摘要：Objectives. We tested the assumption that average job retention duration is shorter for physicians in rural health professional shortage areas (HPSAs) than for physicians in rural non-HPSAs. Methods. In 1991, we surveyed nationally representative samples of primary care physicians who recently had moved to rural HPSAs and non-HPSAs who were without service obligations. We resurveyed these physicians in 1996 and 1997 to learn of any job changes. Results. Physicians in rural HPSAs (n=308) demonstrated retention similar to that of the non-HPSA cohort (n=197) (hazard ratio for leaving=1.28; 95% confidence interval=0.97, 1.69; P =.08), even with adjustments for group demographic differences ( P =.24). Conclusions. Average retention duration for generalist physicians in rural HPSAs is identical to or slightly shorter than for those in rural non-HPSAs. Poor recruitment is likely to be the principal dynamic underlying local rural shortages. In spite of the many public programs developed to recruit and retain physicians in rural areas, physician scarcities continue to threaten health care delivery in many rural communities in the United States. 1 The federal Health Professional Shortage Area (HPSA) 2 designation identifies 2100 rural areas as underserved. The general understanding about physician shortage areas, and the fundamental rationale for recruitment and retention programs, 3– 6 is that these communities suffer from both the inability to recruit a sufficient number of physicians and the inability to retain those they have. We question whether this dual assumption is accurate. Low physician-to-population ratios, the hallmark of underserved areas, reflect only practitioner counts at a given point in time without revealing specifically how often physicians move into and out of these areas. Over time, either inadequate inflow (low recruitment rates) or excessive outflow (low retention rates) alone can yield practitioner shortages. Understanding whether shortages arise from deficiencies in both recruitment and retention is fundamental to creating informed remedies. We are aware of 2 studies that have assessed recruitment into US underserved areas; both concluded that, indeed, fewer primary care physicians move to HPSAs than to other rural areas. 7, 8 Similarly, in reports of physicians’ movement into the least populated rural settings—areas that are generally under-served 9– 11 —in-migration was lower than in more populated rural settings. 7, 12 Studies of retention in underserved areas—the focus of our study—generally have been limited to assessments of physicians working under service obligations to the National Health Service Corps and in special settings such as Indian Health Service sites and community health centers. 13– 17 Few data characterize how long physicians working without obligations, who constitute the majority of practitioners in rural underserved areas, 14 are retained within the full range of practice settings found in shortage areas, including private, public, and nonprofit and large and small practices. Li 8 studied turnover for physicians in HPSAs, and Kindig 10 assessed turnover in very small counties; both concluded that turnover differed minimally from that in non-HPSAs and more populated rural counties. Perhaps then, retention only appears to be a more frequent problem in underserved areas, possibly because its consequences there are more immediately and painfully evident. Regardless of whether retention is especially poor in rural underserved areas, little is known about why physicians leave these sites when they do so and how they can be coaxed to stay. When asked, physicians in rural areas report that their retention is affected by local poverty, social and professional isolation, a lack of amenities, and the hardships of rural work—long hours, frequent on-call shifts, and low income. 18– 22 Because of the especially challenging community and work conditions often found in underserved rural areas, these factors are generally assumed to be particularly salient there. 23 However, it is primarily perceptions that link these factors to retention in underserved areas, and perceptions can be inaccurate. 24, 25 We report data on the retention behavior of primary care physicians working without service obligations in rural HPSAs in all kinds of practice situations. We compared their retention to that of primary care physicians working contemporaneously in non-HPSA rural areas. To identify promising approaches for promoting retention, we assessed how retention in HPSAs varied with the characteristics of physicians, their practices, jobs, and their communities.
