Recruiting New Rural Practitioners

Prepared For Rural Communities By UNMC Rural Faculty. Please copy and use! Contact Dr. Robert Bowman at (402) 559-8873 or rbowman@unmc.edu for further information.

Read and reflect on the following if you truly want to be successful at recruitment and retention. Regarding problems with a too hasty recruitment of a rural physician:

"The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship. For the rural community the trauma is almost as great: it is easier in most instances to be perennially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again." Tom Bruce, MD in Improving Rural Health

In today's highly competitive recruiting environment, rural communities need the best information to be able to compete. This packet should be completed with information about family practice residents, physician assistant students, and nurse practitioner students and others interested in rural practice. This handout includes information about recruitment activities and components of a successful recruitment team. Use this packet to recruit better locally, to train recruitment teams, or to impact on training programs. Recruitment activities need to be coordinated by one person in town and this person should have the time, energy, and resources to do the job well. Recruitment is a "courtship" that hopefully ends up in a quality health professional choosing your town. You will need to have or access expertise in marketing and public relations in order to get your message out! When recruits come to visit, you must know who are the contacts that can best influence the right candidate to choose your community. This is not the job of a single person! Don’t waste time and effort if you do not have the people, the relationships, and the preparation done so that recruits who visit know who they will be working with, who will likely be their potential friends in the town, what their family will do, where they will live, what they will make, how much call, etc. When you want to recruit well, you must start by

GETTING THE WORD OUT!

Send nearby training programs a poster or letter regarding your practice opportunity. Update and repeat this letter at regular intervals. Ask new practitioners, other young professionals, or rural faculty to look it over prior to printing to look at key issues for recruits. Increasing Recruitment Contact with Residents

Every community has a variety of attractive features that you must communicate!

Get and keep an updated list of the names of those in training in the state and in nearby states. Most practitioners have identified their practice site 8 months to 2 years before graduation. Keep track of students or residents who are from your area or who have visited your area for training.

Visit training programs. You can involve yourself in training by sponsoring food for an existing noon conference, giving a conference, or just visiting. Rural faculty can help you with arrangements during the day or even for an evening dinner event for future practitioners and their spouses. Each training program has certain dates where student or residents gather.

Take advantage of teaching days with recruitment events, dinners, etc!

Some communities send their local practitioner to teach. Now that the Rural Training Tracks have opened across the state, the opportunities are much closer (Grand Island, Kearney, Scottsbluff, North Platte. They can recruit by direct contact with residents. The contact also helps retain as well as recruit as the contact reduces isolation and gives some reassurance of the potential for future help.

Recruitment is a team effort. A good combination is a hospital administrator or nurse, a practitioner, and an enthusiastic community member, preferably a young professional. One person can only make connections with a few people. Three people can cover a wide range of topics and answer specific questions by potential recruits. Ultimate Recruitment Experience

Attend Recruitment Fairs and Conferences. Tennessee and Iowa and other states have similar annual events. Each year UNMC has an Annual Rural Recruitment Fair. Next one is in October 2000. Booth space is limited and prioritized to the small communities. FP residents, physician assistants, and nurse practitioners attend training sessions with communities and visit the booths exclusively from 11:30 to 1:30. Communities can interact with these potential practitioners during the training, during breakfast, at lunch, and at breaks. Communities have opportunities to present their opportunity to the recruits. They also listen as the recruits describe what they want. Other students in training attend community booths later in the afternoon.

Most of the future primary care grads in the state will be there in one room!

Get to know the plan for your region

Communities set up a booth with various items to attract interest. The key ingredient in contacts is people. You want people manning your booth who know your community and can represent it well. Again make sure one of your "team" is a local practitioner. CME discounts or credits or coverage bonuses (day or weekend coverage) can help to attract practitioners.

GET RECRUITS TO YOUR TOWN!

1. Be sure to find out what is important to your recruit! Not all needs are financial. Your financial offer should be competitive, however.

Match your search to the recruit. Recruits vary greatly in their methods of finding a practice. Some have specific obligations. Some are looking mainly at the practice situation, some look at relationships between practitioners, others see the town, others want to know how much say they will have in the local practice, others want to make a difference in your town.

Put yourself in their shoes, better yet, ask someone who either is in their shoes as a recruit or who has recently arrived. Ask who is likely to be a friend, colleague, support person, key contact, etc. of this future practitioner. For example if the recruit has been active in local causes, be sure to introduce them to similar folks in your community.

Focus on what you want to say that will attract someone to your site. What is different and special about your community? Does it have things that recruits desire such as group practices, a covered ER, a nice downtown, good schools, proximity to other attractions, good income potential? Those who are interested in rural practice want to know about your rural lifestyle - the local celebrations, the athletics, the fine people who keep things going in your town. This is best done in a group process involving practitioners, hospital personnel, and community leaders, before recruits. The group then is updated on all of these local assets and is prepared to match them to recruit needs.

2. Get the interest of the recruit, but convince the spouse as they are the most important part of successful recruitment. Your ability to address the above is 90% of a successful recruitment effort. This includes spouse job or education needs, spouse friends, potential friends in your town (similar interests, professional people, organizations, etc.) Find out how the spouse feels about small towns and what would make them comfortable. Church contacts are key recruitment and retention factors in small towns. You cannot do enough to address spouse needs. If your location is near family, that is a major feather in your cap.

3. Future practitioners want to meet future colleagues! Serious recruitment involves current practitioners in your town. They should attend any recruitment fairs or other recruitment events. They should be a key part of any visit to your town.

4. Job security is a major issue for recruits. Today’s grads face tremendous debt. They know that the financial situation of the local practices and hospital will effect them. They know that if situations worsen, the last doctor in (them) will be the first one out. If there is little coordination between the doctors, or between the practices and the hospital, they will find other locations. Some recruits ask relevant questions about accounts receiveable, personnel, and other key issues.

5. Critical mass is important. Most practitioners want to join up with at least four others to share call and duties. New graduates are writing contracts that give them call only every 4th or 5th night and weekend. Larger groups and offices allow more specialized functions such as an office manager, billing specialist, techs.

6. Where is your health system going? All practitioners, especially current ones desire a tangible feeling that they will be contributing to a viable and developing system. They want a nice place to practice and a nice place to live.

The Role of Practitioners now and in the future is a key concern for recruits. New physicians need to see themselves as having major input into the running of the practice. Numbers of patients and covered lives, catchment areas, market share, satellite clinics, marketing, and other issues are key questions that top quality recruits are likely to want to learn about.

Recruiting is a year-round operation

Most recruits get organized a year or more before graduation. The time to do recruitment is now and always. Over the past few years some of the best candidates begin looking two years in advance. Others begin to look at material later. It is important to remember that

Recruits are always looking! Recruiting in 2000 will be different than it was. Be sure to keep up by attending training seminars, visiting with practitioners in training, going to recruitment events such as the Rural Recruitment Fair, the Nebraska Academy of Family Practice meeting, the Annual Meeting of Students and Residents in Kansas City, and other events.

Communities must have organized recruiting

Communities need an annual review and planning meeting for mailings, contacts, and focusing on needs; plus regular montly or more follow up meetings to keep track of contacts and make a maximal effort. To get prepared for each meeting or contact or mailing takes a few months so the process extends throughout the year. Other items to consider are brochures, fund raisers, office renovations, contract updating, and other recruitment efforts. Communities with only a few doctors also have few health resources, but if they are less organized than the major health organizations with whom they compete, their local health care will be history.

There are other ways to get potential recruits to you!

Become a training site for students and residents. Nurse practitioner students train at one site for almost a year. Efforts are underway to train medical students for four months or more at one rural site. Physician Assistant students can do rotations of three or more months. These contacts often lead to future jobs. Family Practice residents train at selected shortage sites across the state. Be sure you support such training and try to become a training site. You can even get state funding to set up a site like Indiana did recently. Notify a family practice program director if you would like to be a rural training site. A listing of program directors is included at the end of this document.

Offer moonlighting for residents at your hospital or site. Many have been in the past, but times have changed. To attract residents to your site, send information to FP program directors about moonlighting. Address housing needs, pay, duties, the range of volume for the weekend, local attractions, and backup help. It is getting tougher to attract today’s residents to rural moonlighting due to travel, family needs taking priority, and the high volume urban doc-in-the-boxes that pay $50-80 per hour for weekend or evening work. You might not beat the pay, but you can beat the housing and offer a less hectic pace. Some single parent residents would greatly appreciate a place where child care is available. The critical time in moonlighting is when the first resident comes out to work. First impressions can mean a lot to attracting more residents as well as candidates for future recruitiment. Be prepared! These residents are your window to other residents as well. Their impressions are magnified many times.

Longer Term Recruiting

Focus on Involvement! If you have students or residents out to your site to train, you should make sure that they get a chance to get involved. If you do not have the skills or inclination to do so, find an enthusiastic practitioner’s spouse or community member to invite the student or resident to community events, dinner, church, etc. Keep track of trainees later and make sure they know that you are interested in them. You have the first chance at them if you do so. Studies note that one of the first five sites examined is often selected. Involvement has much more impact than just a clinical experience.

Emphasize what you do well! Many ask what is the best rotation to take or what is the best material for a rural rotation.

You, your colleagues, and your community are the best things to emphasize!

For reasons unknown, rural people, including physicians, under-rate their capabilities. Considering the way the medical profession is going, rural physicians have much to give. You are a problem solver. You deal with uncertainty daily and well. You have procedural skills that students and residents only dream about. Your colleagues also have skills such as these, skills in working with the community, practice management, hospital care, etc. Sit down at a medical staff meeting or have a special meeting to emphasize what you, your colleagues, and your community do well and problem solve as to how to get this to students and residents who come to visit and learn.

A rural experience can be much more; it can involve the trainee in the community.

Generate a list of these assets and review them with students and residents who come to your town.

Do special projects! You can hire pre-medical and other pre-professional students, medical students, or physician assistant students to do assessments of your practice, work with your hospital, do community needs assessments, verify state data regarding your community, or otherwise provide you and your community with the information that can make the difference in targeting the most needed areas, negotiating better with outside entities, pursuing grants to meet needs and more. Call me for further information on this program.

See Building a Practice
See Retaining Rural Docs
Community role for rural docs

WORK WITH YOUR COMMUNITY

Dare to be different. Recruitment is a courtship, a match of your community with the needs and desires of the graduate. Try to do some thinking about what is unique about your community. Discussions with young physicians or professionals in your town can help shape a successful campaign. Before any interviews, strive to show the new practitioner his or her place in the town, their future office and desk, and the patient rooms they will use as well as potential housing, schools, churches, and other community resources that will meet spouse needs.

Develop financial incentives Some communities give scholarships to students or residents in return for an obligation to come there after graduation. More students are looking for sources of funds to meet tuition and living needs or help pay off training debt. These funds help shape their training choices and their practice decisions. Debts for some FP residents average $50,000 to $80,000 at graduation. Some debts run double this amount for out of state, private, or osteopathic medical schools. Loan repayments from various sources vary from $10000 to $30000 repaid for each year of service. Some loan repayments also pay taxes.

Offer guarantees and other incentives. Most communities offer a guarantee of $100,000 - $150,000 a year for one or two years depending on the training, the services offered (procedures, obstetrics), and potential benefit to the community. Bonuses of $10,000 to $25,000 may also be attractive and could save the package from being unmanageable in future years. The non-profit regulations have been easier to work with in this area in recent years. Remind your hospital of this and don’t let them quote IRS regulations as a barrier! Rural communities must explore all options to attract and retain practitioners.

Offer tax and business advice to the prospective candidate to develop a package that minimizes taxes and meets the needs of the new practitioner and the community. Low interest loans and payment of liability insurance are not great costs in the first few years. You can demonstrate your willingness to address the needs of the recruit as well as supporting continued OB services.

Get help from the State Office of Rural Health. Some communities are eligible for shortage area designations from the state or federal government. The State Office of Rural Health can help you to see if you qualify. Designation as a shortage are can mean access to more recruits, increased financial assistance, preference for grants, or reimbursement bonuses to current providers. The ORH also is a site of first contact for new doctors coming to the state as well as those who are looking for a new practice. They can help you track students or residents who are from your area or who have trained with you. They can assist with recruitment/retention problems & solutions. Failure to qualify as a shortage area is a critical recruiting error.

Beware of some problems in recruiting. With thousands of openings, residents are quick to discard any unlikely possibility. Communities or recruiters who seem less than sincere or who promise more than they can deliver will suffer not only with that resident, but with others also as residents do talk to each other about contacts. Be prepared and be polished. One quick look is all that you may get! Other problems include conflicts regarding recruitment:

Local doctors must support recruitment efforts!

Remember that many if not most rural practitioners are too busy and unavailable to do good recruiting. Physicians should delegate key recruiting tasks, go to recruitment events, be key advisors to recruitment efforts, participate in a major way in visits, but use the community as a resource for maintenance of recruitment efforts.

Personalize your approach. In all communications with prospects, try to visualize your situation through their eyes. Find out as much as you can before you write them. Talk with them on the phone and get to know them and their spouse when you are preparing for their visit. Find ways to make them feel part of your community.

Consider Reorganization of Your Local Health System. No longer can rural hospitals and physicians survive apart. Both often get too busy to plan ahead. Hospitals often focus too much on being in the black rather than looking at future needs. Most communities need some major effort with physicians, hospitals, employers, and community leaders coming together to plan for the future. Another role for health leaders is assisting the community with a transition from retirement to new physicians.

Some options to consider are physician networks, physician hospital organizations, rural health clinics, satellite clinics at nearby locations, etc.

Recruits are learning more each passing month. They will want to know about the future of your medical community.

WORK WITH YOUR CURRENT PRACTITIONERS

Retention begins before recruitment. Too often communities recruit a new doctor after they have used others up. It is often easier and more beneficial to retain the current practitioners rather than spend tens or hundreds of thousands of dollars on the new. Retention can smooth out the bumps as it is easier to recruit for one occasional vacancy than desperately when a community gets two or more practitioners down. If you tailored the financial package to the particular financial and tax needs of the candidate, you have taken a step toward retention. Otherwise they might be resentful when they see a huge tax bill.

"Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance." Rosenblatt and Moscovice, 1982

Retention begins with expectations that are formed before arrival. The more broken expectations, the more likely an earlier departure. Communities need to work on building bonds with their practitioners that will withstand the inevitable conflicts and adjustments that will need to be made for the foreseeable future in the rural USA.

Help your new practitioner to get established. New ones cannot come in unless the current ones are established. New doctors need to know the key members of the community that will help them to get good patients. Contacts with other young professionals can result in lasting friendships within the community.

Improve the Local Health Market Share. Work so that local citizens use local doctors and hospital services so that the community can support current and future local practitioners and health services. Studies can target those who are not using local services and how to meet the needs of these people. Satellites may help new physicians to build their practices and not compete too much with established doctors. Doctors need to be busy to feel wanted and successful.

Physicians can encourage recruits to provide OB and women’s health services. They can also teach recruits new skills. If you have the kind of medical community where this happens, you can broaden the services available locally, improve local market share, reduce call burdens on certain physicians, and retain physicians.

The other doctors in town can make or break the recruitment and retention process. If you need doctors and one or more of your current doctors is opposed to recruitment, you have a real problem. Failing to deal effectively with this issue may cost you current and future practitioners as well as your entire health system.

Rural physicians are not easily replaced. Anticipate problems. Keep in touch with your practitioners. Use residents or locums doctors to help cover their call. Help them work with other practitioners to keep call nights and clinic demand down. Give providers assurance of several fully protected nights off each week and more than two weekends off a month. Keeping the number of doctors/practitioners at the four level or above is critical for recruitment success, retention of providers, and viability of the community's health facilities.

Coordinate your efforts. Rural recruitment and retention involves a marriage of the recruit to the doctors, the facility, and the community. In small rural health systems everyone has to work together. The candidate should be accepted by all who will be involved with the recruit. This means meetings prior to and after the interviews, visits, etc. The sooner potential problems are aired, the better.

References and mutual contacts should be checked sooner rather than later.

Choose well! Recruiting any practitioner who is a bad match for the community can disturb the entire rural health system for years. Promise only what you can deliver and work with those that you get. The transition to rural practice is only a start of a (hopefully) beautiful relationship.
Be patient! New rural physicians are young and medically competent, but they often need time and assistance so that they can mature into the physicians that can best help your community. It takes them years to recognize and deal with major deficiencies in career planning, management issues, and finances. There is a way to help them deal with practice and life obstacles without them leaving your town.

Some practitioners come mature, some mature without you, some need assistance, and some never grow up.

Try to choose the former rather than the latter, but keep working with them all.

Self-Assessment of Local Recruitment Effort

Rural Faculty Preparing This Information:
Robert C. Bowman, M.D., and Cheryl Abboud, MPA UNMC Family Practice
Rbowman@unmc.edu
Please complete this handout with listings of family practice residents, physician assistant students, and nurse practitioner students. You can obtain lists of family practice residents by year or residency programs from the American Academy of Family Physicians at 1-800-273-2237. Your state office of rural health may also have listings. Call your state health department.

For additional reading on why doctors go to rural communities, read: http://www.unmc.edu/Community/ruralmeded/

Funding for Life Support is provided by a grant from USDA Rural Development