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Physician recruitment and retention in rural and underserved areas Dane M. Lee Graduate Program of Nurse Anesthesia – Doctorate of Nurse Anesthesia Practice, Texas Wesleyan University, Fort Worth, Texas, USA, and Tommy Nichols School of Business Administration, Texas Wesleyan University, Fort Worth, Texas, USA Abstract Purpose– The purpose of this paper is to identify the challenges when recruiting and retaining rural physicians and to ascertain methods that make rural physician recruitment and retention successful.

There are studies that suggest rural roots is an important factor in recruiting rural physicians, while others look at rural health exposure in medical school curricula, self-actualization, community sense and spousal perspectives in the decision to practice rural medicine.

Design/methodology/approach– An extensive literature review was performed using Academic Search Complete, PubMed and The Cochrane Collaboration. Key words were rural, rural health, community hospital(s), healthcare, physicians, recruitment, recruiting, retention, retaining, physician(s) and primary care physician(s). Inclusion criteria were peer-reviewed full-text articles written in English, published from 1997 and those limited to USA and Canada. Articles from foreign countries were excluded owing to their unique healthcare systems.

Findings– While there are numerous articles that call for special measures to recruit and retain physicians in rural areas, there is an overall dearth. This review identifies several articles that suggest recruitment and retention techniques. There is a need for a research agenda that includes valid, reliable and rigorous analysis regarding formulating and implementing these strategies.

Originality/value– Rural Americans are under-represented when it comes to healthcare and what research there is to assist recruitment and retention is difficult to find. This paper identify the relevant research and highlights key strategies.

KeywordsManagement, Staffing, Recruitment, Retention, Quality management Paper typeLiterature review Introduction Many US physicians are reaching retirement age and new generations tend to have a different approach to medical practice, placing greater value on a work-life balance.

The Office of the Inspector General cites physician scarcities; including obstetrics and family practice specialties, which are considered rural medicine’s backbone and it is predicted that there will be a 20 percent physician shortage in the next two decades.

This effect will be especially detrimental to rural hospitals. Rural hospital managers’ ability to recruit and retain physicians affects their capacity to deliver essential medical care to rural communities (Cohn and Harlow, 2009). Unlike its urban counterparts, rural hospital managers have unique recruitment and retention challenges; i.e. it is estimated that 65 percent of rural US counties lack adequate health professional workforces. Physician distribution favors urban areas, which creates a barrier to healthcare for residents in rural areas, as they must travel further to see a physician compared to urban residents. Rural physician recruitment and retention remains a The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm Received 10 April 2014 Revised 17 May 2014 Accepted 29 May 2014 International Journal of Health Care Quality Assurance Vol. 27 No. 7, 2014 pp. 642-652 rEmerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-04-2014-0042 642 IJHCQA 27,7 challenge and this problem affects access to healthcare for rural residents (MacDowell et al., 2010). Our purpose, therefore, is to identify the recruiting and retaining rural physician challenges, and to ascertain methods that make rural physician recruitment and retention more successful. There are studies that suggest rural roots is an important factor in recruitment, while others look at rural health exposure in medical school curricula, self-actualization, community sense and spousal perspectives in the decision to practice rural medicine.

Methods An extensive literature review was performed using the databases Academic Search Complete, PubMed and Cochrane Collaboration. Key words were rural, rural health, community hospital(s), healthcare, recruitment, recruiting, retention, retaining, physician(s) and primary care physicians (PCPs). Inclusion criteria included peer-reviewed full-text articles written in English, published from 1997 to present and limited to USA and Canada. Articles from foreign countries were excluded owing to their unique healthcare systems.

Rural physician recruitment strategies Healthcare manager’s ability to recruit and retain physicians affects their capability to deliver critical healthcare needs to the communities they serve. Recruiting is difficult owing to increased physician-demand from a limited pool. Additionally, healthcare managers have difficult recruiting process requirements; a simple mistake in recruiting or a careless remark can drive potential candidates away (Cohn and Harlow, 2009).

Recruitment strategies were identified to make physician recruitment and retention successful. The first strategy is to get the chief executive officer (CEO) involved in physician recruitment, who must: first, develop a recruiting team and meet the team at least quarterly to monitor progress and offer guidance; second, participate in developing marketing and recruiting strategies; third, interview all promising candidates; fourth, financially support the recruiting team’s recommended financial incentives for physicians; fifth, hold the recruiting team members accountable by tying their compensation and advancement in the organization to their recruiting performance; and sixth, request the recruiting team to brief candidates regarding abrasive personalities on the existing medical staff (Cohn and Harlow, 2009).

Recruiting and marketing teams must come together to develop compelling marketing materials and programs. Physicians and employees are encouraged to notify the recruiting team of any pre-med students, medical students or residents looking to return home. Also, this request should also be extended to physician spouses. Hospital managers should sponsor a guest speaker and invite the community to the event.

This effort promotes the facility as a good neighbor and great employer. Also, working for the organization and its benefits should be publicized, including focussing on community positives (school systems, recreation, etc.) (Cohn and Harlow, 2009). Based on a community needs assessment that demonstrates a physician specialty shortage, managers should offer appropriate financial incentives; including reimbursing travel and moving costs, legal fees associated with obtaining foreign-physician work visas, student loan repayment or start-up costs for starting a practice, income guarantees for the community practice’s first two years and compensation for on-call requirements.

Importantly, the recruitment team should consult an experienced healthcare attorney to ensure compensation incentive legality (Cohn and Harlow, 2009). With an increased reliance on web-based technology, it is important that rural facility managers familiarize 643 Physician recruitment and retention themselves with web-based recruitment and create a dedicated web page with links to other topics. The web site should have a direct contact with the facility’s recruiter.

Also, it is recommended that the web site has an online application capability, virtual tours, facility maps, testimonials from long-term physicians and their spouses. Social media, like Facebook, should also be considered (Cohn and Harlow, 2009). The recruiting team must screen candidates and review their education, experience, references and credentials. There should be monthly communication with the CEO and other stakeholders. Acknowledgments should be sent to interested candidates within 48 hours of receiving the candidate’s resume. Managers should use a checklist to prepare a contract, which should be modified to meet the facility’s unique needs while conforming to current local, state and federal regulations (Cohn and Harlow, 2009).

The interview process should be memorable and prepared in advance. There should be core interviewers, including a physician with a similar background and training as the applicant. The interview should be scripted and structured, beginning and ending the process with the CEO, chief operating officer or the chief medical officer. Visit logistics should be planned so that the interviewing physician is not burdened with travel, hotel, restaurants and car rental. These expenses should be billed directly to facility managers who should also offer a spouse or family an activity while the candidate attends the interview. A community tour and lunch with other physician spouses may provide useful information and networking opportunities (Cohn and Harlow, 2009). The job offer must be carefully executed and this begins with a verbal agreement. Once accepted the managers should execute a contract. Adding extra incentives, beyond what the candidate expected, creates a positive surprise that makes the physician feel valued and motivated. The contract should include a one- to two-week expiration date. The facility’s attorney should review all contracts and that counsel should be involved in developing the contract to ensure compliance with all applicable laws and regulations (Cohn and Harlow, 2009). Documentation should comply with federal Stark and anti-kickback laws. The employment contract and all other recruitment-related materials must be supported by documentation. The anti-kickback statute, state regulations and Stark laws mean that the manager’s ability to offer recruitment incentives is restricted. To address these issues, documentation is required based on the manager’s need to recruit a specialized physician, his/her relocation to practice, reasonable recruitment bonus based on current fair-market value and leases on space and equipment (Cohn and Harlow, 2009). Facilities that enter into a forgivable loan agreement with the medical practice staff recruiting the physician are more favorable than an agreement with the physician directly. If the physician leaves the practice then managers may be reimbursed for their expenses by practice staff who recruited the physician (Cohn and Harlow, 2009).

There are three main reasons for a rural physician practice’s unpopularity: lifestyle; medical practice; and competitive issues. Lifestyle is prevalent because physicians are concerned about residing in a community that has limited social activities. There may be a perception that rural-practice staff have limited outlets to culture, social and shopping activities. Also, school systems are thought to be sub-par compared to urban arrangements (Full, 2001). Medical practice includes longer hours and more demanding on-call schedules compared to urban colleagues. Medical care can be more challenging without specialist help. The payer mix is a downside; with 70 percent Medicare, Medicaid or self-pay. Additionally, reimbursement for physicians in rural areas is less. The population in rural settings is usually older, poorer, more likely to be uninsured and in poorer health overall (Full, 2001). PCPs are in great demand. 644 IJHCQA 27,7 Rural opportunities are often missed because a rural hospital’s urban competitors have residency programs that lock-in physicians before potential recruits are aware of rural opportunities. Larger facilities are often better suited to offer employment opportunities that rural facilities cannot because fundamental resources are lacking (Full, 2001).

Case study A CEO from a small, critical access hospital in Northeast Indiana outlined a rural hospital recruiting strategy. This particular hospital is the sole provider for approximately 27,000 people, a not-for-profit, county-owned and a stand-alone rural health system. The hospital had a reputation for its dysfunctional medical staff, perceived by community members as providing poor medical care. Over 80 percent of residents traveled more than 30 miles for healthcare. At the CEO’s appointment, there was a physician shortage that had an adverse effect on the hospital’s financial status and survival (Full, 2001). He was the third CEO appointed to this facility in a five-year period. When he arrived, 85 percent of the county residents traveled elsewhere for medical care. Two physicians accounted for 90 percent of all admissions to the hospital, which was in financial distress and operated in the red. He reflected on his strategy to turn this small, critical access hospital around. His main strategy was to recruit quality medical staff in four steps, called plan, locate, screen and sell (Full, 2001).

In the planning phase, emphasis was placed educating the trustees, medical staff, employees and community leaders regarding healthcare trends. The planning process was accomplished through strategic planning retreats, medical staff meetings and community leader presentations. The retreat’s first day consisted of extensive brainstorming sessions and discussions regarding existing medical staff strengths and weaknesses. During this retreat, the trustees identified two physicians to re-build a quality medical staff. Based on one physician to every 2,000-4,000 community members, board members determined that seven additional PCPs would be required to meet their needs. This goal was incorporated into the hospital’s five-year strategic plan. Later, the two core PCPs were brought into the plan with supportive enthusiasm.

The initial planning included updating medical equipment and giving patient care areas a facelift (Full, 2001).

The locating process included utilizing physician search firms, both retainer and contingency, to locate potential candidates. Importantly, the retainer firm, which works exclusively for the hospital, but requires a significant monetary deposit, was unsuccessful. Alternatively, the contingency firm, which is only paid if recruits sign contracts, was more effective. Generally, a contingency firm is paid $15,000-$22,000 when a hospital and a physician come to contractual terms (Full, 2001). This particular hospital managers signed agreements with 16 contingency firms and roughly one staff in seven worked routinely with the hospital. The CEO noted that developing a positive rapport with these firms developed a win-win relationship and he screened several candidates over the years, once a positive rapport was developed (Full, 2001). Another avenue to identify potential candidates was the National Health Service Corps. After the hospital was identified as a health professional shortage area (HPSA), the CEO requested that the Indiana State Board of Health initiate a study to determine if the hospital was a shortage area. The results were favorable and State staff recommended to the federal government that the county be designated as a health professional shortage locality. This designation has many benefits (Full, 2001); e.g. practicing physicians can access federal loan waivers and National Health Service Corps 645 Physician recruitment and retention physicians are required to practice in designated area. Further, PCPs receive a 10 percent quarterly bonus from Medicare for practicing in a shortage area and many PCPs review and respond to such governmental incentives that have access to student loan waivers. The screening process ensues once potential physicians are identified.

When a national practitioner databank inquiry is made and no problems are identified, the physician’s curriculum vitae is scrutinized to determine if the physician job-hops. If this is the case then physician is ruled out. A telephone interview with the candidate assesses his/her communication skills, longevity potential, community sense, professional interests, spouse’s career needs (if applicable), academic concerns for their children (if applicable) and professional requirements (hospital employment vs private practice). If the initial interview is positive then the physician and his or her spouse are invited for an on-site second interview (Full, 2001).

If the physician is a fit for the facility and the community then it is time for the sell.

The CEO dedicates 100 percent to the candidate and his or her family; considered the most important event during the entire recruitment process. To lessen the burden on the physician, all travel arrangements are made by the hospital staff. A fruit basket and flowers are sent to the hotel room and the first meeting is over breakfast before a facility and community tour is given. Key stops are made to meet the school superintendent and a tour of local businesses to meet community leaders. Active listening to physician needs and his or her spouse is paramount. At this point, the CEO reinforces the community’s strengths (Full, 2001). Adjustments were made to recruiting strategies to meet the candidate’s needs. One major change involved the hospital employing the physician; employment usually includes a salary with an incentive program. For those physicians who prefer private practice, an income guarantee is provided for a several years so the physician can build a patient base. School debt is a major concern for many candidates, which is addressed by the Federal Loan Waiver option. Also, committed first-year residents are offered a monthly stipend during residency and the resident in turn makes a five-year commitment to practice in the community after completing the residency program (Full, 2001).

This CEO’s plan, locate, screen and sell philosophy paid dividends. During his tenure, he recruited and retained seven PCPs, a general internist, the areas first obstetrician/gynecologist and pediatrician, an anesthesiologist and an invasive radiologist. With one exception, the oldest physician at the facility is 46 years old.

Five physicians are employed by the hospital and the managers also recruited four family nurse practitioners. Despite the initial cash drain that bringing on new staff caused, the hospital’s gross revenues increased by 19 percent per year. Also, the hospital went from employing 75 people in 1992 to 230 employees (Full, 2001).

Medical education and rural roots Sustainable rural healthcare is a challenge because rural communities suffer from a PCP shortage. Rural populations tend to be older, poorer, less educated and perceived as having lower health levels compared to urban residents. This notion is compounded by recruiting and retaining rural physicians, which is particularly troublesome.

Numerous factors have been identified, including partners in practice, family concerns and recreation, and burdensome on-call schedules. Other deterrents to rural practice include low reimbursement for fee-for-service and low-volume emergency rooms.

Physicians in rural settings are required to perform more procedures than their urban colleagues and this higher responsibility can stress rural physicians, especially in emergency situations (Curran and Rourke, 2004). 646 IJHCQA 27,7 Medical education plays an important role in recruiting rural physicians. The location, mission and medical school organization have predicted the physicians who choose rural practice. Decentralized medical schools, located in rural areas, have a curriculum with a rural focus and provide early and repeated exposure to rural learning experiences, are most successful in graduating physicians who choose to practice in rural areas (Curran and Rourke, 2004; Spencer and Spencer, 2006). There are some medical schools in large cities that have developed specific curricula for educating physicians for rural areas (Rourke, 2010). Outreach strategies employed by medical schools to selectively retain seats for rural medical school applicants enhance PCP career choice and entering practice serving rural areas (Curran and Rourke, 2004).

Students from rural areas in most countries are under-represented in medical schools and students from rural areas should expect to have fair opportunities to attend medical school (Rourke, 2010). Studies show that medical students with rural backgrounds are four times more likely to practice rural medicine than their urban colleagues and this remains the strongest rural-practice choice predictor (Curran and Rourke, 2004; Hancocket al., 2009). A study was conducted with 3,414 physicians who graduated from Jefferson Medical College’s Physician Shortage Area Program between 1978 and 1993 (Curran and Rourke, 2004). The study’s purpose was to identify medical student applicants who would eventually return to rural areas to practice family medicine in Pennsylvania. Several seats were reserved for qualified applicants that had grown up, lived or had strong ties to a physician shortage area. Graduates with a rural background and a freshman-year plan to practice family medicine were more than twice as likely to practice as a rural area PCP. The greatest success for recruiting rural PCPs is for medical school staff to develop strategies to increase rural applicants with plans to practice family medicine.

Hancocket al.(2009) propose that one rural-practice predictor is exposure to rural medicine by providing opportunities for students to choose rural electives in a medical school, which have a greater influence to practice rural medicine for those students raised in urban areas. A Canadian survey examined rural medical educational influence on decisions to practice rural medicine. Questions were broad and included:

how large was the community in which you lived in high school; rate your interest level in rural family practice at different training stages; how much positive interest did rural training, financial incentives, past exposure to rural areas affect your decision for rural practice? Respondents were asked to rank these factors. Respondents were located from the Southam Medical Database – a commercial database widely used in Canada (Chanet al., 2005). There were 784 physicians surveyed, though some were ineligible owing to demographics, providing a 59 percent response rate. One-third grew up in communities ofo10,000 people, while the remainder grew up in varying size urban communities. Rural physicians showed an increase in rural medicine as they progressed through school. When starting medical school, only 28 percent were certain they wanted to practice rural medicine, rising to 77 percent at graduation. At the beginning of medical school, students with rural backgrounds were more likely than those with an urban upbringing to show an interest in rural medical practice, 90 vs 67 percent, respectively. At graduation, this gap narrowed, but remained significant (98 vs 91 percent,po0.0001) (Chanet al., 2005). The two main factors predicting rural medicine practice for physicians with both rural and urban backgrounds were rural medical challenges and enjoying rural lifestyles. Rural residents cited growing up in rural settings as the most important factor in choosing to practice rural medicine and urban residents indicated that it was their exposure to rural practice during 647 Physician recruitment and retention medical school or residency that influenced their decision to engage in rural practice.

Physicians raised in urban areas would have difficulty appreciating rural practice without exposure to rural settings in their medical school curriculum. The authors conclude that rural education during medical school has a significantly greater influence to choose rural practice on physicians raised in urban areas than on physicians raised in rural areas. Physicians with an urban upbringing constitute the main source for rural PCPs, accounting for two-thirds of new rural physicians (Chanet al., 2005).

There are successful initiatives for changing rural-practice perceptions and there are four medical educational program models that successfully attract medical students to rural primary care. In New York, the Continuity Care Program is affiliated with the New York State University. Medical students spend the first two years at Syracuse and each third-year student in the Continuity Care Program spends half-a-day with a rural PCP. Another program uses the Philadelphia Jefferson Medical College’s Physician Shortage Area Program to focus on selective admission policies for rural students. This program reserves 24 of the 223 slots in each class for students who intend on practicing rural family medicine. Another program from the New York State University is the Extended Rural Preceptor Program; third-year medical students are placed in rural areas to work full-time for nine months under PCP or specialist supervision. When the students live and work in these rural areas, they appreciate rural community life. The Michigan Upper Peninsula Program is similar to the Extended Rural Preceptor Program where students come to understand and appreciate rural healthcare and the people in the community (Perchet al., 1997). There are also opportunities for foreign physicians. A law passed in 1976 requires that graduating foreign physicians return to their country for two years before applying for a permanent US visa. However, this requirement can be waived if the foreign physician agrees to practice in a rural, medically underserved area (Perchet al., 1997).

Self-actualization, sense of place and community engagement Two-thirds of rural areas qualify as HPSAs – the ones most underserved (Hancock et al., 2009). Challenges recruiting and retaining staff continue to be a major problem; fewer than 4 percent of graduating medical students plan to practice in small towns, a percentage that is decreasing over the past 30 years (Hancocket al.,2009).Thereis little research examining rural physicianretention; i.e. the community’s role is important in retaining rural physicians and the factors that recruit physicians to the area are not the same aspects that retain them. The community’s broader scope has an impact on retention, specifically location and support (Cameronet al.,2012).Even though retaining rural physicians is assumed to be poor, studies reveal that it is actually comparable to urban retention. Efforts at rural physician retention are increasing to offset the recruiting challenge. There is consistent evidence that practice-related and lifestyle factors play a role in rural physician retention than other factors such as rural roots, training and community service, including compatibility with the medical community or child parenting. Previous studies downplay the physician’s environment, instead emphasizing physicians’ personal characteristics. Two concepts overlookedare sense of place and self-actualization (Hancocket al., 2009); the former describes the emotional ties a person has with his/ her community, providing identity, roots and attachment (Hancocket al., 2009).

In addition to striving for a sense of community and place, individuals are motivated to lead happy and fulfilling lives; described as self-actualization in Maslow’s hierarchy of 648 IJHCQA 27,7 needs (Maslow, 1968), which provide an applicable framework for administrators, policy makers and other stakeholders to understand what motivates physicians (Hancocket al., 2009).

A semi-structured interview and questionnaire was administered to 22 committed PCPs in rural northeastern California and Northwestern Nevada during June and July 2006/2007. The interviewees represented rural PCPs in terms of gender, medical education and specialty. This study investigated rural exposure effects on rural recruitment and retention. Seven respondents stated they chose rural practice because they wished to live in a familiar, natural or social environment. This gave them a sense of trust, comfort and ease. Nine respondents cited a sense of community as their primary motivation for choosing rural practice. Six respondents said their decision was based on a sense of place and seven respondents chose rural practice primarily because they could lead happy and successful personal and professional lives (self-actualization) (Hancocket al., 2009). Self-actualization emerged as a motivator for rural practice. These findings support the need for comprehensive mentorship and development programs for new physicians and should be a policy and funding priority for physicians entering rural primary practice (Hancocket al., 2009).

Spousal perspectives Mayo and Mathews (2006) report many studies that support the critical role physician’s spouses play in the decisions to practice and remain in rural areas. They used qualitative interviews to examine spouse experiences and perspectives to gain a better understanding from the spouse’s satisfaction with rural living. Participants were from rural Canada; 15 physicians met the inclusion criteria and thirteen spouses agreed to the interview (Mayo and Mathews,2006). Several rural living contentment and perception factors were identified, which were organized into two themes:

direct and indirect; the former an immediate influence on contentment. Content spouses and their children are more likely to stay in rural areas. The two direct factors identified with a rural practice were physician workload and community integration. Children influence contentment with a rural community and physicians with young children were more prepared to stay in the rural community than those without children (Mayo and Mathews, 2006). Indirect spousal-contentment factors were licensing requirements, total physicians in the community, remuneration and community characteristics. Importantly, total physicians in the community affect the physician’s workload; i.e. more physicians mean more time off that the physician has with his or her family. Income was not a primary consideration for rural practice.

For those who were content, remuneration did not affect their decision to stay in the rural community (Mayo and Mathews, 2006).

Rural magnet hospitals Another attractive feature is a rural hospital’s magnet designation. Rural hospitals are nominated for magnet status because they offer superior patient care, often removing departmental boundaries. These designated facilities differ from traditional rural hospitals regarding structure, nursing practice and climate. Structural components include: open communication, decentralized decision making, administrative availability and responsiveness, personnel benefits, staffing and scheduling and diversification.

Nursing offers professional growth, teaching, superior skills and current practice models.

Climate is an overreaching category that extends beyond staff cohesiveness but also provides valuable resources to the community (Fuszardet al., 1994a). 649 Physician recruitment and retention These facilities are often the major employer and symbolize the community’s identity and pride. Nurses enjoy the close working relationships with physicians and have been described as the doctor’s eyes and ears. This close relationship is a benefit to physicians because often the nurse can proceed with care and know the boundaries when to notify the physician. Critical to the facility’s magnetism is: respect, pride, teamwork, interdependence, ownership and community connectedness. Researchers found that blurred departmental boundaries and open communication lines between administrative and clinical staff demonstrate a climate that includes oneness, wholeness and ownership in rural magnet hospitals of excellence. The climate extends beyond the facility’s walls and melds into its community in a reciprocal partnership (Fuszardet al., 1994b). Physicians preferring these relationships and values may tend to gravitate toward a rural magnet hospital of excellence.

Cochrane Collaboration A Cochrane Collaboration team conducted a study to assess the effectiveness for interventions focussed on increasing the health professionals working in rural and other medically underserved areas. Databases searched included the Cochrane Effective Practice and Organization of Care Group register (up to July 2007), Cochrane Central Register of Controlled Trials and the Database of Abstracts of Reviews of Effectiveness (up to July 2007), MEDLINE (1966 to July 2007), EMBASE (1988 to July 2007), CINAHL (1982 to July 2007) and LILACS (up to July 2007).

The authors also searched publication reference lists and relevant reviews. Also, authors were contacted regarding any further published or unpublished work.

The selection criteria included randomized controlled trials, controlled trials, controlled before-after studies and interrupted time series studies that evaluated popular interventions’ effects includingeducational, financial or regulatory strategies on health professionals’ recruitment and/or retention in medically underserved areas. A total of 1,844 studies and abstracts were reviewed and no study met the inclusion criteria (Grobleret al., 2009).

According to Grobleret al.(2009), 9 percent of registered physicians in the US practice in rural areas. Based on common interventions to recruit and retain physicians to rural areas, the authors felt it was important for stakeholders and policymakers to understand the scientific evidence supporting intervention effectiveness and impact outlined in previous studies. The study’s objective was to assess interventions used to recruit and retain physicians working in rural, medically underserved areas (Grobler et al., 2009). Interventions or strategies for rural physician recruitment and retention were grouped into four categories: educational, financial, regulatory and supportive.

Educational interventions included student selection criteria, teaching curricula and exposure to rural and underserved areas. Financial interventions included scholarships linked to future practice location, rural allowances and increased salaries.

Regulatory strategies included compulsory community service and relaxed work regulations imposed on foreign medical graduates who are willing to work in rural underserved areas. Support strategies included providing professional support and attending to the practitioner’s family needs (Grobleret al., 2009). The main finding was that there are no well-designed studies in which bias and confounding are minimized to address the rural physician shortage. Studies were mainly observational and strategic impacts were poorly quantified. Despite reliable evidence, these strategies have been implemented to address physician shortages in rural areas. The authors suggest rigorous evaluations of strategies to recruit and retain physicians to rural medically 650 IJHCQA 27,7 underserved areas. This will determine a recruitment and retention tool’s ability to inform and direct future policy (Grobleret al., 2009).

Conclusion It is well known that rural Americans are under-represented when it comes to healthcare. There are numerous articles that call for special measures to recruit and retain physicians in rural areas, though there is an overall research-dearth. Some authors outlined rural roots’ importance for physicians returning to rural practice.

Others argue that early and repeated exposure to rural medicine in the medical school curriculum brings in rural physicians. Also, there is the human dynamic where spousal perspectives and raising young children always plays a role in practice location.

Financial incentives, such as loan forgiveness, have been identified, but there has not been much emphasis on remuneration as a factor in retention efforts. Finally, while some recruitment and retention strategies represented in these papers hold promise, the Cochrane review found no well-designed studies to determine, with scientific evidence, that any strategy is efficacious for recruiting and retaining rural physicians.

This review has identified several articles that suggest recruitment and retention techniques. There is a need for a research agenda that includes valid, reliable and rigorous analysis when formulating and implementing strategies. With techniques in place, perhaps rural Americans will have better access to healthcare because more physicians will gravitate to rural medically underserved areas.

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Corresponding author Dr Tommy Nichols can be contacted at: [email protected] To purchase reprints of this article please e-mail:[email protected] Or visit our web site for further details:www.emeraldinsight.com/reprints 652 IJHCQA 27,7 R epro duce d w ith p erm is sio n o f th e c o pyrig ht o w ner. F urth er r e pro ductio n p ro hib ite d w ith out p erm is sio n.