The U.S. is struggling with shortages of all kinds of physicians. Among the doctors in short supply are subspecialists, particularly those practicing in rural areas, and data shows the problem is worsening rather than improving. The strategies for tackling such a complex problem, therefore, must necessarily be creative and approach the situation on a variety of fronts.
In rural South Dakota, Sanford Health has undertaken a multipronged approach to managing physician shortages in neurology, strategies that include attracting physicians but also retaining them, beginning early on in residency training.
A four-year categorical neurology residency program established in 2023 by Sanford Health and the University of South Dakota “is helping us recruit, and it's a catalyst for retention,” said Nessim Amin, MD, a neurologist who directs Sanford Health’s neurology residency program.
Sanford Health, with headquarters in Sioux Falls, South Dakota, is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine. The health system includes 4,950 physicians, 60 hospitals and 289 clinic locations, and serves more than two million patients in seven states in the upper Midwest.
What leaders at Sanford Health are learning about how to bring in and keep physicians may help turn the tide in rural areas equally in dire need of top-tier subspecialty care.
Struggling to meet a need
The Association of American Medical Colleges projects that the U.S. will face a shortage of up to 86,000 physicians by 2036, and rural communities will likely bear an even larger share of the burden. The AMA has adopted policy to address physician shortages in rural areas, but some areas face more of an uphill climb than others.
South Dakota is one of five states deemed “neurology deserts” where there is a chronic shortage of neurologists and neurological treatments, said Jacki Brewinski, the graduate medical education (GME) program administrator in Sanford Health’s neurology program.
At the same time, there has been a rapid rise in neurological disease. Conditions such as Alzheimer’s disease, other types of dementia and Parkinson’s disease are projected to become significantly more common in the coming years, according to Alzheimer’s Disease International. And U.S. Census Bureau data projects that by 2030, almost a third of those living in South Dakota will be older than 60, and hence at a higher risk of developing a neurological condition.
The situation in the Midwest demanded some creative thinking, Brewinski said.
“There were patients who had to wait for six to nine months for an appointment, and we relied heavily on locum [tenens] physicians,” she added. “We just realized we need a more permanent solution.”
The first step on the journey
After a $300 million philanthropic investment in 2021, Sanford Health committed to significantly expanding its GME in collaboration with universities across the Upper Midwest. Sanford Health plans to have 40 residency and fellowship programs up and running by next year, 29 of which they will fund entirely, training more than 400 resident and fellow physicians annually.
The training programs have already begun to pay dividends. Of those trained in a residency or fellowship program, almost 40% stay with Sanford Health and 70% choose to practice in the Midwest. Even if they depart the health system, therefore, many continue to care for patients in the region, who are in urgent need.
Dr. Amin said that this year there were close to 600 applications for three neurology residency positions, “and we were able to successfully fill the residency for the past four years with high-quality candidates, including this past year, when we had three local medical students from the area.”
He said the program is unusual in that residents have less competition for the opportunity to perform procedures they need to learn, and they often get one-to-one supervision. That means there is a combination of autonomy and supervision that’s tough to beat.
“Oftentimes, they [residents] are getting a lot of exposure sooner than at other places and other programs. They might see something as a PGY-2 that other people wouldn't see until later,” Dr. Amin noted.
Seeing post-training growth
But the good news hasn’t been confined to the neurology residency program. The neurology department at Sanford Health has expanded from six to 19 board-certified neurologists. Sanford officials say that growth has been a byproduct of the residency program, as many physicians are drawn to the opportunity to serve as faculty and help train the next generation of neurologists.
This expanded expertise has been a catalyst for Sanford to broaden the specialized neurological care available to patients across the region. That includes creating a deep-brain stimulation program and recruiting a movement-disorder specialist who treats Parkinson’s disease and other neurodegenerative disorders. In addition, the health system established the state’s first epilepsy monitoring unit and created an infusion program that offers innovative Alzheimer’s disease treatments.
Dr. Amin said that over time, Sanford Health has transformed “into a very strong, well-equipped tertiary center. Our stroke center is certified by the Joint Commission, which is a huge accomplishment that we've maintained, and our new epilepsy center was just accredited as a Level 3 Epilepsy Center, which is a big deal for patients and our team,” he added.
Sanford Health leaders say the changes have also created interest among medical students, with more electing to pursue neurology because of their experiences in the program.
“It was kind of a snowball effect,” he said.
Bringing physicians in to stay
Some of the momentum can be attributed to Dr. Amin’s work as an unofficial recruiter, bringing to Sanford Health colleagues who trained with him as well as other neurologists from around the country. His love for neurology began early in life, in a family full of physicians, where his specialty felt like a natural extension of his personality.
“What attracted me personally to neurology is the puzzle—or the mystery that happens with the diagnosis,” he said. “Over the past 10 years, the advancements in technology and the invention of treatments for many things have made neurology something where you can make an impact in people's lives.”
Dr. Amin moved to the U.S. from Egypt in 2013 and then moved from Ohio to South Dakota in 2018 to join Sanford Health. He found that any worries he had about being a new immigrant in Sioux Falls were unfounded.
“There are misconceptions ... about rural communities that you might not be able to have a lot of community unless you grew up in the same place. Or you might be isolated or bored or have limited resources, or you might not be able to practice what you like,” Dr. Amin said. “I discovered these are myths. On a personal level, and on a career and professional level, it has been very rewarding because in the rural setting, you’ll be surprised how much there is potential for growth and potential to bring new things.”
Inspired to make a difference
Some of the bumps in the road to bring neurologists to the area have smoothed out.
“Now, people have heard of our residency programs, so it has been easier to recruit, easier to retain,” Dr. Amin said. “People are staying here for the mission.”
Once medical students, residents and neurologists experience what it’s like to work for Sanford Health, he said, the work of persuading them to stay is done.
“We created a culture that this is a place where you can learn and you can make a difference,” Dr. Amin said. “Here, everybody is called to be a leader.”
