David Luck and Robert Bowman
The search for a practice is a big step in the career of a physician. Most of the studies in searching for a practice has been done retrospectively. One concern among health care is recruitment of physicians to communities that are under-served. According to the latest AAMC statistics, rural interest among 4th year students dropped from 23% to 12%. Even more frightening is the need to replace over 50% of the 16,000 rural physicians as they are fast approaching retirement.
In a 1985 study, Kindig and Movassaghi showed that family physicians constituted nearly 80% of the primary care physicians in small rural counties, and of all physicians in rural practice 86% of them were primary care physicians.1 When looking for a practice for the first time, 80% said they wanted to go into a group practice while only 7% said they desired solo2, but in rural practice, 44% of U.S. office-based rural family physicians were in solo practice.3 Other studies have shown a correlation between the place of residency and the first practice. In a Texas study, Denton researched the distance of the 1st practice site from a physician's residency. He showed approximately 40% of physicians moved less than 10 miles away and greater than 50% moved approximately 75 miles away from the residency. One flaw in this study was that he ignored the reason the physician chose the residency. Physicians might have made the decision from medical school on where they want to practice and chose the residency for the purpose of practicing there. Another factor is the age of the residency. Graduating residents fill local spots and then move outward. Residency location does seem to be a big factor on practice location.
As shown on the overhead, the process of searching for a practice not only includes the practice itself, but also the region, the availability of loan forgiveness, the ability to meet family needs, the practice package, and the type of practice. Other factors include the fit of the community, the schools, proximity to other things such as the big city, family and friends, and the situation of the hospital.
Methods
I did a preliminary prospective study using the third year residents of East Tennessee State University in all three locations in the Tri-Cities. We interviewed 12 of the 14 residents (two did not want to participate) informally at either the clinic at each respective site or at the hospital. Most of them were at the beginning of their 3rd year, with a couple of them being off-cycle and graduating in November. This study was a qualitative study in which I asked them questions about their search process such as when did or will you begin, what are you looking for, who did you receive information from, and how did you use your rotations to prepare for practice. I also had them fill out a background information sheet such as hometown, medical school, and spouse information. Then I had them rate a set of characteristics we developed about what they were looking for in a practice. Finally we started a diary on each of the residents still searching for a practice site. This diary keeps an account of whom the residents have been in contact and the number of contacts they received in the last two weeks. This diary will be given out periodically and returned to Dr. Bowman.
Results
In our study of 12 residents, only three residents were from a small town (which we classified as less than 50,000). Two of them wanted to return to a small town, and the other one wanted to go to a large city. Seven of the remaining 9 who were from a city larger than 100,000 wanted to go to a small town, and the other two wanted to return to a metropolitan area.
In listing the search characteristics, the two main ones that appeared were geographical search and pursuit of loan repayment. With geography, 8 out of the 12 residents wanted to stay in this area of East Tennessee, Western North Carolina, and Southwest Virginia. Two of the other four are going to Georgia - one because of loan obligation and the other because his wife likes Atlanta. The remaining two want to go up North to be close to family. The resident looking out west is also looking in this area.
Spouses played an intricate part in 6 of the 8 with spouses. One physician even said his wife does all the talking to recruiters.
Interest in rural medicine began before medical school for 50% of them, and three of the remaining six started being interested during medical school. Of the remaining three, one became interested during residency, one is not sure about rural practice yet (waiting for rural rotation), and one is considering urban underserved.
The mode of the search varied from very active to very passive. The very active physician obtained a phone book of the desired area and is starting to call all the surrounding hospitals. Several physicians have or plan on doing rotations near the area they want to practice. A couple of physicians plan on doing a fellowship to give them extra time to find a practice. Several are examining what's available through the mail and recruitment fairs, planning to call the place if it looks interesting. Those who don't find a practice mentioned doing some ER or locum tenums in order to provide more time.
In our study, we found out 50% of the residents had specific deadlines between November and March in which they wanted to find a practice. One resident started after his 1st year and has found a practice, and two others began 1 1/2 year before graduating. The other 50% are just wanting to find something before they graduate.
In dealing with the type of practice residents were looking for, 8 out of 12 said they wanted a group or partnership. One resident mentioned he wanted a solo practice, while one is still undecided. As shown here, one wants to do ER, and another wants to start his own group practice.
One thing that was interesting was last year when Kevin Buchanan did this study on 3rd year residents, a majority of them didn't use a lawyer before signing a contract. In this year's class, 10 of the 12 residents are using a lawyer. Many talked to last year's class and found out they didn't include some of the things they wanted in a practice because of failure to use a lawyer.
Finally, residency was used by most residents to improve their skills at procedures they wanted to incorporate into their practice such as OB and endoscopy. One resident said he made a point to notice the way each practice was managed because he plans on starting his own practice. Four residents used away rotations to get closer to the place they might plan to practice, and one resident did an away rotation because the physician had a practice exactly the way he wanted to practice by being the only general surgeon in town. With family practice being so diverse, interest within family practice was varied. As shown on the overhead, each physician wanted to incorporate a little something different into their practice.
Discussion
The study is useful for several groups. One perspective is that of the community. Just in this preliminary study, it has shown communities should take a more active role in recruiting. Many residents thought most recruiters, which they called headhunters, from big firms were bothersome and untruthful. They would pretend that they were doctors in order to beep them at the hospital, and they would call them late at night at home. One resident said he didn't like paying a person $20,000 to leach off of what he had done for the last 12 years. Also residents said recruiters cared more about getting paid than the actual needs of the physician. A few recruiters were thought useful as long as they were honest with the resident. Communities should work through the hospital, recruitment fairs, and local physicians in their recruitment efforts. Local physicians should get involved in medical associations. Communities should recruit the whole family since so many spouses are involved in the search process. Furthermore, since most physicians are looking for a group practice, communities should make an effort to establish and maintain a strong group of physicians. Finally, many physicians go to a rural area for loan forgiveness. Once physicians arrive, communities should ensure support of their practices and their needs. Additional physicians, if needed, should be recruited as well.
Another perspective is that of the researcher. Rural health care is in need of physicians. Since, in our study, 50% of the residents had interest in rural health care before medical school, medical schools should take rural interest into consideration for applications. Also past studies as well as this study showed students from small towns often return. Schools should concentrate in taking a few students from rural areas. This hypothesis would have to be studied by following students with an interest in rural medicine from the 1st year of medical school all the way into their practices. Also medical schools should incorporate more rural programs (like Kellogg, the Appalachian Preceptorship, etc.) to expose students to rural medicine and the lifestyles of the physician and patients. Some studies have shown that the preceptorships in rural medicine has influenced the career choice of physicians. Residencies should include more community practice and a complete rotation on practice management. Most residents felt this was their weakest area. Residencies should consider students who are not committed to another state for loan obligation or students who have loan obligation to the residency's state. When residencies take physicians obligated to another state, after 3 years they must go back to their state instead of staying in the area. On the other hand, they could be an investment for their return after their obligation.
The final perspective is that of the resident. Through this study, residents who had a set idea of what they wanted in a practice and who started looking early were less pressured. One resident suggested residents should start after the 1st year and do their homework before each interview so unnecessary questions wouldn't have to be asked. They can then get the most out of the interview with the little time they do have. Also residents should maybe plan a rotation in an area they would like to practice in order to get a feel for the area. Setting deadlines may or may not be a good idea for everyone. If a deadline forces the resident to be more efficient with their search, it might be helpful. If a deadline forced the resident into a poor or less than optimal practice, the deadline might be detrimental.
Conclusion
To make this project effective, two more interviews during the third year need to be done - one during the middle and one at the end of their third year. This, coupled with the diaries, will show the progress of the practice search by the residents and help identify critical times and factors in the search. Matthew is starting a study of the physicians now in practice who went through this study 2 years ago. This follow up study would identify if expectations were met and what communities could do to retain the physician.
Residents search for practice in different ways and look for different characteristics. Residents should use their rotations to formulate an idea of the practice and community that they would like. Communities should focus on factors (geography, loans, spouse and family needs, proximity to cities) that would attract physicians in order to make the search and recruitment as effective as possible. Communities should be honest about their limitations. Residents who receive incorrect information will mark that source or community off.