More than three decades after she was born at Hale County Hospital in Greensboro, Ala., Dana Todd spends one night a week at the 20-bed facility in the state's rural Black Belt.
For an aspiring medical specialist, this might sound like a circle of hell, a few years of professional exile in exchange for help with med school loans.
For Todd, this has been the plan since high school. Like a prize football recruit, she was identified between her junior and senior years, mentored through college, welcomed into a one-year master’s program and groomed to become a family medicine physician by her medical school, the University of Alabama’s satellite campus in Tuscaloosa.
“A lot of these patients I’m seeing and treating, I go to church with them or our kids are in school together or I see them in the grocery store,” she said. “I’m actually making a difference that I can see.”
The extent of the nation's overall shortage of physicians remains a matter of considerable debate, but almost no one disputes that primary care physicians for adults — internists and family care doctors — are in short supply. This is especially true in rural communities such as Greensboro (population 2,500) and inner cities, as well as places in between.
In the Washington region, there is a shortage of primary care specialists in the eastern half of the District, stretching into Prince George’s County, portions of Southern Maryland and much of the Eastern Shore, federal data show.
The Association of American Medical Colleges estimated in March that the United States could be 31,100 primary care doctors short of demand by 2025 and would need 63,700 more physicians in specialties such as oncology, neurology and psychiatry. This is largely caused by the aging population of baby boomers, not the increase in people newly insured under the Affordable Care Act, the organization said.
The federal government predicts a much smaller shortage of primary care doctors, 6,400, by 2020. Primary care is composed of general internal medicine, family care and pediatrics.
The association has lobbied for additional federal support to train at least 3,000 more doctors a year by lifting the cap on federal funds for positions in residency programs, the three- to five-year training slots that most doctors take after medical school.
But lawmakers have kept the current level of federal funding for those positions essentially capped since 1997. And some experts say that persuading more doctors to practice primary care in underserved areas is more important than simply producing more doctors.
Last year, the independent Institute of Medicine concluded that “further increasing the number of physicians is unlikely to resolve workforce shortages in the regions of the country where shortages are most acute and is also unlikely to ensure a sufficient number of providers in all specialties and care settings.”
There is ample evidence that increased and improved primary care could have a positive effect on health outcomes in the United States, which routinely places lower than many other western, industrialized nations in rankings of health-care quality, but higher in rankings of cost.
Medical schools across the country have responded with programs like the one that put Todd back in her home town, caring for people she and her five siblings grew up with. At Texas Tech University, for example, the medical school has cut the number of academic years from four to three for family medicine candidates to get them into the community sooner. The University of New Mexico’s medical school now requires eight weeks of family medicine training and additional time with primary care instructors. State and federal governments help doctors pay for medical school, or pay off their debts, in return for a commitment to work in doctor shortage areas.
“The data show that one of the characteristics of successful health systems ... is a workforce that is based on more primary care physicians,” said Richard Streiffer, dean of the College of Community Health Sciences at the University of Alabama. “That’s why primary care matters.”
In the Washington area, the University of Maryland School of Medicine has a primary care track that opened in 2012 and will send its first students on to residencies in May. The program, located in Baltimore, absorbed the school’s family care track, which opened in 2007 and has graduated 85 students. About a third became family care physicians.
At George Washington University School of Medicine and Health Sciences, a scholarship program for a handful of students interested in pursuing primary care is in its second year. Georgetown University School of Medicine exposes third-year medical students to six months of primary care. Howard University College of Medicine has brought 80 minority and disadvantaged undergrads to a six-week residential summer program each year for the past 10 years as part of an effort to groom physicians who will return to practice in their home communities.
But medical schools can do only so much. A 2010 study of 1,554 fourth-year medical students attributed 8 percent of the influence on their career decisions to their schools.
As a result, small communities are constantly struggling to attract and retain primary care physicians. “We work hard sometimes to stay even,” said William Curry, associate dean of primary care and rural health at the University of Alabama School of Medicine. “We have a number of communities where the ratio of population to primary care physicians is two to three times [what’s] recommended.” In inner cities, pay, working conditions, overhead costs and administrative headaches help keep the number of primary care doctors down.
Compensation is often cited as the major obstacle. A career in primary care generally means lower pay, no small matter when, according to the medical college association, the average medical school debt is more than $176,000.
But some data don’t support that idea: When the association asked nearly 14,000 medical school graduates what influenced their choice of specialty in 2015, more than half said debt had no effect at all. More commonly cited were the influence of role models and students’ opportunities for further training.
Studies also have shown that primary care is frequently disparaged in medical school and during residency. The 2010 study, based on an online survey, showed that students were less likely to become primary care physicians if they attended schools where such “bad-mouthing” was more frequent. Other students and resident physicians are most often the culprits in perpetuating this attitude, rather than faculty, the survey showed.
Todd said she has heard it all but was still determined to move back home to a rural section of the state known for its dark soil. “You’re either too smart to be a family doctor and you’re wasting your time,” she said of the attitudes she heard. “Or you’re not smart enough to be a family doctor because there’s so much you have to know.”
Either way, she said, “the focus is not on primary care.”
Alabama's medical educators decided that one of their major problems is cultural. It's simply unrealistic, Streiffer said, to expect a young doctor who grew up in a big city with all of its amenities to enjoy life in small-town Alabama and open a practice there.
In the mid-1970s, the university started the regional medical campuses under Gov. George Wallace, who wanted a family doctor in every county. For the past 20 years, the university has gone further, trying to identify high school students in small towns who might want to go back home and become family doctors.
Of the 450 physicians who have completed their residencies in the Tuscaloosa program, 54 percent have stayed in Alabama, and half of all grads are in rural practice, Streiffer said.
They are people like James L. Parker, a 44-year-old family physician in Aliceville, where the population is also about 2,500.
“I grew up in the town I practice in,” Parker said. “I enjoy hunting and fishing and golf ... and just the slower pace. And not having to commute.”
Parker’s father ran a farm supply store, and his mother was a teacher. He said he admired the local general practitioners as he grew up, “seeing how much they enjoyed what they did and how respected they are,” and soon determined that he wanted to do the same thing.
“What I like about family medicine ... is you get to do a little bit of everything,” he said. “Folks put us down and say ‘jack of all trades, master of none.’ But you have to be pretty close to a master of all of them.”
He sees about 30 patients a day and finally had to hire a nurse to keep up. About 30 percent are poor enough to be on Medicaid, 40 percent are on Medicare and most of the rest are insured.
Parker said transportation is a big problem for his older and increasingly indigent patients, and he battles a cultural bias against preventive care, especially among men, who tend not to see him until something is wrong. But he plans to spend the rest of his career in Pickens County.
Todd feels largely the same way. “I came here with the intent of this being the place where I practice my medicine until I’m done,” she said.
A single mother of a 6-year-old son, she admits that her social life is limited in Greensboro. “I’m 32 and I go to work and I go to church and I go to my mom’s and I go home,” she said.
But Greensboro is the “perfect setting for me,” she said. “I wouldn’t have it any other way.”■
Lenny Bernstein is a Washington Post staff writer. To comment on this story,
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