Doctor Shortages Leave Long Lines for Care

By: Paul F. CuadrosDr. Ruben Rucoba is in a hurry. He strides into the small room where the signs are in Spanish and most of the patients are children.

For the past two years, the pediatrician has been treating the mostly Latino clientele at the Erie Family Health Center, a clinic at the corner of Chicago and Paulina avenues in West Town.

Rucaoba and the Erie clinic are the beneficiaries of a federal program that brings primary care physicians to needy communities. In return for working in West Town, the government will pay off the $25,000 Rucoba owes in student loans. When his obligation ends later this year, Rucoba could move on to a more lucrative practice. But he has decided to stay.

"I feel as though this is where I came from," he said. "I'm working for less but I'm doing something I think is worthwhile."

Chicago is a center of medical science, with some of the finest hospitals in the world. But many of Rucoba's patients would not see a doctor if it were not for the National Health Service Corps.

In Chicago, the service corps currently employs 35 doctors in 31 community areas, according to a survey of clinics by The Chicago Reporter. As of March, 68 positions were vacant.

About 1.1 million people live in these neighborhoods; 74 percent are black, 18 percent are Latino and 7 percent are white.

Chicago might fill more of those vacancies if there were more doctors to go around. In 1993, the service corps employed just 1,151 doctors nationwide. The corps plans to increase the number of scholarships and loans from 900 this year to 2,800 by 2000.

"There's been more money for scholarships last year and the year before and more next year," said Frank Dodge, acting director of the service corps. "A lot of states are going to get more people." And Chicago would qualify for even more doctors if health officials knew where physicians work and what kind of patients they serve.

"It would be nice if we knew who was practicing where, and what percentage (of their patients) was Medicaid," said Steve Carlson, recruitment director for the Illinois Primary Health Care Association, a coalition of community health centers. "The feds don't know it, we don't know it, the city doesn't know it and the county doesn't know it."

In June, federal officials removed four community areas, including West Town, from the service corps list, saying they no longer had a physician shortage.

"Anybody with any sense (who) came down here and saw what was going on would see that this area is high in need," Rucoba said. "If we're not a high-need area, then who is?"

Urban Exposure
Kenwood, a black community on the South Side, has no primary care physician to serve its 18,178 residents, according to a 1993 report by the Chicago Department of Health. Between 1990 and 1992, the area had an infant mortality rate of 22.4 deaths per 1,000 live births. Primary care doctors are family practitioners, internists, pediatricians, obstetricians and gynecologists.

Nearly 80 percent of the city's 1.07 million blacks live in a doctor shortage area, often leading to tragic consequences. A black baby born in Chicago is 2.6 times more likely to die in its first year than a white infant, according to the Chicago health department's projections of 1993 infant mortality rates. Blacks have an infant mortality rate of 20.3, compared to 7.8 for whites.

The U.S. Department of Health and Human Services designates shortage areas as any county, community area, or population group with more than 3,500 people for every doctor. An area with a ratio of 3,000-to-1 qualifies if 20 percent of the population lives in poverty or if the infant mortality rate is at least 20.

The city health department estimated that 1,561 primary care doctors practiced in Chicago in 1993, or an average of one doctor for every 1,783 residents.

But about 28 percent of those physicians worked in the Loop or along the lakefront, and experts say doctors in more affluent areas rarely see poor patients.

"No poor person is going to walk into an internist's (office) on North Michigan Avenue, on the Gold Coast, where the initial visit is $110," said Dr. Linda Rae Murray, medical director of the Winfield Moody Health Center, 1276 N. Clybourn Ave., near the Cabrini Green housing development.

"Many physicians do not want their waiting room to have poor people in it," she said. "In addition to that there are many physicians who are not interested in taking care of black people or Latino people of any class."

Doctor’s Choice
The National Health Service Corps offers loan repayment and scholarships to doctors, dentists, nurses, physician assistants and nurse midwives who agree to practice primary care in an underserved area. Doctors must serve at least two years.

Congress created the service corps in 1970, and by 1979 the program had awarded 2,380 scholarships. In 1990, the corps added a loan repayment plan. A total of more than 18,000 health providers have served in the corps.

Of the 1,606 health providers working in the program in September 1993, 21.1 percent had scholarships and 51.1 percent received loan assistance, according to the service corps. The rest were federal employees and health care providers who are funded in part through state programs.

In 1993, the service corps awarded 883 scholarships and loans; 254 went to minorities. Federal health officials estimate that 40 percent of the health providers will be minorities by 2000.

The service corps is geared more toward doctors than to the communities that need them. The program guarantees a choice of at least three eligible clinics for every doctor, which ensures that many positions will remain vacant. Few doctors would enter the scholarship program without being given a wide choice of where they will work, Dodge said.

Last year, 1,164 doctors applied to the service corps but only 43 percent found a clinic that suited them, according to an April report on the program from the U.S. Department of Health and Human Services' Office of Inspector General.

In Chicago, the demand for service corps doctors is increasing. In 1992, 17 clinics requested 51 doctors but received only 15, the Reporter found. One year later, 28 clinics requested 64 doctors and filled 18 positions.

"There's a misconception among (clinic directors) when they get on the list that they're going to get a doctor," Carlson said. "They're not."

In 1993, Illinois ranked eighth in the nation in the number of service corps doctors, with 32. California topped the list with 118 doctors, followed by New York with 111. Nationwide, about 60 percent of the health care providers work in rural clinics, records show. But Illinois, New York and Massachusetts buck that trend; between 88 percent and 92 percent of the providers in those states worked in cities in 1993.

In Illinois, "it's harder to recruit for rural areas than urban," said Roger Ricketts, program administrator for the Center for Rural Health, a state agency that administers the service corps program in Illinois.

In June 1994, 1,052 students graduated from Illinois medical schools, according to the Illinois Academy of Family Physicians. But only 11 percent chose family practice residencies, 7 percent chose internal medicine and 7 percent chose pediatrics. Three quarters of all graduates selected sub-specialties such as cardiology and orthopedics.

That leaves few locally educated doctors to practice in underserved areas. Since 1985, Illinois' version of the service corps program has awarded 410 scholarships to local medical students. Last September, 46 doctors from the state program were working in shortage areas in Chicago.

In 1993, Illinois spent $2.6 million for 33 new scholarships; 45 percent of the new awards went to minority students, according to the program's annual report.

But few doctors make a long-term commitment to the clinics. Of the 40 doctors who have completed their state obligation, only one has remained beyond five years.

Retention rates have improved on the federal level. In 1993, 42 percent of health care providers left their clinics after fulfilling their commitment, down from 61 percent in 1991.

Money Talks
In Riverdale, on the far Southeast Side, most of the area's health care providers work at The Clinic in Altgeld, a medical oasis in the heart of the Altgeld Gardens housing development.

Dr. Gregory O. Morris has been treating Altgeld patients for 18 months; he is one of two full-time dentists provided by the service corps.

In addition to his salary, he can receive up to $50,000 over two years toward his student loans. Morris, who will complete his obligation in 1996, said he hasn't decided whether he'll stay at the clinic.

"Being helpful and serving is in its own way addicting," said Morris, who grew up in Detroit.

Clinics in poor areas face stiff competition from health maintenance organizations, private practices and hospitals, which usually offer higher salaries.

"Where we get blown away is when an HMO agrees to pay a family practice physician $120,000 out of residency," Carlson said. '"We can't handle that."

Clinic directors say they look for doctors who are motivated by something other than money.

"We want physicians that are dedicated to serving the poor," said Robert Espier, coordinator of association activities at the Community Health Care Association of New York State, which helps clinics find doctors. Espier said salaries at New York clinics range between $60,000 and $80,000 a year.

"We don't want physicians that want high salaries. That's not what we're about," he said.

Rucoba said he chose the Erie clinic over other offers even though Erie paid the least. "I came here because I liked the people, I liked the idea behind Erie and I liked the idea that this was a comprehensive, full-service health center," he said.

"Most sites were equal," Morris added. "It's more a matter of what patient population you want, what type of setting you want to work in."

Not all clinics in shortage areas participate in the program. Some clinic directors say the service corps doesn't always give them what they want.

"It's very hard to get bilingual physicians in primary care," said Carmen Velasquez, executive director of Alivio Medical Center, 2355 S. Western Ave., on the city's Lower West Side.

Velasquez said she has hired only one doctor through the program since 1989. That's because she insists doctors speak Spanish and won't use translators.

"If you were a woman and a doctor needed to perform a gynecological exam and a translator had to be in the same room, there's no dignity in that," she said.

Instead, Alivio has developed its own program to help doctors from Spanish-speaking countries pass U.S. medical exams. "Once they pass those exams, we help them get their residencies. And two of those we've hired," she said.

Catch-22
On June 22, the federal government removed West Town, the Lower West Side, the Near North Side and Uptown from its list of physician shortage areas. But the health problems of these neighborhoods won't go away so easily.

West Town, for example, had an infant mortality rate of 14.2 for every 1,000 five births between 1990 and 1992, according to the city health department. Eighteen people died from pneumonia and influenza, and the area reported 25 cases of tuberculosis, 58 cases of AIDS and 227 cases of syphilis and gonorrhea.

The total population of the four areas is 14.6 percent black, 37.8 percent white and 42.6 percent Latino. Despite their health needs, these communities no longer qualify because they have more doctors than they did in 1988, the last time they were designated by the federal government.

"It becomes a Catch-22," said Patrick Lenihan, a city deputy health commissioner. "As soon as you do a good job in increasing the number of physicians, you lose the ability to attract physicians."

In December 1991, the Illinois Department of Public Health asked the federal government to redesignate 29 Chicago communities as health shortage areas and add 18 new areas to the list.

But on July 21, 1993, federal health officials rejected all of the new areas except Logan Square and proposed withdrawing another 14 because they no longer met the federal requirements.

In response, the city surveyed neighborhood physicians on how many hours they worked, how much time they spent with Medicaid patients, and whether they offered sliding-scale fees and spoke Spanish.

City officials also argued that the health care needs of the communities outweighed the gains made in the number of doctors practicing there.

Some community advocates agree. "Maybe there are a lot of physicians in the area but (they) don't serve Medicaid," said Heidi Romans, executive director of the Chicago Health Outreach Inc., a clinic at 1015 W. Lawrence Ave. in Uptown. "And they might not be there full time."

After reviewing the new physician survey, federal officials reinstated 10 of the 14 areas.

Informed Reform
City officials admit they need better information to show that many neighborhoods are lacking primary care doctors and many clinics are overburdened.

But data about doctors are hard to come by. The Illinois Department of Professional Regulation issues licenses to new doctors, who must renew them every three years. But state law only requires them to state whether they are surgeons and does not require them to say where they practice or whom they serve.

Without better information, "we're just not going to be able to make our case to the federal government," Lenihan said.

Physicians say they will resist any effort to impose tighter regulations.

Dr. Alan M. Roman, president of the Illinois State Medical Society, a doctors' group, said the law should only be used to issue licenses and that "physicians would resist efforts to expand" it.

But Richard H. Sewell, executive director of the Chicago Health Policy Research Council, said doctors should provide an alternative to the current system. "They need to cooperate ... and provide the data. They can't just be naysayers and be in the way of providing more access," he said.

Other states have found ways to obtain information about physicians. Tennessee requires that its doctors complete a survey every two years when they renew their licenses. The state had to use "a little public relations" to persuade physicians that the information would only be used to address shortage issues, said Ann Hogan, a statistical analyst for the Tennessee health department. "Once you can convince them that we're trying to help, they'll come around."

One group of health professionals does provide more information. The Nurse Practice Act of 1984 requires a survey of nurses every two years.

"When the state contacts its nurses it will know (its work force)," said Wendy Young, associate dean for academic affairs at the University of Illinois at Chicago College of Nursing, which conducts the survey. "Then it can decide if we need more scholarships."

Some state health officials say Illinois should worry less about the federal service corps program and concentrate on its own scholarship and loan repayment programs. But Illinois won't be able to do that until it can better diagnose its health needs and where they occur.

"Just as a doctor wouldn't write a prescription without knowing the vital signs of the patient, legislators shouldn't write legislation without knowing the vital signs of the health system," said David Dranove, an associate professor Northwestern University's J.L. Kellogg Graduate School of Management.

'The state needs to make an investment in learning about its health care system," he said. "The payoff is we'll all be far better informed when we enter our prescription for change."

Interns Robert O’Neill, Laura Otto an Gabriel Rosenberg helped research this article.