Physician shortages affect Starr County, rural areas

RIO GRANDE CITY – Dr. Jake Margo took off toward the emergency room as soon as the hospital’s loudspeaker system announced “Code Blue.”

Hustling away from the maternity ward, where he had stopped to check in on an expecting mother, Margo reached the emergency room just as the paramedic brought an unresponsive patient in on the stretcher.

He asked for a quick rundown of the patient’s medical history, checked her vital signs and disappeared behind a curtain with hospital nurses. And when he emerged 10 minutes later with the patient stabilized, Margo was still the only the physician at the Starr County Memorial Hospital.

Margo, a Rio Grande City native who serves as the co-director of the emergency room in his hometown’s sole hospital, can name the handful of physicians who work full-time in Starr County.

Like other rural border counties, Starr County faces a severe shortage of physicians to meet the needs of its residents. Its total number of physicians per capita is barely one-quarter of the national average — which is frighteninly low, according to health care experts.

State legislators took steps last year to entice doctors to underserved areas — two dozen counties in rural parts of the state claimed no doctors last year — by forgiving student loans for doctors who practice in health professional shortage areas.

But Starr County’s unique confluence of circumstances, including its poverty rate, high rate of uninsured residents and small-town atmosphere, may make it a perennially underserved area.

And that will leave home-grown doctors like Margo, who played high school football for the Rattlers and returned to be the team’s physician, to carry a hefty load.

To handle the needs of his community, Margo, 35, keeps a daunting schedule as he supervises the emergency room, handles some night and weekend clinics and works as the medical director at a local nursing home. He specialized in family medicine during his residency in Fort Worth, but his Starr County surroundings helped him learn to do it all.

“In a place like this, you really need someone who is more versatile,” he said one morning as he made his rounds through the hospital’s different wards. “You might be the only doctor in town.”

DOCTORS SHORTAGE

At most times, only one doctor is in at the Starr County hospital.

While other physicians who are seeing patients in the county’s clinics are available to help in emergencies, Margo said, the doctors manning the emergency room on any given day must manage a heavy workload.

Starr County, which counts 15 primary care physicians among its ranks, has a ratio of 23 doctors per 100,000 residents, according to figures from the Texas Department of State Health Services. That ratio is a fraction of the state average of 68 and the national average of 81.

But a nationwide shortage of doctors — projected by the American Academy of Family Physicians to reach 40,000 primary care physicians by 2020 — may eventually mean long hours in the waiting room at busy clinics, less quality time available with the doctor in the examining room and emergency rooms packed with patients who couldn’t find a physician elsewhere.

An impending doctor shortage has been expected for decades as medical school enrollments stayed flat despite the country’s growing population, said Jose Camacho, the executive director of the Texas Association of Community Health Centers. But the problem has grown worse as fewer medical school students turn toward primary care in favor of higher-paid specialties.

Partly driven by an average medical school debt of $160,000, students are opting for residencies in specialties like radiology, oncology and cardiology that can pay three times as much as careers in family medicine.

Only about 8 percent of the students graduating from medical school in Texas last year chose family medicine, where the goal should be about half, Camacho said. Then the state exported half its medical school graduates to residences in other states, where they’re more likely to stay afterward.

“It’s beyond me that we have such a small percentage of (medical school graduates) choosing family practice and half of them leaving to residences in other states,” Camacho said. “It’s a significant gap, and it hits communities along the border, in rural areas and in inner cities the worst.”

SMALL STEPS

Attracting doctors to primary care and then to underserved areas is critical to addressing chronic health care issues like diabetes and heart disease in the Rio Grande Valley and elsewhere, said state Rep. Veronica Gonzales, D-McAllen.

A bill passed by legislators last year could send 225 physicians a year into Starr County and other underserved areas by enticing them there with a student loan forgiveness program, said Gonzales, a member of the House committee on public health, who played a key role in the bill’s passage. Under the bill, physicians who agree to practice for four consecutive years in health professional shortage areas are eligible for an educational loan repayment up to $160,000, the average medical school debt.

The loan forgiveness program — paid for by increased taxes on smokeless tobacco — keeps medical school graduates from choosing higher-paid specialties simply to pay off student loan debt, Gonzales said. It also promises to attract doctors to underserved areas like Starr County, where the high rate of uninsured patients and prevalence of low-paying government-aid programs like Medicaid reduces the earning power of physicians.

“(The loan program) will make a difference in having doctors locate in underserved areas,” Gonzales said. “$160,000 is a lot of money to pay back, especially for a young doctor.”

But with at least 10 years required to get high school graduates through college, medical school and post-graduate training, a long-term view is needed as the state’s population continues to grow, said Sen. Juan “Chuy” Hinojosa, D-McAllen, a sponsor of the bill. More needs to be done to improve the ratio of doctors to patients in South Texas.

“We have 1,000 new people moving to Texas each day and they all need doctors,” Hinojosa said. “It’s going to require a multi-prong approach to address the shortage.”

HIGH COSTS

And if nothing is done to address the shortage, health care experts say, its impact won’t be isolated to waiting rooms.

It will also show in the state’s ledger book.

From 2005 to 2008, Texas residents spent $32.2 billion — including $22.6 billion billed to Medicare and Medicaid — on hospitalization charges that were defined as potentially preventable, an analysis by the Texas Department of State Health Services found. Those hospitalizations — for health problems such as pneumonia, diabetes and urinary tract infections — were likely preventable if the patient accessed outpatient care at the first sign of symptoms.

In South Texas, where the dollar figure for unnecessary hospitalizations was 20 percent higher than the state average, the figures show there is a cost associated with a lack of access to physicians, not just in the quality of care, Camacho said. A healthcare system with too few doctors is an unmanaged system, where patients float between physicians or, worse, wait until small health problems become big, expensive ones.

Because primary care physicians offer the preventive care that reduces health care costs, putting more medical school graduates in those fields will help flatten skyrocketing medical expenses, said Tom Banning, the chief executive officer at the Texas Academy of Family Physicians. The $32.2 billion cost for unnecessary hospitalizations averaged out to $1,794 per each adult Texan, contributing to the rising cost for health insurance.

Giving people access to preventative and primary care is a way to control rising health care costs, Banning said. But it requires the physicians in place to provide that care at the right time and right place.

“When people get sick, they’re going to find access to care. Unfortunately, they’ll find it at the emergency room,” Banning said. “We’re going to be shifting that delivery back to emergency rooms and the cost will be picked up by local taxpayers.”

HOME GROWN

In Starr County’s emergency room, unnecessary hospitalizations are already abundant.

Most emergency room patients come in with complications from illnesses that could have been addressed earlier by a family doctor, Margo said. But many county clinics are at capacity with month-long waiting lists, making it hard for patients to see a doctor at the first sign of symptoms.

Doctors also have a hard time keeping their doors open in a community with a high proportion of Medicaid patients who tend to pay less than the actual cost of running the business.

Margo, who worked at Starr County’s federally qualified health clinic before it shutdown in part because of unreliable payments, almost left his hometown to find steadier income elsewhere. But he found work at the hospital, where he’s made his living since then.

“I didn’t intend to be a full-time ER physician,” said Margo, whose dream was always to practice in his hometown. “We are who our community needs us to be.”

And community is a central attraction for Margo and other doctors who choose to practice in small towns and rural areas.

Most physicians who practice in Starr County grew up there and wanted to come back, said Raul Hernandez, a Starr County anesthesiologist who was raised in Rio Grande City. The county has attracted some outside doctors who are drawn in by the small-town atmosphere.

But the longer days, lower pay and administrative headaches that confront physicians in Starr County keep many more at bay.

As the county’s lone anesthesiologist, Hernandez is constantly on call in case of emergencies.

“I would love to have another (Starr County anesthesiologist) so we can share calls,” he said. “Our town has grown substantially, and we need more physicians.”

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Jared Janes covers Hidalgo County government, Edinburg and general assignments for The Monitor. He can be reached at (956) 683-4424.