to recruit young people to the region. MetroMed is complementing these efforts. It has a website [www. KCMedNet.com] that targets young physicians considering setting up practice in Kansas City.

 

Incentives

Doctor shortages are nothing new, of course. America’s rural areas have been coping with severe shortages for
years. “Here at the school of medicine we have the responsibility of looking out for the rural parts of the state,” KU’s
Chumley said. To address that shortage, the Kansas Medical Student Loan Repayment program was created.

If graduates stick around and work in underserved areas, the state helps repay their student loans—which currently
run about $120,000. While that program focuses primarily on rural parts of the state, parts of Wyandotte County are considered to be underserved, too.

Getting lawmakers to recognize all of Kansas City as “underserved” could be one key to addressing the region’s long-term problem, says MetroMed’s Sheldon.

“One proposal within the Obama administration’s health care reform package addresses the shortage of primary care physicians, and encourages policies of forgiving debt to serve underserved areas,” Sheldon said. “We need to be prepared to prove that the entire metro region is underserved.”