The pathway to rural practice is long and involved. Inherent in the interviews was a series of transitions from one stage to another. Recruiting was noted to be a courtship experience. Starting practice was like a marriage. This was similar to the family life cycle and thus the name Rural Physician Life Cycle. Physicians endure recruitment to move into orientation. They then work to build or establish a practice. They then enter Maintenance. Eventually they begin to taper their practices. Indeed one can make several life cycle observations comparing courtship and recruiting, and marriage with choosing partners and colleagues or even the town. Most of the physicians did seem married to the town. This study deals primarily with the two stages of the Life Cycle regarding Orientation & Establishment. Those who had established a practice or were almost there gave much information on the difficulty of this stage. These physicians highlighted several dilemmas in building a practice.
Family medicine developed a family life cycle perspective to provide a frame of reference for studies of the wide range of stages and relationships of the family (REFERENCE - Carter). Rural health researchers need to develop a perspective that involves a series of stages and transitions that a rural physician undertakes during a lifetime. A "rural physician life cycle" would involve stages such as preparation and training, searching and selecting a practice, initiation and orientation, establishing the practice, and practice succession. The rural physician life cycle perspective would provide a framework to define similar types of physicians for comparison and study. This perspective would simplify the examination and interpretation of key issues such as relationships, practice needs, and personal needs. Studies of physicians at the same stage of practice could reveal much about issues important to retention. For example, new physicians initiating a practice face different issues that physicians nearing retirement. Physicians at different stages may have more difficulty in important areas such as cooperation. A whole series of rural physician life cycle studies could establish the relative importance of personal, family, practice, and community factors. No study has yet attempted such an effort. As Cooper noted in 1972, "the key factors have not been identified or enough effort has not been expended exploiting the known factors." (Cooper 1972).
look to revise:
A proposal for a rural physician life cycle follows: 1) Preparation for Rural Practice (Medical School, Residency, Moonlighting); 2) Search for a Rural Practice (Information sources and methods); 3) Deciding for a Rural Practice (practice opportunity, personal and family needs, community factors); 4) Initiation and Orientation (Logistics, key contacts, referrals, associates, mentors, and friends); 5) Establishing a Rural Practice (Economics, experience, skills, maturity, balance, involvement); 6) Maintaining a Rural Practice (Planning, keeping up, solidify relationships, future security issues); and 7) Transitioning the Rural Practice (preparing for leaving practice or retiring). The use of the rural physician life cycle may clear up some contradictory findings in previous workforce articles.
evashwick cj the role of group practice in the dist of phys in nonmetro areas med care 1976 14 808
harvey 109 gp in canada the vanishing practitioner j med ed 1973 48 718
Hartlaub, P. P. and Gordon, R. L. Rural Practice Preference, Perception, and Reality, Archives of Family Medicine 1993; 2:1198-1201
Madison, D. L. and Combs, C.D. "Location patterns of recent physician settlers in rural america" Journal of Community Health. 1981; 6(Summer):267-274.
Pathman, D. E., Konrad, T. R., and Ricketts III, T. C. "The Comparative Retention of National Health Service Corps and Other Rural Physicians", JAMA, 1992 268(12) 1552-1558
comparison to family life cycle
rationale - compare to methods to increase in fp production, early and often, admit, curric, environ (student interest, research), role model (pc rural urban) several programs and most successful
fulfill mission for states institutions
crisis and in crisis all points are potential solutions if no obvious problems
Ten Steps to Successful Rural Practices
1. Preference for the rural lifestyle - Best candidates for recruitment and possibly longer term retention
Rural background and quality education - Rural education must be high quality, educational programs must overcome problems in some urban and rural populations where expecations of peers, parents, and schools are not high
Premedical career experiences in high school and college
especially for disadvantaged
Rural community and higher education partnership
2. Transition to medical school - more effective admissions policies and committee composition
Best is to force primary care practice for at least four years after residency graduation before specialization allowed. Then all of the priorities fall into place. Students desiring subspecialization will think twice. Faculty will know primary care is the priority. Pick a date in three years and begin notifying high school and college students and colleges.
Reverse current thinking where academic performance is king and rural and primary care are tracked separately. Prioritize rural and primary care (sometimes rural alone for some states) and separate tracks for a few gifted individuals - Ten AHOPS (Academic health opportunity program students) instead of ten RHOPs per class. Choose the 25% that are exceptional as potential leaders, clinicians, and researchers, then make a pool of two to three times the current class size that are the best available candidates, then accept the candidates in this pool that fit criteria for those most likely to serve rural and disadvantaged. Class of 120, pick top 30 exceptional, pick next 240 best, of these 240 choose the 90 most likely to serve disadvantaged ethnic, racial, urban, or rural populations.
3. Early rural exposure
4. Transition to clinical
5. Clinical experiences
Rural experiences
Hands on responsibility for real patients in ambulatory and hospital practice, including comfort with procedural skills
Ambulatory emphasis and training
7. Transition to residency program with rural emphasis or curricula
8. Preparation for rural at the residency level
Curricula
rural experiences
practice management
procedures
Faculty
advisors
8. Transition to rural practice, search process, recruitment
Ready access to key information about the types of rural practices available
Choice of a good "matching" rural practice
State, medical institution, rural community partnership
9. Initiation of practice - Good orientation and practice foundation
groups
role models
adjusting to the workload, the community, the practice, and changes in personal and family
10. Establishing a practice and position in the community
Comfortable with the role
expectations of self
expectations of peers
expecations of community
physician, manager, lead physician or not
overcoming grass is always greener
Truly effective as a physician
delegation, personnel, information
CME
financial responsibility and risk
Best accomplishing last steps - strong local rural health system in partnership with state
Physician is part of an effective rural health system with acceptance by locals of need for own efforts and responsibility, rather than blaming externals for problems
State/med center supportive
If defective system, physician can be sucked into other roles and more easily overwhelmed
Kronhaus AK An Organized Locum Tenens Service and the Cost of free time for rural physicians Medical Care December 1981 Vol 19 (12) p1239-1245 better in solo, 85% exceeded cost done 1976 18 mon
120 days, six clinics, 279 days coverage in 35 episodes 3d to 4wk average of 279/6 or 45 days coverage per clinic or 20 days per doc
Cordes, S. M. "Factors Influencing the Location of Rural General Practitioners," West J. Med. 1978; 128(Jan):75-80.
j kansas med soc 1968 69 84
bible bl physicians view of med practice public health reports 1970 85 11
cooper jk heald k samuels m coleman s rural or urban practice inquiry 1975 12 18
eisenberg bs cantwell jr policies to infl the spatial dist of phys, med care 1976 14 455
Denton, D. R., J. H. Cobb and W. A. Webb. "Practice locations of Texas family practice residency graduates, 1979-1987," Academic Medicine. 1989; July:400-405.
Dorner, F. H., R. M. Burr, and S. L. Tucker. "The geographic relationships between physicians' residency sites and the locations of their first practices," Academic Medicine. 66(9):540-544.
Pathman, D. E., personal communication
The methods used by retention researchers can Another possibility for the confusing results is . Various methods of retention research were examined in a recent study by Pathman. Causal reports or surveys of physicians who leave often report external problems such as poor professional supports, long work hours, and poor pay rather than problems with themselves or other more delicate matters. No one readily admits that the work was too hard or that they had poor interpersonal skills. Satisfaction studies attempt to correlate retention of physicians with job satisfaction issues, but the factors identified may not actually predict attrition. Workload has been associated with satisfaction in one study (Mainous 1994). Other retention studies use statistical correlations, but these have not moved beyond the level of self-reporting to actually test the factors in question such as a specific type of attitude toward work or the balance needed between workoad and time off.