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Long-Term Retention of Graduates from a Program to Increase the Supply of Rural Family Physicians

Rabinowitz, Howard K. MD; Diamond, James J. PhD; Markham, Fred W. MD; Rabinowitz, Carol

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Purpose To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College.

Method Of the 1,937 Jefferson graduates from the classes of 1978–1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11–16 years earlier.

Results After 11–16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p= .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04).

Conclusions These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11–16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

Dr. Rabinowitz is professor, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.

Dr. Diamond is research professor, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.

Dr. Markham is clinical associate professor, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.

Ms. Rabinowitz is programmer and research analyst, Center for Research in Medical Education and Health Care, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Rabinowitz, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Suite 401, 1015 Walnut Street, Philadelphia, PA 19107; telephone: (215) 955-7416; fax: (215) 955-0640; e-mail: 〈Howard.Rabinowitz@jefferson.edu〉.

Today, one out of every five Americans lives in a rural area, but only 9% of physicians practice there.1 In addition, almost 40% of rural residents live in federally designated primary care Health Professional Shortage Areas, making them one of the largest physician underserved populations in the country.2 The resulting lack of access to basic health care for millions of rural people is especially critical, given their greater burden of morbidity and mortality, lower level of health insurance coverage, and lesser financial resources compared with those living in nonrural areas.1 While this rural primary care physician shortage has persisted for most of the past century,3 the recent decrease in the number of physicians entering primary care specialties,4 coupled with the fact that fewer than 4% of recent medical school graduates plan to practice in rural areas and small towns,5 raises even greater concern for the future.

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Programs to Increase the Number of Rural Physicians

A number of programs have been developed over the past few decades to increase the recruitment and retention of rural primary care providers. The best known of these is the National Health Service Corps (NHSC), a federal program that provides scholarships and loan repayment to health professionals in return for obligated service.6 A similar number of providers are also supported through state programs that combine financial incentives with required service in underserved areas.7 Federal programs have also been developed to increase the rural provider supply by improving the education and training of health professional students in rural areas, including the Area Health Education Centers, and those through Title VII of the Public Health Service Act.6 At the graduate medical education level, rural training tracks in family medicine residency programs have been instituted to achieve similar goals.8 Finally, a small number of medical schools have developed comprehensive programs that were specifically designed to increase the supply of rural primary care physicians.9

Each of these programs appears to have had some degree of success in increasing rural physician recruitment (i.e., the number of physicians entering rural primary care practice).6–11 The overall impact of these programs, however, is also highly dependent on how long these physicians remain in rural practice (i.e., retention). While usually mentioned together, recruitment and retention are actually two separate and distinct phenomena. While recruitment is obviously a necessary component in increasing physician supply, retention is also crucial to the rural physician workforce. In fact, retention has the potential to have a multifold impact on the supply of rural physicians (e.g., doubling the practice duration of a single physician from seven to 14 years has a similar impact as training two physicians who each practice rurally for seven years). Similarly, physicians who practice in the same rural area for their entire career (e.g., 35 years) have a five-fold impact compared with physicians who practice there for only seven years. Actually, the value added of retention is likely to be even greater, considering the substantial cost of recruitment,12 and the issues involved in changing physicians every seven years—providing that a community is able to recruit successive physicians.

For rural primary care physicians in general, data have shown that the median duration of unobligated primary care physicians’ practicing in the same rural area is approximately seven years.13 Among programs specifically developed to address the rural physician shortage, and where a cohort of providers was followed up for at least this national norm, retention has been determined only for the NHSC; these studies have shown a median practice duration of only two to four years, similar to their required service time.13,14 No rural program has shown retention duration longer than the national norm.

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The Present Study

Because of the critical impact of increasing the practice duration of rural primary care physicians, we decided to study the long-term retention of graduates of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC), one of the comprehensive medical school programs designed to address the rural physician shortage. The PSAP, which has previously been described,15–17 consists of admission, curricular, mentorship, and financial components. Since 1974, the PSAP has recruited and selected medical school applicants who have grown up or spent a significant part of their lives in a rural area or small town, and who are also committed to practicing the specialty of family medicine in a similar location. PSAP matriculants, most of who grew up in the state of Pennsylvania, spend time working clinically with their faculty advisors in the Department of Family Medicine, and meet regularly as a group with PSAP faculty to discuss issues related to the program and their careers. While PSAP students are eligible for a small amount of additional financial aid, this is almost entirely in the form of repayable loans, and represents only a small portion of each student’s entire tuition and expenses. During their third year, PSAP students take their six-week required family medicine clerkship at a rural or small-town location. In their fourth year, PSAP students take their four-week outpatient subinternship in family medicine, and most take a rural preceptorship, working in the office of a rural family physician. Upon completion of medical school, PSAP graduates are expected to take a three-year family medicine residency at a location of their choice, and to practice family medicine in a small town or rural area; however, there is no mechanism to ensure compliance for residency or practice.

The availability of the Jefferson Longitudinal Study (JLS) of Medical Education—an ongoing cohort study tracking JMC graduates for more than three decades18—has provided a unique opportunity to extensively study the PSAP outcomes. Our previous work has shown that PSAP graduates have been more than eight times as likely as their non-PSAP peers at Jefferson to enter rural family medicine.17 Although the program is relatively small (having averaged only 15 students per year), it has accounted for 12% of all rural family physicians in Pennsylvania.17 Previous research has also shown that approximately three-quarters of the success of the PSAP appears to be due to the admission component.19 As with other rural programs, however, little is known regarding the long-term retention of PSAP graduates. No long-term retention outcomes are available regarding PSAP graduates, nor are there any retention data regarding individual physicians practicing in the same rural area. One prior study did look at the program retention of the PSAP after 5 years, and another after an average of 6.8 years (two-thirds of graduates were in practice for only five years); outcomes for both of these studies combined individual physicians who remained in family medicine in any rural area as well as those who moved from a nonrural to a rural area.16,17 To our knowledge, however, there is no previous study of graduates from a program designed to increase the rural physician supply that has followed the long-term individual retention of a cohort of nonobligated physicians practicing in the same rural area, nor is there any study that has shown a retention duration longer than the national norm.

Thus we undertook this study to follow up the individual PSAP graduates from the first nine years of the program who were practicing rural family medicine when they were initially located in practice, and to determine their long-term (11–16 year) retention rate.

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Method

As part of our ongoing longitudinal follow-up of PSAP graduates, the current 2002 practice locations and specialties were obtained for all 1,937 living JMC graduates from the classes of 1978–1986, including 148 PSAP graduates. These data were then merged with comparable data that were available at five- to six-year intervals from previous studies.15–17 As in prior studies, current practice locations were obtained from the JMC Alumni Association17,19; this information on practice locations has previously been shown to be highly accurate.15 Each graduate’s office address was obtained when available; otherwise, the home address was used, assuming that it was of similar rurality.

Data on each physician’s specialty were obtained from the Jefferson Longitudinal Study. The JLS contains certification information from the American Board of Medical Specialties and self-reported specialty data from the American Medical Association (AMA) Physician Masterfile (2001). As in our prior studies, practice specialty was considered to be that in which board certification was obtained.15–17 Graduates were considered to practice their primary specialty if they were also certified in geriatrics or sports medicine. For all other graduates who had board certification in two or more specialties, or who were not board certified in any specialty, primary self-reported specialty data from the AMA Physician Masterfile were used.

To analyze the long-term retention of PSAP graduates, we identified the 92 physicians (including 38 PSAP graduates) who graduated from JMC between 1978 and 1986 and who were initially found to be practicing family medicine in a rural county (based on Standard Metropolitan Statistical Area designations) when their practice locations were originally determined (1986 for the classes of 1978–1981, and 1991 for the classes of 1982–1986).15,16 Each graduate’s current practice location and specialty data were then compared with similar data from when they were first located in practice. Practice location was considered to be in the same area if it was in the same or adjacent rural county as it was when the graduate was first located. Long-term retention was defined for PSAP and non-PSAP graduates as the percentage of individual graduates who were practicing family medicine in the same rural area in 2002, 11–16 years later. A Kaplan-Meier survival curve was also plotted for PSAP and non-PSAP graduates.

Pearson’s chi-square was used to compare the retention rates of PSAP and non-PSAP graduates. For group differences in survival curves, the logrank test was used. A p value of .05 or less was considered significant in all analyses.

This study was approved by the Institutional Review Board of Thomas Jefferson University.

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Results

Data regarding practice locations and specialties in 2002 were available for all 92 JMC graduates from the classes of 1978–1986 who had been practicing rural family medicine when first located in practice. Of the 38 PSAP graduates who originally entered rural family medicine, 26 (68%) were still practicing family medicine in the same rural area in 2002, including three in adjacent rural counties who were all within five miles of their initial practice counties. Comparable data for non-PSAP graduates showed that 46% (25/54; p = .03) were in the same rural locality (including two in adjacent rural counties approximately 15 and 50 miles from their initial practice counties).

As seen in Figure 1, PSAP graduates remained in family medicine significantly longer than did their non-PSAP peers (p = .04).

Figure 1

Figure 1

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Conclusions

Prior studies have shown that a number of programs developed to address the rural primary care shortage have resulted in an increased number of physicians entering rural practice.7–11,13–17,20 It was not known, however, whether these providers stayed in their rural communities, or for how long. It is clear that extending rural retention is crucial for successfully increasing the rural physician workforce. The typical primary care physician remains in rural practice in the same area for approximately seven years, the time it takes to educate a new physician to replace that physician (through medical school and postgraduate training). The net result is therefore one of mere replacement, if the number being trained is equal to the number in practice. However with the recent decline in the number of physicians trained in family medicine as well as those planning rural practice,4,19 the overall effect will not even maintain the current rural physician supply, let alone improve it. Simply recruiting new physicians is therefore unlikely to improve the long-standing shortage of rural physicians, unless long-term retention is also increased.

Of previous studies on long-term rural physician retention, outcomes for nonobligated primary care physicians followed up for approximately 9–11 years showed that 48% continued to practice in the same rural area.13 These are similar to the outcomes of non-PSAP graduates in the present study, where 46% remained in practice in the same rural area. Of programs specifically designed to increase the rural physician supply, only obligated NHSC physicians have been followed this long—with retention rates showing that 23–27% continue to practice primary care in the same rural areas.13,14,21 The results from our study of PSAP graduates are the first to show long- term retention rates that are longer than the median duration. In fact, these outcomes represent the highest long-term retention rates reported, with more than two-thirds of PSAP graduates remaining in family medicine in the same rural area after 11–16 years. Most of these PSAP graduates—now 16–24 years after medical school graduation—are between 40 and 50 years old, and well established with their careers and families. While future follow-up is obviously needed, it is entirely possible that most will continue in their current rural practice for their entire careers, an outcome predicted by the leveling off of the survival curve over time, and also suggested in recent interviews with a small number of these PSAP graduates.22

Despite the critical impact of retention on the rural physician supply, longitudinally tracking the practice location of rural physicians is difficult, requires a long-term commitment, and has infrequently been done. Our study utilized data from the 30-year-old Jefferson Longitudinal Study in order to obtain our results. Also, while there are different ways to measure rural retention, we chose to focus on physicians who continued to practice in the same area, as this has the greatest impact on continuity of care from the community and patient perspectives. However, defining retention to also include those physicians who have moved to a different rural area represents another important programmatic outcome. Here, in addition to those JMC graduates who continue to practice family medicine in the same rural area, four of the 12 PSAP graduates who moved (33%) are family physicians practicing in another rural area, as are seven of the 29 non-PSAP graduates (24%). It is also important to note that while the absolute number of PSAP graduates is small, the impact of the program has previously been shown to be disproportionately large, contributing 21% of all rural family physicians in Pennsylvania who graduated from one of the seven medical schools in the state, even though PSAP graduates represent only 1% of those graduates.17

Combined with previously reported recruitment outcomes from this and other comprehensive medical school programs,9,15–17,20 the results of this study extend even further the impact of these programs in addressing the rural physician shortage, and their long-term effect on rural communities. Without these special programs, the insufficient recruitment and high turnover would have had an even more serous effect on the frustrating and long-standing shortage of rural physicians. Programs primarily providing financial assistance, while critically important in increasing recruitment, appear to result in relatively short retention rates that mirror the participants’ obligation, and they are costly. Based on this and prior studies,17 the PSAP is the only program whose outcomes have been shown to result in multifold increases in both recruitment (eight-fold) and long term retention (at least 11–16 years). As such, the PSAP and similar comprehensive medical school admissions and educational programs offer the greatest likelihood to substantially improve the rural physician supply. In addition, if the increased outcomes from the more recent six graduating classes (1992–1996) continue—which show a 14-fold increase in PSAP graduates entering rural family medicine compared to their peers—this impact will be even greater. Similarly, should PSAP retention continue longer than 11–16 years, the effect of this program will be magnified even further. In light of recent national recommendations to increase the total enrollment in U.S. medical schools by 15%,23 allocating some of this growth to developing and expanding programs similar to the PSAP would represent a highly effective way to address the rural physician shortage.

While this study did not address why PSAP graduates remained longer in rural family medicine than their peers, prior studies have shown that the PSAP itself is an independent predictor of rural retention, while demographic variables such as age and sex are not. Another limitation of this study is that it focused on graduates of only one medical school. However, prior rural recruitment outcomes of PSAP graduates have been similar to those from other comprehensive medical school programs.9 In addition, JMC graduates from the nine classes studied took their postgraduate training at more than 300 different programs in 42 states, and currently practice in 49 states, with most (58%) located outside of Pennsylvania. Because JMC is located in a major metropolitan city in the northeastern United States (factors related to low outcomes of primary care and rural practice), the results from medical schools located in other areas could be even greater.

In summary, this study is the first to show increased long-term retention of rural primary care physicians from a program designed to increase the rural physician supply. Combined with prior outcomes showing an eight-fold increase in recruitment of PSAP graduates, these results provide important information to policy makers and medical educators who are faced with improving the rural physician shortage. They strongly suggest that medical schools have the ability to make a substantial and long-term impact on the rural physician workforce.

The authors are indebted to Joseph S. Gonnella, MD, J. Jon Veloski, MS, and Mohammadreza Hojat, PhD, from the Center for Research in Medical Education and Health Care, for the data from the Jefferson Longitudinal Study; to the alumni association for the data regarding JMC alumni practice addresses; to Clara Callahan, MD, and Grace M. Hershman, MEd, from the admission office; and to Paul C. Brucker, MD, Thomas J. Nasca, MD, and Richard C. Wender, MD, and thank each of the above individuals for his or her support of the PSAP. The authors also express their admiration of the graduates of the PSAP who continue to practice family medicine in rural areas.

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