The San Joaquin Valley has some of the worst rates of chronic disease in California -- and not enough doctors to deal with those problems.
The valley has fewer doctors per capita than any other region in California, and the shortage is especially acute in rural areas and small towns.
The state's metropolitan areas don't have a shortage, according to Debra Riordan, legislative analyst for the Central Valley Health Policy Institute in Fresno.
Why don't doctors want to practice in the San Joaquin Valley?
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The answer is not a simple one, medical experts say.
Lack of job opportunities for a spouse, a perception that the schools aren't good enough, a lack of cultural opportunities and the lack of a medical school are among the reasons medical school graduates pass over the valley.
Dr. Richard Pan, an associate professor of pediatrics at the University of California at Davis, has studied pediatric residents' decisions about where to practice.
The biggest factor is not money, Pan said, it's family considerations. If there aren't career opportunities for a spouse, the doctor isn't likely to come. That's a societal change that has occurred over the past few decades, he said.
Years ago, doctors were men, and their wives were nurses, teachers or administrative assistants, Pan said. The wives could find jobs in the medical practice or with a school district.
Now the doctor is as likely to be a woman, and spouses of either gender have more specialized careers that may not be found in smaller cities, Pan said.
"If the spouse is a stockbroker or a specialized engineer, unless there is a job in the community, it is not going to fly," Pan said. "If the spouse is a mutual fund manager, it's New York, Boston or maybe Denver. There are just a handful of cities where they can work."
Even if the doctor is single, he or she may not feel there's an opportunity to meet a potential spouse who is on the same professional level in a smaller city, Pan said.
"You have to recruit the whole family, and we run into problems," said Mike Sullivan, chief executive officer of Golden Valley Health Centers in Stanislaus and Merced counties. "The community is too small, they are from an urban area and aren't comfortable here, they aren't sure the education system is adequate."
The perceived quality of education is a stumbling block, Pan agreed. Doctors may be willing to serve a rural area, but as soon as they have a child of school age, they want to relocate, he said.
And what is considered a small town can be surprising. Pan said Sacramento still suffers from the "cowtown" image, even though it no longer applies.
Specialists, in particularly short supply in the San Joaquin Valley, don't come here because they can't find a big enough patient base to support their specialty.
"In an urban area, there are a lot of patients for specialties," Riordan said. "They get more bang for the buck."
Pan noted that even Sacramento, with nearly a half-million residents, doesn't have a pediatrician specializing in rheumatology because the population does not provide enough patients. Multiple insurance carriers further split the potential client base, unless a doctor accepts all coverage, Pan said.
Culture, the environment, poverty and lack of academic support are among the barriers young doctors see in the San Joaquin Valley, Riordan said.
"Medicare rates are higher in urban areas. Doctors want to be by an academic area. There's a perception that the valley isn't a healthy place to live. They may not want to treat poor people. They don't perceive the valley as being a culturally stimulating place to live," she said.
California specialists underpaid
It may not be the primary motivation, but money is an issue, medical recruiters say.
"California specialists are underpaid for Medicare compared to the East Coast," said Dr. Del Morris, medical director for the county's Health Services Agency. "They assumed the cost of living was higher on the East Coast when they set up the system. If a cardiologist comes here and sets up practice, he's paid less than they are in the Midwest, by a substantial amount."
Dr. C.V. Allen, a semiretired Modesto doctor who helps recruit physicians for an area medical group, said doctors in the Midwest and Southeast are paid about 10 percent higher than in California, although it varies by specialty.
High medical school tuition makes those higher salaries even more tempting, said Dr. Gretchen Webb-Kummer, a recent graduate of the residency program in Modesto run through UC Davis. Tuition, books and living expenses for four years at UC Davis medical school runs about $180,000, according to the school.
"It's a consideration. A lot of residents have significant loans to pay off," she said.
Higher pay for specialists draws medical students away from primary care, Sullivan said. Golden Valley pays primary care doctors just out of school $130,000 a year, he said.
"Guys in radiology, orthopedic surgery are starting with at least three times that," he said.
There also are reasons why doctors do choose to practice in the valley, including family ties and the rewards of treating medically difficult patients.
Webb-Kummer is an example. A native of Sonoma, she met her husband while in graduate school in the eastern United States. He was from Lodi.
They returned to the valley, and Webb-Kummer became a chemistry teacher at Modesto Junior College. After eight years there, she entered UC Davis Medical School, and then the residency program in Modesto.
"Staying here for me was relatively easy," she said. "I have family ties, my husband is from the area."
With a house in Oakdale and three children in school, Webb-Kummer was rooted in the community.
Doctors frequently stay in the area where they complete their residency because they develop ties to the medical community, Pan said.
Webb-Kummer agreed. She talked about the challenges of serving low-income and indigent patients, the transportation problems, social and psychological problems, lack of education, and Internet access.
"I've dealt with it in my residency. It's difficult, but there's some satisfaction in working it out," she said. "You get to know a certain number of people, and I didn't want to abandon them."
Dependent on foreign doctors
The lack of graduates from U.S. medical schools willing to locate in the San Joaquin Valley has clinics and hospitals looking for alternatives, Sullivan said.
One source is doctors from foreign medical schools.
"We've had to depend on foreign doctors," Sullivan said. "Almost three-fourths of our new physicians come in on visa programs. If the government got tough with the visa programs, we would probably have to shut down many of our clinics."
Pan agreed. "International medical grads are more flexible," he said.
Once a certain number of doctors from a particular country locate in an area, it attracts more, Pan said. "The community becomes comfortable for them, they have connections and a network. They tend to cluster in certain communities."
Golden Valley clinics also use physician assistants and nurse practitioners for primary care visits, Sullivan said.
The UC Davis residency program in Modesto has helped place doctors in the area. The Stanislaus County medical clinics employ several graduates of the program, and Golden Valley Health Centers have hired several as well.
Area medical recruiters hope the proposed medical school at the University of California at Merced will accelerate that trend.
Bee staff writer Tim Moran can be reached at email@example.com or 578-2349.