Potential Country Docs Face Roadblocks

By Caitlin Meredith

Gonzales, Texas, population 7,298, had a problem. There often weren’t enough family doctors in town, but things were especially acute in the fall of 2008. People who needed medical attention had nothing but bad options: wait months for an appointment at the local clinic or drive 60 miles to Austin or 75 miles to San Antonio. And then Chuck Norris, the CEO of the local hospital, paid a visit to the Valley Baptist Family Practice Residency Program in Harlingen, five hours south.

Valley Baptist is, essentially, the final classroom for the handful of medical students selected to be medical residents there. It offers the required medical residency — supervised medical practice — followed by licensing as a physician. Valley Baptist hosts about 15 residents at a time, from medical schools all over the world.

“I went down there with my line of hocus-pocus, trying to reassure interested residents that they would be able to build a successful practice in my town,” Norris said. The town has the infrastructure for more physicians. It’s home to Gonzales Memorial Hospital and a Community Health Centers of Central Texas clinic. Fortunately for Gonzales, two doctors liked what they heard and came to Gonzales to practice.

“Even as a kid I had this vision of growing up to be small town doctor,” said John Thomas, M.D., one of those two residents who made the move to Gonzales. “I don’t like big cities with all the traffic, the postage-stamp sized yards. Even when I went to medical school my plan was to open my own clinic in a small town in a place where I could enjoy having a relationship with my patients.”

Thomas opted for joining an existing practice–Gonzales Healthcare Systems–instead. Not only did it eliminate the cost of starting his own practice, but Gonzales qualifies for a program from the U.S. Department of Health and Human Services that helps repay medical school loans for physicians willing to work in under-served communities.

Even that’s not enough to help many other small towns in rural Texas which are struggling to provide health care to their residents. They’re mostly like Gonzales, with a median income only two-thirds the state average, high rates of uninsured, low-income patients and too few health care workers willing to provide rural medicine to the farmers, ranchers and itinerant laborers who live there.

But there’s another reason, an official one, that contributes to keeping doctors out of places like Gonzales: a 50-year-old state law that prevents hospitals from hiring doctors. Aiming to keep business profit considerations out of the exam room, the state mandates that only physicians can hire physicians. In most rural areas, that means doctors are self-employed, even if they only practice in one hospital.

The result has been, effectively, a ban on the corporate practice of medicine. Lawmakers passed a bill in 2009 that would have let hospitals hire physicians in counties with fewer than 50,000 people, but Gov. Rick Perry vetoed it, saying it would undermine the medical malpractice reform plan passed in 2003. Along the way, a political tug of war broke out between two physicians’ groups, both wanting the same thing — good health care in rural Texas.

To put the issue in perspective, Harris County–Houston–is home to more than 4 million people. But 194 Texas counties are home to fewer than 50,000 people. When you add them up, difficulty placing physicians in small towns is a big problem.

Attracting doctors is especially important given the demographics of these counties: 80 percent of the state’s land holds only 17 percent of its population. That 17 percent tends to be poorer, less educated and older than its urban neighbors. Although the need is great, there are few healthcare options: The state has declared 70 percent of rural areas in Texas “health professional shortage areas.” Even that federal program that pays for student loans has its pitfalls. “They’ve had lots of people they recruited here (Gonzales) for the student loan repayment deal,” said Dr. Thomas. “But then as soon as the loans were repaid they bail.”

Sean Bingham is committed to treating this underserved population. Now in his second year of medical school in El Paso, Bingham, from a small town in north Texas, says that the close relationship he had with his family doctor growing up is what made him decide to choose rural medicine.

“I like the idea of getting to know whole families, not just seeing individual anonymous patients,” Bingham said in a recent interview on the Capitol steps. He was there in his white coat, advocating for rural health.

He is part of the rural osteopathic medical education, a program that trains well-rounded medical students in the skills they need in rural areas where general practitioners see patients from cradle to grave. Bingham and his classmates, because of the hospital hiring ban, will have to shoulder a burden much heavier than the black-leather country doctor bag when they begin their careers.

If Bingham were to decide to go to a small town like Gonzales after his residency, instead of being hired by the hospital, he would have to start his own practice. The cost would be prohibitive. He’d have to pay for his own health and malpractice insurance, rent space in a clinic or hospital, and fund his own retirement savings — all told, an investment of an extra $50,000 to $100,000. This is in addition to paying off his student loans, which for the average medical student amount to $150,000 to $200,000. Before he sees his first patient, Bingham will be in debt as much as $300,000.

If he chose to work in a rural hospital in New Mexico, the hospital would pay his overhead and include him in its employee benefit package. In Texas, without competitive recruiting packages to offer medical residents, rural towns have few ways of attracting doctors.

The Texas Medical Association actually opposed changing the rules to let hospitals hire doctors. A statement from the TMA pointed out that 80 percent of Texas counties have fewer than 50,000 people and supported keeping physicians in charge of medical hiring. Rural health advocates disagree.

One purpose of the law was to improve the quality of care in hospitals. If a hospital made money performing specialized tests, doctors might be under pressure to perform them whether they were needed or not. Or expensive diagnostics might be discouraged even when they would help patients. The ban on corporate medicine aimed to ensure that physicians made patient care decisions independently from the for-profit businesses they worked for.

But Norris says the ban has had the opposite effect in rural areas. All he can offer physicians like Thomas is a nice dinner and a friendly visit. Sometimes that’s enough–usually it isn’t. Thomas said he’s seen physicians visit rural clinics and like what they saw, but then never make the move. “The practice was nice, it was better than the big cities where they were practicing but the wives just didn’t want to live there.”

Dave Pearson, president of the Texas Organization of Rural and Community Hospitals, says the law is way out of date.

“These were laws from the days of snake oil salesmen,” Pearson said. Since then, he said, a medical oversight board has been created to ensure ethical regulation of medical practices; Pearson points out that Texas is one of the few states with such laws still on the books.

Previous efforts to eliminate this ban have failed, but Pearson is optimistic that the bill might have a little more momentum in the next session. “It’s already so hard to find doctors that want to work in rural areas,” he said. “Can’t we make it a little easier?”