Physician retention and recruitment outside urban British Columbia

Introduction
Physician retention rates decrease sharply and physician recruitment rates increase sharply in communities with fewer than 7000 people. A recent decrease in absolute numbers of rural physicians in these same communities is a worrisome finding.

There is a perceived crisis facing rural medicine in British Columbia—too few physicians serving relatively too many people. Inability to attract physicians to rural communities (low recruitment) and a perceived increase in physicians leaving rural communities (low retention) suggest things are only going to get worse.

Training more doctors likely will not correct the problem, since it is believed Canada already has enough trained doctors. The problem is primarily one of poor distribution—doctors recruited from urban centres, trained in urban centres, not surprisingly, want to work in urban centres. Policies designed to force urban doctors to “do their time” in rural communities have not yet worked.[1,2,3,4,5,6,7]

Review of the literature reveals that the problem of recruiting physicians into rural Canada and retaining them is not a new one; it has been talked about for at least a few decades.[8,9,10] To the best of our knowledge, there are no published quantitative data on how long physicians normally stay in Canadian rural communities, and no published quantitative data on what would be an expected physician retention and recruitment rate for these communities. Almost all the literature we have found concerning retention and recruitment comes from cross-sectional surveys on physician intention to relocate, or on reasons why physicians relocated.[11,12,13,14]

The information does exist, but it is in the form of physician directory information. To practise medicine in the province of British Columbia, physicians have to register with the College of Physicians and Surgeons. Each year, the College prints a directory that includes, among other things, the town, village, or city in which registered doctors are located.[15] The objective of this study was to see if medical directories can be used to identify trends in physician recruitment and retention over the past 21 years and to see if medical directory data can be used to detect differences in retention and recruitment between variously sized communities.

Methods
The study population consists of communities that had less than 30000 people, at least one physician, and have either a hospital or diagnostic-and-treatment centre. Communities lacking a hospital or diagnostic-and-treatment centre were omitted from the study. This was done to avoid including “bedroom” community data; that is, communities that are so close to a larger community that they could be considered regional extensions of these larger communities.[16] Communities located in the Lower Mainland (Fraser Valley, South Fraser Valley, Simon Fraser, Vancouver, Burnaby, North Shore, Richmond Health regions) and southern Vancouver Island (Capital Health region) were also omitted because we were mainly interested in retention and recruitment of physicians working in communities outside the Lower Mainland and Southern Vancouver Island.[6]

Community population was obtained from the 1996 British Columbia census data.[17] Comox and Courtenay were excluded from the study because both communities are so close together that they can be considered one community. Together their population exceeds 30000, and people living in Courtenay can access the hospital in Comox within 10 minutes.

Physician retention and recruitment were calculated from British Columbia Medical Directories (1979–80 to 1998–99).[15] Every physician listed in every directory for each community was tabulated on a spreadsheet. Only family physicians and general practitioners were included in this study; specialists were excluded. Communities were then grouped according to the following population sizes: <3500, 3500 to 6999, 7000 to 10999, 11000 to 19999, and 20000 to 30000.

Comparative physician retention was calculated by assuming all listed physicians for a given community size started in the same year. The total number of listed physicians, at year 1, is expressed as 100%. The number of physicians listed the following years is expressed as a percentage of this year 1 cohort. For example, in communities with populations of 20000 to 30000, there was a total of 420 physicians listed in the 21 directories (1978–79 to 1998–99).

Of these same 420 physicians, 302 were listed for 2 years in a row, 263 were listed for 3 years in a row, 225 were listed for 4 years in a row, and so on. The calculated comparative retention rates equals the proportion that stayed 2, 3, 4, or more years. In this example, year 1 comparative retention is 100% (420/420), year 2 retention is 72% (302/420), year 3 retention is 63% (263/420), year 4 retention is 54% (225/420), and so on.

Year-to-year retention was calculated by:
1. Adding all doctors listed in a given year (total = y).
2. Counting the number of doctors the following year who had been present the year before (retained total = x).
3. Physician retention for that given year = x divided by y. For example, in the 1995–96 medical directory, there were 162 physicians listed for communities with populations of 20000 to 30000. The following year, in the 1996–97 medical directory, 144 of the physicians listed in 1995–96 medical directory were still listed for these same communities. The 1997 retention was calculated to be 144/162 = 89%.

Year-to-year recruitment was calculated by:
1. Adding all the doctors listed in a given year (total = y).
2. Reviewing the doctor list from the year before to determine how many of these doctors were listed for the first time (newly recruited physicians = x).
3. Physician recruitment for that given year = x divided by y. For example, in the 1996–97 medical directory, there were 173 physicians listed for communities with populations of 20000 to 30000. Of that total, 29 were listed for the first time, i.e., they were not listed in the 1995–1996 directory for these same communities. The 1997 recruitment was calculated to be 29/173 = 17%.

The validity of medical directory information was crudely verified two ways. First, by phoning clinics from NIA communities and asking how many physicians were currently living in that community and working full-time or part-time. As might be expected, the larger the community (especially those of 20000 or greater), the less sure the receptionist, office manager, or physician was as to total number of family physicians and general practitioners in that community.

A total of 57 NIA communities were contacted—24 communities with populations <3500, 17 communities with populations between 3500 and 6999, 5 communities with populations between 7000 and 10999, 8 communities with populations between 11000 and 19999, and 3 communities with populations between 20000 and 30000.

Second, we obtained NIA community health-care data from British Columbia Medical Services Plan (MSP) office in Victoria. This MSP data includes family physician counts and calculated full-time equivalent family physician counts, based on billings rather than place of residence.[6,18]

Results
A cohort of 1979 family physicians and general practitioners was identified from the 21 British Columbia medical directories—1978–79 to 1998–99. These physicians were from 78 communities (Table 1).

Comparative physician retention (proportion of physicians remaining) for communities with populations of less than 3500 people, 3500 to 6999 people, 7000 to 10999 people, 11000 to 19999 people, and 20000 to 30000 people is shown in Figure 1. The proportion of physicians remaining 2 years ranges between 64% and 74%. By 3 years, differences in comparative physician retention are discernible between communities with less than 7000 people, and those with more than 7000 people. The differences are clearly apparent by 5 years, and remain pretty much throughout the 21 year study period.

The absolute number of physicians listed per community group is shown in Figure 2. The reason that there are more physicians listed in the 11000 to 19999 sized community group than in the 20000 to 30000 sized community group is that there are more communities in the former group (17) than in the latter group (7). As expected, there has been a steady overall increase in the total number of physician listings since 1979.

Figure 3 shows this same data expressed as a percent of the number of physicians listed in the 1978–79 directory. The data show that there has been a relative drop in physician listings in the smaller community groups (<3500, 3500 to 6999) over the past 3 years.

Year-to-year physician retention is shown in Figure 4. The data show that the lowest population communities have the lowest year-to-year retention rates. Typical retention rates for communities of fewer than 7000 people are between 70% and 80%. Typical retention rates for communities with 7000 or more people are between 85% to 90%. If anything, the gap in physician retention rates between smaller and larger communities appears to be decreasing after the mid-1990s. The exception to this was in 1999, when physician retention in communities with fewer than 3500 people dropped sharply to 72%.

Year-to-year recruitment is shown in Figure 5. The data show that the lowest population communities have the highest year-to-year recruitment rates. Typical recruitment rates for communities of fewer than 7000 people are between 20% and 30%, and can be as high as 38%. Since about the mid-1990s, recruitment rates for the smallest communities has fallen to approximate rates seen in communities with 7000 or more people. The exception to this was in 1999 when physician recruitment jumped sharply to 28% in communities with fewer than 3500 people. In contrast, typical recruitment rates for communities of 7000 or more are between 10% and 15%.

Table 2 summarizes the estimated number of physicians working in various sized NIA communities as derived from the 1997–98 medical directory, from the MSP office in Victoria, and from phone calls to clinics located in each community. The directory and MSP estimates generally agree with one another; the phone survey suggests at any given time there are about 87% (302/348) fewer physicians working in these communities than the directory would suggest—a number consistent with our calculated year-to-year physician recruitment rates.

Discussion
This study shows that provincial medical directories can be used to quantitate differences in physician recruitment and retention between small communities as compared to larger communities. The data show that communities with less than 7000 people have the lowest physician retention rates and highest physician recruitment rates. The data provide community health-care planners with average retention and recruitment rates that can be used as comparative norms to which they can compare their own regional retention and recruitment rates. For example, a community of <7000 people that has two or more physicians who have stayed 5 or more years can consider themselves very fortunate.

A literature search revealed only two articles that contain quantitative information on rural physician retention[19,20] and one article reviewing practice mobility among young physicians.[21] Horner and colleagues found that the average length of tenure for physicians in rural counties in North Carolina was 4.6 +/– 0.12 years.19 The 10-year practice survival rate in Horner’s study was approximately 35%. Our data reveal that the mean (+/– SD) physician stay for rural British Columbia communities with less than 7000 people is similar (4.3 +/– 4.6 years), but the 10-year practice survival rate was a lot lower (between 9% and 13%). Pathman and colleagues compared 9-year retention of physicians serving in rural communities under the American National Health Service (NHSC) Scholarship Program to that of non-NHSC physicians working in the same or similar practices. Using survey methodology, they found that after 9 years, NHSC physicians were much less likely than non-NHSC physicians to have remained in their original communities (22.9% vs 47.9%).[20]

Wilke conducted a large, nationwide survey in 1987 of physicians under age 40 and found that averaged across all physicians, there is a 10% to 12% chance of changing practices for each of the first 3 years, and about 1 in 3 physicians changes within the first 5 years.[21] These three studies suggest 10-year practice survival in rural America is higher than that in rural British Columbia.

Our data show that overall physician supply in communities of all sizes has increased over the past 21 years. This suggests that, for the most part, recruitment has kept up with physician loss. While people living in the smaller rural communities may not appreciate this “revolving door” staffing pattern, health-care planners can at least say they are fulfilling their societal obligation to provide physician services to these areas.[20]

When recruitment fails to keep up with physician loss there is a problem, and this should be reflected in a fall in total physician listings. Worrisome are the data that show that there has been a gradual decrease in physician numbers in the two smaller community groups (<3500 and 3500 to 6999) over the past 3 years.

A 1991 study by Kazanjian and colleagues identified that 14.8% of rural physicians (physicians living in communities of 10 000 or less) in British Columbia wished to move.22 A 1998 survey conducted by the British Columbia Medical Association revealed that almost 25% of rural physicians were considering relocation in the next year, while only 4% of urban physicians were planning to relocate.[11]

The majority of these rural physicians were planning to move to larger communities. Factors motivating this desire to move included on-call responsibilities, daily workload issues, on-call remuneration, cultural opportunities, educational opportunities, spousal opportunities, access to specialists, and retirement.[11]

Our data support the results of these two surveys, adding validity to the use of “intention to move” surveys as a way of monitoring physician loss from British Columbia’s rural communities. A more recent (1999) survey of British Columbia’s NIA physicians revealed that 51% of physicians were considering relocation.[13] If this is true, one would predict that the number of physician listings for rural communities in British Columbia will continue to drop over the next few years.

A decrease in absolute numbers of rural physicians and percentage of rural physicians in British Columbia has been observed by others studying the Canadian Medical Association (CMA) physician listings database.[3,11] According to CMA data, the number of rural physicians in British Columbia has dropped from 576 in January 1994 to 490 in January 1998, and the proportion of physicians practising in rural communities has decreased from 12.0% to 11.1%. Rural, as defined by the CMA, refers to communities with a population of less than 10000.

Reasons for dissatisfaction with rural practice include long hours of work with gruelling call schedules, professional isolation, absence of immediate specialist backup, relative shortage of specialists working in the area, lack of locum relief, inadequate training for rural medicine, relatively low physician-to-population ratio, and absence of modern technology.[10-14,16,23,24] There are currently no obvious solutions to the rural crisis. Things will probably get worse before they get better. Medical students exposed to recent reports of declining morale, increasing anger, and job action by rural physicians would probably think twice about picking rural medicine as a future career option.[25,26]

Acknowledgement
I would like to thank Amy Thommasen for her assistance with data collection and the construction of graphs. This research project was supported by the North American Primary Care Research Group.

Dr Thommassen is a clinical assistant professor in the UBC Family Practice Department.