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In Rural Areas, Recruiting and Retaining Doctors Are No Easy Tasks

By Susan Kreimer
April 12, 2018

Adequate call coverage and autonomy can be as important as salary and other financial incentives. Often, it’s as simple as wanting to step away from the big city.

When Michelle Kenney, MD, finishes a pediatrics residency at the University of Missouri at Columbia in June, she will return to her roots in rural America.

“My goal has always been to go back home, and they definitely have a shortage of pediatricians right now,” says Kenney, 29, whose parents live on a cattle farm north of Kirksville, Missouri.

She will join Northeast Pediatrics, a federally qualified health center in Kirksville, where she completed two monthlong rotations. The practice has been spread thin with only one pediatrician and a nurse practitioner, and she’s eager to fill a critical need.

michelle kenney 1

Pediatric resident Michelle Kenney, MD, plans to practice in Kirksville, Missouri, where her parents live on a cattle farm. In a rural setting, she says, “it kind of pushes you to use more of the broader knowledge you’ve learned because there aren’t as many specialists available.” | UNIVERSITY OF MISSOURI

“It really is hard on families having to travel long distances for a doctor’s appointment,” Kenney says. In a rural setting, “it kind of pushes you to use more of the broader knowledge you’ve learned because there aren’t as many specialists available.”

That factor appealed to Kenney in her decision to work in Kirksville, a city of 17,000 about three hours away from the nearest major metropolitan areas (Kansas City and St. Louis in Missouri, and Des Moines in Iowa). But it doesn’t appeal to every physician.

Recruiting and retaining physicians to serve rural communities is not an easy task for health care organizations seeking to mitigate provider shortages and improve access to health care.

WHAT WORKS?

Some factors beyond salary that smaller health care organizations can use to appeal to physicians they’re recruiting.

Broad experience. With fewer specialists nearby, physicians have a chance to work on cases they might not otherwise get to see.

Autonomy. In smaller facilities, doctors can have a greater voice and can effectively shape policy as true physician leaders.

Quality of life. As burnout increasingly is acknowledged, physicians want to know about the lifestyle available within a short drive — the outdoors, the arts, etc.

Clinical support. Providing a team of nurse practitioners and physician assistants, or having a robust residency program, can help relieve the workload.

Mid-metropolitan and rural hospitals find it particularly challenging to attract physicians, says Steve Worthy, a North Carolina-based consultant who assists health systems and provider groups in designing compensation and benefits programs.

Nowadays, “doctors are much more mobile,” he explains, citing the trend of physicians becoming employees of health systems. “They don’t have the traditional anchors that a private practice would have. This makes them more susceptible to being recruited away, so hospitals are now asking us for creative concepts and ideas — how to use compensation and benefits to retain and reward them for their loyalty and longevity.”

To attract physicians to work in a smaller setting, Worthy says, leaders can consider introducing an incentive-driven corporate executive structure, with a bonus plan tied not only to length of service, but also to productivity, quality and patient satisfaction — the metrics that often propel hospital revenue.

But salaries and other incentives can go only so far in keeping a physician content in the workplace and surrounding community, says Jack Hensold, MD, acting president of the Montana State Oncology Society (an affiliate of the American Society of Clinical Oncology) and a hematologist and medical oncologist at Bozeman Health Cancer Center in Montana.

“We work with the hospital to make sure that our pay is fair, not that we’re looking for the absolute last dollar,” he says of his oncology provider group, adding that compensation is salaried, not based on the volume of patients.

Support goes deeper than pay, though — a factor that can be attractive, too. The practice has become increasingly busy amid a persistent statewide shortage of oncologists, so the hospital has been providing five full-time-equivalent “extenders” — nurse practitioners or physician assistants — to ease the five oncologists’ workload. And when the physicians advocated for genetic counseling, the hospital supported them in the expansion of services, Hensold says.

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Jack Hensold MD Rural-150Jack Hensold, MD, left, jumped from Cleveland to the Bozeman Health Cancer Center, above, in 2004 as its second oncologist. He says he was lured by Montana’s outdoors lifestyle and “incredibly beautiful” location, top. Before his arrival, most oncology patients in Bozeman would travel about 150 miles each way to access a specialist. | BOZEMAN HEALTH CANCER CENTER

Hensold, a native of suburban Chicago, Illinois, joined the Bozeman group as its second oncologist in July 2004. An intriguing employment ad had crossed his desk while he was directing the hematology and medical oncology fellowship program at Case Western Reserve University School of Medicine in Cleveland, Ohio. But instead of distributing the opening to his trainees, he decided to apply.

TECHNOLOGY BENEFITS

The use of technology can help solve isolation concerns for practitioners who feel spread thin amid a rural population or disconnected from peers in larger settings.

“Through the miracles of technology, we have telemedicine as one of the answers to the access problem,” says William B. Moskowitz, MD, FAAP, FACC, FSCAI, FAHA, chair of the American Academy of Pediatrics’ Committee on Pediatric Workforce and professor and chief of pediatric cardiology at the Children's Hospital of Richmond at Virginia Commonwealth University.

“It is an inducement” for physicians of the millennial generation who want to continue collaborating with peers at large academic medical centers in urban areas, Moskowitz says. “They have grown up through medical school and their residences with electronic medical records and are facile with all their digital devices.”

High-quality cameras, digital examination tools and screens expedite subspecialty care without requiring patients to travel hundreds of miles, and they’re a boon “for the family doc and pediatrician who are out in the rural area trying to take care of more complicated patients,” he says.

Offering opportunities for “lifelong learning”  through telemedicine and by granting time for educational meetings helps doctors feel less isolated while allowing them to cultivate  expertise and practice team-based medicine. He says, “Those are the professional satisfiers.” 

An associate professor of medicine at the time, Hensold was conducting leukemia research with funding from the National Institutes of Health, but he suspected that it “might not be viable for too much longer.” Meanwhile, he was considering a lifestyle change, and the job in Bozeman appealed to the outdoorsman in him.

“It’s an incredibly beautiful location here in the mountain valley,” says Hensold, 66, an avid skier who also enjoys hiking and fishing. Before his arrival, most oncology patients in Bozeman would travel about 150 miles each way to access a specialist.

Hensold’s provider group has hired three more oncologists — in 2012, 2016 and 2017, which reduced his on-call nights from every two to every five. The fact that Bozeman is regarded as an attractive place to live helped lure them to the area.

Other towns in Montana and northern Wyoming have experienced hiring and retention difficulties. Determining which incentives to offer a new hire — along with quality-of-life intangibles — to encourage a long-term commitment is the “conundrum of recruitment,” Hensold says.

While some health care organizations entice newly minted physicians with loan payoffs, this recruitment strategy doesn’t necessarily result in retention beyond the obligation period.

Other factors, such as adequate call coverage and autonomy over one’s practice, tend to have a greater influence on loyalty, says Tyler Hughes, MD, FACS, founding chair of  the American College of Surgeons’ Advisory Council for Rural Surgery.

After practicing general surgery for 12 years in the Dallas, Texas, area, where he was raised, Hughes decided to step away from “the politics of big-city surgery,” which were compelling him to compete for market share while managing a six-surgeon group. “I got tired of being the baker and the candlestick maker,” he says.

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Tyler Hughes

In April 1995, Hughes began his practice in McPherson, Kansas, a town of 13,000, about 70 miles north of Wichita, the state’s largest city. Since then, he has performed 10,000 surgeries, including a few on the same patients, from a wider geographic region.

Hughes and his wife, Mary, wanted to raise their school-age children in a smaller setting. “We wanted our kids to be able to ride bicycles all over town,” he recalls.

His wife, who had trained as a physical therapist, capitalized on the change of scenery by earning a second academic degree and embracing acting in community theater, where she wouldn’t have to vie as hard for good parts.

In July 2016, Hughes, 64, became a clinical professor of surgery and director of medical education at the University of Kansas School of Medicine in Salina. He’s still on call two days a month in McPherson and also available for consultation and assistance about 20 days per month.

“The medical school itself tends to attract people from small towns in Kansas interested in rural medicine,” says Hughes, who instructs first- through fourth-year students in basic science and clinical courses.

“My job is to show them you can be a rural surgeon and be involved in research, and have a full life.”

 Susan Kreimer is a freelance health care journalist based in New York.

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