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Keokuk County Hospital needs three physicians to staff its emergency room, but currently has just two. The hospital is seeking to hire a third full-time doctor to work in the ER and help treat patients at the 14-bed facility. Natalie Krebs/Iowa Public Radio hide caption
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Natalie Krebs/Iowa Public Radio
Even by rural hospital standards, Keokuk County Hospital in Sigourney, Iowa, is small.
The 14-bed hospital, in the southeastern part of the state, doesn't do surgeries or deliver babies. The small 24-hour emergency room is overseen by two full-time doctors.
Matt Ives, the hospital's CEO, wants to hire a third doctor, but he said finding physicians for a rural area has been challenging since the pandemic.
"We did have a couple [of doctors] retire during the time frame, and then we've had some physicians that completely wanted to get out of certain types [of care], especially emergency-room type of care," he said.
Matt Ives, the CEO of Keokuk County Hospital and Clinics, and Todd Patterson, the CEO of Washington County Hospitals and Clinics, have struggled to find doctors and nurses since the pandemic. Natalie Krebs/Iowa Public Radio hide caption
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Natalie Krebs/Iowa Public Radio
Another rural hospital is down the road, about a 40-minute drive to the east. Washington County Hospital has 22 beds and is experiencing similar staffing struggles.
"Over the course of the last few years, we've had not only the pandemic, but we've had kind of an aging physician workforce that has been retiring," said Todd Patterson, the hospital's CEO.
The COVID-19 pandemic was difficult for health care workers. Many endured long hours, and the stresses on the U.S. health care system prompted more workers than usual to quit or retire.
"There's a chunk of workers that were lost and won't come back," said Joanne Spetz, who directs the Institute for Health Policy Studies at the University of California, San Francisco.
"For a lot of the clinicians that decided and were able to stick it out and work through the pandemic, they have burned out," Spetz said.
'It's a true crisis'
Five years after the WHO declared COVID-19 a global pandemic, and the Trump administration announced a national emergency, the United States faces a crucial shortage of medical providers, and one that is below its projected need for an aging population.
That could have lasting impacts on care, particularly in states like Iowa with significant rural populations.
Keokuk County Hospital has only 14 beds, which makes it one of the smaller hospitals in Iowa. Natalie Krebs/Iowa Public Radio hide caption
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Natalie Krebs/Iowa Public Radio
Experts say the problem has been building for a while, but the impacts of the pandemic accelerated the shortages by pushing many doctors over the edge into early retirement or other fields.
"Some of them made it through COVID, like, 'Let's get us through this public health crisis,' and then they came out of it saying 'Ok, and now? Now I'm exhausted,'" said Christi Taylor, president of the Iowa Medical Society.
"Iowa is absolutely in the middle of a physician shortage," Taylor said. "It's a true crisis for us. We're actually 44th in the country in terms of patient-to-physician ratio."
A 2022 survey from the Centers for Disease Control and Prevention found a significant jump in health care workers who reported feeling burned out and wanting to seek a new job, compared to 2018.
The number of people in health care has grown since the pandemic, said Janette Dill, an associate professor at the University of Minnesota's School of Public Health, but the growth has not happened fast enough.
"We have an aging population. We have a lot of needs," she said.
The Association of American Medical Colleges projected last year that the U.S. will face a projected shortage of up to 86,000 physicians by 2036 — if lawmakers don't make additional investments in training more doctors.
These shortages could push more people to seek care in emergency rooms when they can't see a doctor in their community, said Michael Dill, the director of workforce studies at the Association of American Medical Colleges.
"We're already at a point where tens of millions of Americans every year can't get medical care when they need it," said Michael Dill (no relation to Janette Dill). "If the shortage is sustained or gets even worse, then that problem gets worse too, and it disproportionately negatively impacts the most vulnerable amongst us."
Iowa lawmakers have made addressing the shortage a priority in the current legislative session. They've introduced bills aimed at increasing medical student loan forgiveness and requesting federal help to add more residency training slots for medical students in Iowa.
Iowa Gov. Kim Reynolds signed a bill into law last year that drops the residency requirement for some doctors who trained abroad to get a medical license. Lawmakers in eight other states have approved similar changes.
Patterson, the CEO of the Washington County hospital, appreciates that Iowa lawmakers are trying to increase the pipeline of doctors into the state, but said it doesn't help address immediate shortages.
"You have a high school student who's graduating right now, they're probably 9 to 11 years away from entering the workforce as a practicing physician, so it's a long-term kind of problem," he said.
The challenge of recruiting — and retaining — nurses
For nurses, workforce experts say the projected national outlook isn't as dire as it was, five years after the COVID pandemic began.
"Nursing education is back up. Nursing employment rates are back up. I think for that workforce, we've largely nationally recovered from all the dislocations that occurred," Spetz said.
But getting nurses to move to the places that need them, like rural communities, will be difficult, she said.
Some rural hospitals in Iowa say an even bigger challenge at this point is finding nurses.
Some of that can be traced to the pandemic, said Sara Bruns, Keokuk County Hospital's nurse manager.
She recalled that some critical COVID patients died when they couldn't be transferred to larger hospitals with more advanced intensive care unit (ICU) equipment, because those hospitals didn't have the staff to take on more patients.
"We had to make the horrible decision of 'You're probably not going to make it,'" Bruns recalled, saying many patients were then listed as a DNR, or "do not resuscitate."
"That took a big toll on a lot of nurses," she said.
Another problem is persuading the area's young nurses to stay, when they would rather live and work in more urban areas, Bruns said.
Her hospital still relies on contracts with traveling nurses to fill some night shifts. That's something the hospital never had to do prior to the COVID pandemic, Bruns said. Travel nurses are more expensive, adding stress to a small hospital's budget.
"I think some people just completely got out of nursing. I think [the pandemic] did take a toll... because of the hours that they had [to] work, the conditions that they had to work," she said.
Why support from hospital management is key
Policymakers and health care organizations can't just focus on recruiting new workers, according to Janette Dill at the University of Minnesota.
"You also have to retain workers," she said. "You can't just recruit new people and then have them be miserable."
Dill said workers report feeling that patients have been more disrespectful and challenging to work with since the pandemic, and sometimes workers feel unsafe at work.
"By unsafe I mean physically unsafe. I think that is a very stressful part of the job," she said.
Research has shown health care workers reporting higher levels of burnout and poor mental health since the pandemic — though the risks decreased if workers felt supported by their managers.
Gail Grimes, an ICU nurse in Des Moines, felt more supported by her employer during the worst parts of the pandemic than she does now, she said. Some hospitals offered pay bumps and more scheduling flexibility to keep nurses on staff.
"We were getting better bonus pay," Grimes recalled. "We were getting these specialized contracts we could fulfill that were often more worth our time to be able to come in, to miss our families and be there."
Grimes said she's seen nurses leave Iowa for neighboring states that have better average pay. This creates shortages that she feels affects how well she can care for her own patients.
"A nurse taking care of five patients will always be able to provide better care than a nurse taking care of 10 patients, and that's just reality," she said.
She feels many hospitals have simply accepted staff burnout as a fact, rather than trying to prevent it.
"It really is significantly impactful to your mental health, when you come home every day and you feel guilty about the things you have not been able to provide to people," she said.
This story comes from NPR's health reporting partnership with Iowa Public Radio and KFF Health News.
