The Cowlitz Family Health Center has been trying to hire a doctor for three years, and it's no closer to filling the vacancy now than it was when the process began.

"We've had a few applicants, but not many," said Tamara Russell, human resources specialist at the Longview clinic. "Since January, we've had less than 10 applicants but not much more than that since the position opened up."

Cowlitz County, like many similar areas across the United States, finds itself struggling to compete with metropolitan areas for a limited number of primary care doctors, and the shortage will, according to health experts, lead to longer waits for appointments, delayed care and poorer health outcomes.

The national doctor shortage took root three decades ago when American medical schools established enrollment caps. The Association of American Medical Colleges projects the nation will be short 63,000 doctors by 2015. The shortage is expected to double by 2025 as federal health care reform expands medical coverage and sends thousands of new patients into the system.

According to an AAMC report, "The United States already was struggling with a critical physician shortage, and the problem will only be exacerbated as 32 million Americans acquire health care coverage, and an additional 36 million people enter Medicare" under the federal Affordable Health Care Act.

The shortage is going to be even more acute in smaller communities, which are at a recruiting disadvantage. Numerous studies and surveys, including one by the American Academy of Medical Management, show that only about 10 percent of doctors want to live in towns smaller than 100,000 people, said Carol Shea, physician recruiter for PeaceHealth St. John Medical Center. In addition, fewer than 15 percent of doctors want to live in the West, Shea said.

"Then you take that percentage and divide it across small-town USA. Then how many of those (doctors) want to live in the Pacific Northwest? You're looking at pretty minuscule numbers when you look at it that way," Shea said.

While doctor salaries in rural areas are competitive and perhaps slightly higher than those in metro areas - they must be to compete - larger hospitals and clinics can offer access to more appealing lifestyles. Quality of schools is important issue, too, Shea said.

"There are many factors involved in being competitive (in the recruitment battle), but the No. 1 thing is location," Shea said.

Kris Sparks, a state of Washington health worker who helps recruit doctors to small communities, said the average doctor leaves medical school with $164,000 in debt, and many are burdened with more than $200,000 in student loans. Larger hospitals and organizations often offer signing bonuses or programs that assist doctors in loan repayment. Smaller facilities usually don't have money for that.

"There's no way we can offer to pay someone's student loans as a signing bonus," said Dr. Rich Kirkpatrick, internal physician at Kirkpatrick Family Care in Longview. "You can just hope you make a positive impression on (recruited doctors) and they may come back later."

Another recruiting challenge for small communities is that doctors' spouses sometimes find it difficult to land jobs.

"Most professionals are married to other professionals, and small towns have limited opportunities," said Dr. Albert Luh, primary care service area director for Kaiser Permanente, which operates a Longview clinic on Seventh Avenue. "Often the spouse has a hard time finding a job, unless they're both doctors, which happens quite a bit here."

Doctors who do chose to locate in Southwest Washington often seek out smaller communities. An example is Dr. Megan Chono Dudley, who started working at Kaiser's Longview clinic two weeks ago after leaving the University of New Mexico and finishing her residency program. Living in Longview puts her close to relatives in Seattle-area, Northern California and Hawaii, she said.

"I wanted to live in a smaller town and have access to a city but not be in a city," said Dudley, 37. "And I promised my husband we'd move closer to water. So we were excited to move here."

She added the area's schools, Lake Sacajawea and the friendly atmosphere were big reasons why she chose Longview over a clinic in Enumclaw.

Luh said Kaiser is increasing its recruitment efforts and offering higher signing bonuses in preparation for meeting a surge in patient numbers expected from the new federal health care legislation.

"(Primary care) is still the frontline of medicine. It's still where the rubber meets the road," he said. "And if we don't get them now, we won't get them in the future."

One troublesome aspect of the doctor shortage is a lack of general practice and primary care doctors. Medical schools are graduating fewer general practice physicians as more med students go into specialties, which pay significantly higher wages.

"There's just going to be an overall shortage of primary care physicians," said Natalie González, recruitment specialist for the state Department of Health's rural health office.

Washington medical facilities may also be contend with what Gonzalez perceives as the Northwest's regional disadvantage. She noted there are far fewer medical schools in the area -when compared to California and the East Coast - and that the University of Washington medical school supplies candidates for residency programs in Washington, Alaska, Wyoming, Montana and Idaho.

"Studies show students tend to practice where they went to school or performed their residency," she said. "Washington is an importer of physicians."

Kirkpatrick said community providers should attempt to rally together to promote the positives of the area. Even though each provider is competing with the others for talent, he said improving the community would benefit everyone.

Luh said medical schools could allow more students into their competitive programs to produce more doctors, and that increasing loan subsidies for medical students could also attract more students to primary care.

However, he's not optimistic the situation will improve.

"I don't see the shortage (of physicians) changing, and the population is growing and we're going to be covering more Americans, so there's going to be more people in the pool," Luh said.