Health centers struggle to recruit clinicians

Community health centers face "substantial challenges" in recruiting physicians and other clinicians, according to a study recently published in the Journal of the American Medical Association.

So far, staffing problems haven't held up Bush administration efforts to expand the number of health centers as a way to provide care to uninsured Americans. But health center officials worry that declining interest in primary care among medical students and proposed cuts to federal primary care training programs could make staff recruitment an even bigger challenge.

The study, based on results of a nationwide survey of health center executives in 2004, found hundreds of vacancies for physicians, nurses and dentists at federally qualified health centers.

The findings suggest that some facilities are not adequately staffed to meet the needs of patients, said Roger Rosenblatt, MD, a professor of family medicine at the University of Washington and the study's lead author. "Vacancy rates we observed are high enough to really impede the ability of these centers to do their job," Dr. Rosenblatt said.

Health centers were hard-pressed for family physicians above all. The survey found nearly 430 vacancies for family physicians, the largest number for any specialty, and 13.3% of the funded positions in that discipline.

Family physicians are the backbone of the physician work force at community health centers, representing nearly half of their physician staff.

By comparison, obstetrician-gynecologists and psychiatrists represent less than 10% of the physician work force at health centers. But their vacancy rates were even higher than for family physicians, at 20.8% and 22.6%, respectively.

The survey also found that rural health centers had a higher proportion of vacancies than urban health centers. For example, their vacancy rates were 15.7% for family physicians and 26.6% for ob-gyns, compared with 12.1% and 19%, respectively, at urban health centers.

The high vacancy rates "are a source of great concern for us," said Dan Hawkins, vice president of federal, state and public affairs for the National Assn. of Community Health Centers in Washington, D.C. "Significant numbers of health centers are experiencing growing difficulties recruiting and retaining physicians and other primary care providers, including dentists and mental health [professionals]," he said.

At the same time, he noted, health centers have expanded physician staffs by 42% and dentistry staffs by 64% in the last five years. "So for all the [recruitment] difficulties that are out there, community health centers grew their staff," he said.

Recruitment is always a challenge for these facilities, said Donald Weaver, MD, deputy associate administrator of the Bureau of Primary Health Care, the agency that oversees the health center program.

But to date, health centers have been able to meet the goals of the Bush administration's initiative to add 1,200 new and expanded health center sites in five years and ultimately double the number of patients they serve, Dr. Weaver said. "Community health centers do a wonderful job of recruitment and retention."

A shrinking pool

Both Hawkins and Dr. Rosenblatt are concerned that trends in medical training will further reduce the pool of primary care physicians from which community health centers are able to recruit. They point to the continuing decline in the number of graduating U.S. medical students entering primary care fields such as family medicine, internal medicine and pediatrics.

"The data show 35% of all practicing physicians today are age 55 and older, and there are not enough physicians training for primary care to replace them," Hawkins said. "It's the same thing with dentistry."

The trend underscores the need to strengthen primary care training programs and not just for the sake of community health centers, Dr. Rosenblatt said. But President Bush has proposed eliminating almost all federal funding for Title VII, which supports training primary care physicians, dentists and other health professionals.

The president's fiscal 2007 budget proposal would cut Title VII funding from $145 million to $10 million and would provide no increase for the National Health Service Corps, which offers scholarships and loan repayment programs for medical students who agree to practice in doctor-shortage areas. "In tight budget times, you have to make difficult choices," Dr. Weaver said.

Nevertheless, the Bush administration is confident that community health centers will be able to recruit enough clinicians. "Whatever pool is available for them to recruit from, health centers are great at finding the right person for the right place."

But Dr. Rosenblatt doesn't share that confidence. "I salute the administration's intent to augment, expand and stabilize community health centers," he said. "But part of that strategy needs to be a health professional training strategy."

If enacted, the proposed Title VII cuts would have a "disastrous impact" on the nation's primary care training programs, he said.

Medical schools and other institutions are scaling back these programs as the result of cuts in fiscal 2006, when Congress slashed Title VII funding from $300 million to $145 million.

The full effect of those cuts is not yet clear, said Emily Froyd, a legislative analyst for the Assn. of American Medical Colleges. But some medical schools have closed geriatric education centers because Title VII funding for those programs was eliminated.

The decision to end the geriatric training grants was "insanity," said Ruth Covell, MD, associate dean of the University of California, San Diego, School of Medicine and the Section on Medical Schools' representative to the AMA House of Delegates.

"If you look at the changing profile of the American population, we're going to be overwhelmed with geriatric patients, and we're going to need geriatricians," she said. "That's going to be a problem at all levels, including for the community clinics."

The University of Washington also might have to give up certain training programs, Dr. Rosenblatt said. "We are scrambling as hard as we can to sustain them, but I don't think we're going to be able to do that totally."