Report rekindles debate on rural veterinary workforce

Methodology questioned in provocative study on Appalachia

Published: December 21, 2015
By Edie Lau

Photo by Christy Brown
Using mobile horse stocks that her husband built, Dr. Mandy Willis examines and files the teeth of a patient. A large animal practitioner in Tennessee, Willis sees a need for more veterinarians in rural Appalachia, but not as many as called for in a new report.

Viewed one way, Appalachia has more than enough veterinarians to serve its animal population. Viewed another way, every one of the 13 states in the region is short on veterinarians — specifically, veterinarians in rural practice who take care of companion animals and livestock alike.

report from the Center for Animal Health in Appalachia (CAHA) at Lincoln Memorial University (LMU) gives both views but focuses on the apparent shortage, concluding that the region needs another 1,907 full-time mixed animal veterinarians in a swath of the United States known for its poverty. It argues that attracting more practitioners to Appalachia, which stretches from New York to Georgia, would create 15,256 jobs and pump $621 million into the regional economy.

A third view — not in the report but emerging among veterinarians reacting to it — is that the study employs an arithmetic trick to force a conclusion that the data doesn’t support.

“For them to say, ‘We figured it one way and we had 264 too many, and then we turned and figured it another way, and we had 1,907 too few’ — that’s hard to believe,” said Dr. Joe Hillhouse, a clinic owner in Panhandle, Texas. “… There are some assumptions here that are so wild ... I just don’t think we can put any validation to this report at all.”

Hillhouse is a board member of the American Association of Bovine Practitioners (AABP), which in 2011 declared that a shortage of rural food supply veterinary private practitioners, a problem that was considered virtually a national emergency in the previous decade, was over. The AABP has not responded formally to the CAHA report, but the association’s opinion on the shortage question is unchanged.

Dr. Jason Johnson, CAHA executive director and the report’s principal author, acknowledged that the Appalachia study conclusion seems paradoxical, but said the explanation is simple. “Actually, the math holds the truth,” he said. “It confirms what we all know: that there’s a maldistribution of veterinarians.”

The study focuses on 420 counties in Appalachia, which encompasses West Virginia and parts of 12 other states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee and Virginia. Taken as a whole, the study says, the 7,178 veterinarians licensed in these states appear to provide more than adequate coverage of the region, which has a population of 25 million people and covers about 203,000 square miles.

In fact, modeling developed by the National Center for Rural Health Works at Oklahoma State University shows “an overall excess of 264 FTEs (full-time equivalents),” the report states; in other words, more practitioners than needed.

But when the numbers are parsed at a county level, the picture changes dramatically. “It turns out, there’s a great deal more need,” said Mark Cushing, a lawyer who serves as Lincoln Memorial’s university counsel, CAHA policy advisor and vice president for public affairs.

That’s because veterinarians aren’t evenly dispersed through the region. The analysis found that 75 percent of rural Appalachian counties “have an apparent veterinary shortage, estimated to be 1,907 veterinarians, which translates into an estimated economic loss of $621 million and 15,256 jobs.”

Researcher notes figures ‘may be off’

Those figures shouldn’t be interpreted as confirmed, but rather, a first attempt to calculate the value of rural veterinarians, Johnson said. “Just because we put on paper here what the needs are and what the potential economic loss and revenues are, it’s (just) a start,” he said. “We may be off.”

The economic calculations, which Johnson said assume an average mixed veterinary practice generates eight jobs directly and indirectly, were made by the National Center for the Analysis of Healthcare Data at the Virginia College of Osteopathic Medicine in Blacksburg, Virginia.

CAHA plans next to check the modeling against reality. “Our next studies will be exploring demand for services,” Johnson said. “… The only way you know this stuff is (by) going out, boots-on-the-ground, and doing surveys to see what’s going on.”

Meanwhile, by releasing the results of the modeling, CAHA hopes to stimulate people in the regional veterinary community to step forward to share their knowledge and experiences, Johnson said. “People don’t come to you to (help you) to figure out the truth until you throw something out there,” he said.

The caveats, which Johnson gave in an interview with the VIN News Service last week, don’t appear in the 201-page study.

The document was presented in mid-October at a conference at the DeBusk Veterinary Teaching Center in Ewing, Virginia, 15 miles east of the LMU campus in Harrogate, Tennessee.

The event generated headlines such as “Veterinarians needed in Appalachia” and “Report pinpoints heavy veterinary shortage in Appalachia.”

The report has revived a discussion in the profession over what veterinary services agrarian communities need, want and can support financially. It’s also elicited skepticism from some quarters, fueled at least in part by the report’s source: LMU opened its veterinary school in 2014 amid ongoing discussions in the veterinary community whether the number of veterinarians in the U.S. workforce is outpacing demand for services.

Concerns remain high, as Arizona prepares next fall to open what will be the 31st veterinary school in the country, and groups in Florida and Texas contemplate new schools. A paper by economist Michael Dicks released last week by the American Veterinary Medical Association examines the impact on the veterinary workforce of more veterinary school seats.

An underlying worry is that the magnitude of educational debt amassed by veterinary students by the time they graduate — $135,000 or $153,000 on average in 2014, depending on how you calculate it — further diminishes the prospect of new veterinarians being able to attain a financially healthy career.

To a profession uneasy about its future, the call by the 2015 State of Animal Health in Appalachia report for hundreds more veterinarians in areas that have failed to naturally attract practitioners raises doubts.

Hillhouse, the practitioner in Texas, said he can’t help but wonder what motivated the report. “The only reason I can [think of] is, to try to fill their seats!” he said.

LMU counsel Cushing said the university is having no trouble filling seats. Figures provided by the university show that the number of applicants was 367 in its inaugural year, 637 in the second year, and 819 for the third year (upcoming).

The number of students accepted in each of the first two years was 95 and 100, respectively.

Cushing said he doesn’t subscribe to the “doom and gloom” view that the profession should shrink its workforce and veterinary class sizes. The CAHA report reflects the idea that opportunity exists where many wouldn’t expect it. “There are thriving practices all over low-income rural America,” he said.

The key to expanding the opportunities, he said, is by educating locals about the possibilities. “You don’t go to Knoxville or Pittsburgh and tell a small animal practitioner, ‘You need to move 125 miles to serve a town of 75 people.’ The trick is, you recruit from there,” he said. “You take studies like this and go to the high schools and the farm extension people, and you tell them, ‘You really can have a good veterinary practice.’ ”

How to measure a shortage?

How to build a viable practice in an underserved area long has been a subject of study and debate.

“The problem with veterinarians trying to service impoverished areas is that unless they have government or other subsidies, they can’t make ends meet; that’s why these areas are underserved,” said Dr. Alan Kelly, a dean emeritus at the University of Pennsylvania School of Veterinary Medicine.

Kelly chaired a committee of the National Research Council (NRC) that in 2013 produced the study “Workforce Needs in Veterinary Medicine.” The study defined a shortage as a situation in which well-paid positions go unfilled; its authors found little evidence of shortages in any sector, with the exception of industry.

For the Appalachia study, researchers collected inventories of animals, including livestock and household pets, from the U.S. Department of Agriculture and other sources; and censuses of practicing veterinarians from state licensing data and AVMA membership data, to identify which counties in the region had too few, too many and just the right number of veterinarians.

Johnson said the researchers came up with species-specific animal-to-veterinarian ratios to calculate shortages and surpluses. The formulas aren’t described in the study. Johnson said the calculations are being submitted for peer review and cannot be shared publicly in the interim.

“All I can tell you is, wait in anticipation,” he said. “All the detail on that is coming out.”

Johnson noted that some of the research team’s ratio data came from the NRC workforce study, which in one section explores varying estimates of demand for dairy veterinarians using ratios of one veterinarian to 5,000 cows and one veterinarian to 10,000 cows.

But Kelly, chair of the workforce study committee, pointed to the same passage to illustrate why using a ratio to estimate veterinary need is problematic, due to variations in herd sizes and herd management styles. For example, a comparison of dairy cows per veterinarian in California and Wisconsin cited in the workforce study shows a striking disparity. In Wisconsin, the ratio was 5,329 cows to one veterinarian. In California, where the average herd is nearly 10 times the size of Wisconsin’s, the ratio was 16,036 to one.

Speaking of the CAHA researchers’ approach, Kelly said, “I don’t know how they came up with a standard figure, but it doesn’t ring true with anything I know.”

The CAHA approach also differs markedly from that used by the U.S. Department of Agriculture for its Veterinary Medical Loan Repayment Program (VMLRP). The program seeks to draw veterinarians to rural communities by providing up to $75,000 in school loan repayments over three years to participants who practice in places identified as short on veterinary services.

The USDA relies on state officials — usually state veterinarians — to nominate candidate locations. The agency doesn’t prescribe a method for states to follow to identify shortages, but does prefer nominations be supported with site-specific data, said Dr. Gary Sherman, who, until recently, served as the program manager.

“We highly recommend that they ground-truth it with the various stakeholders in their states,” Sherman said.

This year, the USDA has 184 “shortage situations,” 38 in the states that make up Appalachia. The shortage situations in those 13 states cover 233 counties.

From the CAHA findings, Cushing said, “It’s clear that the states have underestimated and ultimately under-reported to the USDA the need and opportunity for rural veterinarians within their Appalachian regions.”

The VMLRP is not set up, however, to inventory all possible shortages. Rather, states are invited to nominate between two and eight rural shortage situations, depending on their geographic size and value of livestock sales.

Asked whether the VMLRP underestimates shortages, Sherman said, “I don’t know the answer to that. There is no gold standard for this.”

Cushing said if the Appalachia model were applied nationwide, the results could persuade Congress to direct much more money to attracting veterinarians to rural practice.

“Right now, VMLRP funding is $5 million a year; that’s like a nickel to Congress,” he said. “If you go to Congress and say, ‘We’ve got a problem’ or ‘We’ve got a need, and it involves rural America,’ every member of Congress will sit up. Rural America is a popular topic. We say, ‘We have animals there from cats and dogs to cattle to farm species to horses that are not receiving or having access to veterinary care.’ I think what we’re going to find, you’re going to see VMLRP funding increase dramatically.”

Model validation, more research awaited

Whether the Appalachia model proves robust enough for broader use is an open question. Dr. Danielle Tack, VMLRP’s new manager, said she urged Johnson to submit the methodology for peer review and publication in a scientific journal in order to validate it. Johnson told the VIN News Service that the authors intended from the outset to submit it for peer review.

Tack, who has a background in public health, noted that the U.S. Department of Health and Human Services has an established method for determining medically underserved populations that takes into account socioeconomic factors and infant mortality rates. “We don’t have equivalents in animal health,” she said.

“The CAHA study, I believe, is the first attempt at calculating something like the medically underserved areas used in human medicine,” Tack went on. “To [determine] if it could translate across the United States, seeing it published in peer-reviewed literature and seeing the assumptions that went into the model would help.”

Sherman, like Kelly at the University of Pennsylvania, suggested that devising a single method for calculating the need for veterinarians could be difficult. “There are so many complexities in veterinary medicine versus human medicine,” he said. “There are multiple species, different styles in management, mega operations versus backyard operations. … (In) the unique risk landscape that defines a shortage area, almost every one of them is a one-off.”

At the same time, should the Appalachia model be validated, Sherman said, “It would be the first study that state animal health officials could tap into that could really bolster their shortage nominations.” He called the effort to develop reliable ways to estimate food supply veterinary workforce needs “very important.”

At least one state veterinarian plans to cite the CAHA findings in her next round of nominations for the VMLRP. “We’re going to use this data for our next request,” said Dr. Jewell Plumley, state veterinarian in West Virginia, where all but eight counties were found by the research to be in need of more mixed animal veterinarians. “I find it useful.”

Sherman said the number of veterinarians needed may be overstated in the CAHA report, although, he noted, he has not reviewed the report in detail. “My gut feeling is that it would go down quite a bit from 1,900,” he said.

Dr. Mandy Willis has a similar sense about the numbers.

Willis is a former recipient of a VMLRP grant who works as a large animal veterinarian in Appalachia. From her base in Morrison, Tennessee, she and a part-time associate cover 11 counties, traveling a radius of typically 30 miles; sometimes 50 miles when the schedule permits.

Willis said she agrees with the CAHA report assertion that some regions need more food animal veterinarians. But in her estimation, the figure is nowhere near as many as the authors maintain. “The numbers are kind of outlandish,” she said.

For example, in her county (Warren) alone, the report indicates a need for 10.2 large animal veterinarians. “In my 11-county area, I think it could maybe handle one to two more large animal or mixed animal veterinarians,” Willis said.

For another county Willis serves, Van Buren, population 5,548, the report shows a need for 2.7 large animal veterinarians. “There’s actually no veterinarian in that county at all, and I honestly don’t believe a veterinarian could move into that area and survive on that county alone,” Willis said. “There’s a possibility you could (set up) a satellite clinic and do one day a week, but it definitely wouldn’t support a full-time veterinarian.”

Johnson at CAHA said he knows Willis from veterinary school days and is eager to speak directly with her and others like her to learn more about rural practitioners’ experiences, and what the center can do to help support them.

Another large animal veterinarian, Dr. David Welch in Berlin, Pennsylvania, noted that veterinarians sometimes cross not only county lines to practice, but state lines, as well — and therefore, calculating need by county alone may produce a distorted picture. The four veterinarians in his clinic routinely serve clients in nine counties in three states.

Welch, who serves on the AABP as project leader of the Veterinary Practice Sustainability Committee, called the CAHA report “thought-provoking” and said the authors “should be commended for their initial effort.”

But the research needs to go further, he said. “This is not people saying they can’t get a veterinarian. This is a study saying there’s a shortage of veterinarians because the ratios fall out of line. So we need to find out, who are the people whose needs are not being met, and is it because there’s a veterinarian not available, or are there other issues?”

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