1. Basic Principles: Retaining Health Professionals in Rural and Underserved Areas and Practices Don Pathman, MD MPH UNC Chapel Hill NC Primary Care Conference Asheville June 22, 2012

2. Goal Review general concepts of retaining rural and urban underserved area health care professionals Data are on physicians in underserved settings and mostly rural, but apply (with some variation) to other health professionals and urban I call on your expertise: I ask; you predict; then I present data from our studies of the past 20+ years

3. Why Believe Me? From Los Angeles Studied philosophy and medicine in Philadelphia

4. Why Believe Me? From Los Angeles Studied philosophy and medicine in Philadelphia Practiced in rural Maine (NHSC), Colorado and North Carolina Published 50+ papers over 22 years on rural and underserved health workforce issues Worked with the NC Office of Rural Health Serve on NHSC NAC

5. Fundamental R & R Principles 1.Retention success is achievable in any community. 2.Underserved-area physicians are humans first, professionals second: Relationships are key They are atypical among physicians 3.Rural and underserved practice is a marriage between a community and physician: The match is key The outward characteristics of the physician are not important; what is in their heart is The work situation needn’t be perfect, just not bad

6. 4.Rural physicians are locals at heart 5.What physicians encounter in their practices and communities is key to retention: They need to feel satisfied, valued, invested and fulfilled They need a viable, long-term employment situation 6.Retaining and recruiting differ in important ways.

7. Principle: Retention success is quite achievable in any community. Retention: Rural vs. Urban Location urban site rural site 355 rural and urban generalists p = n.s.

8. 587 rural generalists non-HPSA HPSA p = n.s. Rural HPSA vs. Non-HPSA Location Principles: Retention success is quite achievable in any community. Retaining and recruiting differ.

9. 1086420 1.0.8.6.4.2.0 Years 1086420 Cum Survival 1.0.8.6.4.2.0 Retention: Community Characteristics Urban Adjacent Non adjacent >10K 2.5K - 10K < 2.5K Town Pop Principles: Retention success is quite achievable in any community. Retaining and recruiting differ. 587 rural generalists

10. Rural vs. Urban Raised 587 rural generalists rural raised urban raised p = n.s. Principles: Characteristics aren’t important, only what is in their heart. Retaining and recruiting differ.

11. Rural vs. Urban Raised Spouse 466 married rural generalists p = n.s. rural raised urban raised Principles: Characteristics aren’t important, only what is in their heart. Retaining and recruiting differ.

12. 587 rural generalists prepared neutral not prepared Preparation for the Community p <.001 Principle: Rural practice is a marriage between a physician and a community.

13. Work and Community Preparation CommunityWork 1086420 1.0.8.6.4.2 0.0 1086420 Cum Survival 1.0.8.6.4.2 0.0 WorkCommunity Prepared Neutral Not prepared Principles: Rural practice is a marriage between a physician and community. Rural physicians are human first, professionals second.

14. 587 rural generalists Principle: Rural practice is a marriage between a community and a physician. very sat satisfied neutral dissat very dissat Satisfaction with the Community p <.001

15. Satisfaction vs. Dissatisfaction w/ the Community 611 urban and rural subspecialists % leaving within 2 years Principles: Rural practice is a marriage between a community and physician. Things needn’t be perfect, just not bad.

16. Owners vs. Employees 587 rural generalists owners employees p <.001 Principle: Physicians need to feel invested.

17. 587 rural generalists $60-80K p <.05 Income: $80K < $60K > $80K Principles: Physicians need a viable employment situation. Things needn’t be perfect, just not bad. Rural physicians are atypical ($$ isn’t everything).

18. 1086420 1.0.8.6.4.2.0 1086420 1.0.8.6.4.2 0.0 1086420 1.0.8.6.4.2 0.0 call < 2x/wk call > 3x/wk Years > 25 pts/day < 24 pts/day > 50 hrs/wk < 49 hrs/wk Principles: Physicians need to feel valued and invested. Physicians need a viable long- term employment opportunity.

19. Areas of Satisfaction—Assoc. w/ 2 year retention 499 Clinicians Completing Service Obligations Strong personal connection to my patients Had good clinical back-up from senior/supervising clinicians Relationship with administrator Support from other clinicians Felt work did not encroach on personal time Agrees administrator is effective Agrees s/he is doing important work Financial stability of the practice Satisfied with salary/income Mission and goals of practice Access to specialist consultants Able to practice full scope of services

20. Areas of Satisfaction—Assoc. w/ 2 year retention 499 Clinicians Completing Service Obligations Strong personal connection to my patients Had good clinical back-up from senior/supervising clinicians Relationship with administrator Support from other clinicians Felt work did not encroach on personal time Agrees administrator is effective Agrees s/he is doing important work Financial stability of the practice Satisfied with salary/income Mission and goals of practice Access to specialist consultants Able to practice full scope of services Red = statistically related to retention @ 2 years

21. Teachers vs. Non-Teachers 587 rural generalists teachers non-teachers p =.05 Principle: Rural physicians need to feel fulfilled.

22. Retention by Type of Service Program 353 obligated generalists Principles: Physicians need to feel satisfied. The physician-community match is key. Loan Repayment Loan Incentive Scholarship Resident Support

23. Key Points/Recommendations 1.Heed the fundamental principles presented earlier. 2.Develop separate retention and recruitment strategies. 3.Develop multiple strategies for retention and for recruitment. 4.Develop strategies in advance, not after problems arise. 5.The challenge should only be landing a physician (recruitment): once landed, any community is in good position to keep her/him.

24. Key Points (cont.) 6.Select a physician on their fit w/ practice and community. 7.Identify and remedy problems that trouble local physicians. 8.Sell yourselves and community. Warmly welcome attractive prospects. Embrace the entire family. 9.Create a job that fosters satisfaction, fulfillment, and investment, and is a viable long-term position.

25. Do not use the phrase “recruitment and retention”. It misleads people to think they are the same thing. recruitment and retention