Health care overhaul or no, rural Texas will still lack doctors

Fort Worth Star-TelegramDecember 21, 2009 

BRECKENRIDGE, Texas — It was a typical day for Dr. J.E. Mikeska.

The longtime family practitioner had seen more than two dozen patients, ranging in age from 5 months to 89 years, for a host of ailments at his office is in the Breckenridge Medical Center in Stephens County, west of Mineral Wells.

It's what he likes best about being a country doctor in West Central Texas.

"The patients almost become part of your family," Mikeska said. "You’re doing things you enjoy, and you’re helping other people. What more do you want out of life?"

Mikeska should know. Now 82, he has been a rural family doctor for more than 50 years. He wouldn’t want to do anything else.

Finding doctors to join Mikeska in his life’s work, however, is not an easy task.

Pay for a family doctor isn’t as good in a rural area as in an urban environment, the hours are long, professional support is limited, demands are unending and their spouses often aren’t thrilled to live in a remote area far from relatives and friends.

It has to be a true calling, Mikeska said. "You have to have a passion for practicing in this type of setting," he said.

Despite efforts to increase the number of physicians in rural and other underserved areas, shortages persist. Twenty-two counties, mostly in West Texas and the Panhandle, were without a doctor as of October, and more than two dozen counties listed one physician, according to a Star-Telegram analysis of state licensing records.

The number of new family practitioners, meanwhile, failed to keep pace with the number of new surgeons, anesthesiologists and other specialists. And most of the new doctors licensed in the past five years have set up practice in the state’s largest urban areas, particularly Houston and Dallas-Fort Worth, the analysis shows.

"It’s a complicated issue," said Becky Conditt, executive director of the Texas Rural Health Association. "Mostly, people need family practice [physicians] in rural areas. That’s the discipline that’s needed the most, and there’s a shortage of family practice. They’re going to be wooed by the urban areas."

Making 'a difference’

Dr. Adrian Billings, a family practitioner in Alpine in the Big Bend area, wanted to be a rural family doctor from the beginning.

He grew up in Del Rio, on the Texas-Mexico border, and worked as a technician with the family physician who delivered him. When he went to the University of Texas Medical Branch at Galveston, it was with an eye toward returning to rural Texas.

"I knew I wanted to be a family physician, a rural physician," he said. "I wanted to deliver babies, to do clinics, cover nursing homes.  . . . I felt a calling to come back and serve these people."

It’s not the easiest way to make a living as a doctor. Billings, a solo practitioner for three years in Alpine, is on call all the time. He makes rounds at the hospital on weekends and takes call for other doctors when they are out of town. Billings leaves town when he wants to spend quality, uninterrupted time with his family.

"There are barriers to practicing in rural areas," he said. "You’re out here with sometimes very limited supplies. You often don’t have access to every specialty, every test. It can be a place that can really challenge you. I’m not making as much money as my colleagues in the urban areas."

Still, he says, "You come here to make a difference."

Sweetening the deal

The extra boost Billings needed to firm up his decision to practice in a rural area came through the state’s physician loan-repayment program.

Under the initial program, approved in 1985, the state would forgive up to $45,000 of a physician’s medical school debt if he or she practiced at least four years in an area designated as underserved, including many rural and some inner-city areas.

The Texas Legislature expanded the program this year to cover up to $160,000 in school loans. The expanded program is funded with an increased tax on smokeless tobacco products.

Supporters said many doctors are drawn to high-paying urban areas and to specialties to pay off their medical school loans, and the new program is expected to add 900 physicians to underserved areas over four years.

It’s one of a growing number of incentives to lure doctors out of urban areas. Many rural physician groups, like Breckenridge Medical Center where Mikeska practices, actively recruit doctors, bringing them out for visits and showing their spouses the area.

In many cases, it is the spouse who needs to be persuaded. Mikeska’s wife, Gayle, said some spouses are reluctant to move from an urban area. She said they don’t understand the social and cultural activities that can be found in smaller communities.

And a state law approved in 2003 that limited medical malpractice liability has boosted efforts to keep doctors in family practice and obstetrics, supporters say.

Dr. Bart Pate, a former Alpine physician who teaches residents in family medicine at John Peter Smith Hospital in Fort Worth — and who helped mentor Billings — said the liability caps have helped rural doctors, many of whom treat low-income Medicaid patients.

"I think it’s been very important," Pate said. "You’ve got to deliver quite a few babies to pay for your malpractice insurance before you get to the point where you’re paying your overhead."

Setting an example

At the end of the day, however, the best hope for expanding the number of rural doctors may rest with the existing corps of rural physicians. Their recruitment efforts — and their enthusiasm for the work — may be most effective at overcoming a doctor’s reluctance to open a rural practice.

Mikeska thought at first that he wanted to be a missionary, but decided while working as a medic in a hospital in Japan during World War II that he wanted to be a doctor.

In his practice, he has performed emergency surgery, treated victims of motorcycle and car accidents, and seen patients with high blood pressure, diabetes, obesity, pneumonia, ear infections — a host of medical maladies. The physicians group he has joined handles the administrative chores and paperwork. He has no plans to retire.

"I guess I’m just a country boy and enjoy life," he said. "I enjoy country people. When a rancher comes in, I can talk to him about cattle."

Billings, too, said he is satisfied.

He realizes that he could use some help, though. "Right now, I’m solo," he said. "I’m on call 24 hours a day, seven days a week. I’m actively looking for a partner."

Still, the rural lifestyle is what he expected, and he said his wife, a physical therapist originally from Fort Worth, has also adapted well.

"You’re a rural medicine specialist," he said. "You can treat 90 percent of what comes through the door, although there are times when I do have to get my patients to a specialist. We can deliver babies, we can work the emergency room.

"It’s the true cradle-to-grave practice that I envisioned when I went to medical school."

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