Dr. Jennifer Beaty had a number of choices open to her earlier this year as she debated where to begin her surgical practice. In the end, she chose Waverly.

“A good friend of mine from residency is from here, and I knew she was quite happy, and that’s how the whole thing got started,” said Beaty. In August she replaced a surgeon who recently left the Northeast Iowa community. She now practices at the Waverly Health Center, where she’s one of two general surgeons. “They have a beautiful hospital, beautiful facilities,” she said.

Iowa’s rural communities aren’t always so fortunate in filling physician vacancies, particularly in specialty areas such as surgery. According to a recently completed statewide survey, there are 322 immediate openings for doctors in Iowa in key specialties. The average time to fill one of the 24 general surgery openings, based on the rate of new surgeons becoming available, is about two years.

By early 2007, the Task Force on the Iowa Physician Work Force is expected to issue a report of its findings, which will likely include a request for more state funding for programs that assist rural communities in recruiting specialists. The task force was formed in June by Jean Robillard, dean of the Carver College of Medicine at the University of Iowa, and Donna Katen-Bahensky, director and CEO of the University of Iowa Hospitals and Clinics.

“The charge to the task force was to analyze the data on supply and demand of physicians and make suggestions on how we can improve the supply and distribution of medical specialtists, and other steps we should take to make Iowa practice opportunities more attractive, said Roger Tracy, director of the Office of Statewide and Clinical Education Programs at U of I’s College of Medicine.

Psychiatrists and neurologists are the two most difficult specialty areas to fill, according to the survey conducted by Tracy’s office. The state has 82 practicing neurologists, but has openings for 26 more. In psychiatry, 64 positions are unfilled statewide, in comparison with 220 psychiatrists currently practicing.

At the same time, the demand for family-practice physicians is increasing. There are currently 94 openings for family-practice physicians statewide, a 24 percent jump from last year. However, the number of openings represents just 7 percent of the number of doctors practicing in that specialty, much lower than the 29 percent ratio of unfilled positions among psychiatrists.

“Many of those [family-practice openings] are in very attractive rural communities that have been easy to fill,” Tracy said. “You wouldn’t expect that to happen unless the supply was getting tight.

“Fortunately, this state has nine residency programs, one here at the university and eight community-based programs (three of which are in Des Moines). They’re graduating over 50 per year across those programs and we retain over 70 percent in Iowa, and half of those graduates go into towns under 10,000 residents. If someone says to me the sky is falling in rural medicine, I can’t agree with that.”

However, a shortage of physicians, particularly specialists, in rural communities can result in patients making long drives to urban medical centers or forgoing needed procedures. For these communities, having the doctors they need is also a quality-of-life issue that can determine whether they’re going to thrive or merely survive.

“We need a multidimensional approach, because it’s a multidimensional problem,” Tracy said. Any changes in public policy, such as tax credits provided to physicians in certain specialties, should be made in concert with private and community efforts, he said.

Under existing programs targeting primary-care physicians, the state appropriates approximately $500,000 per year to provide matching funds to assist rural communities in paying down doctors’ school debts. That program should be expanded beyond primary-care physicians and better funded to provide greater incentives, Tracy said.

“Providing $50,000 to a doctor who has $250,000 in debt may not be as attractive as other states that are buying down the entire debt,” he said.

Recruiting physicians to small-town Iowa can often hinge on good networking with the medical schools and residency programs as well as word-of-mouth referrals between doctors, said Eric Lothe, president of Skiff Medical Center in Newton. There, a combination of recruiting incentives and community-based initiatives has enabled the hospital to recruit and keep good family physicians, he said.

“The community has done physician recruitment pretty successfully here since the early 1990s,” Lothe said. “It has focused on primary-care physicians, because the feeling was we were pretty underserved. It’s been a community approach, which is important.”

However, Skiff has been unable to attract a staff urologist; it’s currently served by a visiting urologist from Des Moines. The hospital is also trying to find a second orthopedic surgeon to provide some on-call relief for its sole practitioner in that field.

Through its foundation, the hospital has been able to offer incentive funds to new physicians to offset moving costs or help them pay down their medical school loans, he said. However, the quality of life a community can offer seems to provide a bigger incentive than any signing bonuses it can offer, Lothe said.

“The other thing we’ve really noticed here in Newton is that the physicians come and they stay. I think that says a lot to the physicians that come to visit.”

From Beaty’s perspective, “I feel I get to spend more time with my patients than in Des Moines,” she said. “I don’t necessarily do the same complexity of cases I might in Des Moines. I just don’t have all the specialists available. So I have to select my cases carefully. For some people, it’s a disadvantage. It works out fine for me.”

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At Broadlawns Medical Center, eight out of the 10 doctors who graduated from its family medicine residency program in the past two years have stayed in Iowa, with three going to small towns, said Dr. Larry Severidt, the program’s interim director. Similar ratios hold true for the next two classes that will complete their family-practice residencies.

“Obviously, (rural Iowa) is a pretty high-need area,” said Severidt, who before coming to Broadlawns three years ago practiced for 24 years in Manchester and Pella. “There are a lot of small towns that really need physicians, and our program is really structured such that they’re really prepared to do that kind of practice.

“When people finish (Broadlawns’ program), they’re very well prepared to be a private practitioner in a small community, without a lot of support,” he said. “Part of that is, we don’t have a lot sub-specialties available here either, so we have to figure out appropriate ways to make referrals. So practicing here is in a lot of ways not unlike practicing in rural communities.”

Broadlawns operates one of three medical residency programs offered in Greater Des Moines, along with Iowa Health System-Des Moines and Mercy Medical Center.

Dr. Doug Dorner, senior vice president for medical education and research at Iowa Health, said each year more than half of the residents in his program, which graduates about 30 doctors per year, stay in Iowa.

“And that’s very good,” he said. “Any time you train someone in Iowa and they stay, I think that’s easier than going out to New Jersey or to Texas to recruit physicians. When they train here and stay here, it’s a positive sort of thing because they’re likely to stay a good long time. Also, when they stay here, we’ve had the opportunity to see them in their training and we’d like to think they’re well-trained when they come through our own programs. So we’re happy to have those individuals stay with us.”

Though it competes with programs in areas that can offer beaches or mountains, Iowa Health’s residency programs in the primary-care specialties – family medicine, pediatrics and internal medicine — have filled in each of the past few years, Dorner said.

Both Iowa Health and Broadlawns have experienced declining numbers of medical residents choosing family practice for the past several years.

“One of the reasons for that is that medical students are frequently coming out of school now with $150,000 to $200,000 in debt and quite frankly, a radiologist makes four times as much as a family doctor,” Severidt said. “I think people also look at lifestyle issues. Family practice is a wonderful profession, but it’s hard work, a lot of hours and being on call.

However, both Dorner and Severidt say applications for family medicine residents are back up this year.

“We have twice as many applications to our program this year compared to last year,” Severidt said. “So we’re encouraged by that. We’re hopeful that it’s the beginning of a trend.”