The Role of Community in Midwestern General Surgeons' Practice Location Decisions
University of Kansas
Health Policy & Management
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Introduction. The rural general surgeon shortage in the U.S. is predicted to worsen, leaving nearly one-fifth of the population without adequate access to surgical services. Alleviating this shortage means improving the recruitment and retention of general surgeons in rural communities, but there is disagreement on how to accomplish these goals. The healthcare workforce is often viewed as a pipeline, with decisions about becoming a physician and where to practice taking place in childhood, college, medical school, residency, and continuing after entrance into practice. Previous work has established that physicians who grew up in rural areas are more likely to return to rural areas to practice. This dissertation brings together the fields of behavioral economics, health services research, and sociology to answer one two-part, quantitative question and two qualitative questions: 1a) What individual characteristics are unique to general surgeons who grew up in an urban area and now practice rurally (urban-rural “movers”) compared to their peers?; 1b) What characteristics are unique to rural communities where urban-rural movers are located versus where they are not?; 2) What is the range of community characteristics that is meaningful to rural and urban general surgeons in practice location decisions?; and 3) What is the role of experiential place integration in rural versus urban general surgeons’ practice location decisions? I argue that understanding how the tangible and intangible aspects of community factor into practice location decisions, and how these interact with surgeons’ identities and roles, is critical to informing efforts to improve rural general surgeon recruitment and retention. Methods. This is a sequential, mixed-methods study. It first utilized quantitative analysis of secondary data to guide the collection of primary qualitative data, which was analyzed to produce the main results of the study. Quantitative data detailing characteristics of general surgeons in the 12-state Midwest region were taken from the American Medical Association (AMA) MasterFile and analyzed using univariate, bivariate, and multi-variate testing, including logistic regression in State SE. Qualitative data were collected from general surgeons across 11 of the 12 Midwest states in the form of in-depth, semi-structured interviews. Interviews were transcribed, and analysis was facilitated using NVivo Pro 12. Initial coding utilized principles of grounded theory, and themes that emerged were organized into thematic networks. Results. Multi-variate linear regression analyses found rural surgeons who were born in urban areas were different from their urban-born colleagues who stayed in urban areas. They were slightly older, male, and completed less-urban residency programs outside the Midwest. If urban-born surgeons were DOs, they also had a higher rate of rural practice than MDs. Rural counties that attracted an urban-born surgeon were more likely to have a hospital, have a slightly larger primary care referral base, have an intensive care unit, and have more grocery stores but also have more arrests due to violent crimes. Qualitative results were largely consistent with quantitative in terms of the range of community characteristics that matters to rural surgeons in their practice location decisions. Rural surgeons emphasized communities are on a rural-urban continuum and rejected a dichotomized definition of rural and urban. They discussed an affinity for less crowded, more wide open space; they viewed positively communities with outward appearances of a healthy local economy; they valued healthcare resources, which shaped their scopes of practice; and they placed less value on amenities than their urban colleagues. All surgeons experienced alignment between their personal (outside of work) and professional (at-work) identities, but they varied in the degree of overlap between their personal and professional roles in their communities. Urban surgeons experienced less overlap, and therefore their experiences integrating into their communities were less intense. Rural surgeons experienced significant overlap, which resulted in highly intense experiences of place integration over time. Conclusion. These results can be used to improve many points along the rural health workforce pipeline, but the emphasis here is on the recruitment stage as rural communities seek more surgeons. Communities should focus on having health resources that support surgical practice, but they do not need to be overly concerned about economic development so long as they are on-par with neighboring towns in terms of basic retail. When talking to students, residents, and prospective surgeons, rural communities should help them understand that while being the “town surgeon” comes with recognition, which they may find gratifying, it also comes with a lack of anonymity, which could at times feel stifling. They should also make recruits aware that their professional and personal roles will overlap in a more rural setting, and while this can result in difficult, even emotional, clinical decisions, it can also result in rewarding, long-term patient relationships and intense integration into the tightly-knit social fabric of the place over time. Most rural surgeons found this satisfying and fulfilling, and prospective rural surgeons should be made aware of these lived experiences, not just the quantifiable data on urban versus rural practice.
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