Page 17


Rural medicine and the Legislature Is there a doctor in the county? Austin Where are the doctors? In high-rent sections of town and out in the suburbs, is where. And where are doctors most needed? In poor neighborhoods and rural areas. It’s a hard fact of life that most doctors go where the money is. What’s more, it is nigh impossible to uproot established practitioners and lure them to unmoneyed places where their services are desperately needed. We are not talking here of getting another brain surgeon for Wink or of attracting a heart transplant man to the Deep Elm section of Dallas; we are talking about a scandalous shortage of plain old family doctors general practitioners. \(Twenty-three counties in Texas have no doctors at all. Some 190 haven’t a single obstetrician or gynecologist, and 33 have no hospital or Not to worry, says the Texas House, for we have passed a bill that will send 270 new doctors into needy corners of the state by 1982! Well, maybe. There is no guarantee that the measure will produce anywhere near that number of doctors for “medically underserved areas” of Texas, even though it will end up costing taxpayers $22 million. One lobbyist for rural interests went so far as to tell the Observer that “poor people and rural folks won’t get a single doctor out of the bill.” Paramedics There are a number of solutions to the doctor shortage in poor and isolated areas. An obvious step, long favored by progressives, would be increased enrollments in medical schools. As the supply of doctors began to catch up with the demand, young MDs might think twice before turning down a chance to practice in an impoverished backwater. However, the doctors’ lobby has stood adamantly against such a free enterprise notion, preferring the current artificial shortage that keeps fees up. A solution that is working well in Indiana and Wyoming is paramedical training. Paraencouraged to live where doctors won’t and give routine medical service under the direction of an MD living more comfortably el se hwe re . In its February legislation, however, the House did nothing to increase the supply of medical practitioners; instead, it passed a $22 million appropriation for the establishment of 270 new residency positions in family practice at training hospitals. The bill, sponsored by Rep. Lyndon Texas Medical Association and Texas does not require that the new positions be set up at hospitals in rural or lowincome districts and does not require the young doctors who benefit from the training to practice in areas of need once licensed. In short, the Texas medical establishment is $22 million better off. As we’ve said to them in very lukewarm language is ‘please produce some rural doctors if you find it convenient.’ ” Those pushing HB 282 argued soundly that Texas hospitals need more residents in family medicine. In 1976, 112 graduates of Texas medical schools who wanted to go into family medicine had to compete for 85 residency positions. The 27 who lost out left the state. Since doctors tend to settle within 100 miles of the city where they take residency training, it may be assumed that these doctors educated at a cost to Texas taxpayers of about $150,000 each are lost for good. So, the proponents of HB 282 conclude, if we had some more family practice residencies in Texas, we’d have more doctors for the hinterlands. Good going, said Rep. Head, and to make sure the doctors end up where they’re needed, let’s amend the bill to require that 25 percent of those residencies be located in medically underserved areas. No, said Olson, and the House obliged with a 78 to 59 vote against the Head amendment. Maybe I was asking for too much, said Head, so let’s require that only 20 percent of those positions be in rural and poverty areas. No, said Olson, who prevailed 92 to 46 this time. “If they intend in good faith to help rural people get medical care,” Head said later, “there was no reason to oppose these amendments.” Well, what the hell, there will be some new family doctors as a result of the bill, right? Not necessarily. Critics contend, for example, .that the Texas Municipal League’s support of HB 282 was rooted Rep. Fred Head: four strikes in a hope that city hospitals could spend their share of the $22 million to subsidize on-going family residencies. There is nothing in Olson’s bill that would prohibit such a move, so Rep. Head offered an amendment requiring that the money be spent on “new and additional” family residency programs only. Olson opposed the change, and it was defeated 82 to 53. Strong pablum So the people of Texas are offered a bill, hailed as a major step toward medical reform, that has no more teeth than this: “It is the intent of the Legislature that family practice residency training programs created, maintained or funded [by] this Act shall . . . insofar as possible and prudent, encourage the permanent location [of family physicians] in underserved areas.” Even this pablum was too strong for the Texas medical establishment, and as a consequence, more than half of the text of Olson’s bill is devoted to the creation of an advisory committee of doctors and hospital administrators who would keep the program in check. “This little buffer lets the Texas Medical Association screen everything real well, and if they find anything objectionable they’ll just call up and say ‘we can’t have this,’ ” Head said. He offered a final amendment to drop the advisory committee, but it lost 79 to 58. “In my judgment,” Head concluded, “the Legislature has abdicated its responsibility by sandwiching TMA in there.” The bill has gone to the Senate, where sponsor. March 25, 1977 11