The Buffalo Niagara region lost 10 percent of its doctors from 2001 to 2005, the largest drop in the state and the continuation of the region's physician drain, according to the most recent review of the number of physicians in New York State.
The losses by specialty are even more dramatic, including a 16 percent decline in the number of general surgeons and a 13 percent decline in obstetrician-gynecologists.
The study shows that the number of licensed doctors grew statewide by 5 percent, to 77,471, in 2005. The region was one of only two in the state -- the Finger Lakes was the other -- that lost doctors.
"What's particularly troubling is that Western New York saw decreases in both primary care doctors and specialists," said Gaetano J. Forte, co-author of the study by the Center for Health Workforce Studies at the State University at Albany.
Although the region's population remains static, the use of medical services is on the rise, doctors and hospital officials say. As a result, concern is growing about access to treatment, especially in areas already underserved by doctors.
The drop in numbers also parallels the graying of the physicians here and across the United States just as members of the baby boom generation are becoming senior citizens.
In some specialties -- including allergy, colorectal surgery, gastroenterology and general surgery -- the average age of doctors in Buffalo is near or over 60, according to a survey by the Erie County Medical Society.
The region lost 14 percent of its psychiatrists during the period studied, while the society survey shows that the average age of those left is 61. Similarly, a 2003 survey in Academic Psychiatry found that the percentage of U.S. psychiatrists younger than 40 dropped from 24 percent in 1989 to 8 percent in 2002.
In psychiatry, there are waits for appointments, and care, at times, is fragmented, said Dr. Steven L. Dubovsky, chairman of the University at Buffalo department of psychiatry.
"Many patients end up getting seen by nonpsychiatrists untrained in specialized issues, such as dosage risks for antidepressants," he said. "Some of them may be reluctant to prescribe."
The study supports a 2003 Kaleida Health projection showing that the region's largest hospital system would need 450 new doctors over the next five years to replace those who retire or leave the area.
"It's like nursing. We're not replacing our base of physicians as quickly as they are leaving," said Dr. Margaret W. Paroski, Kaleida chief medical officer.
The looming shortages in Buffalo coincide with a projected tightening of physician supply nationwide.
For several decades, the American Medical Association and other medical groups feared that the nation would have a problem of too many physicians and helped institute policies to limit their number. Now, experts believe that the country will need many more doctors in the future.
The Council on Graduate Medical Education, which advises Congress on physician levels, in 2003 recommended a 15 percent increase in medical school graduates. Last year, the Association of American Medical Colleges called on medical schools to increase enrollment by 30 percent by 2020. Currently, almost 19,000 medical and osteopathic doctors graduate each year.
But it will not be easy to increase the numbers of medical students in the pipeline.
More students generally require more classroom space, equipment and faculty, all of which cost more money.
Moreover, an increase in medical school enrollment requires an increase in the number of slots for residency training, when new doctors learn a specialty after medical school. Residency training occurs in hospitals and is funded mainly by Medicare, the government health program for the elderly.
Congress in 1996 capped the number of hospital residency slots funded by Medicare. Medicare already gives hospitals about $8 billion a year to pay expenses for training new physicians, and additional residency positions would require a significant increase in funding.
>Remedy would be slow
"If you increase medical school enrollment, there is a domino effect," said Dr. Michael E. Cain, dean of the UB School of Medicine and Biomedical Sciences.
Cain recently commissioned a task force to study a possible increase in class size, perhaps to 150 from the current 135. But if it happens, it would happen slowly.
"We're looking at the implications of a gradual increase over a number of years," he said.
The projected shortages are driven by many trends, including population growth, especially of older people who use the most medical services, and the changing attitudes and makeup of physicians.
Younger doctors desire regular hours, and older physicians appear to be retiring earlier, experts say. In addition, the proportion of female doctors is much higher and rising, and many of them will take time off to raise a family.
"Younger doctors are choosing specialties with good salaries and controllable hours. People don't want to be on night call anymore," said Dr. Merril T. Dayton, chairman of the UB surgery department and chief of surgery at Kaleida Health.
He said the shortage has left some smaller hospitals in the region desperate for adequate coverage by general surgeons, who tend to perform hernia, gallbladder and other abdominal operations.
In Buffalo, the shortage is made more acute because of the region's reputation for low reimbursement, long winters, high taxes and lack of a medical school hospital. Physicians joke that the only doctors willing to work here are either Buffalonians or married to Buffalonians.
"It's a tough practice environment," Dubovsky said.
Said Paroski: "When you're recruiting, doctors ask themselves, 'Is it worth the cost to live here?' "
The situation is worrisome but not entirely bleak.
For instance, Dubovsky said he has recruited about a dozen physicians over the last two years by selling them on new treatment models that incorporate interesting research, teaching and patient-care opportunities, such as programs focused on patients resistant to therapy and surgical approaches to depression and obsessive-compulsive disorder.
But Dubovsky said the new programs must prove themselves to obtain coverage by health insurers and, for now, depend on grants for support.
It's possible that Buffalo's primary teaching hospitals could boost recruitment by offering new doctors more financial support to help pay off medical school loans or subsidize new doctors' incomes until their medical practices grow. But Buffalo's biggest hospitals need to improve their bottom lines before they can substantially increase funds for recruitment, Paroski said.
One other suggestion: Loosen U.S. visa restrictions on the thousands of foreign medical school graduates who do their residency training in the United States.
"We spend the money to train them," Paroski said, "and then we tell many of them that they can't stay."