Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice

James Pate, MS3

Oregon Health & Science University

March 14, 2008

ABSTRACT

Background. Coos Bay is a rural city on the southern Oregon coast that struggles to recruit and retain sufficient physicians. The purpose of this study is to assess medical student rural interest and Coos Bay physician perspectives as they relate to recruiting and retention. Methods. A literature search was conducted to identify common recruiting and retention issues. Physician recruiters and practicing physicians at NBMC were interviewed to identify unique issues and their commitment to this community. Finally, OHSU medical students were surveyed to assess their past and current level of interest in rural medicine. Findings. Key to physician happiness is their practice. Most of the physicians interviewed are planning on retiring in Coos Bay. Medical student rural interest correlates with increasing student age, male gender, and rural upbringing. Specialties correlated with rural interest are family medicine, emergency medicine, obstetrics and gynecology, and pediatrics. Medical students showed increased rural interest following their rural clerkship. Conclusions. Successful medical practice is a key component of physician happiness and thus long term retention. OHSU’s third year rural clerkship is a great tool to increase interest in rural medicine. However, it can be further optimized by addressing housing issues, boredom, and misperceptions.

BACKGROUND

In system dynamics equilibrium is maintained by the ratio of inputs to outputs. Likewise, the status quo of physician shortages in rural areas is created either by insufficient new recruits or by excessive attrition. Recruiting and retention aims by rural communities independently seek to address these issues with the long term goal of increasing the number of practicing physicians in their area.

Rural physicians are different from their urban counterparts in that they often work independently with limited specialty backup, treat a broad spectrum of medical conditions and pathology, and perform more procedures. They also have increased workload with longer hours and more call and are apt to feel professionally isolated. Given the increased demands on rural physicians and the unique challenges that rural living brings, rural communities have a long history of struggle in the competition for physicians. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly becoming an important part of healthcare delivery, physicians are irreplaceable and remain highly needed.

Coos Bay is a rural city on the southern Oregon coast that has been deemed a Health Professional Shortage Area (HPSA) with an estimated 2008 population of 42,250. It is also considered a Medically Underserved Area (MUA) with around 15.5% living below Poverty Level and 13.3% without health insurance. Interestingly, general internists outnumber family practitioners more than two to one in this community with 25 and 12 licensed providers respectively. There are also six OB/Gyn physicians, eight pediatricians, and 15 surgeons.

Coos Bay is a unique community. On the positive side, it is a coastal town with beautiful landscapes, outdoor activities, low crime, less hectic lifestyle, and laidback friendly people. On the negative, its population is aging, it is economically challenged, and it has numerous public health issues. In 2005, Coos County ranked second in Oregon for both cancer incidence and arthritis prevalence and fourth for child abuse. Other health issues that have higher prevalence than the state average include chronic lung disease deaths, asthma, cardiovascular disease, poverty level, and smoking by pregnant women.

As is true of all rural areas, Coos Bay struggles to recruit and retain sufficient medical providers for its population needs. Interest in this topic was spurred by observing the insufficient number of providers first hand and by being actively recruited by many of the Coos Bay patients the author encountered during his rural clerkship rotation. The NBMC family medicine group recently lost three of their nine providers. A patient volunteered that she had went through three new physicians over the course of six months due to turn-over. Finally, even the author’s preceptor is planning on leaving for California within the year. Clearly there is a strong need for more rural physicians.

PROBLEM

As is true of all rural areas, Coos Bay struggles to recruit and retain sufficient medical providers for its population needs. It is unknown how many medical students are actually interested in pursuing a career in rural medicine. Their interest is vital to the future of rural communities because they represent future recruits. Additionally, it is unknown how likely current physicians in Coos Bay are to be retained. The purpose of this study is to assess medical student interest in rural medicine and Coos Bay physician perspectives on their practice as they relate to recruiting and retention.

POPULATION

Three distinct populations were targeted in this study in order to better identify and evaluate the independent issues surrounding recruitment and retention of physicians in Coos Bay. They were rural providers, physician recruiters, and third and fourth year OHSU medical students.

Practicing physicians in Coos Bay were felt to be a population of interest because they had chosen to work in rural medicine and had firsthand experience of Coos Bay’s unique issues. Additionally, it was necessary to assess their current level of satisfaction and commitment to Coos Bay as a way to identify issues related to retention. Physician recruiters were also included in the study to learn more about the recruiting process and how it relates to Coos Bay’s physician shortages. Finally, third and fourth year medical students were felt to be an essential part of this study as they represent the future of the recruiting pool for rural areas. Because rural experience is a requirement for graduation from OHSU, this population was additionally suited to evaluate how interests in rural medicine change following this experience.

METHODS

Information for this study was gathered from the following sources: literature review, AHEC documents, physician interviews, physician recruiter interviews, medical student surveys, and Census 2000 US Gazetteer Files.

Common issues regarding the recruitment and retention of physicians in rural areas were identified from a thorough literature review. A Medline Ovid search was executed concatenating the following Medical Subject Heading (MeSH) terms: 1) Rural Health, Rural Population, Rural Hospitals, or Rural Health Services; 2) job application, job description, negotiating, hospital personnel administration, personnel loyalty, personnel selection, personnel turnover, physician incentive plans, or "salaries and fringe benefits"; 3) Physicians; and 4) Patient Selection, Hospital Medical Staff, Personnel Selection, or Rural Health Services. 110 articles resulted from this search and nine were selected for further evaluation.

Coos Bay specific issues regarding recruiting and retention were gathered from face-to-face interviews with local physicians and physician recruiters. A standard set of questions was utilized (Table 1) and interviews were conducted in the participants’ personal offices. This was felt to be the best way to build rapport and thus obtain higher quality data than what would be obtainable from a survey. Data was compiled and evaluated for trends.

Finally, third and fourth year medical student interest in rural medicine was assessed by separate online surveys with nearly identical questions (Table 2). The only difference between the two was necessary modification to address the fact that not all of the third year students had completed the rural clerkship. An invitation was sent by email to all students in the 2008 and 2009 classes. Students who chose to complete the survey followed a link to a SurveyMonkey website where the survey was hosted. The survey consisted of 10 questions and participation was completely anonymous and confidential. Data analysis was performed using Microsoft Excel and descriptive data was explored.

In order to further characterize study participant populations, it was necessary to determine whether they were raised in rural, suburban, or urban environments. Although definitions for these categories are maintained by the US Bureau of the Census, most people are not familiar with them and instead resort to subjective opinions. This was avoided by requesting hometown ZIP codes from all study participants. These were then converted to ZCTA codes, hometown population densities were calculated, and population categories identified using precise definitions. While this method of identification has obvious inherent limitations and sources of error, its ease of application and reproducible objectivity is far superior to subjective alternatives. Study participants who did not provide a valid ZIP code were assigned the largest population density attributable to their hometown. International participants were assigned a population category based on their subjective opinion. Finally, participants who refrained from designating a hometown all together were assigned to the urban category.

According to the Washington State Department of Health, “areas with a population density of 999 persons per square mile are considered Rural.” The distinction between suburban and urban is less wieldy. “Urban populations are those residing in incorporated areas or Census Designated Places with 2,500 or more or an Urbanized Area. An Urbanized Area (subset of Urban) is a continuously built up area of 50,000 people or more. A built up area is an area with a population density of more than 1,000 persons per square mile.  This is calculated at the census block level... Suburban Areas have high commuting relationships with Urbanized Areas.”  As such, Urban was assumed to be greater than or equal to the 95th percentile of ZCTA population densities for the purposes of this study. Suburban was subsequently defined to be everything in between rural and urban, or > 999 persons per square mile and < 95th ZCTA percentile respectively.

The Zone Improvement Plan (ZIP) Code is a registered trademark of the US Postal Service and is used to designate local areas for the convenience of mail delivery. These codes can cross county, state, and census tract boundaries, are not required to be polygonal, and periodically change to meet Postal Service needs. Thus, they are difficult to map. Due to popular demand for ZIP code tabulated summary Census statistics, the US Census Bureau developed and trademarked ZIP Code Tabulation Areas (ZCTAs) for this purpose. In most instances, ZCTA geographical boundaries are identical to their corresponding ZIP Code. Unlike ZIP codes however, ZCTA codes have well defined geographical boundaries and are relatively stable over time. In 2002, the US Census Bureau released the 2000 Census ZCTA files to the public in “AS IS” condition. These files were downloaded and utilized as mentioned above.

FINDINGS

By the end of the rotation a total of two physician recruiters, five general internists, two OB/Gyn physicians, one family practitioner, and one pediatrician were interviewed. Additionally, 116 medical students responded to the surveys.

Physician recruiter interviews

Both recruiters have been in Coos Bay for many years and are very committed to staying in this community. One was a 50 year-old male who was raised in what he felt was an urban environment (suburban by study protocol) and the other was a 60 year-old female who has spent her entire life in Coos Bay. While various non-MD providers are recruited, it has been noted that the internal medicine culture is resistant to “physician extender models.” General internists like to do everything and have difficulty delegating tasks to NPs and PAs. As mentioned above, Coos Bay has many more internists than family practitioners so this does pose a problem. The use of auxiliary providers remains an important topic of discussion. Regarding physician recruitment, there is no concrete number of positions available but they are always actively recruiting. In general, they need a new provider each year for the following specialties: FM, IM, neurology, dermatology, and pediatrics. There are currently three internists who want to retire, but they are waiting for replacement.

Physician recruiters make use of headhunters, contingency firms, internet, and ads to locate potential candidates. On average out of 48 applicants, four receive interviews and one is hired each year. Strong candidates have good credentials, are team players, are not afraid of highs and lows, are trained in procedures, and have a supportive spouse and family. While older female providers are encouraged to apply, they are hesitant to hire young females because babies interfere with an already strained clinic structure. Usual applicant deficits include inadequate training on multiple procedures due to sub-specialization, desire for structured schedules (set hours, shared weekends, light call) and guaranteed income. Incentives offered are specialty dependent but may include medical school loan repayment, grants, and interest-free start-up loans.

Physician Interviews

The physicians interviewed had the following characteristics: two-thirds were male, the average age was 44, and their hometowns were split evenly between rural, suburban, and urban locations. Only three knew they were interested in rural medicine before medical school, and two of these had been raised in rural areas. Their average length of time in rural medicine was nine years with seven of these years being within Coos Bay.

The deciding factors to work in a rural community were varied. One international physician chose to work in Coos Bay as a way to obtain sponsorship and a work visa. Another was inspired by “Marcus Welby, M.D.” a 1970s television show about a rural physician. The remainder was motivated by spouses, word of mouth, lifestyle, the potential for greater income, or simply by stumbling across it.

According to these physicians, rural medicine has many benefits. Compared to their urban counterparts, rural providers are much more autonomous and do not function as “primary care traffic cops.” They are exposed to an intellectually challenging broad spectrum of pathology and are able to perform many procedures they would not otherwise do because they do not compete with specialists. In sum, rural practitioners like having their practices pushed to the limit. When difficult cases present and colleagues are unable to help, OHSU Consult Service is only a phone call away. This service allows rural providers to speak directly to subspecialist attending physicians 24 hours a day seven days a week. Many of the physicians in this study spoke very highly of this service for its professionalism, encouragement, and support.

Continuity of care is very important to these physicians and they readily bond with their down-to-earth patients. They enjoy not being “just another physician” and making a difference in their community. Other practical benefits include hospital and nursing home privileges, more admissions, being able to round on inpatients in only one hospital, less insurance plans and thus less paperwork, better income, and lower cost of living.

Coos Bay in particular is a great place to practice with its beautiful ocean landscape and pleasant climate. Physicians here appreciate the small town experience, the peace and quiet, and being part of the community. It is big enough to have a pool and piano lessons, but small enough that kids can play in the front yard while deer graze in flower gardens. It’s also a great place to fish, hunt, and enjoy the laidback country lifestyle. However, as is true of other rural areas Coos Bay does have its problems.

According to the interviewees, there is limited economic stimulation in Coos Bay and those who want to get ahead leave. Those that remain are either wealthy retirees or poor, largely uninsured locals. Coos Bay has a high prevalence of unemployment, obesity, diabetes, and methamphetamine abuse. Making matters worse, patients are often poorly educated making preventative care difficult.

Because there are not enough primary care physicians, it is easy to become overworked. It is also hard to take time off without impacting other physicians. Working without the support of specialists can also be challenging. It takes a lot of time and effort to get patients into see specialists and some patients are unwilling or unable to commute to larger communities to see them. The end result is that physicians often end up treating outside of their comfort level. In medical emergencies, patients must be stabilized before they can be transported because Eugene is still two hours away whether by ambulance or by helicopter. Finally, anesthesia staff is not in house at the local Bay Area Hospital and it takes an entire hour from telephone call to set up.

In spite of these challenges, the physicians interviewed do not regret their decision to work in Coos Bay. It is true that some admitted to missing city amenities, but they also felt that there were great trade-offs. Urban medicine was likened to having too many chiefs and not enough Indians. They also do not like feeling the loss of control once specialists become involved with patients, the competition, nor the politics. City living has its problems too such as the high cost of living, crowds, noise, traffic, and crime.

The majority of physicians did not receive incentives, though one was a NHSC scholarship recipient. Several did take advantage of salary advancement made possible through NBMC to get set up. One physician was advanced a whole year’s salary but was able to pay off the debt within 6 months. All physicians interviewed felt very satisfied with their practices at NBMC and the income they generated from them.

Key to these physicians’ happiness in Coos Bay is their practice. NBMC is physician owned and physician run. Each provider is an independent entity with their own employees and they pocket what they make. Thus, physicians set their own hours and patient load according to hard how they want to work. Several physicians volunteered that they are indeed making sizable incomes and are near the top of their specialty’s highest wage earners. Finally, call is shared by all physicians in their practice, which works out to be only 1 in 15 for the internists. Only one physician felt somewhat professionally isolated due to the lack of subspecialists. The others felt that their colleagues, OHSU Consult Service, the internet, and conferences were sufficient. These physicians feel they are sitting on a gold mine and the majority plan on retiring in Coos Bay because of it. Only one is planning on leaving in the near future and he is doing so reluctantly to satisfy family needs. So great are the benefits of working at NBMC that one physician confided, “I am 100% committed to staying in Coos Bay because of my practice. I love the practice and don’t care about the town.”

The same cannot be said of their neighbors, the Bay Clinic Physicians (BCP). Unlike NBMC, this entity is run by an administration and earnings are communal. Income is determined by formula and is independent of the amount of work actually performed. Physicians with the most seniority are paid the most and take the least call. Thus, “low man on the totem pole” physicians are not as happy as their NBMC counterparts and subsequently there is much higher turnover.

All of the physicians interviewed would recommend rural medicine to other physicians. They feel that it is a great way for primary care physicians to get experience because you “get to do what you are trained to do” and it fosters autonomy. It is a pleasure to get to know patients personally and “great fun” to do so much medically. Rural practice provides a better balance of professional and personal life and is great business opportunity. Most importantly, you make a real impact in the health of an underserved community and you feel good about things when you go to bed at night. Their only caveats are you that must be willing to “get into it up to your eyebrows”, “have backbone”, and “have the right wife.”

Medical Students

116 medical students chose to participate in the survey. Of these, 57 (49.1%) were MS4s and 44 (37.9%) were MS3s who had completed their rural clerkship. The majority of the responders were 26-30 years old (59.5%) and female (60.3%). Increasing age was associated with increasing interest in rural medicine. Males were slightly more interested than females, 55.3% versus 54%.

Hometown environments were urban leaning with 19% raised in urban environments and the remainder split evenly between suburban and rural (40.5% each). According to study protocol, national averages are 18%, 34.8%, and 47.2% respectively. In agreement with previous studies, the students with the greatest rural interest had been raised in rural areas. (Figure 1).

Student interest in the various specialties is listed in descending order: family medicine (21.2%), internal medicine (19.2%), pediatrics (13.5%), obstetrics and gynecology (10.9%), emergency medicine (10.3%), and others (25%). Among these, interest in rural medicine was most highly correlated with coexisting interest in family medicine (82.8%) followed by emergency medicine (77.8%), obstetrics and gynecology (68.8%), and pediatrics (50%). Less popular specialties that showed strong interest in rural medicine were anesthesia, psychiatry, and surgery. Internal medicine was decisively not interested in rural medicine (56%). (Figure 2).

While fourth year medical students had greater pre-medical school interest in rural medicine (49.1% versus 40.9% for third years), third years demonstrated the greatest change of heart following completion of the rural clerkship (15.9% versus 3.5%). Overall, third year medical students appear to more interested in rural medicine than their fourth year peers (56.8% versus 52.6%). (Figure 3).

Multiple aspects of rural practice were appealing to medical students. First and foremost, many students cited being able to make a difference for an underserved population as an important consideration. They also appreciate the large scope of practice and the variety of medical problems and procedures that it entails. Other benefits listed include independence, collegial work environment, less administrative hassles, forming lasting meaningful relationships with a stable patient population, being a part of a “close-knit” community, beautiful location, outdoor activities, simple lifestyle, family friendly, good compensation, cheaper homes, lower cost of living, and loan repayment. Some rural students identified personally with their rural roots and stated that rural areas fit their personalities and share their values. One student wrote, “I grew up there and understand the needs. I want to make life better for those people who made my life better.”

Medical students also had many reasons to not like rural medicine. Those related to rural practice included being the only physician in town, not wanting to be a generalist, inability to practice academic medicine or other career focus, the potential for being overworked, lack of opportunity for advancement, professional isolation, lack of specialists, lack of anonymity and privacy, and fear of inadequate compensation. Others did not like specific aspects of rural living. These included close-minded conservatism, intolerance, ignorance, lack of diversity and appreciation of it, latent racism and homophobia, separation from family and friends, lack of educational and work opportunities for spouses and children, boredom, and missing city amenities. One student wrote, “People who can do rural medicine are wonderful, dedicated, amazing people, and I am glad they exist. The thought of living in the middle of nowhere makes me want to cry and I could never do it.”

DISCUSSION

None of the physicians that were interviewed made any mention of receiving rural specific training in medical school or residency. However, a previous study (Pathman, 2006) found that adequate preparation is associated with longer retention. While family medicine residency programs tend to prepare their graduates better for rural medicine than pediatrics and internal medicine, a rural residency rotation lasting at least 3 months is also associated with an increased sense of preparedness regardless of specialty.

Previous studies have concluded that physician spouses are highly influential in decisions related to practice location and duration (Mayo, 2006). This consideration was echoed by physicians and medical students alike. As such, spousal happiness is an essential part of physician retention. Physician workload and sense of integration within the community are highly influential in keeping spouses happy. Excessive work hours and/or call place a significant burden on spouses and families. Additionally, boredom from insufficient employment opportunities can quickly lead to discontentment. Other issues that can negatively affect spousal happiness include isolation from family and friends and inability to do the things they enjoy. When children are involved, physicians are more likely to remain in rural practice provided adequate educational and social activities are available to them.

Finally, a successful practice is a key component of physician happiness and thus long term retention. This entails manageable hours and call as well as profitable income. For NBMC physicians, it also includes practice ownership, autonomy, and individual fee-for-service compensation. And happy physicians nearly guarantee that they’ll stay around.

Perhaps physician retention shouldn’t be the area of focus anyway. A recent study (Pathman, 2004) has determined that physicians working in HPSAs stay in their practices approximately the same length of time as physicians who work outside of them. Thus, while retention efforts are necessary and can always be improved, perhaps more emphasis should be placed on recruiting to address physician shortages. Medical school and residency opportunities in rural medicine can go a long way to increasing recruiting potential.

As has been previously shown, this study demonstrates that students with the greatest interest in rural medicine have themselves been raised in rural environments. Former rural residents are more accustomed to rural life and are thus more likely to be happy in a rural practice than their urban colleagues. Additionally, many formerly rural students have family and friends to draw their interest back home and contribute to their sense of community. As evidenced by the NBMC physicians however, rural upbringing is not a requirement. While only a third of these physicians came from rural backgrounds, all but one are planning on retiring in Coos Bay.

Medical schools that produce the largest number of rural practitioners have been shown to have the following characteristics: public ownership, high numbers of family medicine graduates, and few NIH grants. While it is unknown to the author how many NIH grants OHSU has, it is publically owned and family medicine was the most popular specialty among students surveyed. Other OHSU specialties that are correlated with increased rural interest include emergency medicine, obstetrics and gynecology, and pediatrics.

Women outnumbered men in survey response by 20.7% which places an interesting slant on the data obtained and its implications for rural communities. Historically, the majority of rural practitioners have been male and rural communities have not needed to consider the needs of female providers. However, the number of women in medical school and medical practice continues to rise. While this is obviously a good thing for women and their patients, it actually threatens to further exacerbate physician shortages in rural areas unless communities are willing to adapt to the changing workforce. In one study, women were more likely than men to consider spousal employment opportunities, schedule flexibility, family leave, and childcare when considering rural practice placement. For the time being however, Coos Bay recruiters are not interested in making these kinds of accommodations. Instead, they continue to target men and older women in their recruitment strategies. Rural communities like Coos Bay will eventually need to adapt if they are to avoid the loss of future recruits.

Medical school loan repayment remains an important attraction in the recruitment of new physicians to rural areas. The NHSC is one of many organizations that provide temporary staffing to underserved areas through this incentive. However, one study showed that physicians who go willingly into rural practice are much more likely to stay than those who have a commitment contract. Because of this, some people fear that NHSC providers hinder the growth of physician workforce by increasing the competition for jobs. While one study found that 80% of NHSC physicians ultimately left rural practice permanently, another study demonstrated that their presence does result in long term benefits for the communities that use them. One of the more important findings was that NHSC supported populations had a significantly larger growth in physician workforce than those without. This was most likely the result of increased community attractiveness to incoming physicians due to the presence of NHSC scholarship recipients. Thus, medical loan repayment schemes are a win-win situation for providers who utilize them and for the rural communities that they serve. As 21% of survey responders stated that they would be interested in receiving such funds, the willingness to practice in rural areas is clearly there if rural communities are willing to pay for it. Salary advancement loans are another effective recruiting tool to encourage physicians to give rural medicine a chance.

While some students felt that the rural clerkship was a waste of time and should be optional, the majority seemed to appreciate the opportunity it provided. The fact that interest in rural medicine increased following the required clerkship demonstrates its effectiveness. That said, more can be done to make OHSU’s rural clerkship an even more effective tool to increase interest in rural medicine.

Multiple discrepancies among medical student rural experiences were noted from survey responses. For example, the author’s experience was among physicians making sizeable incomes. In contrast, another student wrote, “I'm all for service but my rural attending wasn't even making ends meet with his paycheck.” Another example concerns drug seeking patients. One student’s interest in rural medicine was due in part to their perception of “less drug seekers” in rural areas. However, another student was dissuaded from rural medicine because s/he “saw a much greater amount of drug abuse and drug seeking behaviors.” While no two experiences can be identical, if a student comes away from the clerkship experience thinking all rural physicians are poor or rural populations are filled with drug seekers this is more than a disservice to his/her education. It may also extinguish any desire to practice in a rural location and thus decrease the already limited recruiting pool. It might prove beneficial to allow discussion of rural experiences to prevent students from forming an over simplified idea of what rural medicine entails.

Other complaints that could be easily remedied include housing arrangements and boredom. Housing arrangements were not clarified until right before this clerkship was to start. Two of the students were dismayed to discover that they would be staying in the homes of their preceptors. While this may make sense from an economic standpoint, it does not sit very well with students to have to live with someone for an extended period of time who is grading them. One of these students was able to be reassigned to a new location with independent housing, but the other unfortunately had to reschedule their clerkship to avoid this discomfort. Another complaint was the poor quality of furnishings within the apartments. Broken dirty furniture does not make a great first impression on rural living. Finally, several students complained of boredom. While bouncing back and forth between clinic and a boring apartment might be sufficient for medical education, it does not give students a very good idea of what rural living is all about. It would be very easy to collaborate with locals to arrange at least a guided tour and one weekend local activities for students that desire them. This would serve to alleviate boredom and also open students’ eyes to hidden possibilities within their rural communities.

In conclusion, physicians and their families are happiest when their practices have manageable hours and profitable business. Recruiting efforts must consider the needs of female providers if they are going to continue to be successful in our evolving workforce. Student loan repayment and salary advancement loans are effective tools to draw new physicians to rural areas. Finally, while the rural clerkship has been shown to increase rural interest it should also address misperceptions, housing issues, and boredom to optimize it.

LIMITATIONS

Limitations of this project include but are not limited to the use of previously untested and unproven interview and survey questions, the refined number of questions used in order to improve survey response rate, recall bias, misinformation, and subjectivity. Additionally, all interviews were limited to associates of the North Bend Medical Center and thus data collected may not be representative of all practices in the Coos Bay area.

FUTURE STUDY

It would be interesting to conduct a longer term study of OHSU medical students with periodic assessment of their rural interest beginning from the very first day of medical school and continuing throughout medical school, residency, and beyond. This would provide more objective data on changing interest in rural medicine as well as provide information on how many graduates actually go on to practice in rural areas. A study of this sort would provide concrete evidence of the impact of medical education and the rural clerkship in encouraging future physicians to consider a career in rural medicine. It would also provide a more accurate assessment of the rural clerkship than what is currently obtained through the course evaluation.

References

Coos County Public Health. Coos County Public Health – Annual Plan 05/06. 2005. http://www.oregon.gov/DHS/ph/lhd/ap/coos-05-06-ap.pdf 

Ellsbury KE, Baldwin LM, Johnson KE, Runyan SJ, Hart LG. Gender-related factors in the recruitment of physicians to the rural northwest. Journal of the American Board of Family Practice. 2002;15:391-400. 

Fraher EP. Location, Location, Location: North Carolina Faces a Shortage of Primary Care and Specialty Practitioners in Rural and Underserved Counties. NC Med J. 2007;68:194-197.

Mayo E, Mathews M. Spousal perspectives on factors influencing recruitment and retention of rural family physicians. Canadian Journal of Rural Medicine. 2006;11:271-276. 

Mitka M. What lures women physicians to practice medicine in rural areas?. JAMA. 2001;285:3078-3079. 

Oregon Office of Rural Health at Oregon Health and Science University. Service Area: Coos Bay. 2004. 

Pathman DE, Fryer GE,Jr, Phillips RL, Smucny J, Miyoshi T, Green LA. National health service corps staffing and the growth of the local rural non-NHSC primary care physician workforce. Journal of Rural Health. 2006;22:285-293. 

Pathman DE, Konrad TR, Dann R, Koch G. Retention of primary care physicians in rural health professional shortage areas. Am J Public Health. 2004;94:1723-1729. 

Pathman DE, Steiner BD, Jones BD, Konrad TR. Preparing and retaining rural physicians through medical education. Academic Medicine. 1999;74:810-820.

Pathman DE, Konrad TR, Ricketts TC. The comparative retention of the National Health Service Corps and other rural physicians: results of a 9-year follow-up study. JAMA. 1992;268:1552–58.

Rabinowitz HK, Diamond JJ, Markham FW, Rabinowitz C. Long-Term Retention of Graduates from a Program to Increase the Supply of Rural Family Physicians. Acad Med. 2005; 80:728–732.

Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: Systematic review of the literature. Canadian Journal of Rural Medicine. 2004;9:82-88. 

U.S. Census Bureau. Answers to Frequently Asked Questions about Census Bureau Geography, Maps and Mapping Engines. 2005. http://www.census.gov/geo/www/tiger/tigermap.html#ZIP 

U.S. Census Bureau, Geography Division. Census 2000 U.S. Gazetteer Files. 2002. http://www.census.gov/geo/www/gazetteer/places2k.html 

U.S. Census Bureau. Glossary of Terms for the Economic Census. 2003. http://bhs.econ.census.gov/econhelp/glossary/ 

U.S. Census Bureau. ZIP Code Statistics. 2007. http://www.census.gov/epcd/www/zipstats.html 

U.S. Census Bureau. ZIP Code® Tabulation Areas (ZCTAs™). 2006. http://www.census.gov/geo/ZCTA/zcta.html 

APPENDIX: tables and figures.

  TABLE 1: Recruiter and Provider questions. Return

  TABLE 2: MS3 and MS4 Survey Questions.  Return

FIGURE 1: Hometown influence on rural interest.  Return

FIGURE 2: Specialty influence on rural interest.  Return

FIGURE 3: Changing rural interest among MS4s and MS3s.  Return

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