A dozen miles separate Munster and Gary, but the communities are worlds apart when it comes to physician availability.
"Gary, East Chicago and Hammond are designated as under-serviced for primary care," said Dr. Alex Stemer, president of Franciscan Medical Specialists and vice president of strategic planning for Franciscan Alliance Northern Indiana Region.
"Lake County is not one symmetric or homogeneous thing," he said.
A national doctor shortage on the horizon could change the health care landscape in Northwest Indiana and across the country. The Association of American Medical Colleges predicts the United States will be short more than 90,000 physicians by 2020 and more than 130,000 by 2025.
"There's no doubt, there's a shortage of physicians statewide," said Patrick Bankston, associate dean and director of IU School of Medicine - Northwest and dean of the College of Health and Human Services.
It is not because of waning interest in the field. IU School of Medicine had a record-setting year for applicants, the most in the school's history, Bankston said.
“IU is a very popular medical school, and it continues to be,” he said. “We have no trouble getting applicants.”
The school received 4,700 applications for 344 slots. Of those, 1,200 were interviewed, Bankston said.
A perfect storm
The problem lies in a perfect storm.
The individual insurance mandate in the Affordable Care Act goes into effect Jan. 1, 2014, meaning millions more people will be insured and seeking doctors. At the same time, people are living longer. Estimates show one-third of doctors are a decade away from retirement and medical residency slots have not been increased in anticipation of the Affordable Care Act.
Congress capped the number of federally supported residency training positions with the passage of the Balanced Budget Act of 1997, according to the Association of American Medical Colleges.
In 2006, in response to concerns of a physician shortage, the Association of American Medical Colleges recommended a 30 percent increase in enrollment at U.S. medical schools by 2016, according to the 2011 Medical School Enrollment Survey.
"The call went out and we responded to increasing the number of students to the IU School of Medicine," Bankston said.
The recommended 30 percent bump would bring the class from 280 to 364. Enrollment is at 344, which is near the 30 percent goal, he said.
Even a 30 percent increase won't be enough to cover the anticipated shortage, he said.
The doctor shortage was predicted before the Affordable Care Act became law.
“The ACA is going to compound and rearrange things that were already a problem, because of increasing coverage and, therefore, demand for services,” Bankston said.
A 2007 IU School of Medicine report shows severe shortages of several health professions, especially primary care physicians, have been documented.
U.S. Rep. Pete Visclosky, D-Merrillville, said with 10,000 Americans enrolling in Medicare every day, it is essential to invest in a workforce of well-trained doctors, nurses, physicians' assistants and other medical professionals.
“A significant portion of that investment is the responsibility of states through their institutions of higher learning, as well as the many private educational institutions across our nation,” Visclosky said. “It is my hope and expectation that the state and these institutions will make the investment necessary to educate those eager to serve the American people in the field of medicine.”
Looking for a remedy
A possible response to the shortage is increasing the number of other health professionals, such as nurse practitioners and physicians assistants, working in collaboration with a physician.
These health care professionals are trained to handle more commonplace and routine medical issues, referring more difficult and complex diagnoses to physicians. This results in appropriate and more cost-effective use of all professionals, especially doctors, Bankston said.
"Then what you would do – I think this really is the wave of the future – is to use physicians more efficiently and for problems that are more appropriate for their training," he said.
Many physician groups already rely on help from nurse practitioners and physicians assistants.
At Franciscan Medical Specialists, each primary care doctor keeps three open slots a day for urgent calls. If those fill, a nurse practitioner has an open emergency slot, Stemer said.
"As things get busier after Obamacare kicks in, your new doctor will be a nurse practitioner," he said.
A doctor in a small independent practice may have 20 to 24 appointments a day and not staff a nurse practitioner.
"If flu season hits, there's only so much a guy can do," Stemer said.
An independent doctor may have to visit patients at several hospitals before going to the office for the day.
Compounding the problem is the vast disparity in income for doctors in different specialties, Stemer said.
The training time is comparable, so many students choose the specialty that pays more, such as cardiology.
"The disparity between specialties will continue to cause a relative shortage of doctors in primary care," Stemer said. "I think this relative shortage will become an actual shortage after January 2014 and the full implementation of Obamacare."
The individual insurance mandate under the Affordable Care Act will bring millions more people into physician offices, as opposed to showing up to an emergency room where they are guaranteed treatment, which many uninsured people do.
"They will be in your doctor's office, so when you become ill, your doctor will say, 'Go to the emergency room,'" Stemer said.
Stemer is less worried about the rate of retiring doctors. Retiring at age 65 is becoming less common. Physicians may scale back their hours, but many studied and trained for too long to just stop working at 65, he said.
"Doctors generally enjoy what they do, so those enjoying reasonable health may cut back after age 65, but not retire," he said.
Filling the need locally
Still, Bankston is working to recruit students to the medical school's Gary campus with the hopes they will stay in Northwest Indiana after becoming doctors.
"We have one goal here," he said. "To produce people who walk across the stage (and have) each faculty member to say, 'I would like that person to be my doctor.'"
Local urologist Dr. Bruce Yalowitz, of Urologic Specialists of Northwest Indiana with offices in Munster and Merrillville, spent his first two years of medical school at the IU School of Medicine Gary campus. The Munster native listed Indianapolis as his first choice and Gary as his second.
"I got as good of training there as I could have any place in the country," he said. "I think I was taught by some outstanding professors. They were caring, they were good clinicians. When I went to Indianapolis for my third year, I was better than most of my peers."
Some of those in his graduating class stayed in the area, and some migrated to other parts of the country.
Indiana doctors tend to be busier than those in Illinois, and the malpractice climate in Illinois is much worse, Yalowitz said.
"In Illinois, there's a lot of marketing and posturing," he said. "Here, assuming you're nice and reasonably talented, you get to do more."
Northwest Indiana has a lot of pleasant, humble people and is a half hour from downtown Chicago.
Yalowitz has heard projections about upcoming shortages in his specialty.
But nothing is certain.
“We can't predict what's going to happen,” Bankston said. “We know we're in a time of flux, in a time of change in the medical profession and in health care. There's really no predicting. We just have to be ready to respond, to do our best.”