Rural Health Access to Care: Physician Maldistribution and Solutions

Rural Health Access to Care: Physician Maldistribution and Solutions

Major Matthew L. Tillman
United States Army Baylor Masters in Health and Business Administration

Rural Health Access to Care: Physician Maldistribution and Solutions

Abstract
The purpose of this literature review is to describe the rural health access to care dilemma
facing the U.S in light of physician maldistribution and to consolidate information concerning
effective practices that have proven beneficial in the recruitment of physicians to rural areas. I
conducted a literature review using Pub Med in three distinct phases. First, I reviewed the
literature describing the complexities and problems associated with rural health care. Second, I
reviewed the literature about physician maldistribution in the U.S.; and finally, I reviewed
available literature about effective recruitment programs for primary care physicians in rural
America. I limited the search to scholarly sources no older than 2009 with two exceptions due to
a lack of current literature for economic considerations of practice choice. After review of the
current literature, three distinct causes of physician maldistribution were apparent including: time
spent in a rural community prior to medical school; desire to serve in a specialty versus general
practice; and time spent in a rural environment during medical education. This review
consolidates the diverse but limited research published in the last decade about geographic
maldistribution and includes considerations for the Affordable Care Acts (ACA) continued
implementation. Finally, this review considers two successful educational programs that are
graduating increased numbers of general practitioners and more rural providers than the U.S.
average.

Rural Health Access to Care: Physician Maldistribution and Solutions

Rural Health Access to Care: Physician Maldistribution and Solutions

In 2010, 19% of the 312 million people in the U.S. lived in rural areas (United States
Census Bureau, 2014), but only 11% of the physicians practiced medicine in these areas
(American Hospital Association, 2011). Rural areas and their populations present many health
concerns that complicate the geographic maldistribution of physicians. There is extensive
research on the complications of rural health care specific to the population, but the current
literature about the causes of physician maldistribution is diverse in its conclusions and limited in
quantity compared to the literature of the previous decade.
The rural population has higher rates of preventable morbidities such as cancer, obesity,
and diabetes and a higher prevalence of high-risk health behaviors such as smoking, inactivity,
and poor diets (Crosby, Wendel, Vancerpool, & Casey, 2012). The rural population is aging
faster than the general U.S. population due to out-migration of young adults and in-migration of
retirees (McGranahan, Cromartie, & Wojan, 2010). Further, rural areas have higher poverty
rates than urban areas (U.S. Census Bureau, 2013), and poverty is associated with decreased
access to health care and generally lower health outcomes (OHara & Caswell, 2013). The rural
population is a special health population, with unique and challenging characteristics, some of
which are defined above. However, the rural population and its health care system have
additional problems not directly associated with unhealthy population characteristics.
Rural communities also face professional workforce retention and recruitment issues. An
economic research survey conducted by the United States Department of Agriculture in 2009
found that one in four rural manufacturers faced human capital and recruitment issues primarily
related to the lack of landscape attractiveness (McGranahan, Cromartie, & Wojan, 2010). The
same study found that 70% of counties with high total population out-migration rated in the

Rural Health Access to Care: Physician Maldistribution and Solutions

bottom third of landscape attractiveness, usually defined with little public land, with domination
by farmland, and with an average of 5% forested land. In addition to the lack of attractiveness of
the environment, rural health care providers and hospitals often face challenges due to small
organizational size and constrained resources caused by lower patient volumes and higher fixed
costs associated with diseconomies of scale; all of this results in more restricted financial gain
(American Hospital Association, 2011).
When one considers the daunting task of the rural populations health concerns, the
potentially smaller economic gain, and the less desirable location, it is not surprising that only
11% of US physicians practice medicine in rural communities (American Hospital Association,
2011). Specifically, 34.5 million Americans live in health professional shortage areas where
9,000 additional primary care providers would be required to achieve target population-topractitioner rations of 2,000:1 (Burrows, Shu, & Hamann, 2012). Unfortunately, health systems
based on primary care have shown better health outcomes (Shi, 2012). The implementation of
the affordable care act will increase health care access through insurance by an estimated 7.8
million in rural America (Health and Human Services, 2014). However, the universal insurance
mandate enacted in Massachusetts in 2006 foretells the coming problems associated with access,
specifically with primary care, for the newly insured members where the specialty
maldistribution of physicians has caused a shortage in this critical field (Turner & Persico, 2009).
The high risk and poor health indicators associated with the rural American population,
the shortage of primary care physicians in those areas, and the increased demand from the
affordable care act is likely to increase the primary care physician shortage specifically in rural
America. In order to examine this problem and evaluate potential solutions, we must first

Rural Health Access to Care: Physician Maldistribution and Solutions

understand the reasons for physician geographic and specialization maldistribution and then must
evaluate the literature to uncover proven solutions.
Method
Research Design
My initial review of the literature was very promising. The initial search in Pub Med for
physician maldistribution resulted in 210 articles. When I further constrained the search to
articles since 2009, the same criteria returned only 43 articles. I then screened the abstracts and
omitted those clinical in nature, that did not address a physicians practice selection or training,
and those that utilized the Health People 2010 initiatives data as a primary building block. The
resulting ten articles selected for review were diverse, and only one comprehensive review was
found of the literature that compared the causes of physician maldistribution by specialty or
geographic region. When complete with this screening process, I found one major hole in the
current research and drew on two articles that referenced practice specifics resulting in choice
from 2002 and 2005 respectively. I desired in this review to consider both the qualitative
analysis of scientific studies associated with physician choices and the economic and
socioeconomic environment of rural America without regard for a specific profession. My
analysis desires to look at this problem from both perspectives while omitting the current
incentive systems that appear to be largely ineffective in the recruitment of primary care
providers in rural America. Further, other nations have similar problems with physician
geographic maldistribution. In order to provide a comprehensive, fresh, perspective on the
causes and potential solutions for the lack of rural physicians, I did not omit non-U.S. studies and
drew on several non-health care related governmental organizations such as the Department of
Agriculture and Department of Commerce.

Rural Health Access to Care: Physician Maldistribution and Solutions

After I reviewed the current, applicable literature, I consolidated the findings to answer
two questions. First, I looked for documented research on causes of maldistribution to answer
the question, Why do physicians choose not to live in rural America and serve in a general
practitioner role? Second, I looked for successful models of physician recruitment and retention
to answer the question, How can we provide incentives and recruit physicians to serve in these
areas? During the literature review, I omitted the current government incentive programs unless
discussed in a scientific study. To consolidate the findings of these various studies, I will modify
a model used by Bennett and Phillips (2010). I will consolidate the causes for physician choices
for specialty and location into three broad categories: personal variables such as preferred
lifestyle, community and environmental characteristics of urban and rural areas; occupational
variables such as economic gain, workload, scope of practice, and professional isolation; and
educational variables associated with training and mentorship. I will use this same simplified
Bennett and Phillips model to dissect the programs successful in rural primary care physician
retention and recruitment.
Causes of Physician Maldistribution
Physician maldistribution is not exclusive to the U.S. Primary care shortages in rural and
remote areas are key issues in several countries including Australia, Canada, and Japan (Scott, et
al., 2013). Older research pointed to several key predictors of a physicians likelihood to practice
primary care in a rural setting including rural background; receipt of National Health Service
Corps scholarships; spousal influence; and largely recognized as the single biggest predictor,
time spent in a rural setting during medical training (Rabinowitz & Paynter, 2002). Despite these
well documented predictors and policy attempts to incentivize individuals to choose rural
primary care as their practice, only 3% of medical school graduates planned to practice in a rural

Rural Health Access to Care: Physician Maldistribution and Solutions

setting (Rabinowitz & Paynter, 2002). Again, to dissect the reasons for physician practice
choice, I will break the documented reasons for choice into personal, occupational, educational
variables to address if these previously conceived determinants are viable today.
Personal Variables. One study that consolidated research from 1995 2005, found
evidence that women, public medical school students that were older or married, and physicians
from rural backgrounds, were more likely to select primary care as a specialty (Bennett &
Phillips, 2010). This study seems to identify demographics that could easily account for those
medical students who would likely select primary care and, more specifically, rural health care
following graduation. Another study found that physicians often choose to practice in rural
communities based on positive perceptions of a rural lifestyle, a desire to raise a family in a rural
setting, a level of participation in outdoor recreational activities, decreased crime rates, lower
traffic, and a desire to live in closely-knit communities (Rabinowitz & Paynter, 2002). A
Canadian study found that physicians who had rural or small town addresses at the time of
application to medical school were more than twice as likely to practice in a non-metropolitan
area (Orzanco, Lovato, Bates, Grand'Maison, & Vanasse, 2011). Another Canadian study found
that 38% of practicing rural family practice physicians came from hometowns of less than
10,000 people (Chan, et al., 2005). The combination of these studies seems to point to the fact
that demographics are not as important as the positive perception of rural life gained from
personal experience.
As I identified in the introduction, intuition and one study would argue that the barren
location is a major hurdle that any rural health care provider recruitment policy must overcome.
An Australian study seems to validate this hypothesis. That study asked practicing primary care
physicians what amount of compensation would be required for them to reestablish their practice

Rural Health Access to Care: Physician Maldistribution and Solutions

inland in rural, agricultural areas with less than 5,000 people. The respondents stated they would
require an average of $23,748 per year in compensation to account for the non-urban location
(Scott, et al., 2013). Another study, however, seems to contradict the Australian study where
even rural Hawaii faces geographic physician maldistribution. The islands are cumulatively
short 600 physicians, and the most remote areas have less than one physician per 1,000 in the
population (Ambrose, et al., 2012). While the Hawaii study alone cannot dismiss the likelihood
that the barren landscape is a hindrance to rural recruitment, it does suggest that there is an
individual degree of acceptance for varying degrees of landscape attractiveness.
While physician demographics and location appear to be important considerations for
potential rural health care providers, the Australian study found that the single largest obstacle to
overcome in physician relocation was the lack of social interaction in a rural community. The
average respondent would require an additional $47,228 per year to overcome the lack of social
interaction alone (Scott, et al., 2013). In contrast, another study showed that physicians who
chose to practice in urban settings were influenced by the variety of goods and services available,
the opportunities for diverse entertainment, and the more diverse cultural amenities (Rabinowitz
& Paynter, 2002). Yet another study found that one fifth of practicing rural physician
respondents named the rural lifestyle as a major characteristic for selecting a rural practice
(Chan, et al., 2005). The single personal variable contributing to practice location seems to be
physician familiarity with rural settings largely gained through experiences prior to medical
school. This experience seems to give individuals an affinity for or at least helps them overcome
the perceived negative aspects of rural life.
Occupational Variables. Most studies addressed both geographic and specialized
physician maldistributions. The relationship between the two is clear when you consider that the

Rural Health Access to Care: Physician Maldistribution and Solutions

majority of physicians are specialists and that rural physicians are comprised mostly of primary
care providers (Rabinowitz & Paynter, 2002). The preponderance of the research selected for this
review considered specialty selection for physicians. One study found a linear correlation
between a specialtys residency fill rate and that same specialtys expected income suggesting
that lifetime return on investment is a major consideration for new physicians (Bennett &
Phillips, 2010). While this finding partially answers the specialization maldistribution, it does
not fully explain the geographic maldistribution of primary care providers where rural physicians
tend to have similar net income to their urban counterparts, but their cost of living is generally
lower due to the general lower rate of housing costs in rural areas (Rabinowitz & Paynter, 2002).
Other studies found that respondents identified less with financial incentives than with the nature
of primary care when selecting their specialty. One study found that physicians who chose
primary care as a specialty were less interested in prestige or research (Bennett & Phillips, 2010).
Income differences between specialists and generalists are obviously contributing factors to the
geographic maldistribution, but income does not account for the entire disparity.
The literature points to strong correlations between the perceived work load of primary
care physicians, and more specifically, rural physicians and practice decisions. While rural
physicians generally report greater practice autonomy, they also experience increased
professional isolation (Rabinowitz & Paynter, 2002). A study that proposed scenarios to
primary care physicians found that of potential issues with rural practice, increased on call time
was the largest deterrent followed by lack of social interaction, increased work hours, and lack of
support staff (Scott, et al., 2013). The same study found that for a physician to assume a 10%
increase in work hours, he would require an additional $46,696 in annual compensation and an
additional $49,191 per year if on call time double from once to twice weekly. So while family

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physicians in rural communities share almost identical net income to their urban counterparts,
they tend to work more hours and have a larger practice scope (Rabinowitz & Paynter, 2002).
Occupational variables show two promising correlations between the nature of a primary
care practice and physician decisions. First, the specialty maldistribution is obviously
contributing to the geographic maldistribution as young physicians can earn more money
working in specialized practices less represented in the rural environment. Second, many young
physicians see rural practice as professionally isolating which results in among other things,
increased work load.
Educational variables. One study found that 65% of general practitioners when asked
about relocating for monetary gain or reduced work hours chose to stay in place versus any
change to their work arrangement (Scott, et al., 2013). This study suggests that physicians make
deliberate and accurate choices in their preferred practice location early in their careers. As we
already discussed, physicians raised in rural areas are more likely to practice in a rural setting. In
one study, 27% of rural raised physicians attributed their practice location choice to the time
spent in a rural setting before medical school (Chan, et al., 2005). The same study found that the
second biggest determinate for practice location was the challenge of rural medicine, suggesting
that events in their education shaped opinion about rural practice. Chan, et al, also determined
that almost 19% of urban raised family practice physicians based their rural practice decision on
medical school experiences second only to the challenge of rural medicine that was the primary
consideration by over 24% of respondents (2005). The correlation between practice location and
medical education seems to be very strong. In fact, one study found that medical students placed
in small cities for residencies who did not participate in rural internships were half as likely to
practice in a rural community (Orzanco, Lovato, Bates, Grand'Maison, & Vanasse, 2011).

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Solutions
The qualitative literature defining solutions to physician maldistribution is less dense than
the causes of physician choice with only two programs touted for their success. The University
of Cincinnati Family Medicine Residency Program initiated an international health track in 1994
to meet demand for global health training. A 2011 evaluation of this program determined that
this type of changed curricula increased actual involvement of the graduates in rural and other
underserved practice areas by 10% (Bazemore, Goldenhar, Lindsell, Diller, & Huntington, 2011).
The biggest difference between the international health track and others was time spent in
underserved and rural communities during schooling.
The Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program is one of
the nations most successful models for rural health training (Allen, et al., 2013). This program
began in 1975 to answer the shortage of physicians and medical schools in the predominantly
rural landscape of the northwest regions of the country where 3.5% of the U.S. population lives
on 27% of the land mass. The program has increased the number of physicians practicing in the
five states of the program by 57% since its inception with over 53% practicing in the primary
care field and 47.5% practicing in a rural community. The significantly higher number of
primary care physicians compared to the national average of 41.9% and the higher number
serving in rural communities than the national average of 30.2% indicate a high degree of
success (Allen, et al., 2013).
Results
My review of the literature identifies many key predictors of a physicians choice for
practice location. While there are many personal variables that contribute to an individuals
choice to practice in a rural community as a primary care physician, the most common among

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12

the literature was time spent in a rural community before medical school. The lack of social
interaction, entertainment, and other easily accessible amenities found in an urban setting
coupled with the bleak landscape of rural America are major deterrents to choosing a rural
practice. While the characteristics of a rural community found familiar by those with experience
reinforces their desire to practice in those communities, those same characteristics seem to serve
as a deterrent to others.
The literature clearly shows the association between specialty and geographic
maldistribution. Primary care providers dominate rural practices, but few current medical
students plan to become general practitioners. The literature clearly identifies that the largest
determinant for choosing a specialty is net income. Other characteristics also contribute to this
choice, but none were as dominant as pay. While the net pay between specialists and generalists
explains part of the specialization maldistribution, it does little to explain geographic
maldistribution where rural providers make nearly the same as their urban counterparts. The
perceived increased workload and professional isolation of rural medicine offers clear negative
correlations with practice location choice. Urban physicians view the additional work hours,
lack of professional support and resulting increase of on call time, and lack of support staff as
major obstacles to practicing in rural settings.
The correlation between rural medical education and practice location choice is clear and
applicable. Medical students who spend time in a rural setting are much more likely to serve as a
generalist and to serve in rural communities. While there is likely a relationship between teachermentors represented in this correlation, I believe the relationship primarily reinforces the
personal variable finding. Those more comfortable and acquainted with the rural lifestyle are

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more likely to view the perceived shortcomings in a positive light, embrace the positive aspects
of rural life, and therefore select a rural practice location.
Contributions
Unfortunately, there was only one available literature review that discussed the causes of
physician maldistribution since 2009 found in Pub Med. If the search parameters are extended to
2001 several dozen are available. This emphasis is likely due to the focus of Healthy People
2010 on the elimination of health disparities including geographic disparities (Health and Human
Services, 2009). Healthy People 2020 does not contain this emphasis. This review consolidates
the current research applicable to this area. As the U.S. continues to implement the ACA,
physician maldistribution will become an increasing problem for rural Americans. I have shown
that some of the preconceived notions of physician choice predictors are outdated or not
represented in the current literature when we consider areas such as gender and the economic
costs of rural practice. However, I have shown that previous experience in a rural community
and time spent during medical training in a rural community remains the strong influences and
predictors of practice location choice.
Discussion
There were 861,463 U.S. physicians in 2010 with 20,537 new graduates from U.S.
schools, but only 45% were primary care physicians (National Center for Health Workforce
Analysis, 2013). Rural Americans are generally less healthy, have greater poverty, and are more
geographically isolated from medical care (American Hospital Association, 2011) (Crosby,
Wendel, Vancerpool, & Casey, 2012) (Health and Human Services, 2014). While nearly 19% of
the U.S. population lives in rural America, only 11% of physicians practice in rural communities
(American Hospital Association, 2011) (U.S. Census Bureau, 2013). The problems associated

Rural Health Access to Care: Physician Maldistribution and Solutions

14

with physician maldistribution will only expand with the continued implementation of the ACA,
and it is likely that we will face an even greater population to physician disparity in the coming
years for rural communities.
While some historic predictors have held consistent in the last 15 years, policy can only
easily affect one. The amount of time spent during graduate medical education (GME) in a rural
setting is strongly correlated to rural practice selection (Orzanco, Lovato, Bates, Grand'Maison,
& Vanasse, 2011) (Rabinowitz & Paynter, 2002). GME programs and policies must address
residency location if physician geographic maldistribution is to be reversed. Policy makers
should view the WWAMI as a blueprint for successful medical curricula as it not only has
successfully addressed geographic maldistribution but also specialty maldistribution. This
program selects medical students with characteristics the program claims predict their likelihood
to return to one of the sponsor states to practice medicine (Allen, et al., 2013). While the
literature reviewed for this study did not necessarily reinforce that practice, the remainder of the
program should be considered closely. WWAMIs use of rural training throughout medical
school is obviously effective (Allen, et al., 2013).
The rural population of the U.S. is a poorer, unhealthier, increasingly older population,
with fewer physicians than the rest of the population. Effort should focus on selection of medical
students with familiarity with rural areas. Specialty maldistribution must be addressed with
policy, and medical schools need to include rural training in all programs. If changes are not
made, the rural population will remain at higher risk for chronic conditions than the rest of the
U.S. population.

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