How can we attract the physicians we need and support their practices within our community?

Despite various reports over the past two decades that have predicted or indicated a surplus in the overall supply of physicians, the relative shortage of primary care physicians in rural areas of the United States, including rural Texas, is one of our nation’s most pervasive health care trends. One fifth of the U.S. population lives in nonmetropolitan areas, but less than 11 percent of the nation’s physicians practice in those areas. Compared to their urban brothers, residents of rural areas are older, sicker, poorer, less educated, less likely to be insured and more accident-prone. This hierarchy of medical neediness only magnifies perpetual primary care physician shortages in rural areas.

Attempts to classify where physician shortages exist and why they do is at best an inexact science. Historically, one popular method for determining shortages, at least for statistical reporting and grant application purposes, is the Federal classification of the Health Professional Shortage Area (HPSA). This designation is based on reporting the physician-to-population ratio within a given health service area. In Texas, this translates to entire counties or partial counties that can be designated as HPSAs. This classification recognizes shortages of three professions: primary care physicians, dentists and mental health professionals. It is based on three criteria: the service area rationality for healthcare delivery; a population-to-physician ratio in the service area that is greater than 3,500 to 1 (compared to the Federal ratio for “adequate service” that is 2,000 to 1) and the relative lack of access by the population to surrounding area primary care resources and/or professionals.

This designation opens the door to a broad selection of governmental assistance plans, but because it is geographically weighted, it suffers from a lack of precision. For example, it often does not measure acute shortages of physicians versus relative shortages as compared to staffing levels in a nearby urban area. The impact of other related Federal shortage designations, such as Medically Underserved Populations (MUPs) and/or Medically Underserved Areas (MUAs) must also be taken into account in researching the need to recruit physicians to a given community.

For up-to-date information on which Texas counties or partial counties fit into these designations, which are reviewed annually, see the Health Professions Resource Center (HPRC), Office of Policy and Planning at http://www.dshs.state.tx.us/chs and scroll down to Federal & State Shortage Designation Programs. This site also provides Texas’ supply and distribution information on dozens of health professions, and is a good place to start researching health workforce concerns, including those on physician supply.

But, for a community to determine if it needs to recruit a physician, and how quickly, and what it needs to do to retain that physician once recruited, is not just a matter of statistical analysis, it is a social, cultural and economic phenomenon similar to courtship and marriage. It is all about “making a good match.”

The criteria for keeping everybody happy in community physician recruitment and retention “wedlock” can be divided into three basic categories. First, there is the appeal of the community itself—its geography and climate. Community appeal also includes the demographic and cultural mix of the population, the health of the local economy and its services and diversity, tax rate, availability of housing and cost of living, per capita income and population trends.

Then, there are social and lifestyle factors to consider. For instance, will the physician’s spouse find adequate employment and/or access to volunteer and educational opportunities? Can the physician and family attend “the church of their choice” in the community? Will the physician and family find the schools, and mix of educational opportunities, acceptable? Are there recreational outlets and cultural events readily available—and if not, is there an airport nearby?

Finally, there are the all-important practice considerations, the questions every physician considering a practice site will ask: Will the practice function as a solo or group practice? What are the percentages of daily outpatients and hospital inpatients? What is the expected frequency of nighttime or weekend call? Is there a guaranteed salary, a housing stipend, a buy-in agreement? Who will manage the practice and hire and train the staff? What is the availability of trained support staff, management, daily patient census, equipment, referral/tertiary care patterns, relationship to the community and ability to cope with changes in the healthcare climate?

For the match to work, both the community and the practitioner have to meet in the middle of these criteria. Rural communities need to look for candidates who live by “small-town values,” and express a desire to become an integral part of community life.

Attributes that make rural practices a “hard sell,” include professional isolation, lower fees for services in rural areas, lack of access to hospitals and technology, perceptions that rural areas lack entertainment and cultural features and long hours. Rural family physicians work 10 to 15 percent longer hours and see approximately 20 percent more ambulatory patients per week, while earning 15 percent less than urban family physicians. As a rule, rural physicians also derive a greater percentage of their gross practice revenue from Medicare and Medicaid patients and uninsured patients than do metropolitan physicians. Diminished reimbursements from these federal programs as partial fallout from the federal Balanced Budget Act (BBA) of 1997 have contributed to the fiscal risks of rural practices.

A community can improve its chances of successfully recruiting and retaining needed physicians if it begins with a “needs model.” (See Toolbox section on Assessing Community Needs) Based on current growth and economic trends, what are the community’s needs for physicians now, in two years, in five years, in the next decade? Is there a sudden boom of babies in town, or is there a growing influx of retirees due to a nearby lake/golf resort/casino?

Communities often fail to consider the possibility of losing a longtime physician to retirement or untimely death until pressed to find a replacement. Another common mistake communities make is assuming that young people from their area who enter medical school will be predisposed to returning home to practice, thereby failing to lobby vigorously to strengthen that possibility. A community needing a rural practice doctor should know that there is statistical relevance to the phrase, “rural attracts rural,” and should seek prospective physicians who come from a rural background. And when it comes to background, communities should not forget to perform background checks of physician candidates.

Physician recruitment often takes a year or more, so communities are advised to begin early, ideally beginning with student or medical resident recruitment (See Toolbox section on Recruitment Starting with Students). Many communities form a recruitment team with representatives from the health industry, commercial concerns and marketing entities such as the Chamber of Commerce, who together prepare a realistic recruitment package and conduct committee-based interviews of candidates.