Rural America is in an endless struggle to find enough doctors and nurses willing to practice medicine in relatively remote and isolated locations. While 19 percent of the nation’s population—about 56 million people—live in rural areas, only 11 percent of the nation’s physicians practice in those communities. The registered nurse workforce is somewhat better distributed, but shortages continue. Several factors make matters worse:
“The need is increasing at the same time the supply is decreasing,” says Tim Skinner, executive director of the National Rural Recruitment and Retention Network, a group in LaCrosse, Wis., that helps states recruit health care professionals for rural communities. State budgets for health care recruitment have recently spiked, which could indicate the problem is worsening. Also, the number of nonmetropolitan areas identified by the federal government as having primary care shortages has increased since 1990.
Even determining the scope of the problem is difficult, says Andy Jordan, chief of the primary shortage designation branch in the federal Health Resources and Services Administration. Over the years, various federal programs have offered special privileges to communities with the shortage designation; for example, they might be eligible to hire foreign doctors with a J-1 visa. Nevertheless, Jordan believes that not all medically needy communities apply for the designation: The communities might not have the resources to complete the application or might not think they can benefit from a federal program. “The shortage designation number is not a proxy for need,” Jordan says. “It represents a portion of the need, but what portion we don’t know.”
Physicians
Percentage of physicians in rural vs. urban areas, 2000
The number of physicians lags significantly in rural areas compared to urban settings.
| Physician Type | Urban | Total Rural | Large Rural | Small Rural | Isolated, Small Rural |
| MD (total = 164,375)* | 89.1% | 11.0% | 7.3% | 2.6% | 1.1% |
| DO (total = 11,262)* | 81.8 | 18.2 | 10.4 | 5.3 | 2.5 |
| IMG (total = 26,393)* | 86.7 | 13.3 | 7.9 | 3.7 | 1.7 |
Definitions: Large Rural indicates an area with a population of 10,000 to 49,999 that has a significant number of workers who commute there from surrounding areas. Small Rural indicates an area with a population of 2,500 to 9,999 that has a significant number of workers who commute to work there from surrounding areas. Isolated Small Rural indicates an area with fewer than 2,500 people that is without significant commuting.
*Totals represent clinically active physicians in 2005 who graduated from medical school between 1988 and 1997.
Source: “Medical Education and U.S. Rural Physician Workforce,” The University of Washington Rural Health Research Center, 2007
Salary averages by population
Data from hundreds of salary offers from Merritt, Hawkins & Associates, Irving, Texas, show that rural areas often have to keep up with urban offers and pay a premium for sought-after specialties such as orthopedic surgery.
| 25,000 population or less | 25,001 population or more | |
| Family Practice | $159,000 | $162,000 |
| Internal Medicine | 168,000 | 176,000 |
| Hospitalist | 176,000 | 182,000 |
| General Surgery | 275,000 | 307,000 |
| Radiology | 359,000 | 387,000 |
| Orthopedic Surgery | 462,000 | 409,000 |
| Cardiology | 410,000 | 383,000 |
| OB/GYN | 249,000 | 246,000 |
| Gastroenterology | 392,000 | 363,000 |
Source: 2007 Review of Physician Recruiting Incentives, Merritt, Hawkins & Associates
2006 was a rough year for filling rural MD vacancies
The National Rural Recruitment and Retention Network Inc. posts positions for its members, mostly state offices of rural health, on its Web site, 3RNet. While physician job postings have grown on the site, only a fraction of the needed positions are filled.
| Jobs Posted | Positions Filled | |
| Family Practice | 1,657 | 211 |
| Internal Medicine | 1,066 | 59 |
| Pediatrics | 213 | 45 |
| OB/GYN | 160 | 19 |
| General Surgery | 135 | 12 |
Source: 3RNet Evaluation Membership Activities Report, 2007
Best practices for recruiting doctors
• Carefully assess the skills and qualities needed. “The easy part is the education and experience; more difficult is determining the interpersonal skills and leadership capabilities,” says Jim Tavary, CEO of Prosser (Wash.) Memorial Hospital, a critical access facility.
• Try to find three candidates if possible, in case the top candidate decides not to take the offer. Then you don’t have to start again at the beginning.
• Before doing an in-person interview, have the candidate interview by phone with a physician in the same specialty.
• During the job interview, make the visit comprehensive. Encourage the doctor’s spouse to come, let the couple visit schools and talk with a real-estate agent. By the time a doctor leaves, he or she shouldn’t have questions about the job or your area. “You’re not recruiting a doctor, you’re recruiting a family,” says Cynthia Bagwell, associate vice president of professional staffing at Geisinger Health System, Danville, Pa.
• Flaunt your differences from urban work settings, such as a short commute time or the opportunity to work with a broad range of patients. If your area offers opportunities for outdoor activities, such as kayaking or skiing—or beautiful scenery—make sure the physician sees that during the visit. Show the doctor places where he or she can participate in hobbies. “You need to accentuate your differences, not apologize for them,” Bagwell says.
• If possible, get other physicians in the area—even those who don’t work for the hospital—involved. At Prosser, physicians from a large medical group in town help with the recruiting process by attending receptions for the candidate. Physician spouses can take the doctor’s partner to lunch, so he or she will know someone in the community. “Doctors need to know their families and practices will be supported,” Tavary says. “Having other doctors offer companionship and support is more important than anything the hospital can tell candidates.”
Nurses
Registered nurse distribution in rural vs. urban, 2000
The nationwide distribution of nurses closely matches the population in urban and rural areas in aggregate, but sharply declines compared with the adult population in isolated, small rural areas. A smaller percentage of minority RNs, compared with the minority population, indicates a possible recruiting opportunity. Rural nurses are less likely to have a four-year degree.
| Urban | All Rural | Large Rural | Small Rural | Isolated, Small Rural | |
| RNs by work location | 81.0% | 19.0% | 9.8% | 6.3% | 2.8% |
| U.S. population aged 18-74 | 78.2 | 21.8 | 9.3 | 7.2 | 5.3 |
| Nonwhite and/or Hispanic RNs | 13.2 | 5.3 | 6.4 | 4.8 | 3.8 |
| Nonwhite and/or Hispanic U.S. population aged 18-74 | 18.4 | 11.2 | 11.5 | 11.7 | 9.8 |
| Baccalaureate RN degree or higher | 46.6 | 32.3 | 35.3 | 30.7 | 30.6 |
Definitions: Large Rural indicates an area with a population of 10,000 to 49,999 that has a significant number of workers who commute there from surrounding areas. Small Rural indicates an area with a population of 2,500 to 9,999 that has a significant number of workers who commute to work there from surrounding areas. Isolated Small Rural indicates an area with fewer than 2,500 people that is without significant commuting.
Source: “Characteristics of Registered Nurses in Rural vs. Urban Areas: Implications to Alleviate Nursing Shortages in the United States,”
The Journal of Rural Health, April 2006
Registered nurse full-time salaries by residence and work location, 2000
Urban salaries may be high enough to entice nurses who live in rural areas to make the commute, which may contribute to the shortage of nurses working in rural areas.
| Nurse residence | ||||
| Work Location | Urban | Large Rural | Small Rural | Isolated, Small Rural |
| Urban | $49,627 | $43,767 | $43,621 | $43,201 |
| Large rural | $47,170 | $42,689 | $42,509 | $41,205 |
| Small rural | $46,446 | $41,805 | $41,252 | $41,024 |
| Isolated small rural | $49,226 | $42,822 | $41,367 | $40,516 |
Source: “Characteristics of Registered Nurses in Rural vs. Urban Areas: Implications to Alleviate Nursing Shortages in the United States,”
The Journal of Rural Health, April 2006
Many nurses wanted, but few are hired
The National Rural Recruitment and Retention Network Web site, 3RNet.com, shows that job postings for nurses far outstrip placements.
| Jobs posted | Positions filled | |
| RNs | ||
| 2004 | 261 | 19 |
| 2005 | 290 | 10 |
| 2006 | 890 | 5 |
| Nurse practitioners | ||
| 2004 | 197 | 65 |
| 2005 | 319 | 73 |
| 2006 | 369 | 77 |
Source: 3RNet Evaluation Membership Activities Report, 2007
Best practices for recruiting nurses
• Links with local colleges are important. Leann Anderson, R.N., chief nursing executive at Prosser (Wash.) Memorial Hospital, serves on an advisory board to a local community college. “I work directly with all the instructors and meet with student nurses. It adds a personal touch.”
• Be an ambassador for your facility. Roxie Shrawder, R.N., a recruitment manager at Geisinger Health System, Danville, Pa., makes it a point to talk to waitresses about the health care system because they are often in college. “I even do it on vacation because you never know where life will take you. A nurse’s spouse could end up transferred to the area, and that nurse will already know someone at our facility.”
• Use a nurse residency program for new hires. It helps recruit and retain nurses, Anderson says, and could give your facility an edge over a hospital that doesn’t have such a program.
• If possible, fund an academic assistance program to pay nursing program tuition for employees, in exchange for their working at the hospital for a period of time after graduation. “This wasn’t a hard sell with our CFO because of the money we were spending on agency nurses,” Anderson says. The program has allowed nurses’ aides to become RNs at Prosser Memorial.
• Develop “internships” for high school students to learn about nursing, and serve as a clinical education site for college nursing programs.
• Accentuate differences in your work setting that might be attractive to nurses. For instance, Prosser offers both eight- and 12-hour shifts, while its urban counterparts offer only 12-hour stints. Some nurses also might like the range of responsibilities a rural facility requires. “We don’t have the IV teams or 24-hour pharmacies of an urban hospital, so nurses experience a wider variety of practice,” Anderson says.
How We Did It: This gatefold was produced by researching published studies and articles and conducting interviews with industry executives.
Research: Terese Hudson Thrall I tthrall@healthforum.com
Design: Chuck Lazar I clazar@healthforum.com
This article 1st appeared in the December 2007 issue of HHN Magazine.
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