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

Parlier, Anna, Beth; Galvin, Shelley, L., MA; Thach, Sarah, MPH; Kruidenier, David, MLS; Fagan, Ernest, Blake, MD

doi: 10.1097/ACM.0000000000001839
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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.

A.B. Parlier was research project coordinator, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina, at the time of writing. As of August 2017, she will be a graduate student, Psychology Department, Virginia Commonwealth University, Richmond, Virginia.

S.L. Galvin is director of research, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina, and adjunct assistant professor, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.

S. Thach is director of clinical and community outreach, Western North Carolina Rural Health Initiative, Mountain Area Health Education Center, Asheville, North Carolina.

D. Kruidenier is research and clinical librarian, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina.

E.B. Fagan is chief education officer, Mountain Area Health Education Center (MAHEC), assistant program director, Family Medicine Residency Program, MAHEC, and assistant medical director, Department of Family Medicine, MAHEC, Asheville, North Carolina. He is also associate professor, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable. As this was a narrative review of published literature and not human subject research, ethical oversight for research participants was not required.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A468.

Correspondence should be addressed to Shelley L. Galvin, 121 Hendersonville Rd., Asheville, NC 28803; telephone: (828) 771-5501; e-mail: Shelley.Galvin@mahec.net.

Health disparities exist between rural and urban populations; rural populations in the United States have worse health outcomes than urban populations.1,2 Rural residents have higher rates of smoking, adolescent pregnancy, chronic disease (e.g., ischemic heart disease, chronic obstructive pulmonary disease, obesity), and mental illness. They also have higher mortality rates among children and young adults.1,3 Rural residents have higher risk profiles; for example, on average, rural residents are older and have lower education and income levels. Those rural residents who are under 65 years old are more likely to be uninsured or Medicaid beneficiaries. In addition, in states opting not to expand Medicaid under the Affordable Care Act, such as North Carolina (NC), rural residents are more likely to fall into the insurance “coverage gap.”4 Thus, although the overall proportion of people living in rural areas is decreasing, rural areas have a higher proportion of vulnerable populations. Rural communities will continue to need improved access to health care.5

Rural stakeholders participating in both the Rural Healthy People 2010 and 2020 national questionnaires identified “access to healthcare” as the top rural health priority.6,7 According to 2010 U.S. Census data, 19.3% of the total population lives in rural areas, where only 8.9% of physicians practice.8,9 Accordingly, the overall shortage of primary care physicians in the United States is more pronounced in rural areas.10,11 As of 2010, there were approximately 84 primary care physicians per 100,000 people in urban areas, but in rural areas, there were only 68 per 100,000 people.9 Nationwide in 2004, there was 1 primary care physician for every 1,321 persons; in rural areas, there was 1 primary care physician for every 1,810 persons.12 However, in some states like NC, rural areas that are farthest from academic centers are worse off than statewide rural statistics would indicate.13 This problem is not limited to the United States; rural primary care physician shortages are problematic in other economically developed countries, including Australia and Canada.14,15

The United States, Australia, and Canada have used a variety of strategies to try to ameliorate the shortage of rural physicians. These include implementation of pipeline rural education, rural emphasis and exposure during medical school and residency, legislative funding to increase the number of nonmetropolitan residency training programs, and financial incentives to practice in rural areas. These strategies have achieved varying degrees of success.16–20

Despite the literature including a number of such strategies, we found no comprehensive, evidence-based model for health care education programs to improve the development, recruitment, and retention of rural primary care physicians. Therefore, to help inform strategies for improving health care access in the mostly rural region of our family medicine residency program (Mountain Area Health Education Center Family Medicine Residency Program, Asheville, NC), we examined the literature documenting successes in recruiting and retaining rural primary care physicians.

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Method

We 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.

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Search strategy

In May 2016, a research librarian searched MEDLINE, PubMed, CINAHL, ERIC (Education Resources Information Center), Web of Science, Google Scholar, and the New York Academy of Medicine’s Grey Literature Report for English-language literature published in peer-reviewed journals. Key search terms included “retain*,” “retention,” “place*,” or “recruit*”; and “physician,” “educat*,” “medical student,” “graduate,” or “resident”; and “primary care” or “family medicine”; and “rural.”

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Study selection criteria and process

We included empirical studies in this review if (1) the article was published in or after 1990; (2) the research was conducted in the United States, Canada, or Australia; (3) the study was designed as observational or interventional outcomes research or a literature review; and (4) the article presented outcomes of strategies, implemented at some point from medical school through long-term practice, regarding primary care physician recruitment and/or retention in rural practice (as defined by each study).

We extended our search to 1990 because the rural physician shortage is a long-standing problem that remains unsolved. Because this problem spans multiple countries, we included literature conducted in the United States, Canada, and Australia, which have similar graduate medical education programs and resources.

The librarian’s electronic database searches yielded 73 studies, including 4 literature reviews. (If the focus of the literature review did not meet all inclusion criteria, we considered which of the articles included in the review might. We examined these articles further to ensure their eligibility and that they were not duplicates of the studies from the database searches or of articles referenced in included literature reviews.) We selected 167 additional articles for review from the reference lists of the articles and literature reviews from the database searches. We screened the titles and abstracts of all 240 studies for topic relevance; from these, we identified 165 potentially eligible articles. Then we evaluated the full text of these 165 articles to determine eligibility. Eighty-three studies met inclusion criteria (Figure 1).

Figure 1

Figure 1

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Data extraction

We extracted data from each included study on the (1) type of study; (2) sample size; (3) type of program studied; (4) country where the study was conducted; (5) years of data collection; and (6) results related to characteristics of trainees, medical schools, residencies, placement, and retention. We collected the data using spreadsheets similar to those shown in Supplemental Digital Appendixes 1–5 (at http://links.lww.com/ACADMED/A468) and compared all data reported against the full text of the original studies to ensure accuracy.

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Development of a theoretical model

We synthesized results from the articles and developed a theoretical model that integrates our findings related to individual, educational, and professional characteristics and experiences and proposes how they interact and influence rural physician development, recruitment, and retention.

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Results

Some of the included studies suggested that individual, educational, and professional characteristics and experiences were interrelated, but the majority of studies examined these types of characteristics and experiences separately. Additionally, most of the included studies used observational designs that did not use statistical adjustment of confounding variables, such as self-selection and recruitment biases. Nevertheless, the 83 included studies are representative of the research on rural primary care physician recruitment and retention.

On the basis of our review of the included studies, we found that rural physicians’ characteristics and experiences can be grouped into five dimensions that have important influences on rural identity and practice location: (1) individual characteristics, (2) medical school, (3) residency, (4) placement, and (5) retention (Table 1). We discuss each of these dimensions in detail below. Additionally, we propose a theoretical model that describes the interaction of different factors across the five dimensions and the development of a “rural physician identity”—one’s internalized perception that he or she is a rural doctor (Figure 2).

Table 1

Table 1

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Individual characteristics

Thirty-one studies discussed individual characteristics—including rural upbringing, rural exposure (recreation and job experience), and personal attributes (personal traits [such as resiliency and service orientation], gender, and age)—as predictors of entering and remaining in rural primary care practice (Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A468).20–50

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Rural upbringing.

Among studied characteristics, a rural upbringing was the most common predictor of entering rural practice.21,22,25,27–35,40,42,44

For example, in one study, researchers sought to determine the variables that predicted which Jefferson Medical College graduates chose rural practice. They found that rural upbringing was one of five independent predictors of rural primary care practice.22 In another study, compared with U.S.-born physicians with an urban upbringing, those with a rural upbringing were four times more likely to practice rural medicine; this disparity was even more pronounced among family medicine physicians.44

Individual studies define rural upbringing differently. Most often the definition was based on population density or length of time spent in rural areas. Although the definition of rural upbringing varies, Manusov and colleagues47 suggest it is the student’s perspective of rural upbringing that influences career choice rather than the definition. If students perceive their upbringing to be rural and identify with rural culture, they are more likely to practice rural medicine.21,47

Even though rural upbringing is a strong predictor of rural practice, 50% to 74% of practicing rural physicians were not raised in rural areas.28–33,40,45 Additionally, some studies, particularly among foreign-born physicians, did not find a significant correlation between rural upbringing and rural practice location.26,30,45 Thus, it is clearly important to understand other factors that influence practice location decisions.

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Rural exposure.

A student’s rural identity can be developed by factors other than rural upbringing. For example, spending time in rural areas for recreation or employment during youth can expose students to rural areas. These activities help develop a familiarity with rural areas and culture, which rural physician interviewees reported influenced their decisions about practice location.21

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Personal attributes.

Some studies report that many rural physicians have similar personal traits, including being resilient and service oriented.20,21,36,46 For example, one study found that rural physicians in Australia are more likely to have high novelty seeking scores (high exploratory impulsiveness and low stoic frugality) and low harm avoidance scores (low anxiety proneness, high outgoing vigor, and high risk taking).39

Additionally, several studies report a gender disproportion among rural physicians.23,28,31,32,34,37,38,41 One study reported that men are five times more likely to enter rural practice than women.43 However, other studies suggest that opportunities for flexible work hours may facilitate women’s interest in rural practice,48–50 as U.S. female rural physicians reported reduced or flexible work hours, supportive relationships, and clear work–life boundaries as having contributed to their successful careers.48,50

Studies that looked at age demonstrated mixed results. In Australia, compared with urban general practitioners (GPs), practicing rural GPs were younger (mean age 50 vs. 47 years),32 whereas in NC, practicing urban physicians were younger than rural physicians (mean age 30 vs. 32 years).38

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Medical school

Fifteen studies described the importance of medical school factors (rural exposure [i.e., rural health experiences], rural emphasis, and other school and training factors) in recruiting and retaining rural primary care physicians (Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A468).20,24,28–30,32,34,40,46,51–56

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Rural exposure.

Throughout the United States, 35 medical schools have rural tracks designed to provide longitudinal rural experiences to students who choose to apply and participate,57 while other medical schools have rural-focused curricula that include time-limited clinical experiences in rural settings for students interested in rural medicine.20

The University of Minnesota Medical School’s Rural Physician Associate Program (RPAP) has a rural track in which medical students complete a nine-month rural curriculum and clinical experience. Of the RPAP graduates, 56% of primary care and 61% of family medicine physicians chose to practice in rural communities.54

Jefferson Medical College has a long-standing, family medicine and rural-oriented Physician Shortage Area Program (PSAP) that incorporates rural-focused admission criteria and extensive family medicine and rural health exposure for participating medical students. PSAP participants who graduated between 1978 and 1991 were markedly more likely to practice rural family medicine upon graduation than non-PSAP participants (21% vs. 2%).51 Additionally, from 1986 to 2011, when compared with non-PSAP graduates, PSAP graduates had a significantly higher rural retention rate (46% vs. 70%).53 Further, in 2012, 70% of PSAP participants who graduated between 1978 and 1986 and initially entered rural family medicine remained in the same rural area.52,53

Other medical schools with shorter rural experiences have successfully placed some rural physicians. The University of Calgary requires medical students to complete a four-week rural family medicine clerkship. Of their family medicine residents graduating between 1996 and 2000, 18% became rural physicians.24 According to two other Canadian studies, rural exposure during medical school may be more influential on urban-raised physicians; compared with rural physicians who were raised in rural communities, rural physicians who were raised in urban areas were more likely to indicate that they had received rural exposure during medical school.29,46

Although the type and duration of rural training in the included studies varied, evidence suggests that rural exposure during medical school can influence subsequent rural practice.28,32,34,40 However, the relationship between rural exposure and rural practice is confounded by self-selection bias; that is, those who already desire rural practice may be more likely to opt for programs that offer rural exposure.

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Rural emphasis.

Medical schools that demonstrate a rural emphasis by locating in a rural area, adopting a rural mission, supporting a generalist focus, and employing rural faculty mentors are more likely to produce graduates who choose rural practice.20,56 Many programs with a rural emphasis have specific rural-focused admission criteria to help ensure that students are interested in rural practice; thus, recruitment bias confounds data on the effectiveness of rural emphasis.

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Other school and training factors.

Some other medical training factors, including having a family medicine department and focusing less intensively on research, have been shown to influence eventual rural practice.20,56 Medical schools that are publicly owned, osteopathic, or international are also more likely to produce graduates who choose rural practice.20,30,55,56

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Residency

Forty-three studies discussed the relationship between residency factors (rural exposure [i.e., rural health experiences], rural preparation, and rural emphasis) and entering and remaining in rural practice (Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A468).25–30,33,34,36,37,40,46,58–88

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Rural exposure.

According to one study, rural rotations during residency are the best educational experiences to prepare primary care physicians for rural medical practice and rural living.58 Other studies of current residents and practicing rural physicians suggest that rural rotations in and of themselves may not be sufficient or necessarily the best rural health experiences during residency.25,27,40,59,60 Nevertheless, rural physicians are significantly more likely than urban physicians to have had rural rotations during residency.28,30,34,37

The duration of rural exposures during residency in the included studies varied.28,34,61–70 An Australian study of GPs found that as the duration of rural training in residency increases, so does a resident’s likelihood of choosing rural practice.34 These results are potentially confounded by self-selection and recruitment biases; that is, it is possible that those who are more committed to rural practice pursue additional rural training experiences across their education.

One strategy for providing residents with extensive rural exposure is structuring residency programs as rural training tracks (RTTs). Most RTTs follow a “1 + 2” model that requires one year of training in an urban area and two years in a rural area.89 RTTs have successfully placed 49% to 86% of graduates in rural areas.63–70 Further, 35% to 50% of RTT graduates who began in rural practice remained rural physicians for up to seven years.64,71

Overall, these placement and retention rates demonstrate high success among RTTs. However, the number of total graduates from RTTs each year is relatively small compared with the need for rural physicians.72,90 Despite recent increases in faculty and resident recruitment, historically, many RTT residency programs experienced difficulties with recruitment, retention, and funding.20,72,90,91 Even though RTTs have high rural placement and retention rates, they usually have strict rural mandates and specific admission criteria, so it is likely that these programs help residents who are already interested in rural practice achieve their career goals instead of increasing the number of residents interested in becoming rural practitioners.

Beyond RTTs, other rural exposure strategies during residency are associated with increased placement of rural physicians. In one study of rural-centric family medicine residencies (programs that offer at least eight weeks of rural training, including RTTs), researchers found that 26% of RTT graduates and 36% of other rural-centric program graduates began rural practice immediately after residency.73 Other studies of primary care residency programs with rural experiences, with durations ranging from less than one month to up to six months, report placing 25% to 51% of graduates in rural communities.36,63,74,75

Similar to the results of studies involving medical students, rural exposure during residency may be more influential for urban-raised physicians.29,46 In a Canadian study, among rural physicians who were urban-raised, those who had a rural rotation during residency were more likely to report being prepared for rural practice, rural culture, and rural living than those who had no rural exposure in residency.26

Contrary to the results mentioned above, a small Canadian survey of family medicine graduates comparing residents with any rural exposure to those with no rural exposure found that there was no association between rural exposure during residency and choosing to practice in a rural community.33

Moreover, rural exposure may inoculate residents against rural practice if it is a negative experience. For example, a six-month rural rotation in Australia influenced 14% of female GPs against working in rural areas because of the negative aspects observed within their specific placements, including long work hours, social isolation, lack of anonymity, exhaustion from multiple roles (mother, doctor, wife, etc.), and poor remuneration.27 Similarly, some residents have negative training experiences in their practice sites due to the busy workloads, stressors from increased responsibility, scheduling problems, separation from families, disruption of personal lives, and increased driving times.59,76–78 One Canadian study of family medicine residents found that, compared with urban residents, rural residents reported more motor vehicle accidents due to weather conditions, fatigue, and inattention when traveling to rural sites for work.79 For rural educational experiences to be successful, participants need to be prepared for the complexities of working in rural settings and provided with adequate support.92

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Rural preparation.

Primary care physicians who participate in rural rotations during residency are better prepared for rural medical practice and rural living.58 Preparedness for medical conditions encountered in rural practice was less important for retention than preparedness for rural living. Those who declare themselves prepared for the realities of rural living are significantly more likely to remain in rural practice longer than those who declare themselves not prepared.58

One Australian study identified the two nonclinical competencies most important for rural living as preparedness for rural culture and rural community leadership.25 Rural culture refers to the core values and way of life embodied within rural communities, and rural community leadership refers to the leadership roles that physicians are expected to take as prominent members of their rural communities. Among family medicine graduates in Canada, the majority felt well prepared for rural culture, but not rural community leadership, and those that did feel well prepared for rural community leadership were more likely to practice in rural communities.25

Other studies suggest that community engagement is another nonclinical competency important for rural practice.80–82 Compared with their urban counterparts, rural primary care physicians in Florida were more confident in their ability to build community relationships, understand community members’ perceptions, and interact with their communities to address health problems.30 Providing residents with comprehensive rural training that teaches community engagement skills and about rural culture and rural community leadership may improve confidence and preparedness for rural practice.

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Rural emphasis.

Upon graduation, 56% of family medicine residents stay within 100 miles of their residency program.83 Furthermore, family medicine graduates of residency programs located in rural areas are three times more likely to practice rural medicine than family medicine graduates of nonrural residency programs.84 Family medicine residency programs that graduate more rural physicians tend to have an explicit rural mission, a program director with rural experience, a stand-alone residency with limited training from specialists, and an emphasis on procedures.62 For example, compared with urban primary care physicians, rural primary care physicians report needing more trauma management knowledge and clinical skills.85 Accordingly, some required rural rotations expose residents to the demanding workload and breadth of skills necessary for rural medical practice.86,87 In Canada, residents who participated in rural programs report significantly more experience and competence with a full spectrum of clinical skills (e.g., emergency, diagnostic, and obstetric procedures).88

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Placement

As shown above, the included studies demonstrated that a culmination of individual and educational characteristics and experiences contribute to priming physicians for rural practice. In addition to these characteristics and experiences, 13 studies described the importance of placement factors, including partner and spouse preferences and financial incentives, in decisions regarding practice location (Supplemental Digital Appendix 4 at http://links.lww.com/ACADMED/A468).20,23,29,30,32,36,42,48,77,93–96

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Partner and spouse preferences.

Partner interest in a rural lifestyle influences physician recruitment to rural communities.29,42,77,93 If a physician’s partner is reluctant to move to a rural area, recruitment is less likely.94 Similarly, in an Australian study, rural GPs were more likely to have a partner with a rural upbringing than urban GPs.32 Desirable rural employment opportunities for partners can also encourage recruitment.48,93

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Financial incentives.

Programs designed to address the shortage of physicians in rural and underserved areas, including the National Health Service Corps (NHSC) and state-funded scholarships, demonstrate some success in rural physician placement.20 In February 2011, 1,660 primary care physicians worked as part of the NHSC workforce in health professional shortage areas, including rural areas.97 Compared with physicians without any similar financial obligations, physicians serving commitments in exchange for reimbursed training costs are more likely to work in rural areas.23,30,36,95 However, this effect may be short-lived; compared with rural non-NHSC physicians, rural NHSC physicians were less likely to work in nonmetropolitan areas for 10 or more years (52% vs. 25%).96

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Retention

Twenty-six studies discussed retention factors, including rural medical practice and quality of rural life, for rural primary care physicians (Supplemental Digital Appendix 5 at http://links.lww.com/ACADMED/A468).21,31,35,38,40,41,46,80–82,86,87,93,98–108

In discussing retention, the length of time working as a rural physician is important as many rural physicians do not remain in rural areas throughout their careers. In 1990, only 39% of rural physicians surveyed remained in nonmetropolitan areas a decade later in 2000. Even fewer (29%) remained in their initial rural practice.96 Nationwide in 1997, the median stay for primary care physicians at their initial rural practice was 6 years (95% confidence interval 4.71–7.29).58 But, this varies regionally. Among NC primary care physicians in 1992, the 3-year rural retention rate was 48.1%, and the average length of stay in a rural area was 4.6 (± 0.1) years. However, this was not unique to rural physicians. The 3-year urban retention rate was 48.5%, and the average length of stay in an urban area was 4.4 (± 0.1) years.38 While many factors that contribute to rural physician recruitment also contribute to retention, on the basis of these retention rates, it appears that additional considerations related to rural medical practice and the quality of rural life may influence retention.

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Rural medical practice.

Rural and urban practice characteristics differ. Most rural physicians are in solo practice and have, historically, owned their practice.35,41,58,98 Rural physicians tend to work more hours per week, complete more patient visits, and see more Medicaid patients.31,41,93,96 Many rural primary care physicians practice hospital-based care, emergency department care, nursing facility care, and obstetric and newborn care; they also perform more office procedures and surgery-related services.86,87,93,99

For some physicians, the professional autonomy, challenging setting, and comprehensiveness of this work help recruit and retain them in rural practice.21,46,82 For others, the demanding nature of rural practice causes stress and dissatisfaction.100–104 For example, the main stressors for rural physicians include low reimbursement, insufficient practice management skills, work–life imbalance, heavy workload, too frequent calls, isolation, and inadequate professional support.21,82,100–104 In one study, Australian rural GPs who had seriously considered leaving rural practice within the past two years were significantly more likely to have higher levels of work-related distress and lower levels of morale and work–life balance than those who had not considered leaving rural practice in the past two years.100

Accordingly, addressing physicians’ professional concerns and sources of dissatisfaction can help retain rural physicians.40,105 To ameliorate the stressors that rural physicians face, the Rural Doctors Workforce Agency in Australia implemented Dr. Doc, a program to help improve rural physicians’ health and well-being, job satisfaction, and work-related distress.109 The program offers social and emotional support strategies for rural GPs, including peer-support networks, rural retreats, crisis planning, and emergency telephone support. Physicians who self-selected to participate in the program reported improved social networks.106 Additionally, after participating in the program, fewer physicians reported suffering from work-related physical and mental health issues.106 In another Australian study, the stable and successful GPs in rural areas were more likely to report strong professional support and adequate time off from work.80

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Quality of rural life.

Several studies emphasized the importance of rural primary care physicians developing a sense of belonging within the rural community where they work and/or live.81,82,107,108 The more integrated physicians are into their medical community and the community in which they live, the more likely it is they will stay in that area. Preparing physicians to adapt and integrate into rural medical practices and rural communities, therefore, may help retain rural physicians.

Family needs and preferences contribute to a physician’s perception of “goodness of fit” and can influence retention as well. For many rural physicians, safety and comfort of family members, high-quality education for children, and desirable job opportunities for partners are high priorities.21,81,82,93,100,104 Personal preferences (e.g., preferring the natural over the built environment or the familiarity of small towns to the anonymity of large cities) and rural recreational interests (such as hiking rather than attending an opera) can also influence retention.21,81,82

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Theoretical model for rural physician identity development

Based on our synthesis of the results, it appears that over time individual, educational, and professional characteristics and experiences work together synergistically to help physicians develop a rural physician identity that influences decisions and enables physicians to thrive in rural communities (Figure 2). Developmentally, a rural identity and a physician identity must integrate into a rural physician identity. We believe that characteristics and experiences across three dimensions contribute to the initial forming of a rural physician identity: individual characteristics, medical school, and residency. Within individual characteristics, factors, including perceived rural upbringing and rural-oriented personal attributes (e.g., being resilient and service oriented), foster early development of a rural identity. During medical school, programs with rural emphasis and positive rural exposure encourage rural identity development and foster early rural physician identity. During residency, programs with rural emphasis, positive rural exposure, and rural preparation for both clinical and nonclinical competencies further facilitate rural physician identity development. We speculate that those individuals who form a stronger rural identity, begin developing a rural physician identity, and begin acquiring rural-specific competencies are more likely to go into rural practice. Additionally, we believe placement factors, including partner receptivity to rural living and financial incentives, contribute to the decision to start in rural practice.

Figure 2

Figure 2

Further, we propose that after a physician starts working in a rural setting, the development of their professional identity as a rural physician potentially solidifies. We suggest that this phase of identity development is influenced by two factors within the retention dimension: rural medical practice and quality of rural life. These factors include elements such as a desire for professional autonomy and breadth of practice, acceptance of challenging work settings, development of effective stress management strategies, establishment of a good work–life balance, and integration into the rural community. We believe that rural physicians who successfully address these factors are more likely to solidify their professional identity as rural physicians, remain in rural practice, and thrive there.

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Discussion

Results from our narrative review suggest that individual characteristics and accumulation of rural-specific clinical and nonclinical competencies gained through positive exposure to and engagement in rural communities influence a physician’s choice to enter and remain in rural primary care practice. We believe that this developmental process culminates in the professional identity of a rural physician, a doctor who fully engages in a rural community as a leader and provider of comprehensive rural health care.110,111 We developed a theoretical model that incorporates the various factors across the five dimensions that we believe influence the development of a rural physician identity (Figure 2). As can be seen in this model, we believe that medical educators have many opportunities to cultivate and reinforce interest in rural practice, ensure appropriate rural training opportunities, and enhance the development of a rural physician professional identity.

The literature identifies rural upbringing as the largest predictor of rural practice and suggests that accumulating positive rural exposures throughout the educational process improves recruitment and retention.20–35,40,42,44,62 However, this conclusion may be confounded by both self-selection and recruitment biases. Further, of all rural physicians, 50% to 74% grew up in urban environments.28–33,40,45 Success rates for longer rural exposures are generally favorable, although this relationship is not necessarily linear as there is considerable variation among studies correlating length of exposure to recruitment.36,62–70,74,75 Shorter rural experiences, combined with other strategies targeting rural physician identity development, may also have the potential to effectively increase the supply of rural primary care physicians. Exposing medical trainees of all backgrounds to positive rural experiences with an intentional emphasis on rural-specific clinical and nonclinical competencies (preparation for rural culture, community leadership, and engagement), mentorship, and reflection may help to cultivate rural and rural physician identities.110–112

As a rural family medicine residency program, we conducted this review to support our mission to increase the supply of rural primary care physicians in our region. The organizational strategies we identified that appear to be beneficial at the graduate medical education level, based on the results of this review, include:

  1. locating residencies or extensions of residencies in rural communities;
  2. recruiting and retaining faculty, program directors, and program coordinators with rural experience;
  3. ensuring that the residency program has and communicates its rural mission and the rural-specific training elements it offers;
  4. adding rural physicians to admissions committees and discussing rural upbringing, rural identity, pertinent personal attributes, and career interests in the interview process;
  5. including structured, positive rural rotations of sufficient duration and with sufficient support, encouraging high-quality precepting and mentoring, and providing opportunities for meaningful reflection as to how rural experiences fit with individual characteristics and career goals;
  6. emphasizing clinical training in essential procedures and broad-spectrum care;
  7. providing structured, nonclinical learning experiences related to community engagement, leadership development, rural practice management, and rural culture;
  8. offering rural practice job placement assistance that supports residents in securing a good fit for the physician’s whole family;
  9. establishing a rural physician “welcome” service in regional communities to help integrate physicians’ families into the community socially, civically, and professionally to foster a sense of belonging;
  10. establishing support and consultation services for practicing rural physicians; and
  11. encouraging ongoing participation with medical education programs to maintain and improve the breadth of necessary skills.

These strategies can be implemented with varying levels of ease. However, we believe they may better prepare physicians to enter and thrive in rural practice. Several of these strategies require a close working relationship with the health care systems that are increasingly employing rural primary care physicians.

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Limitations

Although we have discussed some strategies (see above) to increase the number of rural primary care physicians, there are no clinical trials or well-designed interventional studies that assess the effectiveness of these strategies.113 Further, we did not address whether programs’ rural experiences were required or optional; self-selection and recruitment biases may be inherent in many of the rural programs we reviewed, making it difficult to distinguish strategies that attract individuals already committed to rural careers from strategies that increase the number of individuals interested in pursuing rural careers. Therefore, we do not know the ideal combination of individual, educational, and professional characteristics and experiences needed to increase the number of rural physicians. The most common predictor for rural practice is having a rural upbringing. However, we speculate that the development of a rural physician identity through a combination of factors, as described in our theoretical model (Figure 2), is more important. Further research into this preliminary model is needed.

The generalizability of our results is limited as we only reviewed literature from three countries—the United States, Australia, and Canada. However, the majority of rural health literature was published in these countries, which have similar graduate medical education programs and resources. We included only literature on primary care physicians, which included family medicine physicians. Some of the research, especially in the United States, is fairly old—dating back almost three decades. We reviewed literature published over the last 26 years because this is a long-standing problem that has not been resolved, with more recent workforce analyses still identifying relevant shortages.9–11,14,15 We did note similar strategies and outcomes over time. However, we acknowledge that there is still a need for studies that evaluate curricula that positively influence rural placement; the RTTs have begun sharing data to this end.91 We also must consider rural physician development as a more complex, integrated process and address rural physician identity formation as proposed in our model.

Declining rural populations may help mitigate the severity of the health care access problems in rural areas, but it is doubtful that proportional parity in distribution between rural and urban areas can be achieved on the basis of population decline alone. Ongoing careful analysis of the ideal workforce distribution is needed. Additionally, we recognize that health care access, risk profiles, and social circumstances all contribute to disparities in health outcomes; however, it was beyond the scope of this review to address all the variable risk profiles and social issues that contribute to health disparities in rural versus urban areas. In this review, we focused on ways to improve the development, recruitment, and retention of rural primary care physicians to improve access to primary care among rural residents.

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Conclusions

Rural recruitment and retention of primary care physicians continues to be an opportunity to match well-trained practitioners to underserved areas. Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. Although we do not understand all the interrelated factors that result in long-term rural practice, it is clear that multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while also providing trainees with positive rural experiences. Application of these strategies should help trainees and young physicians develop the professional identity of a rural physician and may, ultimately, increase the number of primary care physicians with meaningful lives and successful medical practices in rural communities.

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Acknowledgments:

The authors wish to thank Dr. Bryan Hodge, director of the Rural Family Practice Residency Program, Hendersonville, North Carolina, and Ms. Heather Grimm, staff editor, Academic Medicine, Washington, DC, for their editorial guidance.

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