recruitment and retention of rural physicians: issues for the 1990s

Crandall, Dwyer, and Duncan 19

Rural Health Policy

Recruitment and Retention of Rural Physicians: Issues for the 1990s"

Lee A. Crandall, Jeffrey W. Dwyer, and R. Paul Duncan

ABSTRACT: This paper briefly describes a number of structural and economic changes in the profession of medicine and in the rural medical care delivery system that haveoccurred sinceabout 1970. Changes in the national physician supply; in the training, work, and practice characteristics of physicians; in the demographic characteristics ofphysicians; in the medical resourcesavailable in rural communities; and in federal and state support for the provision of medical services are noted. Four conceptual models that underlie physician recruitment and retention programs for small towns and rural Communities are described. These include affinity models, which attempt to recruit ruralpersons into training orfoster interest in rural practice among trainees; economic incentive models, which address reimbursement or payment mechanisms to increase economic rewards for rural practice; practice characteristics models, which address technical, collegial, referral, and other structural barriers to rural practice; and indenture models, which recruit temporary providers in exchange for scholarship support, loan forgiveness, or licensure. Examples of applications of each model are provided and the effects of changes in the medical care system on the effectiveness of each model are assessed. Finally, it is argued that elements of an optimal model for the recruitment of physicians to rural practice include the promotion of medical careers among rural higk school students, the provision of financial and cultural support for their training, the developmenf of technical and collegial support systems'and the limited use of indenture mechanisms to meet the needs of the most impoverished or isolated rural settings.

Three decades ago there was substantial agreement among health policy analysts that the recruitment of doctors into practice in small towns and rural communities was hindered by a broader problem-an overall national shortage of physicians. Problems of geographic maldistribution were

* This research was conducted as part of a Medical Indigence Demonstration Program funded by the state of Florida Department of Health and Rehabilitative Services under a contract with the University of Florida College of Medicine. The authors wish to thank Patricia Demaras, graduate research assistant in the Center for Health Policy Research, for her assistance in identifying and summarizing physician recruitment models. Address all inquiries or other correspondence to: Lee A. Crandall, PhD, Department of Community Health and Family Medicine, Box J-222, J. Hillis Miller Health Sciences Center, The University of Florida, Gainesville, FL 32610

The Journal of Rural Health Volume 6, Number 1-January 1990

20 The Journal of Rural Health

expected to resolve naturally in the presence of an adequate supply of providers. Responses to the national physician shortage included a series of policies intended to significantly expand the pool of health care personnel, including the expansion of classes in existing medical schools, the creation of 38 new medical schools between 1965 and 1982 (Tarlov, 1988), the development of curricula to train new health practitioners such as nurse practitioners and physician assistants, and relatively open immigration and licensure policies for foreign medical graduates. Together, these measures were dramatically effective in increasing the supply of providers for the nation as a whole. By 1980, the report of the Graduate Medical Education National Advisory Committee (GMENAC) predicted that the overall physician supply would be sufficient to meet national needs around 1990, and would soon thereafter constitute a physician glut.

The widespread belief that a glut of physicians was imminent has been accompanied by efforts during the past decade to limit growth in the supply of physicians and physician extenders. These efforts included attempts to tighten restrictions on foreign medical graduates (Mick, 1987) and new health practitioners (Backup & Molinaro, 1984), cuts in federal capitation grants for the support of medical schools, and cuts in scholarships for medical students (Crozier & Iglehart, 1984). Since the early 1980s, there have been slight decreases in total medical school enrollment nationally. Total places in American allopathic and osteopathic medical schools peaked in 1983 at 18,893 and by 1987 declined to 18,366. However, this number is still nearly twice that of 1965 (Tarlov, 1988).

Whether the current or projected supply of physicians actually consti- tutes a glut is open to question (Hafferty, 1986; Thompson, 1987). Clearly, the combined supply of physicians and new health practitioners has increased faster than the population in the past two decades, and oversup- plies of providers do exist in some specialties (Crozier & Iglehart, 1984). There is, however, no surplus of primary care physicians (Kindig & Dun- ham, 1985). Instead, only an approximate balance of family physicians, pediatricians, and general internists is expected along with a substantial shortfall of specialists in emergency medicine (Crozier & Iglehart, 1984).

The long-term impact of the increased national physician supply on small towns and rural communities is unclear. Newhouse and colleagues (1982) contend that the overall increased supply of physicians is causing a modest diffusion of medical services into nonmetropolitan communities. However, this process does not appear sufficient to meet the physician supply needs of smaller rural counties (Bruce,1985; Kindig & Movassaghi, 1989). Recent statements about needs for rural physicians show that long- standing difficulties in recruiting and retaining rural physicians have not yet been adequately resolved (National Rural Health Association, 1987). Overall, these articles suggest that an increased supply of physicians at the national level may be helpful in recruiting and retaining physicians for practice in some nonmetropolitan areas, but that organized recruitment and


retention programs continue to be necessary to see that the needs of smaller rural communities are appropriately met.

In developing rural recruitment and retention programs for the coming decade it is important to re-examine the effectiveness of traditional efforts in the context of contemporary changes in the profession and practice of medicine, as well as in the context of recent developments in rural medical care delivery systems. This article outlines these changes, describes a series of basic conceptual models that we believe underlie recruitment and retention efforts, discusses contemporary issues in the application of these models, and concludes with some recommendations for effective recruitment and retention programs for the coming decade.

Changes in the Profession of Medicine

In addition to a dramatic increase in the number of practitioners, medicine has experienced changes during the past two decades in the nature of physicians’ work, in the demographic composition of the profession, and in the duration and content of specialty training. Each of these changes has implications for the recruitment and retention of physicians in small towns and rural areas.

Work and Practice Characteristics. The work of physicians has become increasingly specialized and technology dependent. These changes have been accompanied by increased standardization of work, by decreased autonomy and professional discretion, and by the development of an increasingly litigious and regulatory approach to maintaining standards of care. This process, sometimes labeled the deskilling of physician’s work, has been described as a part of a larger process of proletarianization of the physician’s role (McKinley & Stoeckle, 1988).

Changes in medical work are intrinsically tied to changes in the work setting (Relman, 1988; Starr, 1982). The growth of multinational corporations that deliver services and own facilities has been accompanied by the increased likelihood that physicians will be salaried employees. Relman (1988) has stated: ”Among physicians under the age of 35, about 40 percent of all male and nearly 60 percent of all female practitioners are now salaried employees” (p. 784). McKinley and Stoeckle (1988) commented: ”Young medical graduates ... are often prepared to accept a limited job (and role) for a guaranteed fixed income (without heavy initial investment in setting up a practice and obtaining liability protection from astronomical malpractice insurance premiums) with the promise of certain perks (regular hours, paid vacations, retirement plans, etc.)” (p. 195). They also reported that salaried practice is associated with a lighter work load and markedly reduced income: $84,000 per year in 1985 for salaried physicians versus $118,600 for self-employed physicians (McKinley & Stoeckle, 1988).

22 The lournal of Rural Health

Demographic Attributes of Providers. The changing demographic composition of providers is also noteworthy. For example, women constitute a steadily growing proportion of medical school enrollees-rising from 13.7 percent of the first year class in 1971-72 to 33.9 percent in 1985-86 (American Association of Medical Colleges, 1986). There is evidence that younger female physicians are more likely than males to select positions that are salaried (McKinlay & Stoeckle, 1988) and offer limited fixed working hours (Gordon, 1980; Lanska et al., 1984). Female family physicians also are more likely than males to practice in urban areas (Ellsbury et al., 1987).

The proportion of blacks or members of other minority groups among medical students has not increased appreciably during the past two decades. The Association of American Medical Colleges, in conjunction with the American Medical Association and other groups, announced in 1970 a goal of 12 percent minority enrollment in American medical schools by 1975. This goal was not met. Overall enrollment of underrepresented minorities increased from 2.5 percent in 1968-69 to only 8.2 percent by 1974- 75 (Strelnick & Younge, 1984). Although blacks make up about 12 percent of the United States population, black enrollment peaked at 6 percent of all medical students in 1977-78 and then leveled off at a slightly lower level (e.g; 5.8 percent in 1985-86) (Association of American Medical Colleges, 1986). The underrepresentation of blacks among physicians and persons in training to be physicians may exacerbate long-standing difficulties in recruiting physicians to practice in medically underserved and economically de- pressed rural black communities in the South. While there is no guarantee that black physicians will enter practices in such communities, there is some empirical support (cf: Lloyd et al., 1978; Rhodes & Day, 1989) for the assertion that the needs of rural blacks are more likely to be met by increasing the number of blacks enrolled in medical school than by increasing the number of upper middle-class white medical students with family origins in affluent suburban communities.

Rabinowitz (1988) reviewed the geographic origins of medical students and noted that relatively few of today’s medical students are from rural communities of origin. His analysis of national data showed that, during the period 1978 to 1986, the number of matriculants to medical school who were from small towns decreased 15 percent, and the number from rural areas decreased 31 percent. Meanwhile, the total number of matriculants nationally remained nearly constant and the number of matriculants from mod- erate sized cities grew. The decline in rural and small town matriculants occurred because the number of persons from such areas applying for admission declined (Rabinowitz, 1988). The shrinking pool of applicants from rural areas may reflect, at least in part, problems of curriculum and counseling in some rural secondary schools.

The early development of interest in medicine and precollege preparation for medical school have been shown to be important factors in success-


ful matriculation (Maykovich, 1980). Today this process may present special obstacles for rural and small town youths. The resource constraints that impinge upon small rural high schools often result in limited opportunities for science training for their top students (Knopke et al., 1986). For example, smaller faculties and limited budgets may lead to an absence of honors or advanced placement science courses which are the norm in many affluent suburban high schools. Students in small rural high schools may not be encouraged to consider careers in medicine (Knopke et al., 1986). They also may have more difficulty than students from large urban high schools in adapting to the premedical curriculum and premedical culture of large universities which are often characterized by anonymity, excessive com- petitiveness, overachievement, and overspecialization (cf Ahrens & Akins, 1981; Sade et al., 1984). All of these factors may combine to put rural students at a disadvantage in the competition to maintain the high science grade point average that is an admission requisite for medical school.

Specialty Training. The preparation of virtually all physicians entering practice today includes three or more years of residency training in a specialty. The development of family medicine as a board-certified specialty helped put an end to the traditional one-year rotating internship followed by entry into general practice. Thus, aging general practitioners currently practicing in rural communities will not be replaced by similarly trained young doctors.

The increased length of post medical school time required to complete specialty training means that practice location decisions are influenced by more than a decade of post high school professional socialization that usually occurs in urban or suburban settings. Most of today’s doctors are trained in technology-intensive tertiary care hospitals where specialization and narrow expertise may be held in even higher esteem than in the broader medical community. It is simply not reasonable to expect that an interest in rural practice will arise spontaneously (or be maintained) in such settings. Furthermore, there is evidence that students in such settings who express interest in family medicine or rural practice may be actively discouraged from pursuing these goals by their advisors and clinical teachers (Johannet, 1984; Scherger et a1.,1983).

Changes in Rural Medical Systems

Changes in rural medical care systems may be equally significant in their impact on physician recruitment and retention. Despite worsening levels of economic well-being in many rural areas of the United States (Rowland & Lyons, 1989), the past two decades have seen some positive changes in rural medical systems. The delivery of primary care was enhanced by the development of community health centers in many small towns and rural

24 The journal of Rural Health

areas (Rosenblatt & Moscovice, 1982). Many rural emergency medical systems have also been upgraded (Rosenblatt & Moscovice, 1982). How- ever, attempts to address rural physician recruitment and retention in the coming decade may be hampered by issues that are currently affecting the viability of rural community health centers and rural hospitals, by disparities between urban and rural citizens with regard to access to the Medicaid program, by differential compensation from both the Medicaid and Medi- care programs for urban and rural providers, and by cuts in funding for the National Health Service Corps.

Community Health Centers and Emergency Services. The Community Health Centers (CHC) Program has provided financial support for the development of primary care centers in many communities where private practicing physicians were unavailable. The centers provide a consistent, ongoing focus for primary care and an entry point into the medical care system for members of all socioeconomic groups. Currently, however, the long-term financial status of such centers is threatened by economic down- turns in many rural areas (National Rural Health Association, 1989). During the past two decades, federal funding has allowed the physical components of emergency medical services in many rural communities to be upgraded dramatically (Rosenblatt & Moscovice, 1982). The 1973 Federal Emergency Medical Services Systems Act also provided funds that have allowed many rural persons to become trained as emergency medical technicians (Mal- lory, 1988). Both the Community Health Centers Program and financial support for enhanced emergency medical services can help to make the practice of medicine in rural environments more attractive, and a failure to maintain them in the future will have the opposite effect.

Rural Hospitals. Much of the recent national effort to contain costs in the health care sector has been conceptually based on the price constraints that ostensibly exist in a free market and has therefore been manifested in policies that encourage competition among providers of institutional health services. Rural hospitals have been especially hard hit by this competitive environment (Duncan & Miller, 1989). For example, 64 percent of all hospitals that closed their doors in 1986 were in rural areas (Van Hook, 1988). For-profit rural hospitals and nongovernment not-for-profit hospitals have been shown to be particularly at risk for closure (American Hospital Association, 1989). Many other rural community hospitals have remained open only as a result of acquisition by either a for-profit or a not- for-profit chain. Some analysts assert that the acquisition process may result in a more impersonal and bureaucratic orientation, particularly in the case of investor-owned institutions (Lewis & Parent, 1986). Without specific contractual language forbidding it, this process may eventually lead to the elimination of unprofitable services such as obstetrics and pediatrics, which can be consolidated into a chain’s urban locations.

Crandall, Dwyer, Duncan 25

The availability of hospital resources is a powerful factor affecting physician location patterns and physician retention in rural areas (Ahearn &Fryer, 1985; Movassaghi & Kindig, 1989). If the difficulties currently being experienced by rural hospitals continue into the next decade, a significant negative impact on the willingness of physicians to locate and remain in rural communities can be anticipated.

Federal and State Programs. The problems of rural hospitals and CHCs are exacerbated by inadequacies and inequities in federal and state programs for the provision of medical care to the poor and elderly. At the hospital level, the introduction of diagnosis related groups (DRGs) by Medicare in 1983, while helping to control the rate of inflation in charges, has reduced an important stream of revenue. Rural hospitals have felt the impact more dramatically because, under this system of prospective payment, they are paid nearly 37 percent less than urban hospitals for rendering the same services (Van Hook, 1988). At the outpatient level, the algorithm for inflation adjustment has exaggerated urban and rural disparities in physician fees that already existed in 1966 when the Medicare program began. This has led to substantial disparities between urban and rural communities in Medicare payments for outpatient services. Most rural areas receive far less physician compensation per beneficiary than the national average (Dean, 1988). Furthermore, increases in deductibles and premiums for Part B of Medicare that occurred during the past decade have made it quite difficult for many retirees to maintain this coverage for physicians’ services. Because rural retirees have lower incomes (Krout, 19861, this issue is particularly salient.

During the 1980s, the burden of the Medicaid program on state budgets has resulted in significant reductions in compensation for providers and in decreases in coverage for the indigent population (Mechanic, 1986). Be- tween 1976 and 1984, the proportion of poor and near poor persons covered by Medicaid dropped from 65 to 52 percent (Mechanic, 1986). State eligibility standards vary widely and are often inadequate to encompass all who are poor (Brown, 1984). Rural poor persons may have more difficulty gaining access to social service agencies and therefore may be less likely to be enrolled in Medicaid than their urban counterparts (Rosenblatt & Moscov- ice, 1982; Rowland & Lyons, 1989). Compensation under Medicaid has been so meager and slow in many states that private physicians shun these patients (Kurtz & Chalfant,l984). Thus, in rural as in urban areas, the care of poor persons is often left to community health centers, emergency rooms, county health departments, or other institutional providers (Cockerham, 1989) which are often required by law to accept them.

These issues of reimbursement and compensation hamper the recruitment of rural physicians by making rural practice opportunities less attractive. To the extent that they serve to keep physician incomes below some threshold level of acceptability, they may also force some existing rural practitioners to consider relocating.


National Health Service Corps Cutbacks. A heavy, albeit time-delayed, blow to the recruitment of physicians into the rural medical system was struck by reductions in National Health Service Corps (NHSC) scholarships for physicians. Throughout the early 1980s, the availability of NHSC scholarships provided a large cadre of salaried physicians who were available to staff community health centers, migrant clinics, and other governmentally supported institutional providers of rural medical care. However, the NHSC has undergone massive cuts. The overall program was cut from $145 million in 1981 (Mullan, 1984) to $42.3 million in fiscal year 1987 (Update 11. Legislation, 1988). Appropriations for new scholarships were cut even more markedly with only $2.2 million allocated for scholarships in fiscal year 1988 (Update 11. Legislation, 1988) versus nearly $80 million in 1980 (Rosenblatt & Moscovice, 1980). Because of the large number of people in the NHSC pipeline at the time cuts began to be made, the effects are only now being felt most severely as the number of students obligated to provide service has declined from 1,378 in 1985 to 273 in 1989 (Update 11. Legislation, 1988).

Programs to Recruit and Retain Rural Physicians

Programs to recruit physicians for rural practice and to retain physicians in rural areas are based on underlying conceptual models that incorporate assumptions about the health care delivery system and the behavior of health professionals. These models can be classified into four broad types. Affinity models attempt to recruit into the medical profession people with rural backgrounds, or to foster familiarity and interest in rural practice among persons in medical training. Economic incentive models attempt to alter the reimbursement or payment mechanisms to provide incentives, or to reduce the disincentives for rural practice. Practice characteristics models address other structural characteristics of rural practice to provide technical, collegial, and referral support and to diminish perceptions of isolation, overwork, or marginality among rural physicians. Indenture models recruit temporary providers by requiring limited periods of service in rural (and underserved) areas as a condition of training, financial support, or licensure.

Affinity Models. Perhaps the most commonly used approach to gener- ating physicians for rural practice is embodied in what we label the affinity model. Here recruitment to rural practice occurs either because the physician is from a rural background or because exposure to rural practice settings comprises a significant portion of the physician’s training. Affinity models are premised on the idea that physicians choose rural practice because they find it to be desirable. They therefore seek to develop or cultivate an individual’s attraction to the positive aspects of a rural medical


practice or small town life. It has repeatedly been shown that the decision to locate in a rural

community is related to rural origin (Bruce, 1985). Affinity models that emphasize rural origin may assist rural persons in the competition for admission to medical school, foster premedical training at rural campuses, or emphasize the positive weighting of rural background in the admissions policies of medical schools. An innovative approach to interesting rural high school students in medical careers and supporting their professional aspirations is the Biomedical Sciences Preparation Program (BioPrep) at the University of Alabama. Students in selected rural high schools are provided a four-year sequence of accelerated coursework, clinical experience, and summer academic and experiential enrichment. The BioPrep students score significantly higher on the American College Testing Program college entrance exam than matched controls, and they have been shown to select professional careers earlier and more often than matched controls (Knopke et a1.,1986).

A more frequently used method for increasing the number of rural students in medical schools is the use of selective admissions policies. This approach is exemplified by the Physician Shortage Area Program at the Jefferson Medical College (Rabinowitz, 1987). A proportion of each class is admitted through this special program, which selects only students from rural areas who are judged to be committed to practicing family medicine upon graduation. Graduates are seven to 10 times more likely to be practicing family medicine in a rural or physician shortage area than their peers (Rabinowitz, 1987).

Selective admissions policies may be combined with changes in the medical school curriculum in order to encourage students to retain their interest in rural practice throughout the training process. At the University of Arkansas for Medical Sciences at Little Rock, selective admission of students from rural areas has been accompanied by curriculum changes that encourage interest in primary care specialties and by the creation of Area Health Education Centers throughout the state that offer senior medical students extended exposure to community practice (Lancaster, 1985).

Another program that employs elements of the affinity model is an educational consortium that includes the states of Washington, Alaska, Montana and Idaho (WAMI). In recruiting students into training its goal is “to identify that cohort of students whose motivation is consonant with the needs of underserved populations” (Rosenblatt, 1980, p. 15). WAMI emphasizes decentralization of medical education and residency training. Other aspects of the program include support of family practice residencies and scholarship support. Similarly, the New Mexico Primary Care Curricu- lum is an alternative track for medical students that establishes primary care as the learner’s initial and most critical role model (Kaufman et al., 1980). It emphasizes the selection of medical students with rural backgrounds and

28 The journal of Rurul Health

the use of clinical problem-based methods, and it offers clinical training experiences in rural settings. Hospital-based training is deferred to the final stages of the program (Association of American Medical Colleges, 1986; Kaufman et al., 1980).

While there are many examples of successful applications of the affinity model, the goal of recruiting more students from rural backgrounds may conflict with other goals. One example of goal conflict is the Program in Medical Sciences (PIMS), an interuniversity program of Florida State Uni- versity and Florida A & M University. PIMS was created, at least in part, to offer a pathway into medical school for students from Florida’s rural Panhandle region. Admission criteria initially favored persons with rural backgrounds. However, as the number of applicants for medical school declined during the last half of the 1980s, concerns about the program’s ability to compete academically with other medical education programs in the state led to increasing the emphasis on admissions test scores and grade point averages, and to a decrease in the emphasis placed on rural origin. Similar conflicts between societal needs and academic demands are doubt- less quite common in programs that try to attract students with rural backgrounds.

Brief rural preceptorships or externships have long been used by medical schools to expose students to medical practice in small towns and rural areas (Steinwald & Steinwald, 1975). Such rotations may be useful as mechanisms for reinforcing a preexisting affinity for rural practice, but probably do not foster interest among other students. Mauksch (1980) has noted: “Medical students learn early .... What is required is more important than what is optional, what has many hours in the curriculum should influence me more than anything with fewer hours” (p. 43). This would suggest that brief episodes of rural training, even if required, are not effective in interesting students in rural practice and in fact there is little empirical evidence that participation in such limited programs positively influences decisions for rural practice (Eisenberg & Cantwell, 1976; Stein- wald & Steinwald,l975).

Efforts by medical schools to interest students in rural practice should ideally offer trainees the opportunity to develop skills, and attitudes that are needed for rural practice and that may not be fostered in metropolitan training sites. Bruce (1985) has noted that to practice successfully in a rural community requires the development of consultation and referral mechanisms to overcome the professional isolation that is inherent in the rural setting, as well as a specialized approach to practice management and the organizational characteristics of rural practice sites. Such extensive curricula to prepare medical students for rural practice are relatively rare. One example is the Rural Physician Associate Program (RPAP) at the University of Minnesota which places third-year medical students in a 9- to 12-month preceptorship in the office of one of more than five hundred participating rural physicians. Students receive stipends underwritten by the supervis-

Crandall, D q e r , and Duncan 29

ing physicians as physician associates and two quarters of academic credit. Among graduates of this program, 58 percent eventually practice in communities of less than 50,000 people and 75 percent enter a primary care specialty (i.e., family medicine, pediatrics, or internal medicine) (Verby, 1987).

Residency training through family practice and other primary care programs affiliated with Area Health Education Centers (AHECs), or similar programs supported by state funding, can place substantial numbers of residents in nonmetropolitan community hospital settings. In North Carolina, for example, the introduction of a statewide AHEC has corre- sponded with an increase in the proportion of residents in family medicine from 8.2 percent in 1974 to 31.3 percent in 1987. Of 664 residents trained in AHECs between 1977 and 1987, nearly half (295) remain in North Carolina. Of these, 51 percent are in family practice and 10 percent have settled in towns of 10,000 people or fewer (North Carolina AHEC, 1988).

Economic Incentive Models. Central to economic incentive models is the belief that the current health care financing system in the United States produces an economic disincentive for physicians to practice in rural areas. These approaches further assume that physicians act as rational economic beings and that changes in health care financing to eliminate or reduce rural and urban inequities will help to recruit and retain physicians for practice in rural areas. There is some evidence to support this view. In their discussion of the impact of the Canadian system of universal medical insurance, the Hatchers (1984) noted that it "began with a serious maldistribution of doctors. They were concentrated in areas where patients had money and/or private health insurance coverage .... These differentials between over and underdoctored areas have been decreasing.. .doctors have been attracted by health insurance fees to provinces and areas previously underdoctored" (p. 94). The Canadian system created economic demand in rural areas consistent with the medical need in those areas and the marketplace seems to have responded to provide physicians for all except the most remote rural communities.

The adoption of a national health insurance plan like Canada's seems unlikely to occur soon in the United States. However, recruitment and retention models based on salaries, income guarantees, or other local initiatives can also alter the economic climate of rural practice, do not require national legislative action and, thus, may be of use to rural communities. In New Zealand, remote areas where physician recruitment is a problem are designated speciul ureus. Doctors contract on an annual basis to provide services and, in addition to salary, receive special vacation privileges, free housing, free furniture, and an automobile allowance (Mackay, 1984). The District Doctor system in Norway provides similar incentives to physicians willing to locate in the far North (Roemer and Roemer, 1978).

Previous tests of economic incentive models in the United States have

30 The lournat of Rural Health

typically assumed that the rural physician would begin as, or evolve into, a solo fee-for-service practitioner. For example, the Sears Roebuck Founda- tion helped to subsidize startup costs for physicians in small towns and rural areas during the 1950s by providing office space and equipment (Roemer,1976). Other economic incentives that have been employed include tax incentives and the provision of professional liability insurance (Eisenberg et al,. 1976). One economic incentive that has been employed with some degree of success is the provision of a fixed salary or a guaranteed income for physicians willing to locate in rural areas. Such a system of income guarantees was implemented in the state of New York in the late 1970s. The successful recruitment of 60 new physicians into three counties was attributed to this innovation (Korman and Feldman, 1977).

Practice Characteristics Models. Practice characteristics models of physician recruitment and retention assume that rural practice opportunities that lack collegial and technical support, or are isolated, marginal, or excessively demanding, may be viewed as undesirable despite adequate remuneration or the physician’s affinity for rural practice. Thus, practice characteristics models attempt to recruit or retain physicians for rural areas by addressing these non-economic aspects of rural practice.

Physicians trained in recent decades frequently look for professional support systems (such as the opportunity to join a group practice, or to have more technical and/or clerical assistance), and for sophisticated clinical facilities that typify the large medical centers where they trained (Parker & Sorensen, 1978; Paul, 1978). Additionally, many young physicians have not been fully trained in the practical aspects of establishing and operating a medical practice (Murrin, 1982). These factors may deter graduates from choosing rural areas to set up practice (Kibbe, 1979) and encourage them to locate in a metropolitan area where professional support systems and management consultation appear to be more readily available. Carpenter (1982) has suggested that physician location decisions are influenced by opportunities for partnership or group practice, the availability of clinical support personnel, opportunities for consultation and continuing education, opportunities for hospital practice, and arrangements for after-hours coverage. To this list of practice characteristics might be added the need of rural physicians for efficient referral systems to specialists in urban centers (Curry et al., 1980).

Linking rural primary care to hospitals with multispecialty physician groups is one means of addressing these concerns. Madison and Bernstein (1975) identified three subtypes of hospital-based primary care programs. They included: (1) hospital based - physician sponsored programs where the clinic is located in or near the rural hospital and linked logistically and contractually; (2) hospital-based-hospital-spons~red programs following the model of the Indian Health Service Clinics in which primary care is an integral institutional function; and, (3)primary care satellitefacilities sponsored


by hospitals where clinics are located in underserved areas remote from the hospital, but owned by the hospital or linked contractually. Linking primary care programs to multi-institutional networks that include teaching hospitals or AHECs may offer advantages over linkages to small rural hospitals because the latter are often understaffed, financially unstable, and may view publicly sponsored clinical settings as detrimental to the solo rural practitioners that were their original constituents. An example of the use of linkages and cooperative arrangements among rural hospitals, county health units, community health centers, continuing education programs, and fiscal intermediaries to improve rural practice characteristics is provided by the Northern Lakes Health Care Consortium of Minnesota (Christensen & Russell, 1987). This organization has under- taken a variety of morale building, business related, and colleague support activities in rural Minnesota including: the development of a provider coalition; negotiations with nationaI corporations to obtain discounts for members; cooperative planning, marketing, advertising, and public rela- tions projects; health education and prevention projects in local media; and the creation of a group purchasing system for medical supplies (Chris- tensen & Russell, 1987). Such activities may help to reduce physicians’ feelings of professional isolation and enhance morale among existing providers while facilitating the recruitment of additional providers.

Indenture Models. We define indenture models as those that require a fixed period of service in an area designated by society as needy. Often this period of service is required as a condition of licensure, loan repayment, or immigration. This model may be viewed as a short-term attempt to meet the needs of underserved areas awaiting more permanent solutions. Or, it may be viewed as a permanent system that tacitly acknowledges that the three approaches already discussed will not succeed in providing physicians for all medically underserved areas. The pasantia, a brief period of mandatory service to the poor, was implemented by a number of Latin American nations during the 1960s. An analysis of the program in the Dominican Republic concluded that it succeeded in placing physicians in the countryside, but that their success in treating rural peasants was limited by the brevity of their stay, their social class bias, and their resentment at being forced into national service (Ugalde & Homedes, 1988).

Indenture models have been used successully, however, by other nations. Canada, oversupplied with doctors, has acted to restrict foreign medical graduates. However some provinces grant them licenses condi- tional on practice in underserved areas. Both Canada and Australia provide financial support for medical students in exchange for later service in rural areas (Roemer and Roemer, 1978). In the United States, the latter approach was embodied in the National Health Service Corps scholarships, which provided financial assistance for students in the health professions in exchange for an obligation to provide a period of service in medically


underserved areas. In recent years Congress has turned away from providing such scholarships in favor of viewing the NHSC as a loan repayment system. Waxman (1988) has noted: ”It is hoped that students who elect to serve in the corps at the end of their medical training, in exchange for repayment of their loans, will be more predictably suited for the needs and conditions of NHSC sites than ones recruited by scholarships as they enter medical school” (p. 49). However, it remains to be seen whether sufficient numbers of students will select an NHSC placement to repay loans if the alternatives allow repaying these loans by earning a higher salary in an urban or suburban setting.

Discussion

Even in societies where physicians are employees of the state, placement of physicians in rural areas is problematic. Field (1976) reviewed the health care system of the Soviet Union during a period when that society was considerably more authoritarian than today. Yet, he concluded that “the one conspicuous failure of the system has been its inability to deploy professional manpower to the countryside” (p.92). If the more pluralistic and decentralized American health care system is to succeed in meeting rural physician personnel needs, it must take advantage of the most useful aspects of each of the conceptual models presented above. This will require attention to the processes of premedical education, medical student selection and professional training as well as attempts to improve the structural characteristics and financing of practice in small towns and rural areas.

As previously noted, programs that recruit persons from rural communities into medical careers appear to have substantial empirical support while those that attempt to influence location choices later in the training process have less support. Therefore, a variety of mechanisms should be explored to increase the pool of rural persons applying to medical school. These mechanisms might include attempts to encourage rural high schools and rural health care providers to identify top science students and moti- vate them to pursue medical careers, the development of summer employment opportunities in rural community health centers for such students, the creation of scholarship programs for rural and small town students who aspire to become physicians, and the development of orientation and premedical support programs for these students on college campuses.

In the past, admissions policies that favor rural students have been effective in increasing the number that matriculate. However, such policies may not prove effective in the coming decade unless the applicant pool from small towns and rural areas increases. The overall national decline in the number of persons applying for admission to medical school has reduced the ratio of applicants per matriculant from 2.8 in 1974-75 to 1.7 in the late 1980s (the same ratio as in the mid 1960s) (Jolly, 1988). If not for the even


more rapid reduction of applications from rural and small town youths (Rabinowitz, 1988), this trend could provide increased opportunity for their matriculation .

Some potential applicants from small towns and rural communities may be deterred from applying by the high cost of medical education. Money has been described as medical education’s ”admissions criterion of the 1980s” (Strelnick & Younge, 1984, p.150), and it seems likely that the cost of medical education will continue to increase. These cost increases, when combined with the elimination of National Health Service Corps scholarships and increases in interest rates for education loans, have altered the economic realities of entering medicine for those aspirants who must borrow large sums to pay for their professional training. This is especially true when considered in the context of expectations of decreased earning power engendered by perceptions of a physician glut. Thus, we believe that mechanisms to provide scholarships or low-interest loans to rural and small town youths entering medical school are also appropriate and useful mechanisms to increase the number of physicians locating in underserved rural areas during the next decade.

It is important that the lengthy process of medical education and specialty training supports rather than undermines initial interest in rural practice. The provision of primary care tracks and the availability of meaningful rural externship experiences during the years of medical school can help to support and maintain interest in returning to practice in a small town or rural area. Nonmetropolitan Area Health Education Centers that include primary care residencies offer a valuable setting in which to train physicians for rural practice. They can serve as externship sites for medical students and may be especially likely to attract medical students with an affinity for rural practice into their residency programs. The nature of the community in which a physician’s residency was completed has been shown to be an important factor affecting location decisions (Denton et al., 1989). Residency programs based in nonmetropolitan settings, however, will be optimally effective in enhancing the supply of rural physicians only if they extend programs that recruit rural persons into medical school and financially support their training.

In addition to efforts that focus on training for medical careers, efforts to recruit and retain rural physicians must focus their attention on modifying those attributes of rural practice currently viewed by physicians as undesirable. Many contemporary physicians continue to maintain attitudes most consistent with traditional, solo fee-for-service practice. These include high expectations regarding autonomy, task orientation and innovation, as well as low tolerance for managerial control, bureaucracy, or rigidly defined procedural expectations. Physicians may view salaried practice in public sector settings like community health centers or public health departments as likely to violate these expectations (i.e., they may perceive such positions as lacking autonomy or peer support, as bureaucratic, or as inflexible).

34 The Iournal of Rural Health

Unless medical training changes dramatically, these perceptions of salaried positions will continue to present problems in the recruitment and retention of physicians in community health centers and other publicly sponsored practice settings. The incorporation of practice characteristics designed to overcome these perceptions, as well as traditional concerns about isolation and overwork, may help in recruiting and retaining salaried physicians for publicly sponsored rural practice settings.

One rationale for cuts in National Health Service Corps scholarships was that they failed to produce large numbers of graduates who chose to pursue fee-for-service rural practice when their service commitment ended (Mul- Ian, 1984). This may have been less a failure of the NHSC than a realistic assessment by young physicians of the economic, practical, and structural constraints on private medical practice in many rural communities. Fortu- nately, the changing basis of remuneration for physicians’ services described earlier shows that economic incentives for rural practice can be provided by mechanisms other than the free market and fees for services. Continuation of CHC salaried positions into the 1990s indicates that gov- ernment will continue to provide physician salaries for primary medical care services in some rural communities. Recruitment into these positions will have to address affinity issues, but may be more rapid and successful if practice characteristic incentives are applied and if salaries are competitive with urban locations.

A large number of new primary care residency program graduates select salaried positions each year. However, most such positions are offered by corporate-owned ambulatory care centers typically located in attractive suburban locations. It would appear that salaried positions in rural primary care will compete directly with these corporate-owned chains for recruits. While corporate-owned urban and suburban settings also have negative practice characteristics, including bureaucratic management procedures and pressures for exploitation of patients (Bock, 19881, it seems unlikely that these liabilities will be sufficient to promote the choice of rural practice unless salary and benefit packages offered in rural settings are competitive and the practice characteristics issues described above are addressed.

Even in an era of physician surplus, rural communities must compete with urban and suburban areas for physicians, and they must do so by marketing the positive aspects of rural practice and rural life. Marketing refers to something much more than advertising. We recommend multifac- eted campaigns that combine elements of economic incentives and practice characteristics models in recruiting residency program graduates. Market- ing may include guarantees of salary, hospital privileges, referral systems, or other amenities that make rural practice financially and professionally competitive with available urban placements.

Finally, it should be noted that marketing campaigns cannot afford to ignore the physician’s spouse. For a substantial number of young physicians this may mean recruiting the physician‘s husband to the community,


not the physician’s wife. Employment opportunities for the spouse have been shown to play a substantially more important role in location decisions for female physicians than for males. Ogle and colleagues (1986) reported that 50 percent of female family physicians versus 11 percent of male family physicians ranked employment opportunities for the spouse as important in selecting a practice location. Whatever the gender of the physician, it is necessary to address economic and quality of life issues important to the spouse. Bonding the spouse to the community is also critical in retaining the physician.

The retention of physicians in rural practice will also depend on their financial well-being and on their satisfaction with the care they are able to render. Local economic incentives to attract physicians must therefore be combined with broad-based political efforts to alter the current inequities in the financing of medical care in rural and urban areas. This can be addressed by enrolling all eligible rural persons in Medicaid, by moving toward a more uniform national standard for Medicaid eligibility and remuneration, by eliminating geographic and specialty-based inequities in Part B of Medicare, and by eliminating inequalities in the prospective payment system for rural hospitals.

Conclusion

Substantial changes have occurred in the past 20 years in the medical care system of the United States, particularly with regard to hospital and physician roles and the supply and demographics of the provider population. Some of these changes may make it more difficult to recruit physicians to rural areas, especially if rural communities continue to view solo fee-for- service general practitioners as the solution to their recruitment problems. Other changes, most notably the current increase in the supply of physicians relative to need (or economic demand), and the increasing proportion of young physicians in salaried practice, may increase the possibilities of attracting physicians to rural areas and keeping them there.

We believe that recruitment programs will have an optimum impact on recruitment for rural practice only if they begin by promoting health professions careers among rural high school students and continue by supporting, culturally and financially, the premedical and medical education of rural persons. Such support may help to prevent medical school and residency training experiences in metropolitan areas from desocializing these physicians for rural practice. However, even with all of these elements in place, meeting the nation’s needs for physicians in small towns and rural areas will require elements of each of the models discussed here.

An optimal national program for the recruitment of rural physicians would include state-subsidized, community-sponsored scholarships for rural youths. These should be linked to medical school primary care tracks

36 The Journal of Rural Health

and to primary care residency programs. Ultimately, the graduates of such programs must be able to obtain adequately remunerated practice opportunities in rural communities. In many rural communities this will require some combination of salary and income guarantees. Finally, some communities may be too remote, impoverished or otherwise undesirable to recruit physicians on a permanent basis. A system of indenture may be necessary to provide medical care in these communities.

Given the supply of physicians and other practitioners likely to be available over the next decade, it should be possible for rural communities to meet with increasing success in their efforts to recruit and retain providers of medical care. Achieving this success will not be easy, and will require a carefully selected combination of the successful techniques developed to date.

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