Dr. Ted Epperly is CEO of the Boise-based Family Medicine Residency of Idaho, a program that gives medical students their last three years of training before they become doctors. He was an Army physician for 21 years before returning to work in his native Idaho. In addition to managing the residency program, Epperly is active in state and national health policy.
StateImpact Idaho spoke with him recently for our series on Idaho’s doctor shortage. The state currently has a lower number of doctors per capita than every state in the nation except Mississippi.
We wanted to include more from our interview with Epperly, so here is a portion that has been edited and shortened.
Q: How has medical care in Idaho changed because of the shortage of doctors?
A: What it does is slows down the ability to get appointments in a timely way, and then when you do get the appointment it’s usually for less time. That’s a problem with our fee-for-service, volume-driven system.
Part of what’s happened in health care reform is this idea of health care through an expanded medical home. Which means the expanded team of a practice cares for people in the community in a proactive way — to keep them healthier, so they aren’t coming into a clinic as often. We could start to affect the volume of patients that needs to be seen. The payment systems have to start paying for those services so physicians can provide them. Right now, you don’t get paid to do that – so you have to wait until people get sick before they come into your clinic. It’s just backwards.
Q: The U.S. Supreme Court ruling on the federal health law leaves states to decide whether they want to expand Medicaid, the state health plan for low-income people. How does a possible Medicaid expansion in Idaho complicate things?
A: First, I think it’s really important we do expand Medicaid in this state, so all people that qualify can have access. That way, at least they have coverage so it doesn’t become a barrier to them seeking care. The practicality of that though, is we don’t have enough primary care doctors in the state to easily absorb that.
I did a rough calculation of the 100,000 or so new patients that will be added to the system. That means about 40 to 50 new patients to every primary care physician in the state. That will present a timely access issue. But that underscores the real issue we have, and that is not having enough primary care physicians.
Our problem will be exacerbated for a while until we start to train up our workforce. We also need to expand the use of physician assistants and nurse practitioners to augment the health care teams. Family doctors working in conjunction with physician assistants and nurse practitioners should be what we expect.
We have to think more collaboratively of how we work with people. And then we have to have a priority of training more primary care physicians for our communities. Again, if we start taking care of problems in a more timely fashion, keeping people well instead of waiting until they get sick, then downstream we’ll save a lot of money in unnecessary emergency room visits, unnecessary hospitalizations. ER’s are not a default – it’s not where people should be for common problems.
Q: More than half of the residents in your program stay in Idaho. But why do so many other doctors chose to leave?
A: I really admire our family doctors who want to tackle family practice, it’s hard work. There are no short work weeks, and you pretty much need to be available to the community almost all the time. So it’s hard to find the types of people who are totally dedicated to those communities in a way that would give up so much of themselves. It’s a sacrifice.
One thing we found in recruiting and retention in these communities is it’s not so much the physician – the physician typically loves that kind of work. One of the biggest drawbacks is their spouse. If you’ve got a spouse from Chicago and you’re taking them to Salmon, Idaho – good luck. If that spouse comes from a small rural community, the likelihood of them going there is greatly enhanced and the likelihood of them staying is unbelievably enhanced.
The other factor that goes into retention is having a group of practice partners you like. If you’ve got a good team to work with, that’s fun. If you don’t or if you’re on your own, that’s a real turnoff.
Another thing that needs to be remembered is the quality of the education program in the communities. If mom or dad feel the kids aren’t getting a good education in these rural communities, then they’ll leave.
So, Idaho can’t lose the fact of the importance of K-12 education in all of Idaho. We can’t retain a workforce in rural Idaho if we don’t have a good education system to keep them there. The same for small businesses – the small business community has to be right to keep a physician in practice.
There has to be a lot of things going right in a community to keep a doctor – if any of those things aren’t going right, it’s tough for a community to keep a physician. And then if you don’t have health care in a community you can’t attract business, or teachers. Health care, business and education are all interrelated.
Q: What about the cost of practicing in a small community?
A: Usually, it’s a sacrifice. You’re going to make less in a small community. The average income of a doctor in a smaller community can be as much as 30 percent less.
The scope of practice, though, tends to be better. You get to use all the skills you’ve been trained to do. From delivering babies, taking care of sick infants, older adults, a lot of end-of-life issues – and everything in between. Many doctors love that large scope. What happens in the bigger communities – quality of life might be better, but scope of practice is much narrower.
Q: What could be done to entice people to stay, or to come here to practice?
A: A couple of things. The biggest would be the type of education programs we put in the state. Idaho must see, a bigger investment in education, both at the medical student level and resident level. It’s an investment the state needs to make. And what I mean by that is having a medical school that’s providing a good number of students coming out of medical school – that could be in partnership with the University of Washington or other area schools. But before that’s even in place, we have to have more residency programs.
What happens after medical school is doctors go to three to five years of training. We need multiple residencies in Idaho – not just in family medicine, but in general internal medicine, psychiatry, pediatrics and general surgery. That way, we become an importer of young physicians in training, we then train them in the state and the likelihood is they stay in the state. If it’s just a medical school model we become a net exporter of medical students to other states that have residency programs.