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Rural Health Care: Challenges & Opportunities

Workforce Strategies


L. Gary Hart, Ph.D., Director, Department of Family Medicine, WWAMI [Washington, Wyoming, Alaska, Montana, and Idaho] Rural Health Research Center, University of Washington, Seattle, WA

This session provided an overview of the workforce issues related to the delivery of health services in rural areas and discussed workforce distribution and supply in rural areas, including recent research findings and interventions to improve recruitment and retention of health professionals.

Dr. Hart focused his presentation on physician trends and issues in rural areas. He noted that the points he addresses could be applied to other health care professionals as well, such as physician assistants and nurse practitioners.

With regard to workforce distribution and supply in rural areas, there has been a decrease in the number of generalist physicians in rural areas over the last 60 years, with specialists representing half of all rural physicians. This trend, however, has flattened out over the past two decades.

There are a number of gender distribution issues affecting workforce shortages in rural areas. Little is known about how to successfully recruit and retain women physicians in rural areas. Although there is an increasing number of female medical school graduates (30 percent), women are 70 percent less likely to relocate in rural areas. For those that do work in rural areas, women physicians also have different work patterns, such as taking more time off work, seeing fewer patients per week, and working fewer hours per week.

With regard to productivity and income, although there is no significant difference in rural and urban generalist physician incomes, rural generalists:

  • Work substantially more (on average 8-10 hours more per week, plus 3-4 times as many on-call hours).
  • Have broader clinical practices.
  • Receive less pay for the same work.

There are, however, substantial differences in income by specialty. For example, a family practitioner may earn $80,000-$90,000 per year, while a surgeon may earn $200,000-$300,000.

Recruitment and retention of health care professionals is a major issue in rural areas.

Effective training programs are critical. Having a rural background can be important with regard to medical school training leading to rural practice. Dr. Hart cited a framework (Crandall, Dwyer, and Duncan, 1990) that discusses four different models for recruiting and retaining health professionals in rural areas:

  • Affinity models (e.g., that target rural background).
  • Economic models (e.g., that provide Medicare bonus payments).
  • Practice characteristic models (e.g., that reduce on-call burden).
  • Indenture models (e.g., educational provider scholarships or loans in exchange for years of service).

Examples of State recruitment and retention activities include:

  • Loan repayment programs.
  • Clearinghouse and matching services.
  • Generalist training programs.
  • Student rural experiences.
  • Recruitment and retention community technical assistance.
  • Continuing medical education (CME) programs.
  • Remote consultation and library services.
  • Early "pipeline" activities (e.g., career days).

Dr. Hart shared three keys to successful rural training, recruitment, and retention. These keys are relevant for physicians and other medical provider types as well.

  • Reduce the number of rural uninsured, underinsured, and poor.
  • Create a stable and financially sound rural health care delivery system.
  • Allow for health care providers to have stable, rewarding, and fulfilling professional and personal lives.

Nonphysician professionals (i.e., physician assistants, nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists) provide a significant degree of primary care services in rural areas. There are nearly 13,000 nurse practitioners and 6,000 physician assistants in rural areas, making up approximately 20 percent of the workforce in these two nonphysician professions. Dr. Hart commented that although patients may perceive that there are quality differences in receiving primary care from a nonphysician professional, in reality there are no significant differences.

There is a current national shortage of registered nurses. In addition to older nurses reaching retirement age, many nurses have dropped out of the field because of pay, managed care, and other issues around nursing that need further research.

Dr. Hart's key message is that workforce issues are related to the entire health care system and used recruitment and reimbursement strategies as examples. Dr. Hart illustrated their connection, emphasizing that one part cannot be fixed without addressing other parts of the health care system as well.


Crandall LA, Dwyer JW, Duncan RP. Recruitment and Retention of Rural Physicians: Issues for the 1990s. J Rural Health 1990 Winter;6(1):19-38.

Ricketts TC, ed. Rural Health in the United States. New York: Oxford University Press; 1999.

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