[dropcap]A[/dropcap]s those of you who read RHQ know, I am want from time to time to drive the roadways of West Texas. I call it my “windshield survey time.” I usually stop at a local coffee shop or eatery, sometimes they are the same place. I dress the part—boots and jeans and an older plaid shirt—but still the locals know when you’re not from around there. I always get coffee and whatever someone says is their specialty. That starts a lot of conversations. Soon, someone will ask, “Where ya’ from”? I say, “Lubbock.” Eventually, the conversation gets around to where I work. Then the real fact finding starts.

The topic that I hear the most about is health care shortages. But that’s not how they talk. They’ll say something like, “We don’t have a doctor anymore” or “Our doctor is retiring and y’all need to send us one” or “Our hospital closed last year.” Sometimes, the hospital is on shaky footing and they’ll say something like the only nurse they have works over at the nursing home. There’s a lot of worry out in the mostly rural side of Texas about the health care workforce trends.

I am always surprised at how up to date the people I meet are about things in health care – consumerism, technology, lower reimbursements, etc. Don’t misunderstand, recently I had one of those folks take me over to the local big green tractor company to show me a new AI sprayer that distinguished weeds from crops and applies herbicide to the weeds and fertilizer to the crops. These are no Luddites.

I wish I had more good news for them, though. The projections on workforce in Texas and most other non-urban places in the U.S. are not good. If you study the health workforce supply and demand projections of the Texas Department of State Health Services—comparing the supply of and demand for medical care personnel for the next decade (approximately 2019-2030)—then there is cause for concern. First, the supply-demand gap is growing for all professions from now until 2030. For nurses, the unmet demand is 18.5%; for physicians the unmet demand is 14%.

We can surmise that these shortages will force at least three critical changes. First, there will be more consolidation in the market of facility-based providers. That means bigger systems will outpace smaller systems in recruitment which means most small, rural communities will continue to lose infrastructure like hospitals and clinics through consolidation and acquisitions. Second, there will be innovations that are likely to depend on the greater use of virtual technologies such as telemedicine and telehealth to rural areas and some inner-city urban areas. That works for some kinds of delivery changes but will result in a rapid expansion and the cultural lag that goes with it such as electronic record systems that typically do not have good interfaces to deliver information critical to good clinical care or sufficient broadband to support necessary things like image sharing. Third, the expansive use of care extenders such as nurse practitioners, physician assistants and the educational programs that produce them. These will face competing forces such as the limited number of practicum sites and preceptors. That will likely favor programs that offer building block or trolley care options where students can build on a fundamental or entry level credential—such as a CNA to LVN to RN to BSN, etc.—to allow them to continue to work as they pursue the next credential.

I would be remiss if I didn’t strongly recommend that we must begin serious efforts to address health disparities, whether in rural or inner city urban areas. Two important components of that would include what public health personnel call “social determinants”—things like housing, jobs, transportation, etc.—and how they impact another change which is moving toward better risk and lifestyle management, such as in addressing obesity, drug dependence, exercise, nutrition and sedentary lifestyles. In short, we need to be focusing more on prevention as a paradigm shift.

One thing is certain as we approach the next ten years in rural health care: It will likely not look like anything we might predict today. Things are changing so rapidly in so many collateral domains that the only certainty is change itself. There will be change and we must be nimble as we respond to it.


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Dr. Billy U. Philips Jr. is Publisher of Rural Health Quarterly and Director of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.