Recruiting, retaining rural physicians

Before you can fix a problem, it needs to be understood, and rural health care is no exception, according to Kelley Arredondo, PhD.

Thus, to improve care for rural veterans, the Department of Veterans Affairs first had to study physician shortages in rural areas. "To really start to understand what the impact is of this, and how we can really get to the root of how to increase workforce development in rural areas, our team wanted to start from ground zero and understand what [incentive] programs are currently offered and where," said Dr. Arredondo, who is an assistant professor at Baylor College of Medicine and an investigator for the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center in Houston.

She and her colleagues conducted a narrative review of studies published from 2015 through 2022, finding that loan repayment programs, J-1 visa waivers, and scholar programs were the most common incentives offered in shortage areas but weren't always located in the areas that needed them most. The review, which was published in the July 2023 Journal of General Internal Medicine, also detected a lack of evidence regarding metrics for program success.

I.M. Matters recently talked to Dr. Arredondo about the study's findings.

Q: Your study found that most rural incentive programs focus on recruitment rather than retention. How long do physicians usually stay?

A: Loan repayment programs usually have about a two-year time commitment that is tied to the incentive, while J-1 visa waivers have a three-year commitment. Scholar programs, which may or may not be physically located in rural areas, usually don't have a service time commitment.

While some people do stay for another year or two even without an incentive or without a service time commitment, they tend to leave areas after that. … Our next project will be evaluating the success of these programs, and we're defining success as how many people are staying in the rural area after their service time commitment is up. That's really the true metric: How many people are retained and still practicing and building their careers and their lives and engaging with the community?

Q: Has there been much research into what incentives are most successful for retention?

A: There have been a couple of studies. One of the things that's difficult about evaluating programs across the board is that the characteristics and the way that programs report their metrics vary so widely. There isn't a way that people are systematically saying, "For every year, this is how many people have been retained." You might get a metric that says, "In the last 10 years, we've retained 10% of our physicians that participated," and they may give you a total of how many people participated and they may not. That can make it very difficult to quantify what 10% means. Then other programs are great about reporting the results and are very meticulous and tell you exactly how many people stayed each year.

Without having a more unified way of reporting our results, it's very difficult to understand how to compare programs one to the other. With that said, there are studies currently that have looked at comparing, for example, a J-1 visa waiver program versus a loan repayment program, so there are these more niche comparisons that occur, especially within a state.

Q: Your study found uneven distribution of incentive programs within rural areas. What can help with that?

A: Some programs have moved to a kind of a hub-and-spoke model, where a larger facility is the one that takes care of hiring or doing the J-1 visa waiver process—they're the ones who administer and do the paperwork and that heavy lift, because they have more of those resources—and then the physician works in the smaller clinic that is in the rural area. A model like that is a great way to really leverage our resources and make sure that we're supporting these smaller rural clinics. Larger organizations can circumvent or subsume all of those costs, whether that's time, money, resources, workforce, and staff, and the clinic can just see the benefit of having a physician practicing there.

Q: Your study discussed some participation barriers, for example, restrictions that prevent physicians from simultaneously participating in multiple incentive programs. Are there any potential solutions?

A: That was something that was a bit unexpected and that we hadn't really thought about before this study. One thing is, it's not very clear how people are informed, whenever they do take advantage of these incentives, about whether or not they can participate in the future in another incentive, or how those two things can conflict. One possible solution would be to have more of a pipeline mentality whenever we're thinking about these incentives, where we understand that if somebody is taking a scholarship during medical school, they might also need help down the line when they're a resident, or whenever they've just finished residency, and they're now going to be a practicing physician.

We should have a more continuous view of this process versus saying a very finite, "Oh, this is an incentive that is offered to medical students." Making it a standalone thing, I think, is really detrimental to folks, especially from rural backgrounds, who are interested in going back and practicing in these rural areas, who are the ones that will most likely be taking advantage of these programs.

Q: Given that physicians who grow up in a rural area are most likely to be retained, why don't most programs consider that factor during recruitment?

A: That was something else that we were surprised by. … I don't know why more programs are not giving preference to those applicants, as it's not taking away from other applicants. For example, if only people apply who don't have a rural background, then you admit as many people as are qualified. It was surprising to us that people aren't necessarily being explicit about this.

Another thing that came up is that maybe they do give a preference to it, but they're not explicitly stating it on their website or on their application materials that this is a population that they're interested in. But again, if you think back to groups that are rural, minorities, or may not traditionally think about themselves as going into these paths of medicine, if they don't necessarily see those applications or those websites saying that people are looking for them, they might not be as encouraged to apply.

Q: Do you have any thoughts on other potential incentives, or how existing programs could be improved?

A: The reality is that financial incentives are going to be incredibly important to recruit people into these rural areas, but I think it's important to add more of that retention component of having continued professional development and having a support system for folks. They need to be able to have colleagues, whether that's in person or virtually, that they can ping to have a consultation with, to get a second opinion from, so that they're not so isolated, so that they don't feel like everything is on them.

Also, we need to encourage more work-life balance. It's a double-edged sword: We have a shortage of physicians, then they can't take any time off, and so we continue to have more shortages because more people keep leaving. By increasing how much support we have in rural areas for these physicians, it means that they're able to work fewer hours, not necessarily less than a full work day, but fewer than 12 hours a day, which they may be working if they're the only physician.

Some programs have started to take a more hands-on approach to engaging the physicians with the community. They'll have them take part in a local parade or highlight them in the local newsletter, and they share facts about the physician and what they like to do in their free time, so that people start to really get to know that person. Especially if a small community is very tightly knit and everyone knows everybody and you're bringing in a new person who they're not familiar with, who they don't necessarily trust, building that from both ways, from the community side and the physician side, really enhances this feeling of community for everyone.

Also, if we're just bringing people in and we're giving them a financial incentive, and then we say, "OK, good luck, thanks for coming," we're not orienting them to the lifestyle. We're not letting them know what activities are available for their families, what their partners or significant others can do. We have this model in other areas of academia where if somebody's spouse gets recruited to a hospital or an academic setting, the partner or spouse or significant other also will usually get a position themselves. I don't know if we're taking that hands-on approach in these rural areas, and how we're going about incentivizing the physicians and their whole entire life versus just them as a physician.

Q: What are the next steps in this research?

A: As I mentioned, we're currently looking at new programs and coding how many programs are reporting results, and we're looking to see how these programs differ or how they are the same across the board. We're also starting to look at registered nurses in rural areas, seeing what types of programs exist for rural nurses.

Our hope is to eventually have some sort of toolkit or resource for people, be they physicians, nurses, managers of clinics, or policymakers, that presents information in a more unified way, so that if they do have any questions, or they want more information about what is out there—What do these programs look like? What does success look like in these programs? What are examples of programs that are doing this well?—it's all in one place. Hopefully, it'll help to inform them about policies, and it'll help physicians or nurses know what types of programs are available to them, so that they can make a more informed decision. It'll also help clinic managers know what other programs are doing, what people are doing well, and maybe provide them with some resources for help.