Why doctors choose small towns: A developmental model of rural physician recruitment and retention

Abstract

Shortages of health care professionals have plagued rural areas of the USA for more than a century. Programs to alleviate them have met with limited success. These programs generally focus on factors that affect recruitment and retention, with the supposition that poor recruitment drives most shortages. The strongest known influence on rural physician recruitment is a “rural upbringing,” but little is known about how this childhood experience promotes a return to rural areas, or how non-rural physicians choose rural practice without such an upbringing. Less is known about how rural upbringing affects retention. Through twenty-two in-depth, semi-structured interviews with both rural- and urban-raised physicians in northeastern California and northwestern Nevada, this study investigates practice location choice over the life course, describing a progression of events and experiences important to rural practice choice and retention in both groups.

Study results suggest that rural exposure via education, recreation, or upbringing facilitates future rural practice through four major pathways. Desires for familiarity, sense of place, community involvement, and self-actualization were the major motivations for initial and continuing small-town residence choice. A history of strong community or geographic ties, either urban or rural, also encouraged initial rural practice. Finally, prior resilience under adverse circumstances was predictive of continued retention in the face of adversity. Physicians' decisions to stay or leave exhibited a cost-benefit pattern once their basic needs were met. These results support a focus on recruitment of both rural-raised and community-oriented applicants to medical school, residency, and rural practice. Local mentorship and “place-specific education” can support the integration of new rural physicians by promoting self-actualization, community integration, sense of place, and resilience. Health policy efforts to improve the physician workforce must address these complexities in order to support the variety of physicians who choose and remain in rural practice.

Introduction

Reports since the 1920s have lamented the declining availability of doctors in rural and remote areas of the United States, and little has changed despite considerable attention to the problem (Cutchin, 1997a, Owen et al., 2005, Rabinowitz et al., 1999a). Today, twenty percent of the U.S. population lives in rural areas, generally defined as counties with no metro area larger than 50,000 residents, but only nine percent of physicians practice there (Ricketts, 1999). Sixty-seven percent of rural areas are considered Health Professions Shortage Areas (HPSAs), and the most remote areas continue to be the most underserved (COGME., 1998, Hart et al., 2002).

Unfortunately, challenges with rural recruitment and retention are projected to continue (Hart et al., 2002, Ricketts, 1999). The proportion of physicians in rural practice has fallen steadily over the past thirty years, and fewer than four percent of recent U.S. medical school graduates plan to practice in small towns (Rabinowitz, Diamond, Markham, & Rabinowitz, 2005). In the meantime, specialization in the medical workforce has increased while fewer specialists choose to practice in rural areas (AAMC, 2004). How to recruit and retain rural physicians and other health professionals therefore remains a crucial focus of rural health policy and research (Geyman et al., 2000, Hart et al., 2002, Hegney et al., 2002).

Explanations for the rural physician shortage range from a lack of attention to rural concerns at a domestic policy level to physician preference for specialties with highly controllable schedules. Disparities in physician recruitment and retention have been the focus of most studies because they can be influenced more easily than can the economic or political circumstances that also contribute to physician shortages, such as falling Medicare reimbursement rates or the decline of small-scale agriculture (COGME., 1998, Lehmann et al., 2008). In the rural health literature, recruitment has been shown to be the driving force behind most shortages, though retention is thought to hold more promise in resolving them because the factors associated with it are more modifiable. Call schedules can be changed, upbringing cannot (Pathman et al., 1994, Pathman et al., 2004, Rabinowitz et al., 1999b) (Table 1). Nevertheless, effective mitigation programs address both recruitment and retention as well as community and regional development (Porterfield et al., 2003).

Of all of the factors involved in effective recruitment, “rural upbringing,” defined as spending all of one's childhood in a rural location, more than ten years in a rural location, or calling a rural place one's childhood home, is the strongest predictor of rural practice choice (Geyman et al., 2000, Laven and Wilkinson, 2003). However, despite the attention paid to its importance, there is little understanding of the process by which upbringing influences later affinity for rural settings. Furthermore, this finding does not explain the fact that 74% of rural physicians were not raised in rural settings; presumably, some other experience or “component” of a rural upbringing influenced their decision about where to practice (Owen et al., 2005, Pathman et al., 1994).

Scholars in other disciplines have identified characteristics associated with rurality that are thought to influence behavior and life trajectories (Beggs et al., 1996, Bell, 1992, Ching and Creed, 1997, Kahn, 1997, Williams, 1975), but these literatures have generally not been applied to questions of rural health and physician shortages. Specifically, scholars suggest that despite the fact that people's experiences of “rural” are widely variable (Christman, 2004, Woods, 2005), there are fundamental cultural and physical differences between urban and rural spaces which are remarkably consistent and persistent through space and time. Geographically, rural places are defined by their low population and material resource density (Christman, 2004) while psychologists and educators find that rural people interact more with their physical environment and rely more on natural cycles and resources (Lockhart, 1999, Woods, 2005).

Meanwhile, ethnographic studies in rural communities have consistently described characteristics of a distinct “rural culture,” including a focus on community (Slama, 2004) and a valuation of practicality and resilience (Philo, Parr, & Burns, 2003). These studies suggest that rural residents see themselves as pragmatic, community-minded, and able to endure challenges because of their prior experience with hardship. Whether or not these differences are always present, they create functional dichotomies between outsiders and insiders (Bell, 1992, Pugh, 2004, Halfacree, 1994) and can create differences in practice and residence choice between rural and urban-raised physicians.

Importantly, not only do rural-raised students seek out rural environments in general, they also tend to practice in communities in the general size range of their hometown with statistically significant regularity (Costa et al., 2006, Matsumoto et al., 2008). Qualitative studies also show that physicians describe an explicit motivation practice in a community similar to the one where they were raised (Kazanjian and Pagliccia, 1996, Tolhurst, 2006). These findings are consistent with twin studies that show that residential environment as a child accounts for more than 50% of the variance in residence choice for younger adults (Whitfield, Zhu, Heath, & Martin, 2006).

In addition to prior rural residence and familiarity, other experiences, including a rural residency track, a rural medical school track, a history of community service, plans to practice family medicine upon entry into medical school, and loan repayment program participation are also independently predictive of future rural practice (Table 1). Past studies have suggested that these factors are mainly a manifestation of an existing inclination toward rural practice (with the exception of loan repayment program participation), but are sometimes important in identifying or influencing specialty choice in undecided students (Rabinowitz, Diamond, Markham, & Paynter, 2001). It is not known how the initial “rural inclination” is developed or fostered over time.

Though rural physician retention is generally assumed to be poor, four of five relevant studies show that it is actually comparable to urban settings, and is also equivalent between more and less underserved rural areas (Luman et al., 2007, Pathman et al., 2004, Philo et al., 2003). However, keeping physicians in rural areas remains important because they are so difficult to replace. Efforts are now being made to retain doctors in rural areas even longer than in urban settings to help offset poor recruitment (Rabinowitz et al., 2005).

Studies have consistently shown that practice-related and lifestyle factors, such as compatibility with the medical community or parenting a minor-aged child, play much more of a role in retention than “pre-determined” factors such as upbringing, training, and community service orientation (Mayo and Mathews, 2006, Rabinowitz et al., 1999b). In other words, physicians are generally willing to practice in seemingly “undesirable” or unfamiliar communities once they become settled; those who experience intolerable and unmodifiable circumstances emigrate at approximately the same rate as physicians in urban settings. These more flexible factors that do influence retention include workload, financial sustainability of practice, compatibility with the local medical community, owning one's own practice and “sociocultural integration,” the extent to which a physician becomes involved in their new community (Cutchin, 1997a, Pathman et al., 2004) (Table 1).

Another important component of retention is a smooth initial transition to a new cultural and practice environment. Surveys and qualitative studies show that interventions supportive of initial integration, such as informational orientations, introduction to important community contacts (Han & Humphreys, 2006), and “nurturing” of physicians by recruiters, other physicians, and community members (Felix, Shepherd, & Stewart, 2003), can improve integration and retention.

Cutchin (1997a) developed a model of physician integration/retention that describes an obligatory and ongoing process in which doctors attempt to maintain their security, freedom and identity within a particular community and occupational context. While striving to develop these foundations, physicians interact with their “places” in a way that integrates them, barring intolerable conditions that force them to leave (Cutchin, 1997a, Cutchin, 1997b). This study is one of the first to describe integration/retention as a process, moving beyond the identification of isolated “influences.” It also emphasizes the importance of the physician's environment, which many studies tend to downplay, instead emphasizing physicians' personal characteristics. However, the applicability of this model is limited by a lack of description of the psychological processes physicians use to integrate, making the design of interventions difficult.

Two concepts that can potentially fill this gap are sense of place and community participation. Sense of place refers to the affective bond that people form with places, and has also been termed “place attachment,” place identity, and rootedness (Heidegger, 1962, Low and Altman, 1992, Massey, 1994, Tuan, 1977). “Place” in this context commonly refers to the multidimensional nature of a given location, including both the “natural” and “social” aspects of that site (Seamon, 1980, Tuan, 1977).

Chawla, 1992, Sobel, 1996, and Hay (1998) have described the development of a sense of place as a process that mirrors the formation of relationships to places in childhood and moves from empathy for the familiar, to exploration of the home range – particularly natural places such as woods and lakes, to social action, where people move their focus back into town and become more involved in the community and the application of their knowledge.

The development of community engagement and participation is less well-theorized than sense of place, but is highly predictive of rural recruitment (Daniels et al., 2007, Madison, 1994, Tolhurst, 2006) and retention (Carlier et al., 2005, Pathman et al., 1998). Furthermore, as discussed above, community engagement is one of the hallmarks of rural-urban differences and facilitates successful adjustment to rural living.

In addition to striving for community and place integration, physicians are motivated by a desire to live happy and satisfying lives. This idea is succinctly expressed in Abraham Maslow's hierarchy of needs, which suggests that people sequentially work to satisfy increasingly complex “longings,” moving from basic physiological needs to a need for morality, creativity, and truth (Maslow, 1954) (Fig. 1).

While Maslow's work has been extensively criticized for being excessively individualistic (Geller, 1982), nativistic (Neher, 1991), and not reflective of the multiple motivations and strategies that people employ in the pursuit of fulfillment, it is also widely used and intuitively understandable in fields ranging from business to education (Keil, 1999). Therefore, despite limitations, Maslow's hierarchy serves as an effective jumping off point for this study because it provides an applicable framework for administrators, policy makers and program directors to understand physicians' motivations.

A “rural upbringing” is known to be the most important predictive factor of rural physician recruitment as well as a catalyst of retention, but little is known about the means by which this occurs. An interdisciplinary review of the literature implicates a variety of factors in this process, including sense of place, community participation, self-actualization, and familiarity, though little is known about how these components act over time. In this study, we used qualitative methods to examine and describe the process by which both urban and rural-raised physicians choose, settle into, and stay in rural settings. From our findings, we developed a descriptive model, informed by both existing literature and our data.