With funds for physician training set to expire, rural doctor shortage persists

Aaron Rhyner, 29, of Tacoma, Wash., who works for the Puyallup Tribal Health Authority, examined an 8-year-old patient on July 30, 2014. He’s a third-year resident in the Puyallup tribal residency program for medical school graduates and one of 550 in the U.S. whose work is financed by the Affordable Care Act passed by Congress in 2010.
Aaron Rhyner, 29, of Tacoma, Wash., who works for the Puyallup Tribal Health Authority, examined an 8-year-old patient on July 30, 2014. He’s a third-year resident in the Puyallup tribal residency program for medical school graduates and one of 550 in the U.S. whose work is financed by the Affordable Care Act passed by Congress in 2010. McClatchy

After two years as a medical school resident for the Puyallup Tribe of Indians, Aaron Rhyner sees 14 patients a day, works 50 to 80 hours each week and earns roughly $50,000 a year.

Rhyner, 29, of Tacoma, Wash., calls his work “something special,” a chance to make a difference. He’s also doing his part to help fix a growing national shortage of primary care physicians, which is expected to approach 52,000 by 2025, hitting rural regions and Indian reservations the hardest.

Amid fears that the U.S. won’t keep up with the rising demand, Congress is under increased pressure to respond.

Experts say the national shortage is fueled by more doctor retirements, an aging and more rapidly growing population and more people enrolled in insurance coverage. And many worry that if the government doesn’t intervene, too many low-income Americans will simply get locked out of the U.S. health care system.

“If you call up and you can’t get an appointment because there aren’t any primary care physicians, you’re not getting access to health care,” Democratic Sen. Patty Murray of Washington state said in an interview.

Rhyner already owes his job to Congress, which four years ago included $230 million in its landmark health care law to pay for the training of 550 graduate residents in 24 states.

With that funding set to expire next year, Murray wants Congress to spend another $495 million to keep the training program going until 2019.

Murray, the head of the Senate Budget Committee and a veteran Senate appropriator, said her home state is expected to be nearly 1,700 doctors short by 2030.

She called the Puyallup tribe in western Washington state “a prime example” of a community that needs government help.

When the tribe created its residency program for medical school graduates three years ago, it had only two medical residents, including Rhyner.

This year the tribe is training 10 doctors, using $1.5 million in federal grant money. Its facility opened as the first osteopathic family medicine residency in the country with a Native American focus. Now there are two, with Oklahoma’s Choctaw Nation running a similar program. In Washington state, federal officials this year also awarded money for training programs in Yakima, Spokane and Toppenish.

Nationwide, a total of 60 graduate programs are operating in two dozen states this year, including California, Florida, Idaho, Illinois, Kentucky, Mississippi, Missouri, North Carolina, Pennsylvania and Texas.

Alan Shelton, clinical director for the Puyallup Tribal Health Authority, said most doctors are trained in big hospitals and are uncomfortable with the prospect of working on a reservation. As a result, he said, most tribes have a hard time recruiting doctors.

“Generally, the pay is less and the work might be more difficult. So you have to find somebody with a big heart,” Shelton said.

Shelton said he searches for young doctors willing to forgo big-city salaries. Instead, he wants residents who appreciate “the benefits and the beauty” of working in a smaller community and who want to make a personal connection with patients.

“We don’t want to just train technicians _ we want to train healers,” Shelton said. “And the way we train healers is we connect them to the Native American community and they learn about ideas of wellness and spirituality. And when they connect with patients, they connect with them on a deep level.”

Rhyner fit the job description, with Shelton calling him a doctor who’s “really committed to taking care of people that have limited options.”

Rhyner said that most of his medical school classmates at Pacific Northwest University wanted to work in specialty fields that pay more, but he wanted to focus on family medicine and “get a chance to do everything.”

A non-Indian who grew up in Alaska but traveled extensively, he said he liked the idea of working on a reservation and getting to join a start-up residency program, where he could help shape it.

“I have kind of an eclectic background in the sense that my mom is from Pakistan and my dad is from Minnesota,” Rhyner said. “So I’ve lived all over the world. . . . I’ve experienced third-world countries and areas where they don’t have an opportunity to get access to good health care. It makes such a huge difference when we are there and we can help them.”

When he came to the reservation, Rhyner said, he wanted to “experience the community.” He has done just that, attending pow-wows, participating in sweat-lodge ceremonies and the like.

“I see my patients there, and they see me, and it creates such a better connection that I really understand what they’re going through and what their life is like,” Rhyner said. “Everybody knows everybody.”

He said he has gotten an up-close look at drug and alcohol abuse, homelessness and diabetes, all issues that are more prevalent among Indians. And he said that exposure will only aid his future work: “It’s not something that I’m going to be afraid of.”

Rhyner, who uses a hand-beaded stethoscope that’s a hit with his patients, said he takes “a mind-body-spirit approach” to his practice, helping it meld with Native culture. And he said he often discusses proper eating with patients and asks about their spiritual practices.

“If someone has back pain, I can work on their back pain not just with medication, but with my hands,” Rhyner said. “They don’t want to be on medication a lot of times. Their culture is more towards using herbs and berries and other things to heal themselves, and they’ve been doing that for thousands of years, and this is like an adjunct to that.”

He worried when one of his patients, a woman in her 70s with congestive heart failure, told him that she that she wanted to go a sweat lodge ceremony as soon as she left the hospital. But Rhyner said he only issued precautions, telling her not to get dehydrated and to watch for any signs of breathing difficulties when she subjected herself to hours of intense heat.

“I know the level of endurance that you need for a ceremony like this, but I also know how important it is for them to cleanse their soul,” Rhyner said.

While the Affordable Care Act that expanded health care coverage has become a political target for many Republicans, ridiculed by many critics as “Obamacare,” Murray said the teaching program deserves to be extended.

“Look, this was part of the bill that has turned out very successful,” she said. “We are expanding on that.”

On July 31, Murray introduced a bill _ the Community-Based Medical Education Act of 2014 _ to keep the program running at its current level through 2019. At that point, her bill would establish permanent funding under Medicare to train primary-care physicians in community-based settings, creating another 1,500 new residency slots nationwide.

Murray has her work cut out for her, even though no opposition has yet emerged. She introduced her bill right before Congress left Washington for its long summer recess. So far, she has yet to line up any co-sponsors, and no similar legislation has been introduced in the Republican-led House.

Murray wants to pay for her bill by redirecting part of the funding that now goes toward reimbursing already established teaching hospitals, which are generally in large urban areas.

“We’re trying to change that, so that we’re actually training doctors in rural settings or tribal settings so that they will then be employed there, where we have the highest need,” Murray said.

At the Puyallup reservation, none of the residents in the program are Indians. Shelton said that’s because very few Native Americans are enrolled in medical schools, but he’s hoping to lure one to the tribe’s program next year. He wants Congress to extend the program, too.

In the meantime, Rhyner plans to complete his residency next June. He’s uncertain what his future holds, but his goal is to work as a family practitioner in Indian Country, hopefully in Washington state.

“You kind of go where you’ve been taught to be,” said Rhyner.