Preliminary evidence on retention rates of primary care physicians in rural and urban areas

Factors associated with the non-retention of health sector employees recruited in Iran: a survival analysis

BACKGROUND

Health staff are an essential component of the health system and a significant factor in improving health outcomes. As a result, without a suitable number of trained and supported workforces, health-related goals will not be achieved. As a result, one of the most significant tasks of the government and healthcare human resource management in healthcare organizations is focusing on development and maintenance of personnel.

METHOD

This study was a longitudinal and historical cohort study. Data was collected on the 40 medical universities and healthcare organizations under the jurisdiction of Iran Ministry of Health and Medical Education from 2008 to 2018 from the human resources database. In this study the COX regression and survival analysis was used to assess the factors of staff maintenance, retention rate, and the risk of turnover.

RESULT

46,939 health workforces were included in the study, of which 13,328 (28.4%) were men and 33,611 (71.6%) were women. Based on the finding of cox regression model, the retention of staff were statistically different between male and female. Employees whose current work place and birthplace were similar had a significantly higher probability of retention. Accordingly, the cox regression result showed, the risk of employee turnover for single personnel was higher than the married ones.

CONCLUSION

an applicable policy for increasing maintenance among workforce recruitment, could be considering the native born professionals instead of non-natives born which reduce the costs of employee turnover, including re-hiring, initial and on-the-job training, housing, and other extra living expenses away from home and family.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Motivating High School Students From Rural Areas to Attend College and Pursue Careers as Osteopathic Physicians

Context

One potential way to address critical current and future projected health care workforce shortages is through comprehensive programs that could potentially inspire high school students to pursue osteopathic medical careers in underserved areas.

Objective

To determine whether a comprehensive, 5-week enrichment program could promote interest among rural high-school students in careers osteopathic medicine.

Methods

In May 2018, 116 high school students with a grade point average of 2.8 or higher from rural areas, including New Mexico and its surrounding rural areas in the US-Mexico border region, enrolled in а 5-week program offering American College Testing (ACT) preparation and biomedical sciences enrichment at Burrell College of Osteopathic Medicine (BCOM). During the program, students were offered more than 150 hours of interactive in-class lectures and hands-on activities with laboratories focusing on college preparedness, health sciences, and motivating students to pursue osteopathic medical career and practice medicine in rural areas. Clinically-oriented sessions covering osteopathic philosophy and osteopathic manipulative medicine were included. After completion, a voluntary and anonymous survey was sent to students who completed the program students through QualtricsXM©. Blinded ACT scores were collected from participants' schools, along with college enrollment status information.

Results

Of 116 enrolled students, 106 (91.4%) completed the program successfully. In their postcompletion survey responses, students reported that they had gained a realistic perception of the field of medicine and were motivated to attend college (mean [standard error, SE] score on 5-point Likert scale over 2 questions, 4.8 [0.06]) and osteopathic medical school (mean [SE], 4.7 [0.1]). Participants also felt more informed about physician shortage in rural areas (mean [SE], 4.7 [0.07]) and appeared to be inspired to practice medicine in rural areas (mean [SE], 4.6 [0.09]). Students also reported feeling better prepared to take the ACT after finishing this program (mean [SE], 4.9 [0.04]). Finally, we were able to collect the ACT scores of 51 participants (48.1%) who completed the program; the mean ACT score was 24.3, compared with a reported national mean of 20.7 on a scoring scale of 1-36. We also performed a follow-up inquiry showing that 78 of the 81 participating students (96%) who had graduated from high school were enrolled in college or university and 59 (73%) had elected in science, technology, engineering, mathematics, or health majors.

Conclusion

Rural high school pipeline programs could be a tool to motivate high school students to attend college and ultimately to develop physicians who are interested to practice in medically underserved areas.

The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians

PURPOSE

To examine the literature documenting successes in recruiting and retaining rural primary care physicians.

METHOD

The authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural primary care physicians. In May 2016, they searched MEDLINE, PubMed, CINAHL, ERIC, Web of Science, Google Scholar, the Grey Literature Report, and reference lists of included studies for literature published in or after 1990 in the United States, Canada, or Australia. The authors identified 83 articles meeting inclusion criteria. They synthesized results and developed a theoretical model that proposes how the findings interact and influence rural recruitment and retention.

RESULTS

The authors' proposed theoretical model suggests factors interact across multiple dimensions to facilitate the development of a rural physician identity. Rural upbringing, personal attributes, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities, and good work-life balance influence recruitment and retention. However, attending medical schools and/or residencies with a rural emphasis and participating in rural training may reflect, rather than produce, intention for rural practice.

CONCLUSIONS

Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. To help trainees and young physicians develop the professional identity of a rural physician, multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while providing trainees with positive rural experiences.

Attitudes towards primary care career in community health centers among medical students in China

BACKGROUND

Very few of the primary care doctors currently working in China's community health centers have a college degree (issued by 5-year medical schools). How to attract college graduates to community services in the future, therefore, has major policy relevance in the government's ongoing efforts to reform community health care and fill in the long-absent role of general physicians in China. This paper examined medical school students' attitudes towards working in communities and the factors that may affect their career choices in primary care to inform policy on this subject.

METHODS

A cross-sectional survey was designed upon the issuance of community health reform policy in 2006 by the Chinese government. The survey was conducted among 2714 medical students from three medical schools in representative regions in China. Binomial and multinomial regression analyses were carried out using a collection of plausible predictors such as place of rearing, income, etc. to assess their willingness to work in communities.

RESULTS

Of the 2402 valid responses, besides 5.7 % objection to working in communities, 19.1 % expressed definite willingness. However, the majority (41.5 %) of students only consider community job as a temporary transition, in addition to 33.7 % using it as their backup option. The survey analyses found that medical students who are more likely to be willing to work in communities tend to come from rural backgrounds, have more exposure to community health reform, and possess certain personally held value and fit.

CONCLUSION

To attract more graduates from 5-year medical schools to work in communities, a targeted recruiting approach or admission policy stands a better chance of success. The findings on the influencing factors of medical students' career choice can help inform policymakers, medical educators, and community health managers to improve the willingness of swing students to enter primary care to strengthen basic health services.

Predictors of rural practice location for James Cook University MBBS graduates at postgraduate year 5

OBJECTIVE

To describe factors predicting James Cook University (JCU) medical graduates having a rural practice location at postgraduate year (PGY) 5.

PARTICIPANTS

JCU MBBS graduates who had completed their PGY 5 in Australia (n = 260).

DESIGN

Multiple logistic regression analysis involving graduates' application data (age, gender, location of hometown, School Leaving Score, interview score, ethnicity), undergraduate data (scholarship awarded, honours program), and postgraduation data (internship location, specialty training undertaken).

MAIN OUTCOME MEASURE

Predictors of practice in a 'rural' town (Australian Standard Geographic Classification Remoteness Area (ASGC-RA)) 3-5 at PGY 5.

RESULTS

Practice in a 'rural' town in PGY 5 was predicted by 'internship in an ASGC-RA 3-5 location' (prevalence odds ratios (POR) = 3.9, P < 0.001), 'undertaken postgraduate training as a general practitioner or rural generalist' (POR = 3.4, P < 0.001), 'hometown at application located in ASGC-RA 3-5 area' (POR = 2.9, P = 0.023), 'Aboriginal & Torres Strait Islander ancestry' (POR = 5.6, P = 0.031), and NOT undertaken postgraduate training in surgery (POR = 5.4, P = 0.055).

CONCLUSIONS

This study provides evidence that likelihood of early career rural medical practice in Australia is enhanced by education strategies, such as providing rurally located internship places, supporting rural general practice, and selecting applicants with rural origins, Aboriginal or Torres Strait Islander ancestry, and/or a genuine interest in rural, remote, Indigenous, and tropical medicine. This early evidence supports the proposition that investing in rural medical education will produce an appropriately trained medical workforce to meet the needs of rural Australia. Findings also suggest rural workforce may be further enhanced with additional specialty training opportunities in rural tertiary hospitals, in particular, surgery.

Determinants of rural Australian primary health care worker retention: A synthesis of key evidence and implications for policymaking

OBJECTIVE

To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking.

DESIGN

A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention.

SETTING AND PARTICIPANTS

Rural and remote Australian primary health care workers.

MAIN OUTCOME MEASURES

Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural).

RESULTS

A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and 'bundled', addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors.

CONCLUSIONS

The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention.

A qualitative study of factors influencing different generations of Newfoundland and Saskatchewan trained physicians to leave a work location

BACKGROUND

Some studies have suggested that young physicians may have different expectations and practice behaviours than their older generational counterparts, including their reasons for wanting to remain or leave a community. This study examined the factors associated with a physician's decision to leave a work location. We compared different generations of physicians to assess whether these factors have changed over generations.

METHODS

We conducted semi-structured, qualitative interviews with 48 physicians who graduated from two Canadian medical schools. We asked each physician about the number and nature of work location changes and the factors related to their decisions to leave each location. Interview transcripts and notes were analysed using a thematic analysis approach.

RESULTS

Dissatisfaction with the working environment was the most frequently cited reason for leaving a location for physicians of all generations. Elements which contributed to the quality of the work environment included the collaborative nature of the practice, the relationship with administrators, and access to resources and personnel. For younger physicians, the work environment had to meet their personal expectations for work-life balance. While remuneration level was given by some physicians as the key reason for leaving a location, for others it was the "last straw" if the work environment was poor. A small number of older generation physicians moved in response to political events and/or policies

CONCLUSIONS

We documented generational differences in physicians' reasons for choosing a work location. We found that a poor work environment was universally the most important reason why a physician chose to leave a location. A few physicians who were unsatisfied with their work location identified level of remuneration as an additional reason for leaving. Some older generation physicians cited political climate as a reason for leaving a work location. While economic factors have largely been the focus of recruitment and retention initiatives, our findings highlight the importance of the work environment and organizational culture on the retention of physicians of all generations.

Urban-rural flows of physicians

CONTEXT

Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies.

PURPOSE

To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs.

METHODS

Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003.

FINDINGS

Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003.

CONCLUSIONS

The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population.

Predicting rural practice using different definitions to classify medical school applicants as having a rural upbringing

PURPOSE

This study determines the relationship between a medical school applicant's rural background and the likelihood of rural practice using different definitions of rural background.

METHODS

Cohort study of 599 physicians who entered the University of Virginia School of Medicine in 1990-1995 and graduated in 1994-1999. The "rurality" of the applicants' backgrounds was assessed by coding applicants' high school, college, and permanent addresses using 4 definitions of rural. In addition, most physicians responded to a survey question "Did you grow up in a rural area?" The same 4 definitions of rural were used to assess the rurality of practice locations. Logistic regression models were used to predict the simultaneous effect of different definitions of rural background, gender, and applicants' career preference at matriculation on the probability of practicing in rural areas.

FINDINGS

In univariate analyses, the high school, college, and permanent addresses were all predictive of rural practice using 1 or more definitions of rural. In the multivariate analysis, only the "grew up rural" self-description was predictive of rural practice location using 3 of the definitions of rural. In a secondary analysis, the grew up rural self-description and applicants' career preferences at matriculation were predictors of rural practice.

CONCLUSIONS

Readily available addresses were predictive of rural practice. In a multivariate analysis, physicians' self-description about having grown up in a rural area was the best predictor of rural practice. Recruiting more applicants who match this definition of rural background should increase the number of rural physicians.

Retention of primary care physicians in rural health professional shortage areas

OBJECTIVES

We tested the assumption that average job retention duration is shorter for physicians in rural health professional shortage areas (HPSAs) than for physicians in rural non-HPSAs.

METHODS

In 1991, we surveyed nationally representative samples of primary care physicians who recently had moved to rural HPSAs and non-HPSAs who were without service obligations. We resurveyed these physicians in 1996 and 1997 to learn of any job changes.

RESULTS

Physicians in rural HPSAs (n=308) demonstrated retention similar to that of the non-HPSA cohort (n=197) (hazard ratio for leaving=1.28; 95% confidence interval=0.97, 1.69; P=.08), even with adjustments for group demographic differences (P=.24).

CONCLUSIONS

Average retention duration for generalist physicians in rural HPSAs is identical to or slightly shorter than for those in rural non-HPSAs. Poor recruitment is likely to be the principal dynamic underlying local rural shortages.

The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians

CONTEXT

To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed.

PURPOSE

This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida.

METHODS

Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians.

FINDINGS

Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians.

CONCLUSIONS

Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.

The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature

PURPOSE

A systematic review of factors associated with recruitment and retention of primary care physicians in rural areas.

METHOD

Using PubMed and Medline databases, 21 quantitative articles analyzing recruitment and retention of primary care physicians in rural areas from 1990 to 2000 were found. To assess the methodologic strengths of these articles, a formal evaluation was conducted based on study design, study population, response rate, years studied, data source, and statistical methods (total possible score = 60 points). Studies were grouped by whether the factors assessed were related to pre-medical school, medical school, or residency.

RESULTS

A total of six studies (score range: 30-52) analyzed pre-medical school factors, 15 (score range: 30-52) considered medical school factors, and six (score range: 20-52) analyzed residency factors related to rural recruitment and retention. Pre-medical school factors such as rural upbringing and specialty preference were most strongly correlated with recruitment of physicians to rural areas. Training factors such as commitment to rural curricula and rotations, particularly during residency, were most strongly correlated with retention in rural areas.

CONCLUSIONS

Although important gaps exist, scientific studies available to health educators and policymakers show there are predictable factors that influence recruitment and retention in rural areas. Policies for staffing rural areas with primary care physicians should be aimed at both selecting the right students and giving them during their formal training the curriculum and the experiences that are needed to succeed in primary care in rural settings.

The effects of physician in-migration to rural Colorado (1992 to 1995)

This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants.

Using the American Medical Association physician masterfile to measure physician supply in small towns

The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.

Rural and urban physicians: does the content of their Medicare practices differ?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

To stay or not to stay: issues in rural primary care physician retention in eastern Kentucky

An important aspect of primary care physician availability is the retention of physicians once they have located. While retention has been under-researched compared to recruitment, it is especially important in rural areas where physician shortages already exist. This study reports the results of a retention survey completed by 132 primary care physicians in rural eastern Kentucky. The survey sets up an objective, hypothetical retention scenario and asks physicians to respond to structured questions and to an open-ended question about factors not appearing in the survey. In response to the structured portion of the survey, physicians indicate that relief coverage is the most important factor in rural physician retention. A content analysis of 75 open-ended responses reveals that besides the other factors in the survey, "sociocultural integration" is the pre-eminent retention issue for rural practitioners. This article concludes that the role of the local rural community may be more important in retention than in recruitment. Finally, it is suggested that additional in-depth qualitative research be conducted within the local contexts to enhance the understanding of rural physician retention processes.

Meeting the challenges of workload and building a practice: the perspectives of 10 rural physicians

This qualitative study used in-depth interviews to identify and describe factors regarding the retention of rural physicians. A purposeful sample of 10 established rural physicians from counties of fewer than 10,000 people participated in the study. Analysis of the interview transcripts identified the increased workload involved in building a rural practice to be a major concern of the physicians. The physicians expressed this difficulty in the form of two challenging dilemmas: (1) Towns with only a few physicians presented excellent opportunities for a building practice, but the lack of physicians resulted in more difficult working conditions; and (2) building a practice was described as primarily competitive, but staying in rural practice involved working cooperatively with various competitors. The demands of family, practice, and community interact in a complex fashion. The smallest health systems, those in counties with populations of fewer than 10,000, one hospital, and fewer than five physicians, may represent situations where it is difficult to find a workable solution.

General practice in urban and rural Europe: the range of curative services

The variation in the range of services provided by general practitioners (GPs) is not only related to personal characteristics and features of the country's health care system but also to the geographical circumstances of the practice location. In conurbations health services are more widely available than in the countryside, where GPs often are the only providers. With highly mobile populations and a plentiful supply of doctors, in cities the prevailing regulations for access and use of services are more difficult to maintain. It is also more difficult to control access and thus opportunities for inappropriate use are greater. Against this background an international study was conducted on variation in task profiles of GPs, especially focusing on differences between urban and rural practices. In 1993 standardised questionnaires in the national languages were sent to samples of GPs in 30 countries. Various aspects of service provision were measured as well as practice organisation, location of the practice and personal backgrounds of the GP. Completed questionnaires were received from 7,233 respondents, an overall response rate of 47%. Sources of variation have been analysed by using a two-level model. Rural practices provided more comprehensive services regardless of the health care system. Approximately half of the variation was explained by features of a country's health care system. The GP's position at the point of access to health care was strongly associated with the gatekeeper function controlling access to secondary care. In western countries where the GPs were self employed they had greater involvement in technical procedures and chronic disease management. There was a considerable gap between the task profiles of GPs in eastern and western Europe. We found evidence of a reduced gatekeeper role in inner cities in those countries where GPs held this position. GPs with an estimated overrepresentation of socially deprived people and elderly in the practice population reported a wider range of services. Differences also appeared to be related to factors which are largely controlled by the individual doctor, such as level of training and education, availability of equipment and practice staff. The results have important implications for education, policy development and health care planning both in eastern and western Europe.

Community and self: concepts for rural physician integration and retention

Low physician availability in rural areas of the United States is a long-standing issue. While most research has focused upon the locational decisions of physicians to understand the causes of the problem, a relatively new and neglected research focus is the retention of rural physicians. This paper takes the perspective that integration of physicians within rural communities is the basis for retention. It introduces concepts of self and community as a basis for understanding "domains" of rural physician integration. From data collected during in-depth qualitative research in rural Kentucky, a framework of integration domains is developed. The three domains of physician self, medical community, and community-at-large are elaborated with examples from the data. To further explain the relationships among the integration domains and their value, the findings are combined with three concepts from social theory. Social capital, core participation, and community reconstruction add dynamic and meaningful aspects to the context in which integration and retention occur, and they provide a conceptual basis to use when investigating or devising actions to facilitate integration.

Physician retention in rural communities: the perspective of experiential place integration

Rural communities across the United States continue to struggle in their attempts to recruit and retain physicians. In response to this ongoing problem, health services researchers have focused on the recruitment of physicians. More recently, however, researchers have recognized the importance of physician retention. Nonetheless, there is a scarcity of theories to explain the process of rural physician retention. This paper provides an overview of retention in health services research. It then proposes a theoretical perspective on retention called "experiential place integration." The paper subsequently presents an in-depth qualitative study of rural physician integration in Kentucky from which a practical framework of physician integration is constructed. The framework represents integration as an active developmental process based on the enhancement of security, freedom, identity and meaning in place.

Migration of obstetrician-gynecologists into and out of rural areas, 1985-1990

This study sought to determine if county-level demographic, health care resource, policy, and competitive factors are associated with the movement of obstetrician-gynecologists (ob-gyns) into and out of rural areas. County-level descriptive data from the Area Resource File, the American Medical Association Physician Masterfile, and the American Hospital Association Guide were used for hospital descriptions. This was a correlational study that measured the association of ecologic indicators of nonmetropolitan counties with indicators of gain or loss of ob-gyns. Descriptive statistics characterize the supply and movement of ob-gyns by size and location of the counties. Multinomial logistic regression models describe the net effect of the ecologic indicators on physician movement. During the period 1985 to 1990, a total of 962 patient care ob-gyns moved out of 531 nonmetropolitan counties, and 979 ob-gyns moved into 528 counties. Counties in the southern Atlantic states experienced the greatest net inflow, whereas Illinois, Missouri, and Texas had the greatest net outflow. Counties that retained ob-gyns during this period were in the mid-range of population. Positive correlates of outward migration were adjacency to a metropolitan county and loss of hospital bed supply; negative correlates with outward migration were the supply of hospital beds and total population. Inward migration was positively correlated with retention or gain of county family physicians and with adjacency; negative correlates were overall population and total family physician supply. The movement of ob-gyns in nonmetropolitan counties is influenced by state policies, local resources, and relative location. No clear evidence shows that there are competitive relations between family physician supply and ob-gyn supply.

Studying the retention of rural physicians

Rural communities and policy-makers struggle with efforts to enhance the retention of rural physicians. Research available to guide these efforts is often weak methodologically and thus may be pointing retention efforts in nonproductive directions. This article discusses a range of methodologic issues encountered in rural physician retention studies for the purpose of strengthening future studies. Ideal study approaches to answer causal questions, including questions about the "causes" of rural physician retention, must demonstrate good internal validity, for which chance, bias, and confounding are accounted. Retention studies that rely simply on asking physicians why they stay or leave rural areas can be useful at times, but are too prone to bias and their findings difficult to verify. Simply identifying what physicians find satisfying or dissatisfying about rural work also will not reliably reveal why they stay or leave, a related but still distinct question. Stronger approaches to studying retention include the traditional quantitative study--in which retention factors are identified when they are statistically related to physicians' retention, and the increasingly popular qualitative study--in which retention issues are revealed through prolonged, in-depth interactions with physicians. This article also discusses various definitions of retention, the use of survival curves to present retention findings, and the importance of studying retention in inception cohorts. The benefits and downside of studying retention with prospective and retrospective study designs are described.