Delaware exports pharmaceuticals, chemicals, and vacuum-sealed packages of chicken. But when it comes to doctors, the state is an importer by necessity. Along with large rural states such as Idaho, Wyoming, Montana and Alaska, Delaware does not have a medical school within its borders.

This can make recruiting and retaining physicians a challenge. Nearly 40 percent of medical students end up working in the state where they received their degree, according to a 2015 workforce study by the Association of American Medical Colleges. Without that hometown advantage, hospitals, private practices and specialty centers must actively reach across state lines to attract physicians.

“It’s one of those issues that we worry about a lot,” said Dr. Thomas Brown, senior vice president of Nanticoke Health Services and head of the Nanticoke Physician Network. “The ability to recruit physicians is integral to the provision of care. If you don’t have physicians, we can’t meet the mission.”

Nanticoke mainly serves western Sussex County — an area designated as a health professional shortage area (HPSA) by the federal government. A HPSA can be any geographic area, population group, or institution that is underserved by health professionals. Kent and Sussex counties, as well as parts of New Castle County, qualify under the law.

These shortages are expected to increase due to population growth, increased access to health care, and an aging population, according to a 2012 report for the Delaware Health Care Commission on the state’s health-care workforce. Addressing these gaps means overcoming some of the geographic, professional and regulatory challenges that make recruitment a persistent issue in Delaware.

One pressing factor, Brown said, is changing demographics. He said Nanticoke anticipates a drop-off in primary care physicians as older doctors retire.

“A lot of our physicians are in their 50s and 60s,” Brown said. “That group is retiring and also getting a little frustrated with the practice of medicine, especially private practice.”

For now, Brown said Nanticoke is fully staffed. But recent data backs up his concerns. A 2016 analysis by IHS Markit, a financial services company, projected a shortage of between 14,900 and 35,600 primary care physicians across the country by 2025. Increased demand is driving the shortage, according to the study, but an uptick in retirements may also play a role.

On the other side of Sussex, Beebe Medical Group faces similar problems.

“Primary care recruitment in the south coastal area has been challenging,” said Dr. George Jirak, president and CEO of Beebe Medical Group. “Retention has not been as much of a problem.”

The health-care system, which approved a $180 million expansion in June bringing new facilities to Lewes, Millville and Rehoboth, also has gaps in specialty services such as urology, gastroenterology, and endocrinology, according to Jirak. In the meantime, he said, the system has extended recruiting times and brought in temporary substitutes, called locums, to fill the gaps.

Geography is partly to blame for the difficulty faced by rural areas like Sussex and Kent counties — big cities such as Philadelphia and Baltimore, with their large medical complexes and schools, are simply farther away. The relative lack of amenities and choices for people moving into the area is another barrier.

“They ask about the choices they have, choices in entertainment, choices in communities, choices in schools, choices in cultural activities,” Brown said about doctors seeking employment with Nanticoke, “and while there are good options in all those areas, there’s not a lot options.”

Tough recruiting is not limited to southern Delaware, though, or rural areas in general. Some doctors point to cost and regulatory barriers that encompass the entire state, if not the whole profession.

Dr. Prayus Tailor, president of the Medical Society of Delaware and a specialist based in New Castle County, said a number of changes have made it more difficult and expensive to be a doctor, particularly in private practice. He said electronic record keeping, staffing costs, and increased regulation have together raised the barrier to entry for new doctors.

“Operating your own practice has become something that a lot of physicians are not able to pursue at this point,” Tailor said. He added that he’s seen a number of physicians drop out of private practice altogether due to the burden of running a modern doctor’s office.

“The amount of time we spend with patients is dwarfed by the amount of time we spend doing paperwork,” Tailor said.

A 2014 study in the Journal of International Health Services found that doctors spend 8.7 hours per week or 16.6 percent of their working time on administrative duties. Those who use electronic records spend over 17 percent of their time. A similar study from 1995, the study points out, found that doctors used to spend about 13 percent of their time on administration.

Health-care interests seek to convince young doctors to step into this world despite the challenges, which is why the Delaware Department of Health and Social Services offers a series of programs designed draw more doctors into the state, as well as create a pipeline of Delaware students interested in becoming doctors.

The Delaware Institute of Medical Education and Research (DIMER), a program of the Department of Health and Social Services, reserves 25 spots at two Philadelphia medical schools for Delaware students. The Medical Society of Delaware estimates that 169 DIMER graduates currently practice in Delaware. Just 34 of those practice in Kent and Sussex Counties.

The other main state program for doctors is the Loan Repayment Program, which helps alleviate student debt for doctors fresh out of medical school.

Neither program is enough to meet the demand on its own, according to Tailor.

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