As Fewer MDs Practice Rural Primary Care, a Different Type of Doctor Helps Take Up the Slack

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Yves here. Generally speaking, MDs take a dim view of osteopaths. I have a friend who came from a family of MDs who swore by the one her husband saw to treat the various twinges he got from being a dentist and having to stand in unnatural postures a fair bit of the day. In many (most? all?) states, osteopaths can prescribe, so that gets them a long way towards being able to provide similar care to what most people see as more conventional doctors.

In a bit of synchronicity, Paul R recently sent me a 2020 Niskanen Center article, The Planning of U.S. Physician Shortages. If you read only the KFF Foundation story, you’d think the lack of rural doctors is an unfortunate act of nature, when there was a concerted effort to cut back on doctor creation. The top of this important story gives you the drift of the gist:

The number of practicing physicians per person in the United States is lower than in just about any other developed country. Yet from 1980 to the early 2000s, the prevailing wisdom was that the number of physicians within the United States ought to be reduced. During this period, a series of ill-judged reports by the federal government warned of an impending physician surplus. These reports ushered in a period in which both private and public actors took actions to constrain the supply of U.S. physicians, the most significant of which was the medical school moratorium. The resulting dearth of physicians had the effect of making U.S. health care more intensive and less accessible than it otherwise would have been.

The “physician surplus” narrative
In 1976, the secretary of the Department of Health, Education, and Welfare (now the Department of Health and Human Services) commissioned the Graduate Medical Education National Advisory Committee (GMENAC) to intensively study the U.S. physician workforce and provide policy recommendations. The committee’s mandate was to answer the question whether a rapid increase in the number of U.S. physicians that had occurred over the previous decade was cause for concern. Released in 1981, the GMENAC report concluded that the United States was on the verge of a massive physician surplus, recommending immediate action to curtail both the domestic training of physicians as well as the admittance of those trained outside of the country.

It’s difficult to overstate the influence of the GMENAC report in cementing the narrative of physician surplus during the 1980s and 90s. The report is pervasively referenced in medical and policy journals during this period. In subsequent years, the “surplus” narrative would be routinely endorsed by governmental bodies. The congressionally-authorized Council on Graduate Medical Education repeatedly endorsed the need to constrain physician numbers in order to avoid a “surplus” in its annual reports between 1988 and 2000. Workforce modeling by the federal Bureau of Health Professions endorsed the same conclusion. And in 1997, a consensus statement by the American Medical Association, the Association of American Medical Colleges, and other prominent medical associations declared the same.

Now to the main event.

By Tony Leys, KFF Health News Rural Editor/Correspondent, is based in Des Moines, where he worked 33 years as a reporter and editor for The Des Moines Register. Tony was the Register’s lead health care reporter for more than 20 years and served four terms as a board member for the Association of Health Care Journalists. Originally published at KFF Health News

For 35 years, this town’s residents have brought all manner of illnesses, aches, and worries to Kevin de Regnier’s storefront clinic on the courthouse square — and he loves them for it.

De Regnier is an osteopathic physician who chose to run a family practice in a small community. Many of his patients have been with him for years. Many have chronic health problems, such as diabetes, high blood pressure, or mental health struggles, which he helps manage before they become critical.

“I just decided I’d rather prevent fires than put them out,” he said between appointments on a recent afternoon.

Broad swaths of rural America don’t have enough primary care physicians, partly because many medical doctors prefer to work in highly paid specialty positions in cities. In many small towns, osteopathic doctors like de Regnier are helping fill the gap.

Osteopathic physicians, commonly known as DOs, go to separate medical schools from medical doctors, known as MDs. Their courses include lessons on how to physically manipulate the body to ease discomfort. But their training is otherwise comparable, leaders in both wings of the profession say.

Both types of doctors are licensed to practice the full range of medicine, and many patients would find little difference between them aside from the initials listed after their names.

DOs are still a minority among U.S. physicians, but their ranks are surging. From 1990 to 2022, their numbers more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. In that same period, the number of MDs rose 91%, from about 490,000 to 934,000.

Over half of DOs work in primary care, which includes family medicine, internal medicine, and pediatrics. By contrast, more than two-thirds of MDs work in other medical specialties.

The number of osteopathic medical schools in the U.S. has more than doubled since 2000, to 40, and many of the new ones are in relatively rural states, including Idaho, Oklahoma, and Arkansas. School leaders say their locations and teaching methods help explain why many graduates wind up filling primary care jobs in smaller towns.

De Regnier noted that many MD schools are housed in large universities and connected to academic medical centers. Their students often are taught by highly specialized physicians, he said. Students at osteopathic schools tend to do their initial training at community hospitals, where they often shadow general practice doctors.

U.S. News & World Report ranks medical schools based on the percentage of graduates working in rural areas. Osteopathic schools hold three of the top four spots on the 2023 edition of that list.

William Carey University’s osteopathic school, in Hattiesburg, Mississippi, is No. 1 in that ranking. The program, which began in 2010, was intentionally sited in a region that needed more medical professionals, said Dean Italo Subbarao.

After finishing classwork, most William Carey medical students train in hospitals in Mississippi or Louisiana, Subbarao said. “Students become part of the fabric of that community,” he said. “They see the power and the value of a what a primary care doc in a smaller setting can have.”

Leaders from both sides of the profession say tension between DOs and MDs has eased. In the past, many osteopathic physicians felt their MD counterparts looked down on them. They were denied privileges in some hospitals, so they often founded their own facilities. But their training is now widely considered comparable, and students from both kinds of medical schools compete for slots in the same residency training programs.

Michael Dill, director of workforce studies at the Association of American Medical Colleges, said it makes sense that osteopathic school graduates are more likely to go into family practice, internal medicine, or pediatrics. “The very nature of osteopathic training emphasizes primary care. That’s kind of their thing,” said Dill, whose group represents MD medical schools.

Dill said he would be confident in the care provided by both types of doctors. “I would be equally willing to see either as my own primary care physician,” he said.

Data from the University of Iowa shows osteopathic physicians have been filling rural roles previously filled by medical doctors. The university’s Office of Statewide Clinical Education Programs tracks the state’s health care workforce, and its staff analyzed the data for KFF Health News.

The analysis found that, from 2008 to 2022, the number of Iowa MDs based outside the state’s 11 most urban counties dropped more than 19%. Over the same period, the number of DOs based outside those urban areas increased by 29%. Because of the shift, DOs now make up more than a third of rural Iowa physicians, and that proportion is expected to grow.

In Madison County, the picturesque rural area where de Regnier practices, the University of Iowa database lists seven physicians practicing family medicine or pediatrics. All are DOs.

De Regnier, 65, speculated that the local dominance of the osteopathic profession is partly due to the proximity of his alma mater, Des Moines University, which runs an osteopathic training center 35 miles northeast of Winterset.

Des Moines University has one of the country’s oldest osteopathic medical schools. It graduates about 210 DO students a year, compared with about 150 MD students who graduate annually from the University of Iowa, home to the state’s only other medical school.

Many patients probably pay no attention to whether a physician is an MD or a DO, but some seek the osteopathic type, said de Regnier, who is a past president of the American College of Osteopathic Family Physicians. Patients might like the physical manipulation DOs can use to ease aches in their limbs or back. And they might sense the profession’s focus on patients’ overall health, he said.

On a recent afternoon, de Regnier worked his way through a slate of patients, most of whom had seen him before.

One of them was Ben Turner, a 76-year-old pastor from the nearby town of Lorimor. Turner had come in for a check of his diabetes. He sat on the exam table with his shoes off and his eyes closed.

De Regnier took out a flexible plastic probe and instructed Turner to say when he felt it touch his feet. Then the doctor began to gently place the probe on the patient’s skin.

“Yup,” Turner said as the probe glanced against each toe. “Yup,” he said as de Regnier brushed the probe against his soles and moved to the other foot. “Yeah. Yeah. Yup. Yeah.”

The doctor offered good news: Turner had no signs of nerve damage in his feet, which is a common complication of diabetes. A blood sample showed he had a good A1C level, a measure of the disease. He had no heaviness in his chest, shortness of breath, or wheezing. Medication appeared to be staving off problems.

Chris Bourne, 55, of Winterset, stopped in to consult de Regnier about his mental health. Bourne has been seeing de Regnier for about five years.

Bourne takes pills for anxiety. With input from the doctor, he had reduced the dose. The anxious feelings crept back in, and he had trouble sleeping, he told de Regnier, sounding disappointed.

De Regnier noted the dose he prescribed to Bourne is relatively low, but he had approved of the attempt to reduce it. “I’m glad you tried,” he said. “Don’t beat yourself up.”

In an interview later, Bourne said that until he moved to Winterset five years ago, he’d never gone to an osteopathic physician — and didn’t know what one was. He’s come to appreciate the patience de Regnier shows in determining what might be causing a patient’s problem.

“When he sits down on that stool, he’s yours,” Bourne said.

Another patient that day was Lloyd Proctor Jr., 54, who was suffering from previously undiagnosed diabetes. His legs were swollen, and he felt run-down. Tests showed his blood sugar was more than four times the normal level.

“The pancreas isn’t happy right now, because it’s working too hard trying to take care of that blood sugar,” the doctor told him.

De Regnier diagnosed him with diabetes and prescribed medication and insulin, saying he would adjust the order if necessary to minimize Proctor’s costs after insurance. He brought out a syringe and showed Proctor how to give himself insulin injections. Proctor listened to advice on how to measure blood sugar.

“And maybe I should quit grabbing Mountain Dew every time I’m thirsty,” the patient said, ruefully.

De Regnier smiled. “I was just getting to that,” he said.

The appointment was one of the doctor’s longest of the day. At the end, he reassured Proctor that they could get his diabetes under control together.

“I know that’s a lot of info. If you get home and think, ‘What’d he say?’ — don’t hesitate to pick up the phone and give me a call,” de Regnier said. “I’m happy to visit anytime.”

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  1. Pokey

    In the category of for what it’s worth, my daughter, and MD, took one or more osteopathic courses and was favorably impressed. She says that osteopaths take the same boards that MD’s take. I’ve also noticed that a spouse of an MD is more likely to look down his or her nose at the osteopaths that is the doctor.

    1. Yves Smith Post author

      I did not want to say it in the intro but the worst iatrogenic injury I has was from an osteopath who sprained my ankle badly by bracing against the bottom of my calf (prone, leg rotated outward) to adjust my back.

      1. playon

        That’s a shame. The experiences I’ve had with osteopaths, along with those of my friends have been overwhelmingly positive. It sounds like the person you saw was poorly trained or perhaps simply a bad doctor… which can happen in any field of medicine.

    1. hunkerdown

      The US unironically should do this, to destroy the basically religious role and reactionary class interest of the Physician™.

      1. Alan F.

        The US has been doing this for decades now. GOOD LUCK trying to find an American-born physician who is practicing full time in either pediatrics or family medicine in all but the wealthiest areas. Hospital systems need physicians to generate their visits, and if they can’t find or lure good ones they will make do with whoever, whatever they can find.

        Living in the suburbs of a medium size midwestern city most of you would know, we went through three pediatricians in four years, while shopping the entire metro area for anyone willing to take new patients. The overall best of the three was born in Somalia and went to medical school in Nigeria. On his good days he was a B+ doctor; unfortunately he had bad days half the time, and he was a D or worse on those days. Very briefly we had an older woman MD who was US-born, and she was an A for 1-2 visits, but then took a year off due to stress and/or medical problems, and eventually returned on a schedule of maybe 10 hours/week. We then wound up with a different MD in a different system who was from Bulgaria or something, who was a C- on good days and almost incomprehensible, but also clearly having issues with the system that employed him.

        The whole time we had blue cross insurance ($$$) rather than Medicaid or something, and were willing to drive up to 30 miles to find a competent doctor. No luck. This in a metro area with easily 40,000 white collar professionals, another 200,000 or so people with employer-paid health insurance, a major university, two teaching hospitals, etc. etc. Few pediatricians at all, and next to none who would take patients who were not newborns.

        We never found any decent doctors we could rely on there, MD or DO. We left there 10 years ago and in places we’ve lived since we have only had two decent physicians since then, one of them in a cash-only boutique practice after he quit the local hospital’s system.

        Our current area is another college town. The two local hospitals don’t do family medicine using actual physicians; one of them offers nothing, the other offers some clinics with nurse practitioners. There is a non-hospital “federally qualified health center” which is an F- nightmare. It employs 6-8 MD and DO physicians, but none of them are people you want to rely upon. We quit there and take our chances with the one system’s nurse practitioners, who are overall better despite lesser credentials!!!

        1. Vic

          I came to the USA in the 80’s, one of your “low grade physicians”. Just so happened that my med school was then and now harder to get into than the IIT’s. I had done part of a residency in my speciality in the most competitive (and pyramidal program) in my country of origin. I was selected to a second rate residency program where my internal clinical scores were off the wall. And yet I spent my residency, constantly bombarded by my very liberal faculty, about why my clinical opinion was ipso facto not as good as that of my white co residents. Took me a couple of years to regain confidence. This anti foreign born bias was, and is, out and out, deeply entrenched systemic racism. Do I see shades of some of that here. Or am I being excessively sensitive?

          1. Alan F.

            In short no, I do not have any general bias against foreign born physicians. I have encountered plenty of good physicians while outside the US, and a few foreign-born good physicians in the US, but generally in specialties.

            Any country that has good universities should be capable of producing good physicians, and a handful of countries that don’t, like Cuba, may still be able to do so.

            However, my experience is that many primary-care physicians in areas I have lived in are both foreign-born and mediocre. This is probably a combination of more qualified people tending to choose higher paid specialties, hospitals seeking the cheapest people they can find who have a credential, and perhaps to some extent the better foreign-born physicians either staying in their home countries or choosing the wealthier coastal areas of the US rather than my backwater.

  2. LY

    What about other alternatives for primary care? Nurse practitioners? Physician assistants? From what I know, what they can and can’t do vary from state to state.

    I’m also reminded of China’s barefoot doctors.

    1. Amfortas the hippie

      barefoot doctors is one of my favorite ideas, ever.
      i also really dig that Cuba’s number one export, last i looked, was medical professionals…and that where we deploy implements of destruction, they deploy nurses and doctors.
      tickles giddy my moral sense.

      1. Travis Bickle

        Hey…you may not want to sell those Cuban docs short too fast.

        OH…on second glance I see you aren’t dissing them!

        Anyway. medicine is where Cuba channels their best and brightest, who learn to leverage their brains instead of hi-tech. They read/study all the Western stuff, then figure out how to make do without.

        I’ve been living in South America, mainly Ecuador, and when you run into one of them, versus what may be some guy with family connections who graduated at the bottom of his class at a US med school, the difference is stark.

        As primary care diagnosticians they’re great. They rarely (never?) get into speciality medicine, but I’ve found them able to explain what’s going on and the alternatives wonderfully.

        Living abroad you have to do your own research and be real critical of health care providers. Even those trained in Europe tend to be suspect when you probe a bit. With the Cubans, not so much (at all).

        1. Dwight

          Doing without could be a good thing in many cases, giving all the iatrogenic illness we get here!

  3. synoia

    AIs will fill the shortage of Doctors. As well as many other professions, such as Accountants and Tax preparation. When AIs learn to prevaricate, dissemble and obfuscate, AIs will become politicians.

      1. Alan F.

        We are, kind of. “Expert systems” which are a sort of earlier, very limited AI are in use. The practice I see, which is just two PAs overseen by an off-site MD, has all encounters run through the health system’s computer which quite obviously prompts the PA for diagnosis, testing and treatment options. On the plus side this means that obvious problems will be noticed; on the minus, it means that there is no inherent creativity and real treatment depends on a knowledgeable patient raising questions with the PA. I put up with this because all of the local alternatives are much, much worse, and I’m interested in researching and focusing on my health concerns. But someone of less intelligence or interest would receive McDonald’s level care. (Although, in my remote area of professional shortages, that would still be better than the main local competitor by orders of magnitude.)

        1. Travis Bickle

          For anyone without the money for concierge care, conventional primary health care in the US now means McDonald’s Medicine™

  4. Henry Moon Pie

    That’s the only kind of doctor I ever had until I was 21. He was an osteopath with a little clinic in a town of 1,000. Practiced there all his life. Had admitting privileges at a hospital in St Joe.

    His successor was an M.D. who somehow had gotten possession of Einstein’s brain. It was the biggest tourist attraction next to Slim Findley’s giant ball of twine.

  5. flora

    Thanks for this post.
    Here’s hoping PE vultures, asset strippers, investors don’t know about DO practices.

  6. Carolinian

    We have a fairly new osteopath school here in town. And a good friend of mine ran the office for an osteopath in another city. My understanding is that, going back to the origins, some osteopaths champion rather odd and not fully proven treatments and that has something to do with the “looking down.”

    In my friend’s case her boss had a somewhat checkered history and flirted with quackdom but anecdotes are not data. Meanwhile the deliberate restraint on the number of US doctors is shady as hell and let’s not pretend everything the AMA advocates is on the up and up. It’s good that rural people can find care. It’s bad that they have no other option.

  7. Adam

    A single data point: My step son is a fairly new DO practicing in rural Wisconsin. He mainly picked going to a DO medical school so that he could focus on the whole patient and their overall needs and mentioned many times the detailed level of training he received to do this proficiently. (And now my wife gets to say how happy she is that her son is a Jewish doctor :-) )

    He has also told me there is now a single residency match program for all DO’s and MD’s as of a couple of years ago instead of separate matching for each which makes it much easier for DO’s to get into their desired specialty. It seems there is a real recognition that DO’s are now an important part of the healthcare field.

  8. Posaunist

    I have had primary care physicians who were osteopaths. My current PCP is an M.D. A good doctor is a good doctor, regardless of the initials after the name.

    1. Alan F.

      I agree; over the years I have seen a mix of MDs and DOs, and have not discerned a significant categorical difference between them. Whatever differences the schools may have in philosophy, or in past practices, they appear to be minimal today. I have visited good, mediocre, and poor doctors with each type of degree. I know of a married couple where the husband has an MD and the wife a DO, without controversy, and I also am friends with a general surgeon holding an MD whose only practice partner holds a DO.

      The article is slightly puzzling to me, as it discusses an issue that I would not have thought controversial, or even particularly significant, for decades now.

  9. Spork

    I graduated with a DO degree in 2011. There does seem to be a higher level of “kookiness” in the DO world. The osteopathic portion of the education has both intriguing parts that have obvious scientifically verifiable merit, as well as what I consider embarrassing pseudoscience. Most DO’s never use “OMM” after graduation and their practice is indistinguishable from an MD. The way I look at it the pandemic has demonstrated there is plenty of intellectual bankruptcy and strange beliefs to go around in both the DO and MD world, so take your pick. The underlying problems in the profession are mostly shared.

    Another layer to the system to consider is that around that time I was a student multiple brand new DO schools had been built around the country. They were all for-profit and had no hospital or residency training program associated with them. Several other well established DO schools had previously sold off their associated hospitals and so had nowhere to send their upper level classes for clinical training. So third and fourth year students from these types of schools were farmed out to other programs around the country lucky enough to still have teaching hospitals, like the one I attended.

    The worst part was that increasing the number of med school graduates without also increasing residency positions at teaching hospitals at the same time had led to a scarcity of residency spots. It used to be there were unfilled residency spots every year and now it is possible to graduate and fail to find any residency opening at all. Med students now have the prospect of graduating with med school level debt while taking orders at Starbucks and praying they can land a spot the following year. Primary care is usually one of the lowest competitive residencies BTW so many end up there in desperation not desire.

    1. Carolinian

      Dean Baker used to cite the requirement that all US doctors must have a US residency as yet another rule to keep out foreign doctors and to keep down the competition (his view).

      1. Arizona Slim

        Think of the AMA as a cartel, y’know, like OPEC, and you have the idea. Supply restriction is what cartels do.

      2. ChrisPacific

        I don’t think an H1-B style program for doctors would be an improvement. It would be used by large hospitals as a way to create a captive medical workforce and apply pressure on working conditions for full time doctors.

        A residency requirement doesn’t necessarily keep out foreign doctors – it just means that anybody who wants to hire them must sponsor them for residency (which they should arguably be doing for all jobs). Or if they want to practice on their own they can use the entrepreneurship or investor categories.

        If the US really wanted to keep foreign doctors out, they could refuse to recognize medical qualifications from outside the US for practice purposes. That would shut them down very effectively.

  10. Amfortas the hippie

    the artificial doctor shortage part of all this is what gets my gorge up(and nurses, too, it seems).
    my doctor, of 23 years…whom i consider a friend, by now…is about 4 years older than me(53)….and has been making noises about retiring for several years.
    ergo, ive been cultivating a relationship with the single local doctor…whom my wife played tennis with, and transferred her and the boys stuff to when covid happened…for that eventuality.
    my long term doctor buddy is acclimated to my idiosyncrasies…(i speak doctor, and am a hard ass about my vicodin regimen, etc. in spite of ‘fitting the profile’ for “dope fiend”)…which all saves me a lot of hassle that so often derives from being an impersonal number and not fitting easily into boxes….ie: the whole priesthood thing.
    combined with the corporisation of doctorhood, of late.
    ive been fortunate to be my guy’s patient.
    and i wish i could clone him.

    our other local option(my guy is 40 miles away) is the witch doctor…real diplomas and such regarding herbal things…shes whats called a homeopath.
    and she knows her stuff, apparently…but i am not well informed enough to trust all that, as yet.

  11. jackiebass

    Where I live the majority of physicians are a DO. Mine is and I no little difference in how I’m treated. Where I live the only health care corporations are using physician assistants, or nurse practitioners in basic care facilities.What amuses me is it doesn’t matter who you see, the charge is the same.I only will see my doctor not one of these substitutes. He is willing to spend time with you and it isn’t a 20 min. in and out appointment. I believe all of this is a move toward consolidating , limiting a persons choice, and making a bigger profit. Doctors in my area are employees and don’t run their own practice.There seems to be no real choice because all use the same business model.

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