DEVILS LAKE, N.D. - Dr. Heidi Bittner and her colleagues at the Altru Health Clinic here have been chronically short-staffed from the scarcity of primary care doctors in rural settings.

"We're short right now," looking to hire one or two physicians, Bittner said during a break between appointments. "We have been since I got here 20-plus years ago."

Bittner and her colleagues aren't alone. The latest health provider vacancy survey by the University of North Dakota, for January, showed 40 unfilled family practice physician openings and 31 for nurse practitioners or physician assistants across North Dakota.

"What we find is a really dramatic increase in physician vacancies," said Mary Amundson, an assistant professor of family and community medicine at UND, who tracks health care workforce trends.

A longstanding primary care challenge likely will become even more daunting.

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Conservative projections forecast that North Dakota will see a shortage of physicians ranging from 260 to 360 within 10 years - a shortage that could swell to 500 if North Dakota's population reaches 800,000, as expected.

The growing population - and increase in those with insurance coverage - is only part of the story. The rising demand for medical services also is driven by the aging population.

A national study, cited by North Dakota health analysts, has shown that patients 75 and older make more than four times as many annual visits to the doctor's office than those aged 15 to 24.

Training more doctors

Despite the daunting trends - and even with two of the 10 physicians at Bittner's clinic likely to retire in the next few years - she finds cause to be optimistic.

As many as seven medical students or residents could join Bittner and her colleagues when they finish their training at the University of North Dakota School of Medicine, though only three so far have signed letters of commitment.

At least four of the students came from the area, and some possibly were introduced to the idea of pursuing a health care profession because of outreach efforts targeted at secondary and even elementary students, Bittner said.

That was one strategy - another is tuition waivers for medical students who agree to practice in rural areas - identified by advocates for strengthening North Dakota's pipeline of health professionals.

Recognizing the looming potential crisis, health policy analysts launched an effort in 2007 called the North Dakota Health Workforce Initiative, which proposed a wide range of steps to increase the pipeline of health care professionals.

In the years since, North Dakota has made significant investments to expand for medical residency training programs and build a new, $124 million medical school that, when it opens next year, will enable bigger enrollments.

The number of medical students in time will increase by 16 per year to 64, for example, and an increase of 30 health sciences students per year, for a total of 90.

Because most doctors in training tend to establish practices in the states where they spend their residencies, expanding residency programs is a priority in North Dakota.

UND has a rural residency track for surgery that has 10 slots, each $150,000 per year or $1.5 million. It also has 18 rural family medicine residency slots, six each in Devils Lake, Williston and Hettinger, for a total of $2.7 million per year.

Also in support of the health care workforce initiative, UND's School of Medicine and Health Sciences has hired 20 faculty, at a cost of $3 million per year.

"The rest of the country talks about this stuff and we're doing it," said Dr. Joshua Wynne, dean of the UND medical school.

Larger cities seeing more openings

Stiff head winds remain, however, as shown by the tracking surveys of North Dakota's health care workforce.

Although the challenges in maintaining primary care long have plagued rural areas, they now show signs of spreading to the state's urban centers, Amundson said.

"It really is alarming to me to see those numbers," she said, referring to the spike in vacancies for family practice physicians, a rise she said reflects openings in urban centers.

"It's just ever challenging," Amundson said.

There still will be shortages, Wynne said, but the state's execution of plans set in motion years ago will produce "measurable differences."

"The future is a lot brighter in Devils Lake now, even though the sun hasn't come up yet," Wynne said.

Bittner agreed, but added that she and her colleagues are careful to make sure that prospective physician hires are comfortable with a rural practice.

Having the residency program in Devils Lake helps, she said, and expanding the medical residency programs will better enable North Dakota to keep its "best and brightest."

"I think, based on what we have going on right now," she said, "it's going to be successful."

A look at ND doctors

• 1,548 practicing physicians, including 582 in primary care

• 40 percent graduated from UND

• Two-thirds of primary care doctors are in metropolitan areas, 15.5 percent in rural areas

• North Dakota has 28.4 doctors per 10,000, 88 percent of U.S. average

• 13 of 53 counties, comprising 4 percent of the population, have no doctor

• Top specialties: family medicine, 21.7 percent; general internal medicine, 10.5 percent; general surgery, 6.9 percent; psychiatry, 5.4 percent; general pediatrics, 5.4 percent

Source: Source: 2015 Biennial Report, UND School of Medicine and Health Sciences