When his longtime physician retired, Southern Maryland lawmaker Thomas "Mac" Middleton faced a predicament: The senator needed a new doctor but couldn't find one who was taking new patients. "I had to go through three different doctor groups before someone would take me," he said.
He ran right into the critical doctor shortage facing rural Maryland - to the west of Baltimore, to the south, on the Eastern Shore.
There are not enough primary-care doctors setting up practice in these areas, leaving some residents without access to basic health care and leading to more costly and serious illnesses, doctors say. Those doctors - and many specialists - are reluctant to leave the city for the country, where they typically get paid less, work more and find fewer job opportunities for their spouses, who aren't always ready to give up the trappings of life near an urban area.
Middleton and other legislators in Annapolis are now seeking ways to recruit and retain physicians to care for people in large swaths of Maryland.
"We have areas where you just can't get care - you have to leave and go to another jurisdiction," said Gene Ransom III, executive director of the Maryland State Medical Society, or MedChi. "It's a real problem for people, especially for people who can't afford to do that."
There used to be 10 obstetrician/gynecologists in Allegany County, for example; now there are four. There is just one psychiatrist in St. Mary's County. The wait to see a new primary-care doctor on the Eastern Shore can be weeks - if that doctor is even seeing new patients.
Lawmakers - who worked on two task forces last year that looked at different parts of the issue - are considering both short- and long-term fixes. Solutions could include a loan forgiveness program for primary-care doctors and specialists in rural areas who agree to remain in those communities for a certain number of years. Newly qualified doctors come with as much as $200,000 in student loan debt, and earning enough to keep up with the payments can be difficult, especially in rural areas.
There has been a small loan forgiveness program in the state, but Sen. Rob Garagiola, a Montgomery County Democrat, called it "very inadequate."
He worries that in this tight economy it might be difficult to sell a plan that sends money to such a program, but he thinks that the current proposal could fly. By building a fraction, less than 10 cents per $100, into state hospital rates, a fund could be created to pay down close to $14 million in debt for doctors who agree to practice in underserved areas.
Rural doctors are saddled with more than school debt. They must also deal with the same high medical malpractice insurance rates and the lower-than-average reimbursements for services that all doctors in Maryland face. Another piece of legislation being championed by Garagiola would set minimum medical insurance reimbursement rates for certain procedures.
Another proposal would create a rural residency program so that doctors could get some or all of their training in an underserved area - with the hope that they would stay there and set up practice. About 50 percent of doctors go on to practice where they do their residency, where they have established friends and begun families.
"When a physician does their residency program, they tend to settle there," said Del. Adelaide C. Eckhardt, a Dorchester County Republican. Eckhardt figures if a primary-care doctor does her residency on the Eastern Shore, there's a good chance she'll set out her shingle there, too.
But setting up a residency program is not simple. Such a program would have to be developed in conjunction with a hospital, such as the University of Maryland, that already has a residency program, would require oversight and training, and would have to take into account many logistical issues. All of that would cost money to carry out.
An even longer-term solution that Eckhardt likes would model a "grow your own" program in Alabama that encourages rural children to pursue careers in medicine.
"The whole concept is when you've got a physician who comes from a rural community, they'll go back to that rural community," said Nancy Fiedler, spokeswoman for the Maryland Hospital Association.
Dr. Claudia Baquet, dean of policy and planning at the University of Maryland School of Medicine and a member of the task force that studied the rural issue, thinks that some progress can be made. "I think we stand a good chance of making some meaningful changes to address physician shortages in rural and underserved areas, despite the economic issues."
Added Middleton: "We should have done something yesterday."
Meanwhile, the shortage is only expected to worsen. A study last year by the Maryland Hospital Association and MedChi found that by 2015, 32 percent of the state's physicians are expected to retire. The state's overall population is also aging, and those Marylanders will require more medical care than they are now receiving.
"The need is going up, and the supply of physicians is going down," said state Health Secretary John M. Colmers.
In some places, the shortage is already felt every day.
The waiting room at Dr. Matthew Allaway's Cumberland office is always packed, with waits of up to 90 minutes. On a recent Wednesday, he started at 7 a.m., took no lunch break and saw 60 patients.
"The bottom line is, you have to limit what time you can spend with your patients," said Allaway, who is president of the Allegany County Medical Society.
Allaway, 38, is from Chicago, and his partner is from Florida. He chose Cumberland for his urology practice after training in nearby Morgantown, W.Va.
The inadequate number of primary-care doctors in Western Maryland is evident nearly every day in his practice. They are so overworked, he said, that routine screening tests can fall through the cracks.
So by the time patients are diagnosed and come to Allaway, they often have larger kidney cancers, more advanced prostate cancers - cancers that often won't respond as well to treatments and that end up being more costly to the health care system.
Sometimes Allaway has to pull strings to get his patients in to see primary-care doctors. He doesn't know what will happen when the county's two neurosurgeons - both in their 60s - decide to retire. And he knows women must be suffering - or at least traveling long distances to see a doctor - since the number of obstetricians in the county has been cut in half.
"We haven't been able to recruit," Allaway said. "Where are these women getting care, and what kind of care are they getting?"