1. Recruitment with Retention: Rural Medicine Eron G. Manusov, M.D. Robeson Healthcare Corporation

2. Rural Medicine “Beauty is truth, truth beauty,”--that is all Ye know on earth, and all ye need to know. Ye know on earth, and all ye need to know. John Keats

3. A National Rural Health Snapshot Rural Rural % of U.S.25% Population % of U.S.10% Physicians Number of 40.1 Specialists/1000Urban75%90%134.1

4. Barriers to Health Care Poverty Physician Practice Substance and Alcohol Abuse Health Insurance Health, Disease, and Danger Mental Health Religion

5. Poverty Poverty level is 18,000 dollars/family of four Poverty level is 18,000 dollars/family of four Of the 250 poorest counties in the U.S. 244 are rural Of the 250 poorest counties in the U.S. 244 are rural Average rural family makes 27% less and the poverty rate is 21% higher Average rural family makes 27% less and the poverty rate is 21% higher

6. Poverty Persistent poverty counties: 386 in America, 340 are rural. Persistent poverty counties: 386 in America, 340 are rural. Unemployment rate 9.3% compared to 5.8 %. Unemployment rate 9.3% compared to 5.8 %.

7. Eliminate Poverty and Eradicate Health Care Dilemmas

8. Physician Practice There are 2,157 Health Professional Shortage Areas (HPSA’s) compared to 910 in urban areas. There are 2,157 Health Professional Shortage Areas (HPSA’s) compared to 910 in urban areas. J-1 Visa J-1 Visa National Health Services Corps National Health Services Corps NHSC is complemented by the AHEC NHSC is complemented by the AHEC The bottom line is there are not enough MDs

9. Physician Practice Poor management and financial skills Poor management and financial skills Long hours/patient churn Long hours/patient churn Coverage Coverage Financial Strain Financial Strain Productivity based pay Productivity based pay No support No support Difficulties with rural life Difficulties with rural life For patients it equates to disparate care and reduced access For patients it equates to disparate care and reduced access

10. Substance and Alcohol Abuse LME, treatment centers, counselors LME, treatment centers, counselors Alcohol and Substance Abuse Alcohol and Substance Abuse Controlled Substance Use: The Physician’s Bane! Controlled Substance Use: The Physician’s Bane! “I need Percocet 10/650 four times a day and can you refill my Xanax 1mg TID. I can’t sleep and need my Ambien.”

11. Health Insurance Uninsured 20.5%. Uninsured 20.5%. Nearly four million of rural families (30%) had at least one uninsured member in 2002. Nearly four million of rural families (30%) had at least one uninsured member in 2002. State Children’s Health Insurance Program (SCHIP). Nearly 40 percent of families in which one family member is uninsured also have a member with public coverage State Children’s Health Insurance Program (SCHIP). Nearly 40 percent of families in which one family member is uninsured also have a member with public coverage

12. Health Insurance

13. Barriers Continued Health, Disease and Danger in Rural America Health, Disease and Danger in Rural America Mental Health: 87 percent of the 1,669 Mental Health Professional Shortage Areas Mental Health: 87 percent of the 1,669 Mental Health Professional Shortage Areas Religion Religion

14. Recruitment Family Physician Family Physician Osteopathic education Osteopathic education Rural Health Experience Rural Health Experience

15. Factors Important to Graduating Family Practice Residents in Choosing First Practice Site by Rank Significant other’s wishes Significant other’s wishes Medical community friendly to family physicians Medical community friendly to family physicians Recreation/culture Recreation/culture Proximity to family/friends Proximity to family/friends Significant other’s employment Significant other’s employment Schools for children Schools for children Size of community Size of community Initial income guarantee Initial income guarantee Benefits plan Benefits plan Proximity to spouse’s family/friends Proximity to spouse’s family/friends Weather/geography Weather/geography Need for physicians Need for physicians

16. Factors Important to Graduating Family Practice 12-24 Significant other’s school opportunities Significant other’s school opportunities Maximum potential income Maximum potential income Familiar with physicians in area Familiar with physicians in area Community service commitment Community service commitment Affordable housing Affordable housing Opportunity to teach Opportunity to teach Familiar with hospital Familiar with hospital Loan pay-back plan Loan pay-back plan Signing bonus Signing bonus Residency nearby Residency nearby Medical school nearby Medical school nearby Military service commitment Military service commitment

17. Initial Choice Costa, A.J., S.L. Schrop, and G. McCord, et al. 1996. To stay or not to stay: factors influencing family practice residents’ choice of initial practice location. Family Medicine 28:214-19. Costa, A.J., S.L. Schrop, and G. McCord, et al. 1996. To stay or not to stay: factors influencing family practice residents’ choice of initial practice location. Family Medicine 28:214-19. Psycho-social variables are most important

18. Factors that Influence Retention Physicians who receive part of their residency training in rural areas stay longer in rural practice. Physicians who receive part of their residency training in rural areas stay longer in rural practice. Physicians who feel better prepared to handle emergencies, tough medical situations and busy outpatient practices without consultants or high-level technology are more likely to stay in rural practice. Physicians who feel better prepared to handle emergencies, tough medical situations and busy outpatient practices without consultants or high-level technology are more likely to stay in rural practice. Physicians in rural communities are no more likely to leave their practices than are their urban counterparts. Physicians in rural communities are no more likely to leave their practices than are their urban counterparts. Urban-raised physicians who enter rural practice stay in rural practice longer than physicians who were raised in rural areas. Urban-raised physicians who enter rural practice stay in rural practice longer than physicians who were raised in rural areas. Own their own practice Own their own practice

19. Factors that Influence Retention Physicians whose spouses are from urban areas stay in practice as long as those whose spouses are from rural areas. Physicians whose spouses are from urban areas stay in practice as long as those whose spouses are from rural areas. Physicians involved in teaching remain in rural practice longer than those who are not involved. Physicians involved in teaching remain in rural practice longer than those who are not involved. For obligated National Health Service Corps scholars, students from private schools are more likely to stay in a rural pay-back site after they have fulfilled their obligation period than are those from public medical schools. For obligated National Health Service Corps scholars, students from private schools are more likely to stay in a rural pay-back site after they have fulfilled their obligation period than are those from public medical schools. Although many urban physicians assume otherwise, rural physicians do not necessarily view professional isolation and an inability to access medical information as drawbacks to rural practice. Although many urban physicians assume otherwise, rural physicians do not necessarily view professional isolation and an inability to access medical information as drawbacks to rural practice. Lack of quality of rural school systems, perceived or real, is related to length of stay for physicians in a rural practice. Lack of quality of rural school systems, perceived or real, is related to length of stay for physicians in a rural practice.

20. Solutions to Address Rural Health Physician Retention Solutions to Address Rural Health Physician Retention Orientation to peculiarities of rural practice Orientation to peculiarities of rural practice Use of incentive programs to address retention in underserviced regions (and investigation of sabbaticals) – Be creative! Use of incentive programs to address retention in underserviced regions (and investigation of sabbaticals) – Be creative! Coordinated locum services Coordinated locum services Medical education availability and postgraduate rural training programs Medical education availability and postgraduate rural training programs The availability of additional colleagues The availability of additional colleagues Opportunity for group practice Opportunity for group practice Consider generational differences Consider generational differences

21. Solutions to Address Rural Health Physician Retention Specialist services Specialist services Alternative compensation mechanisms Alternative compensation mechanisms Continuing medical education opportunities Continuing medical education opportunities Improved health care facilities & emergency transportation Improved health care facilities & emergency transportation Medical education: Mentors and Medical Schools Medical education: Mentors and Medical Schools Improved hospital facilities Improved hospital facilities Reasonable working conditions Reasonable working conditions Spousal factors Spousal factors

22. Community Involvement Orientation Orientation Educate communities on physician needs Educate communities on physician needs Community leadership Community leadership Family involvement: Schools, exercise Family involvement: Schools, exercise Community involved in physician choice Community involved in physician choice Community origin: Recruit at Junior High Community origin: Recruit at Junior High Low interest loans/start up help Low interest loans/start up help

23. Education Recruit rural friendly medical students Recruit rural friendly medical students Rural training or electives Rural training or electives Train, pay, and support rural educators Train, pay, and support rural educators Involve, educate, and reward communities Involve, educate, and reward communities Recruit and educate rural physicians Recruit and educate rural physicians Reward, support, educate, and involve Reward, support, educate, and involve rural physicians and their families rural physicians and their families

24. GRADUATE MEDICAL EDUCATION FOR RURAL PRACTICE AAFP POSITION PAPER/NRHA POLICY BRIEF A joint statement of the National Rural Health Association and the American Academy of Family Physicians July 2008

26. Resources for Information about Rural Health American Academy of Family http://www.aafp.org American Academy of Family http://www.aafp.orghttp://www.aafp.org Rural Policy Research Institute http://www.rupri.org Rural Policy Research Institute http://www.rupri.orghttp://www.rupri.org Rural Medical Educators Home Page http://www.unmc.edu/Community/ruralmeded/ Rural Medical Educators Home Page http://www.unmc.edu/Community/ruralmeded/ http://www.unmc.edu/Community/ruralmeded/ National Rural Health Association http://www.nrharural.org/ National Rural Health Association http://www.nrharural.org/ http://www.nrharural.org/ North Carolina Rural Health Research and Policy Analysis Center North Carolina Rural Health Research and Policy Analysis Center http://www.shepscenter.unc.edu/research_programs/rural_ program/rhp.html http://www.shepscenter.unc.edu/research_programs/rural_ program/rhp.html

27. Security, Freedom and Identity Security Security Confidence in medical abilities. Confidence in medical abilities. Commitment to goals. Commitment to goals. Ability to meet needs of family. Ability to meet needs of family. Comfort with local medical community and hospital. Comfort with local medical community and hospital. Not too much on-call. Not too much on-call. Social networks available. Social networks available. Respect by community at large and by the medical community. Respect by community at large and by the medical community.

28. Security, Freedom and Identity Freedom Freedom Challenge and diversity in medical work. Challenge and diversity in medical work. Ability to spend time with patients. Ability to spend time with patients. Cooperation from medical community and larger community. Cooperation from medical community and larger community. Power in medical system Power in medical system Ability to develop health care delivery system Ability to develop health care delivery system Involvement in the community. Involvement in the community. Personal and family activities. Personal and family activities. Developed sense of self and place Developed sense of self and place

29. Security, Freedom and Identity Identity Identity Loss of anonymity. Loss of anonymity. Like-minded practice group. Like-minded practice group. Responsible role in hospital and community. Responsible role in hospital and community. Respect. Respect. Fulfilling aspirations for job. Fulfilling aspirations for job. Seeing self as belonging in the community. Seeing self as belonging in the community. Awareness of self in time and place. Awareness of self in time and place. Creation of future goals without needing to relocate. Creation of future goals without needing to relocate.