MUG mm! 3 U.S. DEPOSITORY UCT 2 31979 US. DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE momma-us DEPARTMENT NOV 1 5 1979 LIBRARY UNEVERSLW 0F CAUFORNM Pubiit Healh Service Health Resources Administration This report will be entered into the National Technical Information Service (NTIS) publications. Prices for paper copy and microfiche are available by writing to: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 The findings and conclusion of this study (Contract NOl-Ml-44l39) are thoee of the authors and do not necessarily reflect the views of the Department of Health, Education, and Welfare. x‘ . .7 , Pei/{1.4. Res-raw by Edward ngassinger Lucille . ill Daryl J. Hobbs Robert Hageman Department of Rural Sociology University of Missouri—Columbia US. DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE Pubic Health SeMco Health Resources Administration Office oi annuals Medical Education DHEW Pubicallon No. (NRA) 79-634 ‘ ,———___—_J ,9 ~ FOREWORD Results of "A Restudy of Rural Physicians in Twenty Rural Missouri Counties" show that rural physicians, in general, have a different pattern of early and professional socialization from those in metropolitan areas. Indications are that there is sufficient evidence linking these apparent patterns experienced early in life with choice of a physician's practice location. This, then, is an important factor in establishing policies designed to influence the future distribution of physicians. The "restudy" was sponsored by the Division of Medicine, Bureau of Health Manpower, Health Resources Administration, and is published by the newly established Office of Graduate Medical Education to assist the Graduate Medical Education National Advisory Committee and other organizations in developing policies and procedures required to insure an adequate supply, specialty mix, and geographic distribution of health care providers needed for the health care system in the United States. The study and conclusions of the authors add a valuable facet to solution of the problem of many rural areas where there is now an inadequate supply of physicians and supporting personnel. The information obtained in this study will be of use to those persons responsible for admissions policies and procedures in health professions schools as they attempt to impact on underserved areas, to the extent possible, by their choices of students. ,/£2£22(;6ZLzflf/457§:§é;4zfif David R. McNutt, M.D., M.P.H. Acting Director, Office of Graduate Medical Education September 5, 1979 ‘ Mrs/ UL; PM L CONTENTS Foreword . . . . . . . . , . . .-. . . . . . . . . . . . iii The Study in the Context of Relevant Literature . . . . 1 The Study . . . . . . . . . . . . . . . . . . . . . . . 7 Physician Samples . . . . . . . . . . . . . . . . . 7 The Study Site . . . . . . . . . . . . . . . . . . . 8 The Doctors in the 20 Counties . . . . . . . . . . . 9 Biographical Characteristics by Resident-Type of Physician 12 Early Years Socialization . . . . . . . . . . . . . 15 Early Socialization of Physicians' Spouses . . . . . 23 Location of Professional Training . . . . . . . . . 24 Stability of Practice Location . . . . . . . . . . . . . 32 Practice Organization . . . . . . . . . . . . . . . . . 39 Sources of Physicians' Satisfaction-Dissatisfaction . . 47 Sources of Dissatisfaction . . . . . . . . . . . . . 53 Difference Between Rural and Urban Practice . . . . 54 Reasons Given for Choosing an Urban or Rural Practice . 56 Perception of the Community as a Place to Live . . . 57 Advantages of the Community as a Place to Live . . . S9 Disadvantages of the Community as a Place to Live . 6O Hypothetical Situations in Which Physicians Would Move . . . . . . . . . . . . . . . . . . . . . 61 Genera ization of Decisions to Practice in Rural or Urban Areas . . . . . . . . . . . . . . . . . . . 64 Socialization . . . . . . . . . . . . . . . . . . . 64 Opportunities . . . . . . . . . . . . . . . . . . . 66 Recommendations for Increasing the Number of Physicians in Rural Areas . . . . . . . . . . . . . . . . . . . 67 Suggestions for Further Research on Decisions of Physicians to Practice in Rural Areas . . . . . . . . . . . . . 68 Bibliography . . . . . . . . . . . . . . . . . . . . . 70 A RESIUDY 0F PHYSICIANS IN TWENTY RURAL MISSOURI COUNTIES The Study in the Context of Relevant Literature Variables in location decision research. Rushing's 1976 perspective on the causal factor of maldistribution of physician manpower has as its locus differences in community attributes. Further, he nests a community's actual physitian manpower within its other "properties" in his determin— ation of what constitutes a community's attributes. Thus he declares re- search on the characteristics of individual physicians irrelevant to physician location, and hence, to attempts at influence. A sensitive and comprehensive portrayal of the complexity of nal~ distribution is to be found in the work of Davis and Marshall (1977). The authors effectively convey that underserved areas may not only be por~ trayed by deficits in physician manpower or under utilization of what health care personnel may exist, but go further, by suggesting that appropriate criteria for defining an underserved area might be "excessive inciuence of preventable morbidity, disability or mortality" (p.2). Far reaching re- commendations for social change that would wipe out physician maldistribu— ion in its wake is in the fabric of Navarro's conceptualization (1976). The scope of intervention needed to solve the problem of maldistribut— ion implied from these portrayals is certainly beyond the capacity of our contemporary social institutions within a society in which only the vagaries of economic and social forces, not planning or policy, exert constraints upon practice choice. If we can at all improve medical care for the under; served, the only avenue now available is to uncover the motives and in— centives among the physicians who elect to attend the disadvantaged with the hope of recognizing for recruitment more of their kind. However, that a disadvantage area may be chosen, is coincidental, from the standpoint of problem resolution addressed in this work; it is happenstance in the sense that the fact of disadvantage does not mediate choice. A behavorial analysis of location choice displays it largely as emerging from intrinsically motivated factors - preferences - acquired from prior experience. Physicians tend to locate in areas similar in size to those in which they were reared (Bible, 1970; Champion, and Olsen, 1971; Diehl, 1951; Hassinger, 1963; Martin, 1968; Mattson, Stehr and Will, 1973; Parker and Tuxill, 1967; Taylor, Dickman and Kane, 1973). For example, Bible (1970) reports?m§:gtors in towns of less than 2,500 persons, one-half had come from towns of similar size. Our work shows that such determinants operate equally for urban and rural physicians. More impressively, considerable proportions of urban and rural primary care physicians are found to have established practices in their actual hometowns; and, the tendency to choose a hometown practice 10cation was somewhat greater among metropolitan pri- mary care physicians. Studies have also shown the importance of prior acquaintances in a location in which a physician subsequently elects to practice (Bible, 1970; Hassinger, 1963; Peterson, 1968; Parker and Tuxill, 1967.) The present study adds to that accumulating evidence. Cooper, Heald and Samuels (1972) question whether or not "family and friends" already in the area chosen is a "surrogate for ethnic or racial concerns" (p. 940). we have no data to assess this directly; however, we interpret the importance of prior acquaintances in location decisi\ns quite differently. To a physician about to establish a practice, anticipat- ed success is perhaps not simply a function of professional skill; it is also dependent upon the Quality of the interpersonal relationships that can be established. The frequency with which prior acquaintances appear among the important factors in decision gives salience to an interpersonal dimen- sion. The hypothesis is strengthened by the magnitude of physicians elect- ing a hometown practice; hometown settings may be seen to provide maximum potential for interpersonal interaction. Additional validation emerges from the finding that primary care physicians, and not specialists, are far more likely to establish practices in their honetowns; continuity in patient interaction is not a necessary concern among specialists. Nevertheless, there must be more than expediting and facilitating the interpersonal component inherent in a successful practice when a hometown is choosen. Evidence for this lies in Bible's (1970) and our finding of practitioner's who choose "analogues" of the places in which they were reared. "Quality of life" is the rubric researchers have used to identify the qualitative reasons offered by physicians in explaining location choices (Bible, 1970; Coleman, 1976; Cooper, Heald, Samuels and Coleman, 1975;. Martin, 1968). The frequency distribution of explanations for location choice derived from Cooper, Heald, Samuels and Coleman's (1975) national sample display the quality of life factors of "climatic and geographic features" and "preferences for urban and rural living" as the second most cited determinant of location choice (the most cited determinant is group practice). Similarly, our data convey sharp distinctions between urban and rural physicians as they conceptualize what it is they valued in the lifef styles they anticipated in a location in which they chose to work and live. Our data are sufficient to allow us to show that polar lifestyle pre— ferences is not the only dimension that distinguish determinants of choice -among urban and rural physicians. A unique addition to the location decision literature is the data we report concerning perceptions of the essential differences between an urban and a rural practice as reported by each type of practitioner. While these factors too are a function of acquired pre- ferences, they are perhaps less direct correlates of the character of the location in which formative years - youth — are spent. Acquisition of preferences such as these is more likely to have occurred during professional education and training. A location determinant that is unequivocally related to professional- ization is the opportunity for affiliated practice — partnership or group practice; it is a factor in location decision that may have figured im- portantly in choice to the disadvantage of rural areas. Scott and Meyer (1972), in a survey of established physicians, found 3 in 5 to declare that if they had it to do all over again they would choose group practice over solo practice. Cooper, Heald, Samuels and Coleman (1975) convey that a national sample of 1965 medical school graduates cite "the opportunity to join a desirable partnership or group practice" as the most frequently mentioned determinant of location choice. In an analysis of change in the organization of practice in non-met- ropolitan areas, Evashwick (1976) found 20 percent of "patient—care doctors" in group practices in 1970; in 1960, 12 percent of these nonmetropolitan area physicians had been in groups. Consonant with Evashwick's findings, our study conveys solo practice as the norm among rural physicians; however, among the youngest rural doctors, the majority have succeeded in entering affiliated practices. Finally, we put in context a descriptive finding that is not directly a location determinant. Cooper, Heald and Samuels (1972) offer an hypothesis to explain Champion and Olsen's (1971) finding that rural doctors make as much money as urban doctors even though they are unaware of it. Cooper et al suggest that this equal income must come from seeing more patients be- cause rural physicians' fees are lower,rura1 household incomes are lower and there is less health insurance coverage in rural areas. While we did not assess income, our data confirm the suggestion of a greater work load among rural physicians. The number of patients seen by rural doctors per hour worked exceeds that reported by urban doctors. Rural doctors average 3 patients per hour, while the metropolitan physicians' average is ap4 proximately 2 patients per hour. Further, our finding is constant with that of Held and Reinhardt (1975) who report that rural physicians make 30 per- cent more patient visits per week. The methodology of location decision research. Studies that explore determinants of the location of physicians differ along two coordinates: the size of the basic area unit used for comparison and the indepth nature and complexity of the variables employed to explain location behavior with— in the area unit. The usefulness of any method relates to the aspect of the problem of distribution to which it will subsequently apply. Examples of the area units between which distribution is compared are: multistate regions (Evashwick, 1976), states (Yett and Sloan, 1974), counties (Coleman, 1976), postal zones (Hambelton, 1972), census tracts (Rees, 1967) and neighborhoods (Guzick and Hajiel, 1976). Since under— served areas tend to be microcosms within larger geographic entities such as states or counties or postal zones, how well determinants of location choice are penetrated by a study is greatly dependent upon the basic area unit it employs. Our study is a census of physicians in 20 rural counties; \ a personal interview was conducted with each physician at his practice 1 location. I An important example of the inadvertant limitation introduced by the i basic area unit employed in location research can be found in the dis— 1 agreement uncovered by Hadley (1976) in contrast to that found by Yett and Sloan (1974). The former cite professional factors as critical to locat- ion decision, while the latter argue that previous contact determines the choice of a state in which to practice. Coleman (1976) declares that in neither work is the methodology capable of distinguishing between the two hypotheses. J From our perspective, the problem lies in the use of states as the basic area units. Drawing upon our own restudy of primary care physicians and specialists in practice in metropolitan and rural Missouri, we found both determinants valid, but each applies to a different kind of practit- ioner. Among primary care physicians, previous contact determines location w I l 1 choice; and, that determinant is as strong among urban primary care phy— sicians as it is among those in the rural areas. In contrast, the strong- est explanatory variable uncovered for the location of specialists is pro- fessional factors. Maximizing information on location dynamics does not depend entirely upon the use of smaller area units. Guzick and Jahiel's (1976), work shows that getting down into distribution by neighborhoods conveys much more about location than stopping at the county line. However, the location motivation of incumbent physicians remains unavailable — physicians were merely located; they were not interviewed. -7- The Study This report presents a comparative analysis of rural and urban phy- \Sicians with particular attention directed toward differences in biographical factors predisposing practice location choices. In recent years, much at— tention has been devoted to medically underserved areas of the country; prominent among these are rural areas. National data indicate that the ratio of physicians to population in metropolitan areas is more than twice that in non-metropolitan areas. Furthermore, the difference is increasing rather than decreasing since rural physicians lost through death or retirement are not being replaced. Therefore, unless there is some change in the current pattern of location and relocation of more recently trained physicians, it can be ex- pected that access to professional health care will become more problematic in rural areas in years to come. An underlying implication of this research is that if it is known what factors are associated with choice of practice location, these factors can be taken into account in policies designed to influence future distribution of physicians. This report shows that rural physicians generally have a dif— ferent pattern of early and professional socialization than metropolitan phy- sicians. Physician Samples. The study focuses on comparison of physicians in a rural area with physicians in a metropolitan area. The rural physicians con- sisted of all medical and osteopathic doctors in a 20—county rural area of Missouri. We are confident that we identified all physicians in private prac— tice in the area and, with two exceptions, all were interviewed — 63 medical doctors and 56 (of the 58) osteopathic doctors. Two samples were randomly chosen from Kansas City, Missouri stratified to match the age distribution of the rural medical doctors. One metropolitan sample consisted of primary care physicians*, the second of other special- ists. The intention was to interview 50 physicians of each metropolitan type. However, because of information obtainable only at the time of interviews, several of the physicians were misplaced as to specialty, and a few refused to be interviewed. As a result, 52 primary care physicians and 44 specialists are included in this analysis. Interviewing for the study was completed in the spring and summer of 1975. Physicians in the same 20—county area were also interviewed in 1961 providing the basis for longitudinal analysis. In addition, physicians who practiced in the area in 1961 but subsequently had practiced in other places were identified and information regarding their decision to move was solicited by a mailed questionnaire. In the analysis, medical doctors in the 20 counties (R MD's) represent the focal type of physician and were compared with the other resident—types; namely rural osteopathic physicians (R DO's), metropolitan primary care physicians (M Pr's), and metropolitan specialists (M Sp's). In the discussion, these categories are referred to as resident—types of physicians and R MD's, R DO's, and M Pr's as primary care resident—types. The study site. The rural study area consists of two sets of 10 contig- uous counties, one set north and the other south of the Missouri River (Figure 1). The economy of the area is agriculturally based, with related commercial services. In addition, there is some light manufacturing; and in the southern area, a tourist industry based on man-made lakes and the scenic Ozark mountains. *general practice, family practice, internal medicine, pediatrics, and obstetrics—gynecology. Each of the 20 counties in this study “as less than 25,000 population. The‘largest population center in the area is under 10,000, but 10 incorporated places were urban (2,500 or larger) in 1970. Four of the counties (two in the north and two in the south) are contiguous to metropolitan areas. On the whole, however, this area has remained rural in population and orientation with relatively little direct influence from metropolitan centers. While there is considerable variation among the counties, in general the population of the 20 counties is older, poorer, less well educated and has lower birth rates and higher death rates than the population of the state as a whole. This of course is characteristic of midwestern rural areas in general. The doctors in the 20 counties. National data on distribution of phy— sicians is but slightly affected by the exclusion of osteopathic doctors since they comprise only from 3 to 4 percent of the physicians in patient care. In Missouri, however, it would be a gross misrepresentation to exclude DO's in physician manpower analyses since they comprise about 16 percent of the state's physicians and a larger proportion in rural parts of the state. If only med- ical doctors are included, the 20 counties have an average of 29 physicians per 100,000 population. When DO's are added to the MD's, the ratio improves to 56 per 100,000 population, fairly typical for rural areas not having a larger population center. Other characteristics of physicians in the_area were that only four were women (three MD's and one D0), and there were no black doctors. Nine of the rural doctors (7 MD's and 2 DO's) were foreign born. Six, all of them MD's, had graduated from foreign medical schools. About 92 percent of the phy- sicians (both MD's and DO's) identified themselves as practicing full—time, with part—time practice attributed to age and/or poor health. The rural phy— sicians were overwhelmingly general or family practitioners - only five of -10- the MD's (8 percent) and 2 of the DO's (3 percent) identified themselves as being full—time in Other specialties. Solo practice was the modal form with 67 percent of the MD's and 78 percent of the DO's in such practices. Practice sites ranged from incorporated places under 500 population to almost 10,000. In smaller places physicians were likely to be without practicing colleagues, whereas there was some concentration of physicians in the larger places. Since the rural area included the total population of physicians, it is informative to look at their age distribution. As indicated in Table 1, 24 percent of the R MD's and 12 percent of the R DO's were over 65 years of age. More than half the R DO's and nearly half of the R MD's were 55 or over. These data on age correspond almost exactly with the statewide data for Missouri for all counties having a population less than 25,000, As indicated previously, it was attempted to match the age distribution of the rural phy- sicians with the metropolitan primary care physicians and specialists. The matching was successful except for the metropolitan specialists — they were in general, younger than either the rural or metropolitan primary care phy— sicia. All of the data included in this report were analyzed on the basis of age (dicphotomized under 55, and 55 and over). Where age is associated with the variable being considered, it will be reported. Otherwise, data will be reported on the basis of the total for the four resident-types. From 1961 to 1975 the number of physicians in the area declined from 157 (6 of whom were not interviewed) to 121 (2 of whom were not interviewed). Since the population remained quite stable from 1960 to 1970, this represents a substantial decline in the physician/population ratio of the area. The decline in osteopathic physicians was greater than medical doctors; whereas, in 1961 82 osteopaths were practicing in the area, by 1975 the number was 58; Age of Physician -45 years 45—54 years 55-64 years 65 years and over -11- Table 1. Age of Physician by Resident-type - 1975 R MD No. Percent 17 27.0 17 27.0 14 22.2 15 23.8 63 R DO No. Percent 18 32.1 8 14.3 23 41.1 7 12.5 56 M Pr No. Percent 12 23.1 18 34.6 9 17.3 13 25.0 52 M Sp No. Percent 17 38.6 13‘ 29.5> 7 15.9 7 15.9 44 -12- this compared with 75 medical doctors in 1961 and 63 in 1975. In general, the number and characteristics of physicians in the 20 county study area are similar to what would be expected in rural areas in the mid- west with the exception of the prevalence of osteopathic physicians which, has been noted, is characteristic of the state of Missouri. It is suggested, therefore, that the study area is typical for rural areas and that findings from this research should be applicable beyond the 20 county area. Biographical characteristics by resident-type of physician. Of partic— ularly concern in this study are the socialization factors associated With practice location. Important among these is the occupation of the phy- sicians' fathers. It was found that about 40 percent of the fathers of all MD's (both rural and metropolitan), were professional men (Table 2). The only notable difference between rural and metropolitan MD's was the higher percen- tage of R MD's whose fathers were farmers and the higher percentage of met- ropolitan physicians whose fathers were proprietors, managers and officials. For all resident—types, the occupations of the fathers were not much different for younger and older physicians. A significant difference does exist between R MD's and R DO's with regard to fathers' occupations. Generally more of the fathers of R DO's were operatives, service workers and laborers and a lower percentage were professionals. It is frequently assumed that the children of physicians are more likely to be interested in medicine and to be admitted to medical school. The data reported to Table 3 bear this out to a considerable extent. More than 20 per— cent of the fathers of all three MD resident—types were physicians. There was no difference between rural and metropolitan MD's in that regard. A lower but still important number of R DO's had fathers who had preceded them as physicians Occupation of Father professional farmers and farm managers proprietors, man- agers, officials clerical and sales craftsmen operatives, service workers and laborers -13- Table 2. Occupation of Father by Resident—type N5. 27 14 63 of Physician — 1975 R MD R D0 Percent No. Percent 42.9 13 23.2 22.2 14 25.0 12.7 5 8.9 12.7 9 16.1 4.8 3 5.4 4.8 12 21.4 56 M Pr No. Percent 19 38.5 5 10.2 17 34.7 4 8,2 4 8.2 49 M Sp No. Percent ‘17 38.6 3 6.8 -14- Table 3. Father's Occupation Medical Relation by Resident—type of Physician — 1975 Father's Occupation Medical Relation MD D0 Other Medically Related Occupa- tions Not Medically Related No. 13 44 63 R MD Percent 20.6 9.5 69.8 R D0 No. Percent 8 14.3 48 85.7 56 M Pr No. Percent 15 29.4 36 70,6. 51 M Sp No. Percent 9 20.5 1 2.3 1 2.3 33 75.0 44 -15- Combining the information from Tables 2 and 3, however, would lead to the conclusion that fathers' occupation is not an important predictive variable from the standpoint of understanding eventual practice location. With the exception of a somewhat higher percentage of farmers among the fathers of R MD's the pattern of fathers' occupation including the practice of medicine is very similar for rural and metropolitan MD's. The data on fathers' occuPati-Onwere compared for the population of rural physicians for the two time periods - 1961 and 1975. The change in composition of the population of physicians in the rural area during that 15 year interval had little or no effect on the distribution of fathers occupation. Early years socialization. An important assumption of this research is that the location of early socialization has an influence on subsequent pract~ ice location. To determine that effect, a variety of information was collected including sizeof place at time of birth and at other times during youth, location with regard to states, and if the present location is the hometown of of physicians. Table 4 reports the size of place where physicians were born by resident— type. While the size of place of birth of rural medical doctors and rural osteopathic doctors is similar, a highly significant difference emerges when R MD's are compared with M Pr's and M Sp's. The R MD's were three times as likely as M Pr's and twice as likely as M Sp's to have been born in a place of less than 2,500. An interpretation of the data in Table 4 is that all three resident- types of primary care physicians, R MD's, R DO's, and M Pr's, were likely to return to practice in places similar in size to where they were born. That is, a majority of R MD's and R DO's were born in places of less than 2,500 and a majority of M Pr's were born in places of more than 50,000. —16— Table 4. Size of Place of Birth of Physicians by Resident—type and Age of Physician — 1975 Size of Place of Birth* farm or open country under 2500 2500-49,000 50,000 and over farm or open country under 2500 2500-49,999 50,000 and-over farm or open country under 2500 2500—49,000 50,000 and over No. 17 17 9 13 56 28 28 R MD Pe Age of Physician 2.112323. R DO rcent No. Percent 30.4 20 37.7 30.4 10 18.9 16.0 10 18.9 23.2 13 24.5 53 W years 28.6 7 28.0 28.6. 3 12.0 21.4 6 24.0 21.4 9 36.0 25 WW 32.1 13 46.4 32.1 7 24.9 10.7 4 14.3 25.0 4 14.3 28 *Size of places not in U.S. not included. No. 10 27 47 17 29 10 18 M Pr Percent 10.6 10.6 21.3 57.4 10.3 13.8 17.2 58.6 11.1 5.6 27.8 55.6 No. 18 11 41 11 27 14 M Sp Percent 12.2 17.1 i 43.9 26.8 11.1 18.5 40.7 29.6 14.3 14.3 50.0 21.4 _17.. 't The M Sp's were most likely to have been born in town and smaller cities, (2,500 - 50,000). This is a pattern quite different from the M Pr's. One can hypothesize that the lack of relationship between size of place of birth, and size of practice location for the M Sp's is attributable to the constrain- ing influence of specialty on practice location. Although there is a significant and direct relationship between size of birthplace and size of practice location for the primary care physicians, it is equally important to point out that nearly one-fourth of the R MD's-and R DO's were born in places of greater than 50,000 population, and that similar proportions of M Pr's and M Sp's were born in places of less than 2,500. Thus, even though there is a significant relationship, the predictive validity is limited. Since size of place of birth may not be the best indicator of where early socialization actually occurred, the physicians were also asked to indicate the size of the community where they grew up and graduated from high school. The data on size of place at the time of high school graduation are reported in Table 5. They tend to correspond closely with the data on size of place of birth. All of the relationships are in the same direction, but the differences commented on above are magnified. The R MD's and R DO's differed significantly from both the M Pr's and the M Sp's. Nearly two—thirds of the R MD's and R DO's were residents of small towns or the open country at the time of high school graduation compared with fewer than 20 percent in this size of place for the M Pr's and the M Sp's. The modal category for the M Sp's was small cities and for the M Pr's it was the larger cities. As further measure of locality influence on practice location, the place where various youth socialization experiences occurred with regard to state are summarized in Table 6. The metropolitan site of this study (Kansas City) ”18" ' Table 2: Size of Place Completed 12th Grade by Resident; type and Age of Physician ~ 1975 Age of Physician EEETEEEE Size of Place when . Graduated from High R MD R D0 M Pr M Sp School* No. Percent No. Percent No. Percent No. Percent farm or open country 17 30.4 16' 29.6 3 6.1 3 7.1 under 2500 20 35.7 13 24.2 5 10.2 5 12.0 2500-49,999 9 16.1 15 27:8 10 20.4 18 42.9 50,000 and over 10 17,8 10 18,5 31 63.3 16 38.1 56 54 49 42 under 55 years farm or open country 5 17.9 6 24.0 .2 6.7 ' 1 3.6 under 2500 11_ 39.3 6 24.0 5 16.7 2 7.2 2500-49,999 6 21.4 7 28.0 '4 13.4. 14 50.0 50,000 and over 6 21.4 6 24.0 19 63,3 11 ' 39.3 28 25 30' 28 WW farm or open country 12 42.9 '10 34.5 1 5.3- 2 14.3 under 2500 9 32.1 7 24.1 - - p 3 21.3 2500—49,999 3 10.7 8 27.6 ' 6 31.6 a 28.6 50,000 and over 4 14.3 4 13.7 12 I 63.2 ‘5 35.7 23 29 ‘19 14 *size of places not in 0.8. not included. -19- is on the extreme western edge of Missouri and part of a metropolitan area which extends into Kansas. Therefore we regard the most local state location (referrud to as "same state") as Missouri or Kansas for metropolitan physicians and Missouri for rural physicians. A high proportion of each resident—type spent at least some of their youth in the "same state" as their current practice,ranging from 67 percent of the M Pr's to 48 percent of the M Sp's. When adjacent states are added to same state", the R MD's appear to be the most localistic with 83 percent having spent at least part of their youth in the region even though 11 percent were reared outside the 0.8. The R DO's as well as both types of metropolitan physicians were more likely than R MD's to have all their youth experiences in nonadjacent states. The origin of metropolitan specialists was least con- fined to the "same state"; more than 50 percent spent their youth outside the "same state" and 32 percent in nonadjacent states or outside the country. When physicians were considered by age groups, with the exception of R DO's, older physicians were somewhat more likely to have had youth ex— periences within the state. For R MD's, 72 percent of the older physicians compared with 53 percent of the younger physicians had youth experiences in the state. The greatest difference, however, was for M Sp's in which case 79 percent of the older and 33 percent of the younger physicians spent a least' part of their youth in the state. In contrast, younger R DO‘s were more likely (64 percent) than their older counterparts (53 percent) to have youth exper— iences in the state. The most specific instance of the influence of youth‘experiences on practice choice is those physicians who return to their hometown to practice. As reported in Table 7, this is a strong tendency for the R MD's, the R DO's, -20- Table 6. Any Youth L0cation (Birth, Started School, Completed 8th Grade, Completed 12th Grade) in Relationship to Location of Current Practice by Resident—type and Age of Physician — 1975 Location same state* adjacent state** non—adjacent state not in U.S. same state* adjacent state** non—adjacent state not in U.S. same state* adjacent state** non-adjacent state not in U.S. *Includes Kansas for Kansas City Doctors No. 39 13 4 7 63 18 2 1 29 Age of'Physigian :fiTges’. R MD R DO Percent No. Percent 61.9 32 58.2 20.6 9 16.4 6.3 13 23.6 11.1 1 1.8 55 W years 53.0 16 64.0 23.5 3 12.0 5.9 6 24.0 17.6 - — 25 waeamam 72.4 16 53.3 17.2 6 20.0 6.9 7 23.3 3.4 1 3.3 30 **Does not include Kansas for Kansas City Doctors M Pr No. Percent 35 5 11 .1 52 19 30 16 22 67.4 9.6 21.2 1.9 63.3 13.3 23.3 72.7 4.5 18.2 4.5 M Sp No. Percent 21 47.7 9 20.5 12 27.3 I 2 4.5 44 10 33.3 9 30.0 9 30.0 '2 6.7 30 11 78.6 3 21.4 14 -21- Table 7. Any Youth Location (Birth, Started School, Completed 8th Grade, Completed 12th Grade) in Hometown of Current Practice by Resident—type and Age of Physician — 1975 Age of Physician BIT—gas Location R MD R D0 M Pr M Sp No. Percent No. Percent No. Percent No; Percent hometown 23 36.5 17 30.9 24 46.2 7 15.9 not hometown 40 63.5 38 69.1 28 53.8 37 84.1 63 55 52 44 under 55 years hometown 11 32.4 7 28.0 13 43.3 3 10.0 not hometown 23 67.6 18 72.0 17 56.7 27 90.0 34 25 30 30 55 years and over hometown 12 41.4 10 33.3 11 50.0 4 28.6 not hometown 17 58.6 20 66.7 11 50.0 10 71.4 29 30 22 14 -22- and the M Pr's. In fact, nearly half the M Pr's grew up in Kansas City and returned there to practice. It is perhaps more remarkable, given the fact that no town in the rural study area was larger than 10,000 population, that over one-third of the R MD's and almost as large a proportion of R DO's re- turned to their hometown to practice. The M Sp's were the least likely of the types of physicians to have grown up in their place of current practice. A comparison 0f the rural physicians for 1961 and 1975 reveals that the effect of location of childhood and youth on practice location did not change much during that 14 year period. Seventy—two percent of the 1961 R MD's were born in places of less than 2,500 compared with 61 percent of the 1975 R MD's. For the R DO's, 61 percent of the 1961 physicians were born in places of less than 2,500 compared with 57 percent of the 1975 physicians. With regard to state of origin, again little change occurred in the population of physicians during the 14-year interval. Eighty seven percent of the 1961 R MD population was born either in Missouri or an adjacent state, compared with 76 percent of the 1975 physicians. That difference, however, is accounted for totally by the fact that in 1975, eleven percent of the R MD population was foreign born in comparison withponly one percent of the 1961 population. For the R DO's, 66 percent of the 1961 population was born in Missouri or adjacent states while 71 percent of the 1975 population was born in that region. There was also considerable stability in the hometown experience of rural physicians when data for 1961 and 1975 are compared. R MD's were almost as likely in 1975 as in 1961 to return to their hometowns (1961, 38 percent; 1975, 36 percent) and R DO's were more likely to be hometown products (1961, 18 percent; 1975, 30 percent). -23- The conclusion, then, is that rural physicians were equally localistic in 1961 and 1975 and that the relationship between early socialization and eventual practice location is just as strong today as it was 14 years ago. This stability of association is of practical relevance since it is reason‘ able to expect that place of origin will continue to have an influence on physicians' practice location decisions. Early socialization of physicians' spduses. It is commonplace in discussions about factors influencing physicians' location decisions to take into account the background of the physician's spouse. The physicians in this study were asked whether or not their spouses had a rural background. A majority of the spouses of rural physicians had a rural background while a majority of the spouses of metropolitan physicians did not (Table 8). In general, then, the locational background of the spouse reinforces the tendency for physicians of rural origin to practice in rural localities and physicians of urban origin to practice in urban areas. Location of professional training, A substantial relationship was found between physicians' locations of early socialization and eventual practice location. We also determined the location of professional training of phy— sicians. Table 9 reports the location of the medical school attended for each physician resident—type. In evaluating these data, it is important to bear in mind that Missouri did not have a publicly supported four—year medical school until 1955 with the first class graduating in 1958, and the twa private medical schools located in St. Louis are nationally oriented. In contrast, Missouri is a center of osteopathic training with two of five * . osteopathic schools located in the state. Therefore, it 13 not unexpected *In addition there are three new osteopathic schools, two of which had not graduated classes in 1975. -24- Table 8. Rural Background of Spouse of Physicians by Resident—type of Physician — 1975 Spouse's Background R MD R D0 M Pr No. Percent No. Percent No. Percent had rural background 41 68.3 41 73.2 20 39.2 did not have rural background 18 30.0 14 25.0 31 60.8 No spouse or no answer 1 1.7 1 1.8 - - 6O 56 51 No. 14 28 44 M Sp Percent 31.8 63.6 4.6 -25- Table 9, Location of Medical School by Resident—type and Age of Physician - 1975 Location of Medical School Missouri Kansas (K.C. Drs. Only) Adjacent State Non—Adjacent State Not in U.S. Missouri Kansas (K.C. Drs. Only) Adjacent State Non-Adjacent State Not in U.S. MiSSOuri Kansas (K.C. Drs. Only) Adjacent State Non—Adjacent State Not in U.S. No. 29 18 10 63 14 34 15 10 29 Age of Physician SET—gas R.MD R D0 Percent No. Percent 46.0 55 98.2 * * * 28.6 1 1.8 15.9 - — 9.5 - — 56 W— years 41.2 25 96.2 * * * 23.5 1 3.8 20.6 — — 14.7 - — 26 55 years and over 51.7 30 100.0 * * * 34.5 - — 10.3 - — '3.4 - — 30 No. 5 20 17 52 10 11 30 10 22 M Pr Percent 9.6 38.5 32.7 15.4 3.8 6.7 33.3 36.7 20.0 3.3 13.6 45.5 27.3 9.1 4.5 No. 6 11 11 12 3 44 30 14 M Sp Percent 18.6 25.0 25.0 27.3 6.8 16.7 16.7 30.0 23.3 10.0 7.1 42.9 14.3 35.6 —26- that fewer than 50 percent of the R MD‘s attended medical schools within the state while 98 percent of the R DO‘s attended osteopathic schools in Missouri. Because of these circumstances, the data do not accurately re— flect the relative localism of these two types of physicians. It is more instructive to compare the R MD‘s with M Pr's and the M Sp's. However, another local factor influences the data for the metropolitan phy- sicians. Although Missouri did not have a public four—year medical school until fairly recently, the state medical school of Kansas — located in Kansas City, Kansas- is in the metropolitan study area. When metropolitan physicians who attended the University of Kansas Medical School are added to the "in—state" total, the percentage corresponds almost exactly to the 'in—state" percentage for the R MD's. In general, we find that both the R MD's and the metropolitan phy- sicians were trained within the state or adjoining states. An exception is the somewhat higher percentage of M Sp's who attended medical schools out side the region. Additional important components of professional socialization especially for younger physicians are the location of internship and residency. We say for younger physicians because among the R DO's, 15 of the 30 who were 55 years of age or over did not take an internship. Virtually all the rural and metropolitan MD's regardless of age interned. Residencies, however, were a different matter: Only 32 of the 63 R MD's took residency training and only four of the 56 R DO's did so; Among the metropolitan physicians, the likeli- hood of residency training was much greater — 39 of the 52 M Pr's and 40 of the 44 M Sp's. There was some difference on the basis of age with older phy— sicians less likely to have residency training. Thus, 30 percent of younger and 21 percent of older R MD's had residency training; the comparable figures -27- for metropolitan physicians were 48 percent and 27 percent for M Pr's, and 100 percent and 41 percent for M Sp's; The data on location of internships and residency training are reported in Tables 10 and 11. Except for M Sp's, more than half of each of the resident—types of physicians who interned did so in Missouri. A virtually uniform 30 percent of each of the primary care types interned in non-adjacer states, while a high percentage of M Sp's interned in non—adjacent states. As has been true of the other location variables, it appears that place of internship is less predictive of practice site for M Sp's than for other resident—types. It is frequently contended that the location of residency training is an important influence on practice site because it represents the most recent socializing influence prior to choice of practice location. The information included in Table 11 however, does not necessarily corroborate this point of view. Nearly two—thirds of the R MD's with residencies took their training out of the state. This is, however, in marked contrast to M Pr's among whom nearly three-fourth took residencies in Missouri or the Kansas City metro- politan area. The M Sp's displayed yet a different pattern with more than one- half taking residencies in non-adjacent states while less than one-half received their training in Missouri or adjacent states. It is difficult to draw a clear conclusion about the effect of professional socialization on eventual practice location. The only consistent difference is that between the three categories of primary care providers and the metro- politan specialists. The R MD's, R DO's, and M Pr's were relatively confined to the region for medical school and postgraduate training while a signifi- cantly higher percentage of the specialists took their post—graduate training outside the state and those adjacent to Missouri. -28- Table 10_Location of Place of Internship by Resident~ type and Age of Physician Place of Internship Missouri Kansas (K.C. Drs. only) Adjacent State Non-Adjacent State Military Not in U.S. Missouri Kansas (K.C. Drs. only) Adjacent State Non-Adjacent State Military Not in U.S. Missouri Kansas (K.C. Drs. only) Adjacent State No. 32 60 14 32 18 Age of Physician R MD Percent 53.3 8.3 30.0 3.3 5.0 all agé? R D0 No. Percent 26 63.4 * * 2 4.9 13 31.7 41 under 55 years 43.8 12.5 37.5 6.3 16 61.5 * * 2 7.7 8 30.8 26 __________________. 55 years and over 64.3 .3.6 10 66.7 No. 28 51 15 ’13 M Pr Percent 54.9 5‘9 5.9 31.4 2.0 50.0 6.7 6.7 36.7 61.9 4.8 4.8 No. 11 44 30 M Sp Percent 25.0 .6.8 9.1 50.0 2.3 6.8 20.0 3.3 13.3 53.3 10.0 35.7 14.3 -29- Table 10.(continued) 55 xears and over Place of R MD R DO M Pr M Sp Internship No. Percent No. Percent No. Percent No. Percent Non—Adjacent State 6 21.4 5 33.3 5 23.8 6 42.9 Military 2 7.1 — — - — 1 7.1 Not in U.S. 1 3.6 - - 1 4.8 — ~ 28 15 21 14 Note: 3 R MD, 15 R D0, 1 M Pr did not intern. -30- Table ll.Location of Place of Residence by Resident— type and Age of Physician - 1975 Age of Physician 3711—?"— 323' Place of Residency R MD R D0 ' M Pr M Sp No. Percent No. Percent No. Percent No. Percen- Missouri 12 37.5 2 50.0 24 61.5 12 30.0 Kansas (K.C. Drs. only) * * * * 5 12.8 5 12.5 Adjacent State 10 31.3 - - 2 5.1 l 2.5 Non-Adjacent State 8 25.“ 2 50.0 7 17.9 19 47.5 Military 1 3.1 ~ - - — 2 5.0 Not in U.S. 1 3.1 — — 1 2.6 1 2.5 32 4 39 40 W years Missouri 8 42.1 2 66.7 14 56.0 10 33.3 K’nsas (K.C. Drs. only) * * * * 4 16.0 3 10.0 Adjacent State 6 31.6 - - 1 4.0 l 3.3 Non—Adjacent State 5 26.3 1 33.3 6 24.0 14 46.7 Military — - - - — - 1 3.3 Not in U.S. - ~ - - - - 1 3.3 19 3 25 30 WW Missouri 4 30.8 - ~ 10 71.5 2 20.0 Kansas (K.C. Drs. only) * * * * 1 7.1 2 20.0 Adjacent State 4 30.8 - - 1 7.1 - - Place of Residency Non—Adjacent State Military Not in U.S. -31- Table 11.(continued) Age of Physician 55 years and over R MD R D0 M Pr No. Percent No. Percent No. Percent 3 23.1 1 100.0 1 7.1 1 7.7 — — ~ - l 7.7 — — 1 7.1 13 1 14 M Sp No. Percent 5 50.0 1 10.0 10 -32— There is support for the conclusion that specialists are less locality bound in their practice location decisions than any or the categories Of primary care providers. It would seem to be particularly relevant to note the differences between M Pr's and M Sp's with regard to both youth and professional socialization. The typical M Pr is a phydiCIJn who grew “P in Kansas City, went to medical school closeby and completed his postgraduate work there. In contrast, the origins and training of M 5P'8 were more diverse. Stability of Practice Location. Although early Hocialization and place of medical education may be important influences on eventual practice loca- tion, yet another factor of significance is experience in the location and A measure of relative satis- degree of satisfaction with that experience. faction with practice locations is the degree of practice mobility exhibited ‘by the physicians. Table 12 reports the number of different places of practice I for each of the four resident~types. With the exception of the R D0 8; change in practice location after the initial selection is the exception I rather than the rule. The least mobile of the four types were M Pr 3 (who as noted before were quite often born, reared, and educated in the metropolitan area in which they are practicing). Eighty—one percent of them had not changed from their first practice location. Age made no difference among the M Pr's in practice relocations; eighty-two percent of those 55 and over had only one practice location compared with eighty percent of those under 55. Age (and therefore greater opportunity in terms of time) was associated With practice mobility among R MD's and H Sp'S. For both grOUPs, a higher propor— tion of those 55 and over than those under 55 had Changed.Pr3CtiCe location one or more times, Even for those 55 and over, about sixty percent were in their first place of practice. Table 12.Number of Places of Practice by Resident-type and Age of Physician — 1975 Number of Places of Practice 1 2 4 or more 4 or more 2 3 4 or more No. 44 11 8 63 27_ 34 17 29 Age of Physician EYE—gee. R MD R D0 Percent No. Percent 69.8 22 39.3 17.5 20 35.7 12.7 6 10.7 - 8 14.3 56 _____._________ under 55 vears 79.4 15 57.7 17.6 8 30.8 2.9 1 3.8 - 2 7.7 26 55 zears and over 58.6 7 23.3 17.2 12 40.0 24.1 5 16.7 - 6 20.0 30 No. 42 52 24 30 18 22 M Pr Percent 80.8 13.5 1.9 3.8 80.0 13.3 3.3 3.3 81.8 13.6 4.5 No. 34 44 25 30 14 M Sp Percent 77.3 13.6 9.1 83.3 10.0 6.7 64.3 21'4 14.3 -34- R DO'S exhibited greater practice mobility with more than sixty per- cent having changed practice location. This was particularly prevalent among the older osteopaths. For those 55 and over, more than three-fourthshad changed practice locations. In addition to their actual practice mobility, the physicians were asked about their intentions to remain in their current practice location (Table 13). In each resident-type, well over eighty percent of the physicians reported they were either "almost sure" or "probably would" remain in their current practice location. The most committed to their current location were the M Sp's among whOm ninety-eight percent indicated plans to remain. The greatest degree of probably mobility was expressed by the rural practitioners — six- teen percent of the R DO's and thirteen percent of the R MD's were either un- certain about remaining or planned to change their practice location. Age of the physician was related to responses on this question but only in terms of degree of certainty of staying which increased with age. Younger physicians were much more likely to report "probably will stay" in contrast to the greater likelihood of older physicians saying they "almost surely will stay". From the standpoint of predicting the number of rural physicians who will remain, the important factor appears to be the extent to which those who report that they "will probably stay" either become moreor less satisfied wit} their current practice location. The same question regarding plans to remain in their current practice location was asked of rural physicians in the 1961 survey offering an op- portunity for comparison. It is of interest to note that the response to this question was virtually identical in 1961 and 1975 for the R MD's. However, for the R DO's there was a slightly less tendency in 1975 to report a high level of commitment to remaining in the current practice location. -35- Table 13. Probability of Remaining in Current Location by Resident-type and Age of Physician - 1975 Age of Physician all ages Probability of R MD . R D0 M Pr M Sp Staying No. Percent No. Percent No. Percent No. Percent almost sure to stay 40 64.5 33 60.0 40 76.9 35 79.5 probably will stay 14 22.6 13 23.6 7 13.5 8 18.2 uncertain 5 8.1 5 9.1 2 3.8 — - likely to move - - 1 1.8 3 5.8 1 2.3 certain to move 3 4.8 3 5.5 — - - - 62 55 52 44 under 55 years almost'sure to stay 16 48.5 9 36.0 19 63.3 21 70.0 probably will stay 12 36.4 11 44.0 7 23.3 8 26.7 uncertain 3 9.1 2 8.0 2 6.7 1 I ~ likely to move - - l 4.0 2 6.7 1 3.3 certain to move 2 6.1 2 8.0 — - — - 33 I 25 30 30 55 years and over almost sure to stay 24 82.8 24 80.0 . 21 95.5 14 100.0 probably will 'stay 2 6.9 2 6.7 — . i ~ ~ uncertain 2 6.9 3 10.0 — — — — likely to move - -, - - 1 4.5 — « certain to move 1 3.4 1 3.3 — — _ _ —36— ‘A possible inducement to practice location (and stability of location) is the extent to which the physicians had prior acquaintances (either personal or professional) in the community in which they established practices. Again, reinforcing the seemingly localistic pattern of the M Pr's, 87 percent of them reported personal and professional friends and acquaintances in Kansas City prior to establishing practice there; a somewhat lower proportion (77 percent) of acquaintances were reported by M Sp's (Table 14). Understandably, because of smaller community population and therefore fewer opportunities, a lower percentage of each type of rural physicians reported friends and acquaintances in the community in which they chose to practice. Even so, 56 percent of the R MD's and 61 percent of the R DO's reported such prior acquaintanceships. The same question was asked of rural physicians in 1961 with almost the same results. With regard to practice mobility, an examination of the experiences of the physicians present in the area in 1961 who subsequently moved is-pro- fitable. As indicated in Table 15, there were 7 R MD's and 18 R DO's practic- ing in the area in 1961 who changed practice location prior to the 1975 study. As of 1961, all R MD's who moved were less than 45 years of age. The mobility of R DO's was somewhat less confined to the youngest age group with 72 percent being under 45 years of age in 1961. For both types, however, there is strong evidence that practice mobility occurs early in physicians' careers. Reasons given for moves tended to emphasize professional opportunit— ies elsewhere rather than specific dissatisfactions with current locations. A majority of those who moved went to places larger than 10,000 population and outside of Missouri. There appears to be some predictive relationships between statements of intention to remain in the community and subsequent behavior. 0f the R MD's who in 1961 said they almost surely or probably would stay, only six percent Did Physician Know Anyone yes 10 Table 14. Did Physician Know Anyone in His Place of Current Practice before Coming by Resident— No. 35 28 63 type of Physician - 1975 R MD Percent 55.6 44.4 No. 34 22 56 R DO Percent 60.7 39.3 M Pr No. Percent 45 86.5 7 13.5 52 M Sp No. Percent 34 77.3 10 22.7 44 Age of Physician under 30 30-44 65—69 70 and over Table 15. Age in 1961 of Physicians Who Left the 1961 Place of Practice and Practiced in Another Area and All Physicians in the 1961 Study MD'S DO's HD's who all MD's DO's who all DO's left area in 1961 Study left area in 1961 Study No. Percent No. Percent No. Percent No. Percent 1 14.3 3 4.2 2 11.1 3 3.7 6 85.7 25 35.2 11 61.1 27 33.7 ~ — 12 16.9 4 22.2 23 28.7 — — 13 18.3 1 5.6 18 22.5 _ — 4 * 5.6 — — 6 7.5 — — 14 19.7 — - 3 3.7 -39- subsequently moved to practice elsewhere; whereas among those who were un- certain or expressed intention to move, 33 percent subsequently did so. For R DO's the relationship was not as strong; among those who expressed certainity or probability of staying, 18 percent moved compared with 29 percent who expressed uncertainity or intentions to move. Practice Organization. A difference emerges between metropolitan and rural physicians with regard to characteristics of practice. When compared with metropolitan physicians, a higher percentage of both R MD's and R DO's were practicing alone (Table 16). This may be an important factor in location stability since "affiliated" practices offer opportunities for a professional division of labor and practice coverage. A comparison of type of practice by age, however, (Table 17) reveals the extent to which affiliated practice is becoming the norm among younger physicians in both rural and metropolitan com— munities. Well over half the R MD's under 45 years of age were involved in such practices in comparison with only 13 percent of the R MD's who were 65 and over. The greatest difference between rural and metropolitan physicians with regard to affiliated practice is found in the 45-64 age group. It is apparent that the younger rural physicians have to a considerable degree emulated the urban norm of practice. This undoubtedly represents an adjustment to one of the frequently stated disadvantages of rural practice, i.e. lack of pro- fessional division of labor and practice coverage. A popular conception of rural practice is that because of the smaller number of physicians in relation to population, rural physicians are required to work longer hours. To determine the extent to which this is true, phy- sicians were asked to indicate the number of hours worked per week. The data reported in Table 18 generally fail to substantiate popular impressions. In terms of hours worked per week, there is little difference ambng the four resident—types. Each worked a mean of from 57—59 hours per week. Age does -40- Table 16.Type of Organization of Current Practice by Resident—type and Age of Physician — 1975 Type of Organization No. solo 42 group 8 partnership 13 63 solo 17 group 7 partnership 10 34 5010 25 group 1 partnership 3 29 Age of Physician Zita—fee. R MD R D0 Percent No. Percent 66.7 44 78.6 12.7 10 17.9 20.6 2 3.6 56 under 55 years 50.0 17 65.4 20.6 7 26.9 29.4 2 7.7 26 W 86.2 27 90.0 3.4 3 10.0 10.3 — — 30 No. 24 14 14 52 10 10 10 30 14 22 M Pr Percent 46.2 26.9 26.9 33.3 33.3 33.3 63.6 18.2 18.2 No. 21 8 15 44 13 13 30 14 M Sp Percent 47.7 18.2 34.1 43.3 13.3 43.3 57.1 28.6 14.3 -41- mm on no ma no no qH 0H «c N CH HH N ma m H m w HF on mm mw mm mm om cm on m 0H 0 HH 9 q 0 mm 0H we qo nq ¢w «o mq #0 ¢o me v :3 A u :3 A v d? A am 2 um 2 on m whoa I Guacammsm mo om< wan oahuuucowammm mp ouauuwnm uaouuso mo coaumuaamwuo mo mama .NH canny ma mm mm N m 0H ‘nw Hm flq ma mm n «0 ¢o m¢ V Inc A a: m unmouum .oz anSmuoaunma no anouwv :vuuafiaammw: ucoouom .oz oaom coaumnficmwuo mo mama -42- Table 19. Average Number of Patients Seen Per Week/Per Hour by Resident—type and Age of Physician — 1975 Age of Physician all ages R MD R D0 M Pr Average Number Patients/Wk. 173.27 165.41 137.00 Average Number Hrs. Worked/Wk. 59.50 57.00 59.40 Average Number Patients/Hr. 2.91 2.90 2.31 under 55 xears Average Number Patients/Wk. 189.65 191.50 153.67 Average Number Hrs. Worked/Wk. 62.90 65.80 64.70 Average Number Patients/Hr. 3.02 2.91 2.38 55 and over Average Number Patients/Wk. 153.96 143.67 114.27 Average Number Hrs. Worked/Wk.- 55.50 50.00 52.30 Average Number Patients/Hr. 2.77 2.87 2.18 116.54 58.10 2.01 122.00 61.30 1.99 104.86 51.10 2.05 -43- make a difference in the number of hours worked but again, there is little difference among the four resident-types when age is controlled. Those under 55 worked a range of from 61~65 hours per week,while those over 55 were in the range of 50-55 hours per week. Although there was no difference in the number of hours worked between rural and urban physicians, differences exist in the number of patients seen (Table 19). R MD's reported seeing an average of 173 patients per week, R DO's, 165; M Pr's, 137; and M Sp's, 117. Dividing these by the number of hours each category reports working, it is found that rural physicians see an average of three patients per hour while urban physicians see an average+ closer to two. Again, age makes a difference in number of patients seen per week with younger physicians seeing more. However, for both older and younger physicians, the rank order of resident—types in terms of number of patients seen is the same as reported above. Other conditions of medical practice include physician participation on hospital staffs and the extent of referral of patients to other physicians. As indicated in Table 20, virtually all of the younger physicians (including R DO's) are on the staff of one or more hospitals. An important difference, however, exists between older rural and metropolitan physicians. A substantial percentage of both R MD's and R DO's 55 years and over are not on the staff of a hospital. It is obvious, however, that among the younger physicians, this rural—urban difference in practice situation has disappeared. From the data reported in Table 21, it is apparent as well that referral of patients is the norm for rural physicians (both MD's and DO's). Over one—half of each type of physician reported making referrals daily while an additional one- third made referrals at least weekly. It is therefore the exceptional rural physician who does not make frequent referrals to other physicians. -44- Table 18. Average Number of Hours Worked Per Week/Per Day by Resident—type and Age of Physician - 1975 Age of Physician all ages R49; am Mr MB Total Hours Worked 3750 3080 3090 2555 Average Hrs./Wk. 59.52 57.08 59.42 58.07 Average Hrs./Day for 5—day week 11.90 11.41 11.88 11.61 for 6—day week 9.92 9.51 9.90 9.68 for 7—day week 8.50 8.15 8.49 8.30 under 55 xears Total Hours Worked 2140 1580 1940 1840 Average Hrs./Wk. 62.94 65.83 64.67 61.33 Average Hrs./Day for 5-day week 12.59 13.17 12.93 12.27 for 6—day week 10.49 10.97 10.78 10.22 for 7—day week 8.99 9.40 9.24 8.76 55 and over Total Hours Worked 1610 1500 1150 715 Average Hrs./Wk. 55.52 50.00 52.27 51.07 Average Hrs./Day for 5—day week 11.10 10.00 10.45 10.21 for 6—day week 9.25 8.33 8.71 8.51 for 7~day week 7.93 7.14 7.47 7.29 0n Hospital Staff yes no yes no yes no -45- Table 20.?hysician on Staff of Hospital by Resident—type and Age of Physician —-1975 No. 53 8 61 33 33 20 28 Age of Physician R MD R D0 Percent No. Percent 86.9 63 76.8 13.1 13 23.2 56 W years 100.0 25 96.2 - 1 3.8 26 iii—WW 71.4 18 60.0 28.6 12 60.0 30 No. 51 1 52 30 30 M Pr Percent 98.1 1.9 100.0 No. .43 1 44 3O 30 M Sp Percent 97.7 2.3 '100.0 -46— Table 21. Number of Referrals to other Physicians by Resident~type and Age of Physician — 1975 Age of Physician EYE—"gas. Number of Referrals R MD . R D0 No. Percent No. Percent almost daily 37 58.7 30 55.6 almost weekly 20 31.7 18 33.3 almost monthly 3 4.8 4 7.4 several times a year 3 4.8 2 3.7 63 54 under 55 years almost daily 20 58.8 18 72.0 alrwat weekly 11 32.4 6 24.0 almost monthly 1 2.9 — - several times a year 2 5.9 1 4.0 34 25 55 years and over almost daily 17 58.6 12 41.4 almost Weekly 9 31.0 12 41.4 almost monthly 2 6.9 4 13.8 several times a year 1 3.4 1 3.4 -47- Frequency of collegial interaction is often cited as a difference in rural and urban practice and the data from this study substantiate that difference to some extent. As indicated in Table 22, almost all metropolitan physicians report interacting with colleagues on a daily basis. In contrast, only 76 percent of the R MD's and 61 percent of the R DO's report that frequency of professional interaction. Given that there are important differences between rural and metropolitan practice, particularly with regard to frequency of collegial relationships, it could be expected that that would have some influence on the sources of information physicians depend on for professional currency. As shown in Table 23, there are some differences in information sources rated as very im- portant by rural and metropolitan physicians. These differences include greater emphasis by metropolitan physicians on professional journals, by M Pr's on colleagues, and by R DO's on continuing education. With the exception of professional journals, however, the differences in percentages reported in Table 23 are not large. Regardless of the sources of information depended on, the R MD's are least satisfied of the resident—types with opportunities for professional continuing education (Table 24). Practically all the metropolitan physicians and almost 90 percent of the R DO's reported being satisfied with continuing education compared with 75 percent of the R MD's. Sources of physicians satisfaction-dissatisfaction. As shown previously, most rural and metropolitan physicians expressed intentions to continue to practice in their same location. However, rural physicians were less strongly committed to their present practice location than were the metropolitan phy- sicians. The degree of satisfaction with the present work situation,reP0rted in Table 25,reveals much the same pattern. Although few of the phy81613n8 in ~48— Table 22. Frequency of Seeing Other Physicians by Resident—type of Physician - 1975 Frequency R MD R DO M Pr M Sp of Seeing No. Percent No. Percent No. Percent No. Percent Almost daily 48 76.2 34 60.7 50 96.2 42 95.5 Several times Weekly 9 14.3 12 21.4 0 -— 1 2.3 Several times a month 1 1.6 9 16.1 1 1.9 l 2.3 About once a month 4 6.3 l 1.8 l 1.9 O —- Seldom or Never 1 1.6 0 —— 0 -- O -— 63 56 52 44 -49- Table 23. Ratings of Four Sources of Information Where Response Was "Very Important" by Physician—type — 1975 R MD Very Important percent journals 38.1 professional meetings 36.5 colleagues 29.5 continuing education 41.0 R DO percent 28.6 30.9 33.9 51.8 M Pr percent 50.0 39.2 50.0 42.3 M Sp percent 61.4 36.4 34.1 36.4 Satisfied with Continuing Education yes no -50- Table 24. Satisfaction with Opportunities for Continuing Education by Resident-type of Physician - 1975 R MD R D0 M Pr No. Percent No. Percent No. Percent 47 74.6 50 89.3 51 98.1 16 25.4 6 10.7 1 1.9 63 56 52 No. 43 1 44 M Sp Percent 97.7 2.3 -51- any of the resident-types reported being dissatisfied with their work situation, there were differences in the level of satisfaction expressed. Clearly, met— ropolitan physicians were the most satisfied, especially the M Pr's, of whom 94 percent reported being either 'very satisfied or satisfied with their cur- rent work situation. A higher percentage of the M Sp's than any other resident-type claimed to be very satisfiedjbut 15 percent reported being either neutral or dissatisfied. The R DO's were close to the M Pr's in the percentage reporting being either very satisfied or satisfied but with a greater concentration in the satisfied category. - The important difference appearing in Table 25 concerns the R MD's. Only one—third of them reported being very satisfied and one-fourth reported being either neutral or dissatisfied. This lower level of satisfaction for the R MD's becomes potentially more significant from the standpoint of their remaining in their current practice when analyzed by age. Younger R MD's — the age cate- gory of greatest potential mobility - were more likely than their older counter« parts to report being neutral or dissatisfied with their work situation. Although it is important to know whether or not physicians are satisfied with their work situation, it may be more useful to know the sources of satis faction and dissatisfaction. Physicians were asked in an open-ended question to indicate first the advantages and then the disadvantages of their par- ticular work situations. The question was asked independently of the general assessment of work satisfaction and therefore a physician who was satisfied or very satisfied with his work situation might be able to cite specific dis— advantages, and those who were dissatisfied in some degree might at the same time be able to cite advantages of their practices. For rural physicians, the advantage most often cited was associated with the quality of doctor—patient relationships. Patient-centered sources of satisfaction were reported by 52 percent of the R DO's and 43 percent of the -52— Table 25. Satisfaction of Work Situation by Resident— type and Age of Physician - 1975 Age of Physician $3.331 Satisfaction R MD R DO M Pr M Sp No. Percent No. Percent No. Percent No. Percent very satisfied 21 33.3 22 42.3 27 52.9 24 54.5 satisfied 26 41.3 25 48.1 21 41.2 13 29.5 neutral 14 22.2 3 5.8 2 3.9 5 11.4 dissatisfied 1 1.6 2 3.8 1 2.0 2 4.5 very dissatisfied 1 1.6 - — — — - - 63 52 51 ' 44 W years very satisfied 10‘ 29.4 7’ 29.2 11 37.9 15 50.0 satisfied 13 38.2 13 54.2 15 51.7 11 36.7 neutral 9 26.5 2 8.3 2 6.9 2 6.7 dissatisfied 1 2.9 2 8.3 l 3.4 2 6.7 very dissatisfied 1 2.9 — — - ~ - - 34 24 29 30 rm W very satisfied 11 37.9 15 53.6 16 72.7 9 64.3- satisfied 13 44.8 12 42.9 6 27.3 2 14.3 neutral 5 17.2 1 8.3 T — 3 6.7 dissatisfied — - — _ — _ — _ very dissatisfied ; — — — — L _ _ -53- R MD's. Among the metropolitan physicians, those in primary care (M Pr's) were also quite likely to report patient-centered advantages of their prac— tices (39 percent), while this type of advantage was perceived by a smaller percentage of M Sp's (21 percent). Almost equal proportions of R MD's (14.8 percent) and R DO's (14.3 percent) cited the autonomy or independence of the practice as being an advantage while few metropolitan physicians indicated this advantage (6 percent M Pr's, 2 percent M Sp's). Perhaps as a conscious effort to counter the reputation of rural areas for deficiencies in health facilities, 18 percent of the R MD's and 12 percent of the R DO's indicated the advantage of good facilities. Similarly perhaps because of their general availability of high quality facilities in metropolitan areas, facilities were not commonly cited as advantages by metropolitan physicians (12 percent of the M Pr's and 5 percent of the M Sp's). On the other hand, metropolitan specialists were more likely than other resident—types to find satisfaction in the technical aspects of medicine, that is in curing and healing — 49 percent of the M Sp's compared with 22 percent of the M Pr's, 27 percent of the R DO's and 13 percent of the R MD's gave this type of response. In addition, 21 percent of the M Sp's and 18 percent of the M Pr's compared with 9 percent of the R DO's and 12 percent of the R MD's indicated that the challenge of medicine and interesting cases were advantages in their work situation. Overall it appears that rural doctors find more of their satisfactions in the quality and continuity of doctor—patient relationships which are rooted in small town life while metropolitan physicians tend to emphasize the tech— nical side of medicine as sources of satisfaction. Sources of dissatisfaction. About one—fifth of the metropolitan phy— sicians and smaller proportions of the rural physicians (7 percent of the R MD‘s -54- and 16 percent of the R DO's) stated that there was no disadvantage in their practice. Bureaucratic interference of practice, most often directed against government programs but including hospital administration and third party payers, was the disadvantage most commonly cited being the top“ ranking disadvantage for M Sp's (43 percent), M Pr's (24 percent), and R DO‘s (29 percent). For rural medical doctors (R MD's), bureaucratic interference was cited by 18 percent, but the most frequently mentioned disadvantage by them was the heavy work load involving long hours and many patients (30 percent). This dissatisfaction was cited by 16 percent of the R DO's, 14 percent of the M Pr's, and 9 percent of the M Sp's. Con- fining work situation (inability to get away from patients) was also a disadvantage reported by a Substantial proportion of R MD's (20 percent), R DO's (13 percent), and M Pr's (14 percent) but fewer M Sp's (7 percent). Lack of facilities and support personnel was almost exclusively reported by rural physicians as a disadvantage (R MD's, 15 percent; R DO's, 20 percent; M Pr's, none; MSp's, 2 percent). Lack of colleagues, specialists or the disadvantage of solo practice was cited by 15 percent of the R MD's, 9 percent of the R DO's, 6 percent of the M Pr's, and none of the M Sp's. The difference between rural and urban practice. Pursuing the question of the difference in rural and urban practice further, physicians were asked in an open—ended question to indicate the basic rural/urban practice distin— ctions. Consistent with the pattern for satisfactions, among rural physicians, the outstanding differences focused on the quality of the doctor-patient relationships — knowing the patient better, longer, and in context of the social setting. Thirty-seven percent of the R MD's and 52 percent of the R DO's made this assessment. The advantage of the more general qualities of rural life and rural communities was also mentioned by -55- about one-fourth of each type of rural physician. AutonOmy of practice was given a positive connotation by 11 perCent of the R MD's and 12 percent of the R DO's; and 12 percent of the R DO's and a smaller percent of the R MD's (3 percent) indicated a greater variety of work as characteristic of rural practice. These perceptions of the differences between rural and urban practice were not mentioned by metropolitan doctors. Lack of facilities, equipment, and.consultation were differences stressed less than patient and community centered qualities by rural physicians. Metropolitan physicians tended to organize their responses to the same question differently. For the most part, they stressed the disadvantages of rural practice rather than advantages of urban practice. The most frequently occurring response offered as a difference between urban and rural practice by M Pr's (25 percent) is that rural areas lack hospitals and other facilities; 12 percent of the M Sp's also cited this difference. The single difference reported most by M Sp's (19 percent) is that a specialty practice is not feasible in a rural area. Twenty percent of the M Pr's cited the strain of rural practice using such terms as "overextended", "confined", "expected to know everything and do everything", and 16 percent said that consultants were unavailable in small towns. Twelve percent of both metropolitan cited the isolation of rural physicians as a negative characteristic of rural practice. To summarize, when rural physicians characterize the salient differences between urban and rural practice, they emphasize the quality of interaction between doctor and patient and a sense of community. Urban physicians, on the other hand, cite rural deficits in facilities and support personnel as the major differences. In a senSe,deficiencies of technological support in rural practice from the perspective of metropolitan respondents tend to -56- be compensated for by the quality, pervasiveness and duration of doctor- patient interaction from the perspective of the rural physician. Similarly what is described as the advantage of autonomy by rural respondents, is seen as the disadvantage of isolation by urban physicians. Thus, urban physicians tend to join other commentators in perceiving rural practice as a medical wasteland, a perception, that rural doctors do not seem to share. Reasons given for choosing an urban or rural'practice. All respondents Were asked to relate specific reasons thgy established practice in rural or urban areas. In interpreting the responses, interest was focused on distinguishing between formative, or at least antecedent reasons,as opposed to decisions emerging from the more immediate contingencies of the situation. For each type of physician, preference for either rural or urban lifestyle was the most frequently given reason for rural/urban choice of practice (R MD's, 50 percent; R DO's, 48 percent; M Pr's, 57 percent; M Sp's, 44 percent). Among rural physicians, many had been reared in small towns and elected either their hometown or another small place as a site for practice. For some, rural choice grew out of a strong negative feeling about city life. Metropolitan doctors expressed preferences for urban life-styles rooted in their youth experiences in proportions similar to those of rural doctors. Thus, in the perception of reasons for choice of location, socialization during youth for a preferred life-style was an important consideration for a substantial proportion of physicians. The characteristics of typc of practice preferred was the second most frequent type of reason given for chOice of rural or urban practice locations (R MD's 25 percent; R DO's, 29 percent; M Pr's, 20 percent; M Sp's, 35 percent). For rural physicians this was often expressed in terms of -57- wanting to practice family or general medicine, some saw themSelves in the image of the "country doctor" and some had a negative perception of urban practice. Specialization, avoidance of professional isolation, and superior facilities were characteristics of type of practice that led to urban locations. Thus, seventy-five percent or more of each type of physician perceived their choice of practice location to be based on life—style preferences or type of practice preferences. The remainder of the reasons were divided among choice of practice site as the area of medical education (R MD's, 3 percent; R DO's, none; M Pr's, 8 percent; M Sp's, 9 percent); opportunities of practice such as a practice to buy or an invitation to join a group (R MD's, 12 percent; R DO's, 16 percent; M Pr's, 14 percent; M Sp's, 7 percent); and a limited number of choices of location related to constraints consisting of such things as limited finances, limited opportunities of foreign doctors, location of employment of spouse and substitution for military service (R MD's, 10 percent; R DO's, 7 percent; M Pr's, 2 percent; M Sp's, 5 percent). From these responses one is impressed with the influence of youth socialization and the preference for type of practice (general and family versus specialization) as mediating the choice of location, and'the relative insignificance of immediate contingencies such as specific opportunities or constraints as the underlying basis for decisions regarding rural or urban practice. Perception of the community as a place to live. Although they are conceptually distinct, it is difficult if not impossible to separate physicians' perceptions of the community as a place to work from their perceptions of the community as a place to live. As shown in Table 26 -53- Table 26- Satisfaction with the Community as a Place to Live by Resident-type and Age of Physician — 1975 Satisfaction with Community very satisfied generally satisfied not satisfied' or_dissapointed generally dis- satisfied very satisfied generally satisfied not satisfied or dissapointed generally dis— satisfied very satisfied generally satisfied not satisfied or disappointed generally dis— satisfied No. 26 33 63 15 18 ll 15 29 R MD Age of Physician all ages R DO Percent .No. Percent 41.3 32 59.3 52.4 16 29.6 4.8 5 9.3 1.6 l 1.9 54 under 55 years 44.1 ' 13 52.0 52.9 8 32.0 2.9 3 12.0 - 1 4.0 25 55 years and over 37.9 19 65.5 51.7 8 27.6 6.9 2 6.9 3.4 — - No. 38 12 51 21 29 17 22 M Pr Percent No. 74.5 .28 23.5 14 — 2 2.0 — 44 72.4 17' 27.6 12 — 1 30 77.3 11 18.2 2 ~ 1 4.5 - 14 M Sp Percen- 63.6 31.8 4.5 56.7 40.0 3.3 78.6 14.3 7.1 -59- Ithe vast majority of each type of physician expressed at least general satisfaction with their community as a place to live (R MD's, 94 percent; R DO's, 89 percent; M Pr's, 98 percent; M Sp's, 94 percent). It would appear that most physicians were not living in community situations which they found disagreeable. Advantages of the community as a place to live. Advantages of living in their respective communities were elicited in an open-ended question followed by a similar question asking for disadvantages; The advantage most commonly reported by rural physicians was their general preference for rural areas, and they often cited their rural background as a basis for the preference. Thus, "I was born and reared in a small town and wouldn't live anywhere else". Over one-half of the R MD's and R DO's gave responses of this type (R Mm's 52 percent; R DO's, 64 percent). Similarly, metro- politan physicians gave responses classified as pro—city in proportions as great or greater (M Pr's, 64 percent; M Sp's, 61 percent). The general tone of the responses is that they wOuld consider no other setting. In responses identifying more specific rural/urban advantages, 19 percent of the R MD's and 20 percent of the R DO's mentioned the crime- free qualities of their communities. 0n the other hand, some metropolitan doctors (M Pr's, 12 percent; M Sp's, 20 percent) mentioned the special qualities of the particular metropolitan area; for example, that it was not too large and had qualities of a small town. Although somewhat more commonly mentioned by rural physicians, qualities of the people were considered an advantage by a substantial number of each residentvtype (R MD's, 44 percent; R DO's, 34 percent; M Pr's, 25 percent; M Sp's, 27 percent.) l_—___¥ -60— The advantages of schools, churches and other services were mentioned as often by rural physicians as by metropolitan physicians (R MD's, 30 per- cent; R DO's, 21 percent; M Pr's, 23 percent; M Sp's, 20 percent). Another advantage mentioned by both rural and urban physicians was that both rural and urban areas were accessible (R MD's, 16 percent; R DO's, 5 percent; M Pr's, 15 percent; M Sp's, 18 percent). To summarize, the most common advantage of the community as a place to live was either a preference for rural or metropolitan settings. This may seem quite general and perhaps vague, but it is not trivial. It fits well into what is known about the background of rural and metropolitan physicians (that is rural physicians are likely to be reared in rural communities; the opposite is true for metropolitan physicians). Thus to a considerable degree, the socialization of youth carries forward to community preferences of adult years. The general and pervasive nature of the advantages of the area ex- tends to the large number of physicians who referred to the general qualities of the people in their respective communities, to references of friendly and personal social interaction, and to the indication of advantages for children and spouses. Disadvantages of the community as a place to live. A substantial number of physicians of each type reported that their community had no disadvantages as a place to live (R MD's, 14 percent; R DO's, 20 percent; M Pr's, 29 percent M Sp's, 20 percent). In contrast to advantages reported in the previous section, reported disadvantages tended to be more specific. While some metro- politan physicians regarded the community as too large, and some rural physic— ians cited social interaction problems and lack of personal privacy, more com- monly lack of services or specific situational problems were mentioned; Lack of cultural activities ranked highest among disadvantages reported by —61— rural physicians (R MD's, 52 percent; R DO;s, 50 percent). Although it is a subjective impression, the lack.of cultural activities appeared to be a cliche' among rural doctors which for many did not present a serious disad— vantage. It is interesting that "too far from recreation" was cited almost exclusively by metropolitan doctors 0A Pr's, 8 percent; M Sp's, 18 percent) - 'the complaint was often that activities such as skiing and water sports were inaccessible. It should be observed that inadequate schools were not ex- clusively a rural problem (R MD's, 14 percent; R DO's, 11 percent; M Pr's, 4 percent; M Sp's, 18 percent). Concentration of economic, social, and political problems cited by metropolitan doctors (the largest category for metropolitan doctors) reflects perceived conditions of poverty and crime (R MD‘s, 5 per— cent; R DO's, 11 percent; M Pr's, 33 percent; M Sp's, 18 percent). Hypothetical situations in which physicians would move. Physicians were asked if they would consider moving to larger or smaller places with the as— sumption that their incomes would not change. As shown in Table 27, rural doctors would be reluctant to move to a large metropolitan area such as Kansas City or St. Louis. Only 10 percent of the R MD's and 4 percent of the R DO's said they would even consider such a move. There would be less re- luctance to move to a medium size city of about 100,000 population such as Springfield or St. Joseph, but still 73 percent of the R MD's and 86 percent of the R DO's would not choose such a location. If rural physicians would not choose to move to larger metropolitan areas or medium size cities, neither would‘they choose a place half the size of their present location. Sixty-nine percent of the R MD's and 84 percent of the R DO's would be opposed to such a move. Metropolitan physicians were asked parallel questions (Table 28). When asked if they would consider moving to a medium size city such as Springfield -62— Table 27. Would Consider Moving To A Large Metropolitan Area/A Medium Size City/A Place One-Half the Size of Current Location (Assuming Equal Income) for Rural MD's and Rural DO's — 1975 Consider Moving To: R MD R D0 No. Percent No. Percent large metropolitan yes 6 9.5 2 3.6‘ no 57 90.5 54 96.4 63 56 medium size city yes 17 27.0 8 14.3 no 46 73.0 48 85.7 63 56 filace one—half the size of current place yes 19 30.6 9 16.1 no 43 69.4 47 83.9 62 56 Table 28. Consider Moving to: medium size citz yes no place 10,00 or less yes no Would Consider Moving to a Medium Size City/ A Place of 10,000 Population or Less (ASSuming Equal Income) for M Pr's and M Sp's — 1975 M Pr No. Percent 28 54.9 23 45.1 51 10 19.6 41 80.4 51 M Sp No. Percent 26 59.1 18 40.9 44 13 30.2 30 69.8 43 -64- ’or St. Joseph (approximately 100,000 population), more than one-half in each resident—type said that they would be willing to consider it. Metropolitan physicians would be more reluctant to consider a small town (under 10,000 pop— ulation) even though their income remained the same. Eighty percent of the M Pr's and seventy percent of the M Sp's rejected such an idea. To summarize, the image of rural areas as a medical wasteland and as a place to live does not match well the perceptions of physicians who practice in the ZO-counties although it comes closer to the perceptions of the phy- sicians practicing in the metropolitan area. However, it must be acknowledged that location choice of physicians is heavily weighted toward urban practice sites and those who choose rural areas have special characteristics which in- cline them toward satisfaction with rural practice and rural life. Generalization of decisions to practice in rural or urban areas. Finally, the question is how the findings of this research might be generalized in order to apply to policies of health manpower. Much of the data can be subsumed under the categories of socialization and opportunity. Socializatigp, Choice of a career and induction into it is a continuing process beginning in youth and extending through adult years. Vital in the process is the internalization of a set of values and norms of behavior which constitutes the socialization process. As part of career decisions, selection of a practice site is based on preferences developed in the socialization of early years and altered through training and career experiences. Family background is a factor in choice of career and decisions of practice location. Physicians for the most part were born and reared in fam- ilies of entrepreneurs (professionals, managers, and propiétors, and farmers). A substantial number came from families engaged in medical professions which provided early models for career goals. —65— Socialization experiences of youth are important in making decisions for rural or urban practice. Thus there is a strong correspondence between "youth place history" and location of Practice. Rural experienCe, in the early years, however, is not Sufficient to insure choice of rural practice sites; the experience must be interpreted positively. In general, physicians in the 20 counties made such interpretations of rural practice and rural life. They emphasized the advantage of "personal relationships" and would he must reluc- tant to move to metropolitan settings. Socialization to the desirability of rural areas is more precisely focused in decisions to practice in hometowns of youth. It appears that selection of rural hometowns is based primarily on youth experiences since training sites take physicians away from such settings and numerous other places offer at least equal practice opportunities. In a more general way, localism is observed in the dependence of the 20- county area on physicians reared in Missouri or states adjacent to it. Thus a strong case can be made that decisions to locate in rural areas and in particular places are affected by socialization in youth. The socialization process does not end with youth, but continues through- out life. In the vital training years, physicians tend to be taken away from rural settings and inducted into the thoughtways of specialized medicine. For the most part these experiences do not provide an analogue for rural practice. And if training produces specialists, the option of rural practice is largely foreclosed. Socialization continues in the career years. Decisions to practice in a particular location may be changed but such decisions tend to be made early in careers. By the time a physician practices in a community 10 years or so he has become so enmeshed in the community with friends and professional ob— ligations that there is little likelihood of his moving. -66- Comparing the youth and training backgrounds of rural phySicians wno practiced in the area in 1961 and 1975 gives added weight to the importance of socializing factors in practice location choices. Except for the tendency of R DO's to be more localistic at the latter time, places of socialization and professional training were similar at both periods. This suggests that factors predisposing rural practice are quite stable given the present or— ganization of the health care delivery system. Opportunities. The opportunity structure for physicians is represented by a place to practice compatible with their training and perferences of prac- tice characteristics and life—style. It should be pointed out first of all that the 20 county rural area had a declining physician/population ratio at a time when it was increasing in the nation. The loss of osteopathic physicians was especially severe. Thus this area (and supposedly others like it) has not been suffieiently attractive to maintain its relative position among practice sites. Speciality training constrains physicians to practice in larger populat— ion centers while opportunities in rural areas are limited largely to gen- eralists; to this point, residency was the most common time at which M Sp's made a decision to practice in metropolitan areas. Furthermore, physicians trained in modern medicine require quality hospital facilities, colleague support, and auxiliary staff. In these respects, the view of rural areas as a medical wasteland, however, may be overdrawn. Physicians in the area studied found satisfaction in their work, were not isolated from colleagues, had opportunities for referral and consultation, and were hospital staff members. The perception of rural practice 33 a medical wasteland, however, persists and may deter consideration of rural areas by physicians entering practice. Effects of opportunity'on selection of practice sites is clarified by observing changes in attraction of the 20 county area for osteopathic physic-. ians. Rural areas of Missouri traditionally have had a greater attraction for osteopathic physicians than for medical doctors. It is suggested that this results from the fact that in the past osteopathic physicians had more limited opportunities for practice elsewhere. As osteopaths have gained wider public acceptance and their training has become more specialized, more practice options are available and the attraction of rural areas for them has diminished. In a parallel arguement, at the present time, limited options for private practice may be a factor that attracts foreign doctors to the area. Finally, opportunities are a matter of perception. Opportunities for general practice in relatively simple medical settings may be perceived by some as an advantage. And the life—style of rural communities may be an attraction for some - and surely a deterrent to others. In these matters of preference, socialization is influential; thus socialization and perceived opportunity are complementary to each other. Recommendations for Increasing the Number of Physicians in Rural Areas: Recommendations for attracting physicians to rural areas are based on the pre« Vious interpretation of the findings of this research. In general they em- 'phasize recognizing and reinforcing preferences for rural areas and providing opportunities for physicians to practice in rural areas. It should be empha- sized that whatever is done must take into account conditions of youth soc— ialization or must occur in training or in early career since there is little mobility beyond that time. 1. The most obvious suggestion is to select persons for medical training who have rural backgrounds. Such selections should be more finely tuned in order to choose those who have a positive evaluation of rural areas and indicate a preference for rural practice. 2. Since the pool of potential rural practitioners is largely general and family physicians, emphasis on training larger numbers of these types of physicians might have a positive effect for rural areas. —68- 3. Programs might be developed in medical schools to encourage rural practice by reinforcing the desirability of rural practice among students with rural backgrounds who have positive evaluation of rural communities as a place to live and practice. This type of program probably would be effective among physicians who intend to enter general or family practice and perhaps other primary care physicians. Students might be introduced to rural practice through rural preceptor ships, rural clinics, or similar experiences. In all cases, it would be essential that the experiences were positive and not negative. 4. It is probably futile to attempt to attract physicians to the smallest places. The "natural regionalization" taking place in rural areas whereby services are becoming concentrated in fewer and larger places should be utilized as the basis for delivery of health services. 5. In larger rural communities, group practice should be encouraged. This might be a means of attracting primary care physicians other than general and family physicians and thus increase the pool of potential rural physicians. 6. Communities seeking physicians should emphasize the positive qualities of rural practice and rural life. They should enlist the support of local physicians who find work and life-style satisfaction in rural communities. Attempts should be made to dispel the image of rural communities as a medical and social wasteland. Suggestions for Further Research on Decisions of Physicians to Practice in Rural Areas: Among research strategies this study represents a longitudinal case study. It has the advantage of collecting comprehensive data from the entire universe of physicians in a defined geographical area. The principal use of case studies is to gain insight to problems and to generate hypotheses that can be tested for wider applicability. The obvious question is the generality of the findings of this research to other rural areas. It might be suggested that the relationships found in this study between physicians' background and career decisions stated in hypothetical form should be tested using a national sample of rural physicians. However, such an effort seems to be premature. An understanding or rural society convinces one of its great socio—cultural variability. Consequently there is a need to understand career choices in a variety of well—defined and limited rural situation. This could be done by replicating the present study —69- in other rural settings carefully selected to represent different socio- cultural situations. Selection could be made from major regions 95 the nation, from communities representing different racial and ethnic groups, from areas of different economic levels, and from communities offering different organi— zation of medical care delivery. Such comparative studies might not only reveal common factors across commdnity lines which are associated with career location decisions, but also variations that could be interpreted in terms of particular socio-cultural situations. These delimited studies, then, might be the basis for a more general study using a random sample of rural physicians. In such an undertaking, the situational delimited studies would provide the basis for selecting and interpreting independent variables. They would also guard against the "averaging out" effects of a general study and the myth that all rural situations are alike. -70- BIBLIOGRAPHY Bible, Bond L. 1970 "Physicians' views of medical practice in nonmetropolitan com‘ munities.” Public Health Reports, 85;11. Champion, D.J. and D.B: Olsen, 1971 "Physician behavior in southern appalachia: some recruitment factors." Journal of Health & Social Behavior, 12, 245—252. Coleman, Sinclair 1976 Cooper, 1972 Cooper, 1975 Ehysician distribution and rural access to medical services. Santa Monica, The Rand Corporation. K., K. Heald, and M. Samuels "The decision for rural practice." Jouranl of Medical Education, 47, 939—944. J.K., K. Heald, M. Samuels, and S. Coleman Rural or urban practice: factors influencing the location de- cision of primary care physicians. Inquiry, XII, 18-25. Davis, Karen and Ray Marshall 1977 "Primary health care services for medically underserved populations," The Priorities of Section 1502, Papers on the National Health Guidelines, DYTW, PHS, ERA, Publication NO: 77-641, 1-23 Diehl, 3.8. 1951 "Physicians for rural areas: a factor in their procurement." Journal of The American Medical Association, 045, 1134. Eisenberg, Barry S. and James R. Cantwell 1976 "Policies to influence the spatial distribution of physicians: a conceptual review of selected programs and empirical evidence." Medical Care, XIV, 6, 455-568. Evashwick, Connie J. 1976 "The role of group practice in the distribution of physicians in nonnetropolitan areas." iedical Care, XIV, 10, 808-823. Fein, Rashi and Gerald I. Weber 1971 Guzick, 1976 Hadley, 1976 Financing Medical Education, New York: McGraw Hill Co. David S. and Rene-J. Jahiel "Distribution of private practice offices of physicians with specified characteristics among urban neighborhoods." Medical Care,-XIV, 6, 469-488. Jack Models of physicians' specialty and location decisions. Washing— ton D.C., National Center For Health Services Research, Technical Paper Series. Hambleton, J.W. 1972 "Foreign medical graduates and the doctor shortage." Inguiry, 9,68. Hassinger, E.w. 1963 Background and community orientation of rural physicians com- pared with metropolitan physicians in Missouri. University of Missouri, College of Agriculture, Research Bulletin 822. Held, P.J. and Reinhardt, U.E. . 1975 "Health manpower policy in a market context." Paper presented at annual meeting of the American Economics Association, Dallas; Texas, Dec. 28-30, Martin, ED., R.E. Moffat, R.T. Falter and J.D. Walder, 1968 "Where graduates go. The University of Kansas School of Medicine: a study of the profile of 959 graduates and factors which influenced the geographic distribution.q Journal of The Kansas Medical Society, 69: 84489. Mattson, D.E., D.E. Stehr, and R.E. Will, 1973 "Evaluation of a program designed to produce rural physicians." Journal of Medical Education, 48, 223. Navarro, Vicente 1976 "The political and economic determinants of health care in rural America." Inguirz, XIII, 111-121. Parker, R.C. and T.G. Tuxill 1967 "The attitudes of physicians toward small community practice." Journal of Medical Education, 42, 327. Peterson, G.R. 1968 A comparison of selected professional and social characteristics of urban and rural physicians in Iowa, Iowa City: University of Iowa, Health Care Research Series 8. Rees, P.H. 1967 "Movement and distribution of physicians in metropolitan Chicago.” Chicago Regional Hospital Study, Working Paper, 1.12. Rushing, William A. 1975 Community, physicians and inequality: a sociological study of the maldistribution of physicians. Lexington, D.C. Health & Co. Scott, B. and P.E. Meyer 1972 "Physicians' attitude survey. If physicians had it to do over: The new medicine." Medical Opinion, 8, 47—51. Taylor, M., W. Dickman, and R. Kane. 1973 "Medical students' attitudes toward rural practice." Journal of Medical Education, 48, 885. Yett, Donald E. and Frank A. Sloan, 1974 "Migration patterns of recent medical school graduates", Inguirz, XI, 125-142. out. WIMHNT PRINTING OFFICE: 19"“ fill-Z‘HIM 2‘ S US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE POSTAGE AND FEES PAID Public Health Service US. DEPARTMENT OF HEW Health Resources Administration H.E.W. 396 Office of Graduate Medical Education Center Building > _ 3700 East~WesI Highway U.8.MAIL Hyattsville, Maryland 20782 — OFFICIAL BUSINESS PENALTY FOR PRIVATE USE $300 HR4®I DHEW Publication No. (HRA) 79-634 September 1979