The Three R's of Rural Physicians

Ripen, Recruit, and Retain

Robert C. Bowman, M.D. 

 

Ripening rural physicians

The choice of a career as a rural physician begins in many different ways. Some students have  always known that they wanted such a choice. Others get a taste of rural or family medicine  through their local doctors. Some select rural practice in medical school under the influence of  experiences or the need to pay debt. It is well documented that rural background students are  more likely to choose rural, however half of rural physicians come from urban areas and little is  known about what influences them to choose rural. Rural experiences, programs, faculty, and  preceptors influence some students. Most medical students enter interested in primary care.  Many have rural interest. The challenge in ripening is keeping these students interested  throughout their training so that they resist the urban subspecialty tertiary environments of  medical education. 

What Communities Can Do to Ripen Rural Physicians

Educate students well - The community starts the process of becoming a rural physician by  maintaining educational quality in local schools and supporting health career education efforts.  Offer preceptorship training - Communities can help by offering community-based training.  There is some evidence that the most influential rural experiences are those which get the  students or residents involved in their communities. Students should meet local health providers  and local leaders. They should have a chance to visit community events and churches and  meetings. What most impresses the medical students during rural experiences is the time that  rural physicians spend with them. They also appreciate how the office, hospital, and community treat them. The effort of Nebraska rural communities in educating students and  residents is a critical part of their education.

Track previous students and residents - Communities should keep track of those who have  spent time with them and should keep in contact with them. Periodic contact with them will help  identify those who are actively seeking practices. Generally the practice search begins 12 to 18  months before graduation from residency. The first step in medical school is selecting those most likely to choose rural health careers. This  involves overcoming obstacles that rural health interested students might note, such as 

The best method of overcoming these obstacles is a two directional outreach from both the  medical center to high schools and colleges and from the community to the medical school.  UNMC's RHEN and RHOP programs and career fairs, visits by faculty to rural communities,  and efforts by health professions associations, local rural providers, and local schools are such  examples.

The selection process itself is important. More and more the goal of admissions  committees is to come up not only with top-notch students, but with those who are likely to choose rural primary care. Studies have shown that rural citizens and rural physicians may be a  great help here. Rural physicians and faculty who have been rural physicians serve on the  admissions committee. Dr. Jeff Hill is the dean of admissions. He was a rural physician  for several years in Geneva.  Rural preparation involves:

  1. Good fundamentals of medicine
  2. A comprehensive scope of training 
  3. Taking responsibility for patient care, not just watching 
  4. Comfort with a hands on style of medicine, including procedures

Current medical education also raises some concerns for those in rural communities. Small  towns have always had doctors who could do procedures and they expect this. Students and  residents have much less training in procedures. Specific rural preparation addresses this need. New additions to medical training that should improve the quality of future rural physicians  1. Training in talking to patients 2. Specific ambulatory and primary care training 3. Increased use of rural training tracks and rotations

A key area for many students is a role model or mentor. Some are encouraged in medical  pathways by home town physicians. Others meet role models in medical school or residency.  Role models are people that can help them fulfill their plans and dreams. Medical training  includes little career preparation and role models can help greatly.

 

Recruit 

Recruitment must be a total community effort. This involves current rural physicians and other  local providers, community leaders, and facilities. There must be a need for a new physician.  Communities must assess this first. If there is not enough demand yet, but the new physician will  attract market share, there must be support for the first years or even permanently. Another option is a PA or nurse practitioner. Important to the calculations is a stable or improving local  economy. Bringing a new physician in without dealing with these basics will lead to increased  turnover of providers and ultimately a loss of market share. Each time small communities lose  doctors, they lose a few more patients to more stable medical communities outside their locale.  With delays of 12 to 24 months to recruit new physicians, many people can permanently leave  for care elsewhere in a short time. Communities must maintain a constant effort to improve  quality and increase market share. They cannot afford to wait until someone leaves.

What Communities Need to Recruit Well

  1. Financial support for personnel, meetings, and planning This is a total community effort by individuals, facilities, local governments, recruitment  fund raisers, and foundations. The process of working together is as important as the  money. One person half or full time should focus on recruiting.
  2. Identification of likely candidates Involvement in training, contacts with medical students and residents (send your physician  to teach at the residency program once a month as some communities do), use of state and  federal resources and lists, recruitment fairs here and at Kansas City each August.
  3. Utilization of all local resources Use community people of all walks with various talents
  4. Identification of areas of strength and areas of weakness Areas of strength can be emphasized, areas of weakness addressed.
  5. Specification of the call and duties with attention to equitable distribution Working out this area can be a pain but it is a key area for losing candidates
  6. Satisfying the needs of current physicians Current physicians can assist the process or impede it totally
Recruitment Trends
  1. The demand for primary care is going through the roof as doctors retire or leave active practice and ERs and city-based HMOs recruit. The competition is tough and organized.
  2. Nurse practitioners and Physicians Assistants are in similar great demand
  3. Many small rural communities with one or two doctors will lose their services without special efforts.
  4. Hospitals will be less able to shoulder the leadership in recruitment
  5. Salaries and benefits for new primary care doctors will continue to rise
  6. Current rural physicians will often be upset by recruitment packages 
  7. Current rural physicians will be doing a bit better with changes in reimbursement, if they access them
  8. More and more women will graduate in primary care fields A special note about female physicians - Women physicians may focus a bit more on support  issues such as call, referral networks, and colleagues. Some need more flexibility to be able to  function as a mother and spouse as well as a physician. Split call and alternate office hours can  be worked out to meet these needs. If the spouse is also a physician, there needs to be great  flexibility in the arrangements for call and practice hours. Some female doctors will have a  deluge of female patients that can be overwhelming to them as well as disturbing to other  physicians. Other women physicians or professionals in town can be a great help in the  recruitment process.
Common strengths to emphasize
  1. Good call arrangements of every five or six nights or a covered emergency room some or  all weekends
  2. Physicians already in the community that are the same age or sex or family status 
  3. A group practice to join
  4. Nice clinic or hospital facilties
  5. Cooperative physicians, administrators
  6. Good schools with high (over 80%) college attendance rates
  7. Stable or improving economy 
  8. Nearby recreational or cultural opportunities
  9. Practice management help
  10. Specialists rotating in town or otherwised available for backup or consultation 
Common weaknesses to address
  1. Inadequated (inadequate and antequated) clinic space
  2. Promises that cannot be kept - At best the candidate will not come, at worst they will come  and stay a year and destroy your medical community in dissatisfaction.
  3. Inadequate financial support for guarantees, start up costs, and debt. Most start at over  $90,000 or more based on their training and procedures. Start up costs can run over $20,000,  less if starting with an existing group. Debts depend on many factors, but a loan repayment over  3 - 5 years can aid recruitment and retention It is important to remember that each candidate is unique. Each has different personal, family,  social, and financial needs. Each has different training and different strengths and weaknesses.  A candidate with local connections, family, procedural training, and an loan obligation to stay  may be worth over $50,000 more than one who has little of these assets. Communities must be  flexible and have the resources to make these kinds of offers on the spot.  Resources must be gathered to support extra packages to meet the current market situation. It  may take over $100,000 for support of salary, overhead, loans (practice, educational, home),  facility, and startup for each physician. Those who choose primary care do not do so because of  the money. Money and the salary package is not as important as security and knowing that one's  needs are being addressed. Practice management and consultation is money well spent for new  physicians. They have little interest in learning this during training. Upon graduation it  suddenly becomes important. A supportive group practice can help much in this process.
  4. Seeming too desperate - Physicians react to how things feel or the potential for overwork.
  5. Lack of local housing - Some communities have a nice house available for the new physicians  to use for a year or so if this is a problem.
  6. Local job for a spouse to ensure involvement with the community
  7. Poor utilization of interview time - A few key enthusiastic individuals may be better than a  whole host of citizens. Interviews should target the interests of the recruit and the spouse.  Someone in the community or the recruitment committee needs to interview the candidate over  the phone to identify their needs and interests, and then decide how best to use the community  resources to address these. Communities that show that they have people that can be colleagues  and friends are more likely to succed. 
  8. Trying to appeal to everyone - Each community is unique, as recruits soon find out when they  arrive. It is better from them to discover this in the search process. Communities should focus  on their uniqueness and implement this in their mailouts, contacts, and interviews.
  9. Inadequate use of available resources outside the community (State and UNMC) - Any time a  physician decreases his or her practice, communities should notify the state office. Once a  county is a shortage area, current physicians can qualify for better reimbursement and state and  federal resources can help more with the recruitment process.
  10. Stopping the recruitment process - The time to recruit is always. Stable medical communities  have 4 or more physicians. Sometimes it will take two or three towns working together to  accomplish this as Nebraska has 75 counties with less than 6 physicians. Many doctors are  nearing death or retirement. With the average stay of rural physicians being 5 or 6 years and the  average recruitment time being over a year, one physician will be needed every year.  Communities that plan ahead can sponsor students or residents or target students or residents who  train there on rural rotations. Other opportunities may arise and smart communities will be  ready. For instance a husband and wife team may be interested or two physicians may want to  practice together in their community. Communities that have the resources collected will be most  likely to endure the difficult recruiting times to come.
  11. Involving local physicians in the process or depending on them too much - It is important to  attend to the needs of current providers. They must be involved in the process. They need to be  enthusiastic. Rural practices are highly competitive. For established physicians to fully help out,  they must feel secure as well. Some communities depend on the physicians or the hospital to  recruit. Recruitment must be continuous and must involve the total community. Those who wish to recruit must work to establish a good relationship or "marriage" of the  provider with the community - financially, socially, and emotionally. 
 

Retain 

Recruitment begins with adequate retention of current providers. Areas with high turnover suffer  from patient frustration, loss of market share, and are suspect in the eyes of new recruits. It is a  tough process to ferret out problem areas, but many communities must do this or lose their health  care entirely. The initial expectations of the recruit must match the real world situation in the practice -  business management, referral networks, personnel situations (nurse and office) Retention is every bit as important as recruitment and needs similar resources.  Retention needs a committee and a personal touch to deal with difficult situations and individuals.  Physicians go through periodic crises due to family, personal, peer, patient, and other situations.  Paying attention to these needs can do much to keep physicians and help them with their  services. A few key areas include

  1. Lack of practice management skills Physicians learn by doing. Practice is the first time that they learn about PM. A little  help or consultation can prevent some big mistakes.
  2. Getting the spouse involved in the community
  3. Identifying expectations and assuring that they are met. Physicians are great at leaping to diagnoses and conclusions. They may develop unrealistic expectations of those around them. The recruitment and orientation process  can help remedy this.
  4. Rural practice is hard, but rewarding work. Most physicians do not anticipate this. Support and some advice by key individuals can  help ease the transition into and established practice. Rural practices are not given, they  are made by those who choose them working with those who are there.
  5. Most physicians need to grow up and mature. To get into medical education, many have focused on academics to the exclusion of  personal development. Many are so critical of themselves and others that they are  difficult to deal with. Advice from peers, colleagues, and key community leaders can  help them mature rather than having them "take their ball and go home." One suggestion is to keep up with the needs of current physicians and use resources to meet these  needs. Some have not provided for college for kids or retirement. Others are active in the  community, but have no support for these efforts. Some would benefit from increased mental  health or social worker assistance available at their clinics. 

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