Basic Principles:

Retaining Health Professionals in Rural and Underserved Areas and Practices

Don Pathman, MD MPHUNC Chapel Hill

NC Primary Care ConferenceAshevilleJune 22, 2012

Goal

• Review general concepts of retaining rural and urban underserved area health care professionals

• Data are on physicians in underserved settingsand mostly rural, but apply (with some variation) to other health professionals and urban

• I call on your expertise:

I ask; you predict; then I present data from our studies of the past 20+ years

Why Believe Me?

• From Los Angeles• Studied philosophy and medicine in Philadelphia

Why Believe Me?

• From Los Angeles• Studied philosophy and medicine in Philadelphia • Practiced in rural Maine (NHSC), Colorado and

North Carolina• Published 50+ papers over 22 years on rural and

underserved health workforce issues• Worked with the NC Office of Rural Health• Serve on NHSC NAC

Fundamental R & R Principles

1. Retention success is achievable in any community.

2. Underserved-area physicians are humans first, professionals second:• Relationships are key• They are atypical among physicians

3. Rural and underserved practice is a marriage between a community and physician:• The match is key• The outward characteristics of the physician are

not important; what is in their heart is• The work situation needn’t be perfect, just not

bad

4. Rural physicians are locals at heart

5. What physicians encounter in their practices and communities is key to retention:• They need to feel satisfied, valued, invested and

fulfilled• They need a viable, long-term employment situation

6. Retaining and recruiting differ in important ways.

Principle: Retention success is quite achievable in any community.

Retention: Rural vs. Urban Location

Years

86420

Prop

ortio

n Re

mai

ning

1.0.9.8.7.6.5.4.3.2.1

0.0

urban site

rural site

355 rural and urban generalists

p = n.s.

587 rural generalists

Years

1086420

Pro

porti

on R

emai

ning

1.0

.8

.6

.4

.2

0.0

non-HPSA

HPSA

p = n.s.

Rural HPSA vs. Non-HPSA Location

Principles: Retention success is quite achievable in any community. Retaining and recruiting differ.

1086420

1.0

.8

.6

.4

.2

.0

Years

1086420

Cum

Sur

viva

l

1.0

.8

.6

.4

.2

.0

Retention: Community Characteristics

Urban Adjacent

Non adjacent>10K 2.5K - 10K< 2.5K

Town Pop

Principles: Retention success is quite achievable in any community. Retaining and recruiting differ.

587 rural generalists

Rural vs. Urban Raised587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning 1.0

.8

.6

.4

.2

0.0

rural raised

urban raised

p = n.s.

Principles: Characteristics aren’t important, only what is in their heart. Retaining and recruiting differ.

Rural vs. Urban Raised Spouse466 married rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning

1.0

.8

.6

.4

.2

0.0p = n.s.

rural raised

urban raised

Principles: Characteristics aren’t important, only what is in their heart. Retaining and recruiting differ.

587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning 1.0

.8

.6

.4

.2

0.0

preparedneutral

not prepared

Preparation for the Community

p < .001

Principle: Rural practice is a marriage between a physician and a community.

Work and Community Preparation

CommunityWork

1086420

1.0

.8

.6

.4

.2

0.0

1086420

Cum

Sur

viva

l

1.0

.8

.6

.4

.2

0.0

Work

Community

PreparedNeutralNot prepared

Principles: Rural practice is a marriage between a physician and community. Rural physicians are human first, professionals second.

587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning 1.0

.8

.6

.4

.2

0.0

Principle: Rural practice is a marriage between a community and a physician.

very satsatisfiedneutraldissatvery dissat

Satisfaction with the Community

p < .001

Satisfaction vs. Dissatisfaction w/ the Community611 urban and rural subspecialists

0102030405060

Ver

yD

issa

tifie

d

Dis

satis

fied

Neu

tral

Satis

fied

Ver

ySa

tisfie

d

% leaving within 2 years

Principles: Rural practice is a marriage between a community and physician.

Things needn’t be perfect, just not bad.

Owners vs. Employees587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning

1.0

.8

.6

.4

.2

0.0

owners

employees

p < .001

Principle: Physicians need to feel invested.

587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning

1.0

.8

.6

.4

.2

0.0

$60-80K

p < .05

Income: < $60K vs. $60-80K vs. > $80K

< $60K

> $80K

Principles: Physicians need a viable employment situation. Things needn’t be perfect, just not bad. Rural physicians are atypical ($$ isn’t everything).

1086420

1.0

.8

.6

.4

.2

.01086420

1.0

.8

.6

.4

.2

0.0

1086420

1.0

.8

.6

.4

.2

0.0

call < 2x/wk

call > 3x/wk

Years

> 25 pts/day

< 24 pts/day

> 50 hrs/wk

< 49 hrs/wk

Principles:

Physicians need to feel valued and invested.

Physicians need a viable long-term employment opportunity.

Areas of Satisfaction—Assoc. w/ 2 year retention499 Clinicians Completing Service Obligations

• Strong personal connection to my patients

• Had good clinical back-up from senior/supervising clinicians

• Relationship with administrator

• Support from other clinicians

• Felt work did not encroach on personal time

• Agrees administrator is effective

• Agrees s/he is doing important work

• Financial stability of the practice

• Satisfied with salary/income

• Mission and goals of practice

• Access to specialist consultants

• Able to practice full scope of services

Areas of Satisfaction—Assoc. w/ 2 year retention499 Clinicians Completing Service Obligations

• Strong personal connection to my patients

• Had good clinical back-up from senior/supervising clinicians

• Relationship with administrator

• Support from other clinicians

• Felt work did not encroach on personal time

• Agrees administrator is effective

• Agrees s/he is doing important work

• Financial stability of the practice

• Satisfied with salary/income

• Mission and goals of practice

• Access to specialist consultants

• Able to practice full scope of services

Red = statistically related to retention @ 2 years

Teachers vs. Non-Teachers587 rural generalists

Years

1086420

Prop

ortio

n Re

mai

ning

1.0

.8

.6

.4

.2

0.0

teachers

non-teachersp = .05

Principle: Rural physicians need to feel fulfilled.

Retention by Type of Service Program353 obligated generalists

Principles: Physicians need to feel satisfied. The physician-community match is key.

Years

6543210

Prop

ortio

n Re

mai

ning

1.0

.8

.6

.4

.2

0.0

Loan RepaymentLoanIncentive

ScholarshipResident Support

Key Points/Recommendations

1. Heed the fundamental principles presented earlier.

2. Develop separate retention and recruitment strategies.

3. Develop multiple strategies for retention and for recruitment.

4. Develop strategies in advance, not after problems arise.

5. The challenge should only be landing a physician (recruitment): once landed, any community is in good position to keep her/him.

Key Points (cont.)

6. Select a physician on their fit w/ practice and community.

7. Identify and remedy problems that trouble local physicians.

8. Sell yourselves and community. Warmly welcome attractive prospects. Embrace the entire family.

9. Create a job that fosters satisfaction, fulfillment, and investment, and is a viable long-term position.

Do not use the phrase “recruitment and retention”.

It misleads people to think they are the same thing.

recruitment and retention