Rural Recruitment and Retention Factoids and Links
Prepared by Robert C. Bowman, M.D. for use in workforce assessments and
reports
Indicators of future and persistent problems for rural
workforce
- Declining rural
origin students are a problem for rural primary care and specialty care.
- Visa programs that previously diverted international
graduates to rural primary care, specialty care, and mental health needs
have been changed. Visa Programs: Do They Help
In Primary Care and Rural Areas?
- Distribution:
Index Concentrations of Physician Distribution - various types of
physicians are compared for top levels of distribution. The percentages
found in underserved or rural areas are compared to the proportion of the
actual workforce. For example 2% of the total physician workforce is rural
born family physicians, but this group is 9.1% of total rural underserved
workforce for the nation, an index of 4.56. Comparisons include
international, US, various specialties, and medical school types.
- Declines in family medicine are a problem for all
lower and middle income areas of the nation because family medicine is the
only specialty with a majority found outside of major medical center
locations. Family medicine is the most efficient and effective specialty for
converting urban origin physicians to rural location. Family physicians
remain 98% in family medicine and 90% in primary care and can be expected to
provide 85% of 30 years of physician
services in primary care with the highest physician or practitioner
concentrations in rural and underserved areas.
Primary Care Retention
- With fewer in primary care and fewer in family
medicine, urban areas and served areas of the nation will recruit more
heavily and successfully, leaving rural areas and underserved areas with
declining workforce and access.
- Declines in
admissions of rural origin, white, lower income origin, and male physicians
are a problem since each factor is associated with greater rural location
than urban, foreign born, non-white, highest income, and female physicians.
- Military obligations continue to attract osteopathic,
male, older age, rural origin, family physicians that have 50% probability
of rural location. Minority males are also lost from potential rural careers
or obligations due to military service.
Military support packages are a best fit for the students with the above
characteristics and recruit these students any time from high school to
residency and even in the first years of practice. Loan repayments are
too far away and unpredictable for some types of students who have more
immediate needs. They are often those with the highest probability of
distribution.
- Academic careers continue to attract minority females
away mainly from urban underserved careers and some rural careers. The needs
for minority females in rural and underserved areas are significant.
- Declines in family medicine choice are a disaster for
rural areas in need of the broad scope, primary care, mental health, women’s
health, public health, emergency care, procedural capabilities, hospital
services of family physicians, and the 1 – 2 million in economic impact for
a rural community. By the numbers:
Rural Doctors and Rural Economies
- Declines in family medicine choice have most impacted
small and rural programs, the inner city and rural training programs that
graduate the highest concentrations of needed primary care in inner city,
rural, and rural underserved areas.
- Declines in specific forms of family medicine and
rural training mean less preparation for rural careers. Procedural, critical
care, emergency care, and women’s health areas may be most impacted.
- Rural areas can expect decreases in workforce
contributions from general internal medicine, physician assistants, and
nurse practitioners as more leave primary care and rural locations to return
to major medical center careers and locations. In the next decade the NP and
PA contributions will be at or below the current 10% physician levels.
Current rural contributions have depended upon expansion of NP and PA
programs that are now maximizing. The nation has discovered that expansions
of physicians have not improved rural workforce. Graduating more NPs and PAs
while total NP and PA rural percentages decline will not alleviate rural
workforce problems. Primary Care
Retention
- The primary factors involving poor rural distribution
are policy-related distributions of reimbursement and support involving
lower and middle income areas of the nation and the distributions of
opportunity and development to lower and middle income children.
- Policy related distribution problems also impact
admissions of potential rural physicians and family physicians for the two
or three decades prior to admission. Education
References, Distributions, Inequities, Child Development
- Medical students born in 70% of the nation’s lower and
middle income populations have higher levels of rural location than the
current 10% average, but these students are only 30% of admitted medical
students. Only medical students from 30% of the nation’s population have
lower than average levels of distribution, but this group is 70% of medical
school admissions. Distribution: The 70-30
Distributions That Complicate Physician Distribution
- A rapid medical school expansion favors admissions of
the highest status, the ones with the lowest probability of rural
distribution. Cost, Quality, Access, and Physician
Workforce Expansion
- An expansion of graduate medical education positions
also would contribute to a decline in family medicine choice, also a
disaster for rural distribution as family medicine is the only remaining
permanent form of primary care and one that concentrates in rural areas.
- Training programs can be significant sources of
current and future workforce, but current policies involving accreditation
and training prevent distribution of training location and the associated
higher levels of workforce. Family physicians in particular are forced to
train over 95% of graduate in major medical centers yet 50% of family
physicians practice outside of major medical center locations.Accreditation
and Demands of Rural Practice
- Residency and student rotations in rural areas that
are longer in duration are linked to improved contributions to health care
in rural areas and also have been found to have equivalent levels of medical
education quality, however accreditation continues to limit residency
training and student preceptorships to shorter duration with trainees more
of a burden upon rural communities instead of a blessing.
Why a Rural Preceptorship Is Best
What Could Have Been: Maximal Primary Care
Training Capacity
Head to Head: Physician Assistants in 2000
Compared to Family Physicians in State and National Location
Logistic Regression: Career
Choice
Primary Care Years: New Measures of Total
Workforce Contribution
Poverty Locations and
Physicians
Primary Care Health Policy
Primary Care Retention
Top Workforce Outcomes Rankings
Understanding Rural Workforce
Five Periods of Health Policy and
Physician Career Choice
Physician Workforce Studies
www.ruralmedicaleducation.org