Solving the Rural Recruitment Dilemma

By Jennifer Larson, contributor

June 28, 2014 - The need for care continues to grow in rural areas of the country, and it’s an ongoing challenge to recruit enough healthcare professionals to provide care in rural hospitals and clinics.

Approximately 20 percent of the U.S. population lives in a rural area, while only 9 percent of the nation’s physicians practice in these areas. It’s not hard to spot the significant problem created by that disparity.

Additionally, the expansion of health insurance rolls via the Affordable Care Act is driving up the demand for care even further.

Amy Elizondo of National Rural Health Association
Amy Elizondo said that health reform has increased demand for healthcare professionals in rural areas, widening existing workforce gaps.

“And there were already gaps in the rural healthcare workforce to begin with,” said Amy Elizondo, program services vice president for the National Rural Health Association (NRHA).

The challenge of selling new doctors and doctors-to-be on rural communities may get even harder in the future. A 2011 survey of final year medical residents by physician recruitment firm Merritt Hawkins, an AMN Healthcare company, found that less than 1 percent of newly trained physicians prefer to live and practice in a community with less than 10,000 residents.

Recruitment strategies may need updating

Some of the traditional recruitment approaches deployed in the past--tuition reimbursement and loan forgiveness--are still being used. And they can still be effective.

But many health systems in urban and suburban areas now offer those financial incentives, making it less unusual to potential jobseekers.

“They can [offer it)], but everyone’s offering it, so it doesn’t make it unique,” said Kurt Mosley, vice president of strategic alliances for Merritt Hawkins and Staff Care, an AMN Healthcare company which recruits temporary physicians (locum tenens) and advanced practitioners.

Not that financial incentives should be discounted, given the debt load that many new physicians have accrued during their education and training. Loan forgiveness or tuition reimbursement could also be offered in tandem with other offerings, such as mortgage assistance.

Factors that influence physician recruitment

Physicians tend to base their relocation decisions on four primary factors, according to research by Merritt Hawkins:

  1. Quality of life
  2. Quality of practice
  3. Geographic location
  4. Financial compensation

Given this information, rural practices and health systems may need to address other factors that could be attractive to practitioners. They may want to downplay certain qualities that they can’t change, like geographic location, but play up the factors that they can change.

Quality of practice is one area where rural facilities can differentiate themselves.

Make your workplace top-notch, Mosley advised. Some of the factors of an attractive workplace include an excellent nursing staff and medical staff, timely test turnaround and good coverage for times when the provider may need to not be on call or on site. If the work situation is very appealing to the prospective employee, that can be very persuasive.

“Put your best foot forward,” Mosley said.

Another factor to consider is that a prospective new doctor or nurse practitioner may have a spouse and/or children in tow. Rural healthcare employers may want to provide job-seeking assistance to the spouse, as well as informal support to ease the transition to the new community for the family; this can be very reassuring to a candidate who is perhaps still on the fence about making the move.

“You really have to sell it,” Elizondo said. “If there’s a resident that’s married, that spouse is going to need a job in that area, too. So recruitment includes looking at that whole picture.”

Kurt Mosely oversees physician recruitment strategies for Merritt Hawkins, Staff Care.
Kurt Mosely said that emphasizing quality of practice is an important factor in physician recruitment for rural facilities.

“It’s a retention issue,” added Mosley. “Our recruiter spends as much time with the spouse as they do with the doctor.”

Mosley also recommends that rural health leaders conduct regular “stay” interviews with their doctors and other healthcare professionals that they’ve recruited. Similar to an exit interview, a “stay” interview involves sitting down and checking in with the person. That allows the employer to address any problems that might be developing, either on the professional side or on the personal side, with a spouse or family member.

“Smart administrators will bring a doctor in after 30 days and ask, ‘How is your practice doing, and how are you doing?’” he said. “Then again after 60 days, and 90 days, and so on.”

Larger-scale solutions: Boosting rural training opportunities  

Doctors, as well as nurses and other healthcare professionals, tend to gravitate toward areas where they were born, trained or licensed. That can pose a problem, given that fewer training opportunities exist in rural areas.

“It’s like that song: ‘How do you keep them down on the farm, after they’ve seen Paris?’” said Mosley.

One long-term solution is to provide or support more training opportunities in rural settings so the healthcare workforce can become more familiar with the setting.

The Health Resources and Services Administration (HRSA) has funded a few initiatives to address the problem, including the Teaching Health Center Graduate Medical Education (THCGME) program, which was designed to provide primary care training in community-based programs, including some rural programs. HRSA has also funded rural training track residency programs to provide those opportunities to physicians.

Elizondo noted that the rural training track program provides that crucial additional exposure of training for a year in a rural setting, plus it includes stipends for the interviewing process and support to the spouse.

“It’s a multi-faceted approach in trying to recruit folks to the community, as well as to practicing in that area,” she said.

According to the Rural Assistance Center, the training track programs have achieved significant success in addressing the ongoing shortage of primary care physicians in rural areas, with about 70 percent of the graduates opting to practice in a rural area. The THCGME programs also have shown promise in placing their graduates in rural and underserved areas.

HRSA also provided funding for the Rural Training Track Technical Assistance Demonstration Project to analyze the effect of policy and technical assistance on training programs for physicians in rural areas.  According to Elizondo, the NRHA is working with the demonstration program to provide support to the training programs and build a strong partnership for sustaining rural health education in the future.

That support will be even more crucial in the future, as the baby boomers age and require more care, she added.

More solutions could be on the horizon, as well. Just this month, the Missouri state legislature approved a bill that would allow medical school graduates to practice primary care in rural areas even without having completed a residency. However, there are restrictions, including a requirement that they work under a collaborating physician and have completed the first two steps of their licensing exam. The state’s governor will now decide whether to sign the bill into law.

Related articles:
HRSA Reports on Nursing Supply and Education Trends



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