Obstacles to Attracting Physicians to Underserved Communities

Abstract

In his article, Thomas Weil notes correctly that attracting physicians to certain historically underserved inner-city and rural communities appears to be an intractable social and public policy dilemma. He suggests that this problem may be amenable to solution if health networks interested in capitalizing on those markets provide leadership in building systems of care in those communities. He posits that the existence of such systems might attract physicians to establish practices in underserved communities, provided that the networks also provide financial incentives. Implicit in Weil's thinking is that physicians will be unlikely to establish practices in the target communities, unless viable systems of care are in place. On this point, we believe he is correct. At issue, however, is whether establishing systems of care in historically underserved urban and rural communities, while necessary, will prove sufficient to attract physicians to those communities. Weil suggests that over the years policymakers have implemented three specific strategies to address this problem: (1) increase the number of U.S. medical school graduates; (2) allow graduates of non-U.S. medical schools to enter the country for residency training and practice; and (3) establish the NHSC. He concludes that individually and collectively, those policies failed to accomplish the stated goal. Weil's analysis is only partially true. While there is no question that the policies he describes did not solve the problem of geographic maldistribution of physicians, it is important to recognize that only the last one of the three was intended to do so. With the limited space available for this commentary, we cannot review in detail the history of the policies referenced, but we would assert that increasing the number of U.S. medical school graduates and allowing graduates of non-U.S. medical schools to enter residency programs in this country were not policy initiatives intended primarily to provide physicians for inner-city and rural communities. It is therefore not surprising that the programs established to implement these policies did not resolve the problem of medically underserved communities. By contrast, the NHSC was established specifically to fill this need. However, this program has never been funded by the federal government at the level required to place physicians in all of the communities of need. Moreover, the NHSC has been plagued over the years by congressionally mandated changes in the program's goals and objectives. Regardless of how one interprets the relevant policymaking events of the past quarter century, the fact remains that certain urban and rural communities in which residents lack ready access to physician services continue to exist. If one hopes to create systems of care to remedy this situation, one must first identify and understand the reasons that more physicians have not chosen to establish permanent practices in those communities. Decisive Factors We believe that three major factors determine whether an individual physician is likely to establish a practice in an urban innercity or rural community that has historically been without a physician: 1. the physician's specialty; 2. the economics of medical practice in the community; and 3. the living conditions in most medically underserved communities in relation to the legitimate lifestyle aspirations of most physicians. Let us consider each factor in turn. First, the greatest need in medically underserved communities is for physicians who practice primary care medicine. Accordingly, physicians trained as family physicians, general internists, or general pediatricians (the kinds of physicians who generally practice primary care medicine) are virtually the only physicians likely to consider practicing in these communities. Furthermore, given the broad range of primary care services (e.g., routine obstetrical care) that physicians must be prepared to provide in underserved areas, family medicine physicians are much more likely than general internists or general pediatricians to succeed in relatively isolated practice (particularly in rural communities). …