Retention of Rural PCPs Linked to Location, Individual Factors

Tara Haelle

July 21, 2017

Approximately 17% of primary care physicians (PCPs) younger than 46 years move counties every 2 years, and many more of these physicians are leaving rural areas than moving into them, according to a study published in the July/August issue of the Annals of Family Medicine. Location factors associated with rural departures included a smaller population, lack of a hospital, and a lower physician supply, the researchers report.

"These results...highlight the difficult battle to improve physician availability for small rural communities," which remains "a major problem nationwide," write Matthew R. McGrail, PhD, from the Monash University School of Rural Health in Churchill, Victoria, Australia, and colleagues.

Overall mobility among older physicians, ages 46 to 65 years, was close to half that of younger physicians, at just under 9% every 2 years.

However, movement out of rural areas occurred across the age spectrum. Overall, an average 9% of PCPs move from a rural area to a metropolitan one every 2 years, yet only 1.2% moved to rural counties from metropolitan ones, Dr McGrail told Medscape Medical News.

The loss of physician supply in rural communities, unlike larger metropolitan areas, "is not easily absorbed by nearby services in small populations of low density," Dr McGrail and colleagues write.

The findings were not necessarily surprising to senior author Andrew Bazemore, MD, director of the Robert Graham Center in Washington, DC, but they remain concerning, he told Medscape Medical News.

"A number of my colleagues in rural remote training say, yes, this is a real problem, and this is confirming what we think we're facing," Dr Bazemore said.

"If all of your training at the residency level tends to be in big, urban areas and large academic health centers, you probably don't have much chance for a rural health care workforce to persist if you don't foster rural training opportunities," he continued. Rural training tracks, teaching health centers, and smaller community-based decentralized training programs are all components of a long-term solution to the problem, he added.

In the current study, the researchers used multiple data sources to conduct three different analyses covering a 14-year period: one on overall biennial mobility of PCPs, one on which counties did not retain physicians, and one on physicians moving from rural to metropolitan counties. They used 2000-2014 data from the American Medical Association Physician Masterfile to identify mobility trends for all clinically active US PCPs.

The researchers aimed to determine when family practice physicians, general pediatricians, geriatricians, and general internal medicine physicians moved from one geographical location to another across each 2-year period (2000, 2002, 2004, 2006, 2008, 2010, 2012, and 2014). They took into account county population density data, using the Rural-Urban Continuum Codes for 2003/2013 to identify the rurality of counties and collapsing the six nonurban codes into three categories: counties with a population below 2500, those between 2500 and 20,000, and those above 20,000.

Physician characteristics gathered from the American Medical Association database for the analysis included age (up to age 45 vs ages 46-65 years), sex, graduation from an international (rather than US) medical school, family or nonfamily physician, osteopathic or medical physician, rural place of birth or not, and Health Professional Shortage Area status. The researchers also factored in the following location characteristics that could potentially affect retention rates: proximity to a hospital, higher house values, the PCP-to-population ratio, proportion of affluent communities, population size, higher uninsured rates, and unemployment rates.

The findings revealed that on average, 16.9% of physicians younger than 46 years moved during each 2-year period compared with 8.9% of those aged 46 to 65 years. A clear trend for decreasing mobility with increasing age emerged from the data: 30-year-old physicians, for example, had a 30.4% biennial mobility rate, which dropped to 21.2% at age 35 years, 14.8% among those age 40 years, 11.3% at age 45 years, and 7.5% among physicians aged 65 years.

Most physicians who moved out of a rural area went to a metropolitan one, particularly if the rural location was adjacent to a metropolitan area. Among younger physicians who left a rural location, 68% headed to a metropolis, as did 58% of older physicians who moved from a rural area. In other words, of the 16.9% of younger physicians who moved every 2 years, 12.2% moved to a rural area and 87.8% moved to a metropolitan one. Similarly, of the 8.9% of older physicians moving every 2 years, 16.3% went to rural counties and 83.7% moved to metropolitan ones.

When the team looked at location factors associated with poor retention of physicians, they uncovered just three: not having a hospital in the county, a county with a population below than 2500, or a very low supply of physicians.

"The higher nonretention of the existing rural physician workforce in the most remote rural communities (those in [Rural-Urban Continuum Codes] categories 8 and 9: population <2,500) and counties without a hospital is likely more problematic because of a lack of alternative service choices for these populations," the authors write. "Targeted policy support to rural physicians in these small and often isolated communities, who are likely struggling without a critical mass of other health professionals nearby, is needed."

In terms of individual physician factors, the authors underscore the difficulty of rural counties' retaining female physicians and those originally from metropolitan areas.

"Female physicians, international medical graduates, and those not born in rural areas were all more likely to move back to metropolitan locations irrespective of age, as were as older osteopathic physicians," the authors reported. "Physicians located in areas with poorer supply (measured by [physician-to-population ratio]) were also significantly more likely to leave rural areas."

Female physicians up to age 45 years had 24% greater odds of leaving a rural area for a metropolitan one than male physicians did, and older female physicians had 46% greater odds of doing the same (P < .01). Younger and older international medical school graduates had 65% and 41% greater odds, respectively, of moving from a rural area to a metropolitan area compared with domestically educated physicians.

Younger physicians who had been born in a rural area had 43% lower odds of moving from a rural to metropolitan location, and older physicians from rural hometowns had 36% lower odds of doing so. Those who lived in a rural area adjacent to a metropolitan one had modestly greater odds of leaving the town for the city: 10% greater odds for younger physicians and 28% greater for older ones (P < .01).

"I think more decentralized rural training of more rural-born [physicians] would be a big start" to addressing the rural retention problem, Dr Bazemore told Medscape Medical News. "We know that rural-born are more likely to stay rural and work rural, and yet there's been a huge decline in rural matriculation in med schools," although he noted that some of that has been improving.

Dr Bazemore said a number of programs have shown that "taking rural-born, and even non-rural-born, [residents] and giving them good, positive experiences in rural healthcare delivery" can help nurture an interest in working in rural areas.

One unexpected finding, according to the authors, was the lack of association between rural departures and rural poverty.

"Economic aspects appear to have only a minor role in mobility decisions of [PCPs] compared with geographic aspects of population size and hospital access," they write. "Stronger economic aspects, in particular, were expected to be important when choosing between rural locations — for example, given a choice between a rural town with strong growth vs a rural town with no growth or even slowly dying, the latter would deter most individuals; however, this pattern was not reflected in the results of this study over and above physician shortage levels."

Yet the study did uncover some economic associations with mobility as well as links to county-level demographics.

"Higher house prices and areas with larger numbers of African American residents were significantly associated with greater mobility for older physicians only, whereas higher household income was consistently associated with increased odds of mobility," the authors report. "Younger physicians had a higher risk of mobility only in areas with smaller numbers of older residents, higher unemployment, and greater numbers of Hispanic residents."

Given the importance of increasing rural physician supply and retaining the current supply, the authors write, their data "may be useful in guiding more effective targeting of rural health policies and workforce planning and incentives, as well as highlighting the specific needs of the most vulnerable communities."

Dr Bazemore emphasized the value of rural training tracks in meeting rural workforce needs, citing his prior research that found only 5% of all residency trainees will head to a rural area.

"America is at least double that in rural population," Dr Bazemore told Medscape Medical News. "Rural training tracks will have closer to 40% or higher retention in rural [practice], so you get a very large return in investment from those training programs."

The research was funded through a visiting scholar grant to the Robert Graham Center for Policy Studies in Family Medicine and Primary Care through the Australian Primary Health Care Research Institute. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2017;15:322-328. Full text

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