Physician Recruitment in Rural Areas

Physician recruitment is a national problem, particularly in rural areas. Although the Federal Bureau of Health Manpower projects a nationwide surplus of physicians by 1990, this surplus is no guarantee that the geographical distribution will improve. On the contrary:

There is still the likelihood that most primary care graduates will end up in the affluent suburbs of large urban areas or in smaller urban areas. Thus, specific incentives and policies are needed to influence a better distribution to rural areas.

Georgia Situation

Studies show Georgia's rural areas need primary care physicians. The Joint Board of Family Practice's study concludes that a serious shortage of primary care physicians will exist in Georgia through the year 2000. Some reports suggest a shortage of physicians, while others project surplus. However, virtually all research agrees-a physician shortage in rural areas will continue. The issue isn't the supply of well-trained and qualified physicians, but poor geographical distribution. The real problem is recruiting physicians to rural areas. Many physicians entering practice aren't aware of some of the benefits of a rural practice. Some physicians assume a rural practice will leave them isolated with inadequate equipment and facilities, on-call 24 hours a day, and with a lesser quality of life. Many small communities offer adequate and up-to-date medical facilities, as well as desirable living conditions for the doctor and his/her family. In fact, there now seems to be a growing perception that the "good life" is outside of metropolitan settings. One practicing rural physician says:

... the family practitioner . ~ . can feel every day the appreciation of patients who are almost flattered at his arrival, and can experience a closeness to them unique to rural medicine. He knows what it is to drive past grazing cattle, painted hills, or even a startled deer, and to arrive on time at the office or hospital. He can relax, knowing he can have a family hike, a quail hunt, or an afternoon of native trout fishing at a moment's notice. He will know the friendship of other young couples who by choice are raising children to cherish, respect and protect the beauty that is their own backyard. He can know a pace and an environment that are therapeutic for family and physician.

The quality of health care in Georgia is reflected to a degree in the distribution of physicians. While rural communities may not be able to influence everything that affects health, community leaders are increasingly being asked to improve health care services. Modern community hospital facilities are important incentives for attracting and retaining physicians. Although facilities are important, they aren't the only factors to consider. Social, cultural, recreational, religious, and economic conditions also play a major role in the recruitment of physicians.

Recruitment Strategy: Coordination Problem

Olive identifies three major problems in physician recruit ment. He says "one major problem seems to be the lack of communication, cooperation, and coordination between agencies." To be effective, agencies and organizations concerned with physician recruitment and/or placement should try to positively influence the many factors involved in a physician's selection of a practice location. Some of the factors include physician and spouse social background, medical training curriculum and location, and the prospective community's cultural, social, and economic conditions. One way to affect these factors is to enlist the cooperation and coordination of agencies and organizations that can influence these factors.

Approaches dealing with problems of physician distribution should not be unrelated to each other. Rather, policies and incentives to solve this problem must include a combination of strategies coordinated with each other and related to an overall plan that can be directed by the state. States should give serious consideration to developing untried and sophisticated combinations of strategies to deal with the problems of health manpower distribution. While the specific combination of strategies and coordination will vary from state to state, the greater will be the likelihood that better physician distribution wii be achieved.

Medical Fair

In Georgia, agency coordination has focused on a cooperative effort to plan and provide a Medical Fair, a physician recruitment program for rural areas. The Georgia Cooperative Extension Service, the State Medical Education Board, and the Medical College of Georgia sponsored the first annual Medical Fair in 1979.

The purpose of the fair is to bring together representatives of small communities in Georgia to meet with resident physicians, medical students, dental students, and their spouses to discuss present and future practice opportunities in the state. The communities have a population of 15,000 or less and usually have a hospital. Physicians can choose from over 40 towns representing every part of Georgia. They can then select from among the communities those with the most desirable qualities as well as other key factors that will determine his/her practice location. For those residents who are close to completing their training, they can arrange site visits to communities of particular interest to further explore practice opportunities.

Additional Agencies

In 1980, the Joint Board of Family Practice and the Medical Association of Georgia joined as sponsoring organizations. Additional sponsors in 1981 included the Georgia Academy of Family Physicians, the Georgia Hospital Association, and the Southeastern Institute for Community Health, Inc. In 4 years, the fair has attracted more than 480 representatives from 165 Georgia communities, with 287 residents, 200 medical students, 104 dental students, plus spouses attending. As a result of the fair, 60 physicians have located practice sites in eligible Georgia communities, according to a survey of participating communities.

No agency or organization has solved the problem of poor distribution of physicians. And, although the Medical Fair isn't the total answer, this approach offers a significant contribution to the recruitment of physicians to rural areas. One of the unique features of the fair is the inter-organizational cooperation to mobilize resources. The result of these public and private organizations working together, cooperatively and collectively, to solve the problem hinges on identifying the needs of each group.

Information Problem

According to Olive, a second major problem is a lack of information for communities. Many small communities know very little about physician recruitment and don't know where to get help to recruit physicians. Extension plays a major role in the Georgia program through its county delivery system to make communities aware of the physician recruitment program and other health care resources. Extension specialists and county Extension agents help community leaders develop a physician recruitment strategy. As with any community development effort, the social situation and current conditions determine Extension's role. In some cases, at the county level, Extension merely functions as a catalyst to provide communications and information about the recruitment program. In other instances, Extension may perform more of a facilitator role and even become the prime mover of the local effort. The strategy depends on local community conditions.

Each spring, an orientation session is held for communities to discuss the most effective ways to use the three-day Medical Fair. The communities receive a seminar on effective recruitment strategies. Such topics as "What Physicians Look for in Selecting a Place To Live" and "Problems Encountered by Physicians Entering Practice" are discussed by doctors who have recently located. "Marketing Your Community To Attract Physicians" is a popular topic presented by Extension community development specialists.The orientation session helps communities assess their present medical services and stresses the importance of involving local practicing physicians, hospital personnel, and other community leaders in the decision to recruit doctors. Communities receive instruction on preparing exhibits that summarize the community's medical, industrial, and social setting. The orientation also helps communities have realistic expectations of the Medical Fair. They learn they won't necessarily go home with a doctor under contract, and that successful recruitment many involve months and even years. The orientation session also serves as a two-way forum in which community representatives evaluate and suggest changes to the sponsors for the upcoming fair. Residents also receive an orientation. There are five Family Practice Residency Centers in the state. Represent tives from the sponsoring organizations meet with these residency center directors and residents to explain the purpose of the fair. Also, visits are made to medical schools to discuss the fair with family practice and other primary care departments. In addition, a great deal of interpretative information is mailed to participants before the fair. Communities receive a list of background information on each resident and use this list to screen and establish initial contact with residents. Residents also receive a community list and hospital information before the fair.

Follow-Up Problem

The third major problem with physician recruitment programs, says Olive, is the lack of follow-up to find out how effective the agencies' recruitment methods and procedures are. The sponsoring agencies carefully monitor physician placement. After all, the bottom line in measuring this program's success is the number of physicians permanently placed in eligible communities. As mentioned previously, 60 physicians have located practice sites as a result of the fairs, and all communities and residents are surveyed annually to monitor progress. Several of the sponsoring organizations work with residents and community representatives between fairs in following up on mutual placement interests. The Medical Fair isn't just a three-day conference, but a year-round statewide recruitment effort.

Interest and participation in the contact concept of the fair has grown over the four years. The state legislature has passed a resolution each year commending the sponsoring organizations for their efforts in this program. In a unique way, it has brought together a significant number of health care organizations to focus on the placement of physicians in rural Georgia. In addition, the fair creates an opportunity to educate medical and dental students on values and opportunities available in rural practices. We believe this annual event will continue to have a strong and positive influence on the location of physicians in rural Georgia.

Extension Implications

In developing a statewide program to focus on the placement of physicians in rural areas, consider a number of key elements. Pull together a core group of organizations as primary sponsors that design and build the mechanism to carry out the program. Additional health-related organizations may serve as resources. The Cooperative Extension Service in each state has a network of county offices already in place in rural communities and can provide linkages to community leaders. State and private medical schools provide the supply of trained physicians. Organizations such as the State Medical Education Board, which provide state scholarships to medical students who agree to practice in a rural area, can contribute to the primary goal of placing physicians in such areas. The State Medical Association and State Hospital Association have contact with local practicing physicians and hospital personnel.

Organizations like the Academy of Family Physicians and Joint Board of Family Practice are in many states and have contact with residency training centers and influence curriculum development and resident training. Other organizations such as State Health Planning groups and Rural Health Associations are interested in improving health care in rural areas. The State Farm Bureau supports the Georgia program financially, as do many other organizations such as pharmaceutical companies and corporations that own hospitals in rural areas. One strong statewide recruitment effort avoids competing for participating communities, residents, and financial contributors. Two essential ingredients in the success of a physician recruitment program for rural areas exist. One is an adequate supply of well-prepared community representatives and the other is an adequate supply of well-informed physicians. A program of this type can do a great deal to strengthen Extension's community development efforts statewide.

Footnotes

1. "Influencing the Distribution of Physicians: Manpower Policy Strategies," Issues in Higher Education (No. 13, 1978), P. 9.
   
2. Philip W. Russell, "Primary Care Physician Manpower Report of the State of Georgia, 1980-2000" (Atlanta, Georgia: Joint Board of Family Practice, 1980), p. 33 and Joe B. Lawley and John W. Smith, "A Strategy To Improve the Geographic Distribution of Physicians in Georgia," Georgia Family
   Medicine Newsletter, V (No. 3,1981), 1.
   
3. Jack Roof, "The Personal Joys of a Country Practice," Georgia Academy of Family Physicians Journal, IV (No. 2,1982), 6.
   
4. James T. Olive, "Physician Recruitment in Rural America: A Summary of Programs in the United States" (Atlanta: Georgia Institute of Technology, School of Health Systems, 1979), p. 32.
   
5. "Influencing the Distribution of Physicians," Issues in Higher Education (No. 13,1978), p. 8.
   
6. Olive, "Physician Recruitment in Rural America," p. 32.
   
7. Ibid., p.33.