PIERCE — A photograph sits on the desk in Dr. Lane Handke's office.
The face of his father — Dr. Leon Handke, a family physician who cared for patients in Northeast Nebraska for more than 25 years before retiring — is among those smiling in that captured moment in time. It serves as an everyday reminder of the hard work, sacrifice and the dedication embodied by small-town doctors.
"I'm not worthy to put on my dad's stethoscope,” Lane Handke said.
His words aren't a reflection of the degree of his devotion to his own patients. As the only full-time family physician in Pierce, the younger Handke devotes more than his fair share of hours to providing care for Pierce and area residents.
But Handke said he believes his own sacrifices are a far cry from the ones his father made when he practiced medicine — when there weren't any hospitalists to make rounds in the place of the family physician; when late-night calls to the emergency room in Norfolk were followed by long days at the office; and when patients expected access to their family doctor at all times.
“In 25 years, he spent only seven nights without being called out,” Handke said of his father.
Over the past several years, expectations of young health care professionals fresh out of medical school have changed while the need for their services has grown.
Recent indicators have shown that it takes nearly two doctors to do the work that was once performed by one family practice physician. But more money, better hours and greater prestige are among factors leading medical students to choose specialty medicine over family practice.
These factors — combined with the greater number of physicians who will be needed to meet increased demand resulting from health care reform — are contributing to the creation of a serious shortage of primary care physicians in rural Nebraska.
Some Northeast Nebraska hospitals are already feeling the effects. Late last year, a University of Nebraska Medical Center study showed that 11 rural counties in the state — including Keya Paha and Wheeler — don't have any primary care physicians.
It also revealed the state will need 1,685 primary care physicians by 2014 to meet the demands when new portions of the federal Affordable Care Act go into effect. Currently, there are only 1,410 primary care doctors, or 63 for every 100,000 residents. That ratio is a 30 percent disparity in the numbers previously reported in a study by the American Medical Association.
While the AMA data might report a physician available in two rural counties, the reality is that — more often than not — one physician is covering both counties with a practice in one and satellite office in the other, said Jim Stimpson, director of the University of Nebraska Medical Center’s Center for Health Policy.
"We're just starting to feel it here," Jack Green, administrator of Antelope Memorial Hospital in Neligh, said of the shortage.
Until recently, Antelope Memorial had three physicians and two mid-level caregivers. One physician has since left the hospital and another mid-level was hired. But the loss creates a strain on the remaining medical staff because physicians are needed to back up mid-levels and to cover the emergency room.
"Our emergency room is busy enough — not super busy, but it's busy enough — to where it's a drain on the physicians," Green said. "That's probably our biggest problem."
Rural physicians don't expect the issue to remedy itself. Some health care professionals said they expect the need for family care physicians to increase even more as baby boomers age into their senior years and as lawmakers consider expanding Medicaid coverage to more Nebraska residents.
Dr. Brad Lockee is the only physician at Plainview Area Health System. Mid-level caregivers — such as physicians assistants and nurse practitioners — support him in patient care, but they require the supervision of a physician. As such, he’s technically been “on call” for several months.
“The last time I was totally away from my phone was in May when I went to China,” he said. “Every night, I have to have the phone on.”
Lockee said mid-level caregivers have the ability to provide excellent care that will fill in some of the gaps left by the shortage of physicians, but they likely will be presented with conditions they aren't comfortable treating. If a physician is not readily available to take over those situations, mid-levels will be forced to send patients to larger facilities located farther away. In many of those instances, the speed of treatment can affect the degree of recovery, he said.
"Disability (issues) will happen more likely because somebody wasn't there who could have taken care of that," Lockee said. “Those types of issues especially are going to happen more and more.”
Handke, who returned to provide health care in Pierce after practicing medicine in Lincoln and Omaha for several years, said communities need to become more involved in working with their young people who are going to medical school so they know how important it is that they consider returning after graduating.
“I always felt like I was part of the problem and not part of the solution,” he said of staying in the metro areas after medical school.
Now, he looks at the example set forth by his father when he thinks about the role played by small-town family physicians. He hopes more young doctors will understand their importance to their communities and feel drawn to serve in rural areas.
"It's almost like a minister sees their job as a calling," he said. "If you're going to do family medicine right, and you're going to practice in a small town, you have to see it as a calling. That's what will attract you and keep you there and keep you from burning out."
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Coming tomorrow: Age and the federal Affordable Care Act play multi-faceted roles in the physician shortage.