The Specialist Squeeze: How to Fix the Shortage of Doctors in the Rural North

Shasta Community Health Center is a non-profit federally qualified health center in Redding California serving approximately 40,000 patients with a mission to care for the medically underserved. Their patients include residents of Shasta, Trinity, Siskiyou, Humboldt and Modoc counties. Photo by Annelise Pierce

This reporting is part of a collaboration with the Institute for Nonprofit News, Shasta Scout, The Daily Yonder, Carolina Public Press, and Honolulu Civil Beat. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible. 

Since the COVID pandemic began, the need for pulmonologists, the doctors who specialize in lung care, has soared in Shasta County. That’s a huge problem because Shasta County, like many rural counties across America, is experiencing a serious shortage of pulmonologists and the many other physician specialists who treat specific medical diseases or parts of the body. 

Shasta is part of California’s rural north, which has significantly worse health care access than the rest of of the state. The barriers to treatment are even higher when residents try to access care from specialist physicians. 

Tara Ray, whose name has been changed to protect her privacy, is a 24-year-old Shasta County resident who’s been living with a chronic medical condition since childhood. She said her medical care requires ongoing visits to a rheumatologist, but she has found accessing specialist care almost impossible. “So much energy goes into seeking care once you are referred to a specialist out of the area,” Ray said. “How far away is the specialist? Do you have a car? A license? A family member who can take the day off work to drive you?”

Complex social factors that affect medical care mean Ray and others may fail to receive the ongoing care needed to maintain their health and often end up in local emergency departments, clogging up the emergency system and costing significantly more. Even worse, many of these patients don’t reach ERs until their health has become a crisis, leading to an increase in hospitalizations and longer stays, at still higher financial and societal costs.

When patients or families experience difficulties accessing needed medical care, it multiplies existing social needs, increasing patients’ risk of things like substance use, housing uncertainty and domestic violence.

Paul Davis is chief of medicine for the Redding Rancheria Tribal Health System, which includes four clinics and serves both Native and non-Native patients. He says lack of access to physician specialists is a problem that health center staff face every day. For example, the clinic Davis works at lost its orthopedic specialist to retirement in September, leaving patients with time-sensitive injuries like broken bones with few options.

As the medical director of Neonatal and Newborn Services at Mercy Medical Center, Ashlee Smith said she also sees how the rural nature and low incomes of Shasta County affect patients and families everyday. Smith, who runs the only NICU north of Sacramento and south of Medford, Ore., said outcomes are far better for NICU patients if families are able to be near them during their stay, but some lack gas money to drive to visit their babies.

Maribel Gonzales, a child psychiatrist, waits on-screen for her next patient in one of Shasta Community Health Center’s telemedicine exam rooms. Gonzales is one of about 20 telemedicine providers that work part time at SCHC to provide access to critical specialist care. Photo by Annelise Pierce

A shortage of all kinds of doctors

It’s always been harder to bring doctors to rural areas like Shasta County, said Dean Germano, CEO of the nonprofit Shasta Community Health Center. But factors including wildfires and the COVID pandemic, which convinced many aging physicians to retire early, have worsened that shortage. “Over the last 5 to 10 years, some real holes (in the system) have developed,” Germano explained, “and over the last several years it’s been horrendous.” 

The lack of both primary-care doctors — who provide the first line of care for their patients —  and specialists has a compounding effect. As primary-care doctors struggle to get their patients into specialist care, they’re left managing health conditions they weren’t trained to treat, worsening their stress and liability, extending their patient loads and wait times, and reducing their overall quality of life. 

A disparity rooted in costs and social climate

California’s rural north comprises about a fifth of the state’s geographical area, but a relatively small percentage of its overall population. That population is also unevenly distributed, worsening health care disparities.

Redding, which is home to more than 50 percent of Shasta County’s population, has two hospitals, but much of Shasta County and the rural north consists of “frontier” areas when it comes to health care access, says Lisa Pruitt, a professor at UC Davis School of Law who specializes in rural issues. Outside of Redding, Shasta County averages only 23 people per square mile, and many areas of the county have far fewer.

That matters because “rural counties are usually older, sicker, poorer,” says Doreen Bradshaw, executive director of the Health Alliance for Northern California, which works with federally qualified health centers at 30 clinic sites in northern California. More than one third of Shasta County is on Medi-Cal, the state’s Medicaid program, which offers free or low-cost government health coverage for residents who meet eligibility requirements. High numbers of Medi-Cal patients and low Medi-Cal reimbursement rates contribute to the complexity of providing rural health care, she and others said. 

“It’s not that nobody cares about specialists in far-flung areas, it’s that nobody cares enough,” Pruitt explained. “As a political matter, anytime you’re providing any service to a rural area you struggle to achieve economies of scale because there aren’t very many people and they’re spread across the countryside. If you’re going to commit to providing that service in a rural place, it’s going to cost more per person.”

Shasta is one of eleven counties in California’s rural North State region. The area is geographically large but also the most sparsely populated part of California, making providing equitable healthcare coverage extremely daunting. From California’s Economic Development Department.

Fixing the specialist squeeze

California Sen. Brian Dahle, who represents the rural north, says he’s been working on the specialist problem for the last 10 years. New laws might help, he said, but they have to make sense financially.

Coordinated statewide assessment could be a start. While California data clearly show Shasta County lacks primary care doctors, Germano and Bradshaw both said they are unaware of any statewide planning or policies to respond to the lack of specialist physicians in rural areas. The lack of central planning is one reason no one knows exactly which or how many specialist doctors are missing in Shasta County. That understanding is complicated by rapid turnover in the physician workforce, Bradshaw said.

But in the midst of overwhelming need, local collaborators continue to develop and implement short- and long-term solutions. Shasta Community Health Center has increased telehealth services through its telemedicine center, which provides real-time video calls with physician specialists via a screen rolled into the patient’s room. Since the pandemic, telemedicine has grown rapidly, and has provided new access to care for some of the patients falling through the cracks in the system, said Michelle Carson, who manages psychiatry, specialty care and telemedicine.

The health center also contracts with a variety of private-care physician specialists to come to the center a half day or more each month to see patients. The reimbursement of these specialists varies, but money isn’t their main motivation, she said, explaining that many are mission-driven people who just really want to help with the overwhelming need. 

Being able to see a specialist on site helps because of all the psychosocial issues patients have, Carlson said, including low income levels and transportation. Shasta Community Health Center has been seeing specialty patients from other counties, including as far as Humboldt County, for years, due to the lack of resources in these counties for patients who have Medi-Cal. 

Finding long-term fixes requires widespread collaboration, and the Shasta Health Assessment and Redesign Collaborative is working to identify needs. So far, the organization sees medical workforce shortages as a primary problem. “The recruiting challenges are immense,” Bradshaw said, “and they’re at every level of the medical workforce.” 

The collaborative has brought together local educational institutions through a program called Shasta Health Rockstars, which recruits individuals to the medical workforce beginning in high school and recognizes local medical providers’ careers to promote their value to the community.

Germano is using a similar pathway with medical scribes, individuals who help doctors document patient care in real time, by providing ongoing education and support to help them move towards medical school. 

Another important university connection is a family practice medical residency that annually brings six medical students to the North State, where Germano and Davis hope they can convince them to stay and practice. Davis said most doctors end up practicing within 250 miles of where they’ve done their residency. 

The pipeline plan seems to be slowly working, both said. Many doctors at both Shasta Community Health Center and the Rancheria have come to the area via the residency program. Last year, four of the residents committed to staying and practicing locally, Davis confirmed. 

But there’s still a very long way to go. As part of the California Future Health Workforce Commission, Germano is working with other leaders across the state to find ways to solve the complex problems California’s rural populations face. He says the commission has estimated it will take $3 billion to address the commission’s top 10 priorities for building California’s workforce, including improving rural health care access to psychiatrists and other physicians. 

Germano noted that state lawmakers should be working towards funding to expand medical residency training programs like the one in Redding to include specialist training. The government could also set up loan forgiveness programs for specialty physicians who work in rural and underserved regions, and compensate them based on Medicare rates, not Medi-Cal rates, he said.

Finding solutions to the lack of specialty care is in everyone’s best interest, he said, because more specialists would reduce medical complications, costs and social risks.

“I’ve seen how (traveling for specialty care) really taxes and stresses a family that may be already on the edge,” Germano said, “and it’s not in anyone’s interest to see a child or family fall apart.”

CORRECTION: An earlier version of this story stated that most physicians wind up practicing medicine within 50 miles of where they did their residency. The actual distance is 250 miles.

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