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Historical Background

The Country Life Commission

Health Care in the Rural West: Persistent Problems, Glimmers of Hope

Giving a typhoid innoculation at a school in rural San Augustine County, Texas, 1943. (Photo: John Vachon via Library of Congress)

Giving a typhoid innoculation at a school in rural San Augustine County, Texas, 1943. (Photo: John Vachon via the Library of Congress)

 

By Michael De Alessi and Robin Pam

“In general, the rural population is less safe-guarded by boards of health than is the urban population. The physicians are farther apart and are called in later in case of sickness, and in some districts medical attendance is relatively more expensive. The necessity for disease prevention is therefore self-evident and a betterment of these conditions is a nation-wide obligation.”

– Report of the Country Life Commission [1]

Fearing a loss of agricultural productivity and rural community, Teddy Roosevelt formed the Country Life Commission in 1908 to investigate why the social and intellectual, as well as economic, aspects of country life were not keeping pace with city life.[2] Of the six “deficiencies of country life” highlighted by the commission, “health in the open country” featured prominently.[3]  The report emphasized issues such as differential access to doctors, numbers of physicians per capita, and costs of rural health care, and all remain contemporary concerns. The Commission’s call for “increasing the powers of the Federal Government in respect to the supervision and control of the public health”[4] could be pulled straight from today's health care debates.

In spite of a broad increase in the number of doctors per capita in the United States and in the American West over the past century, many rural areas in the West have seen little or no increase. This is a cause for grave concern. The fact that much of the rural West has seen little improvement in this basic measure of health care access is surprising, and it underscores the persistent remoteness of vast stretches of the rural West. But it also underscores the importance of improving physician access in the rural West. And the state of Utah shows a way forward.

In this report, we examine the best empirical data available on access to physicians across the West, and we investigate the state of Utah in more detail to test a prevailing hypothesis that registered nurses and nurse practitioners are substituting for doctors in health care delivery. We find evidence that the hypothesis is not true in Utah, and moreover, that for now many of Utah's rural areas provide a counterexample to the prevailing trend in the West. Recent developments in the state, however, raise concerns about whether this trend will continue in Utah.

Urban-Rural Disparity

The greatest geographic disparity in the number of doctors per capita over the last one hundred years has been between rural and urban/suburban areas. While the number of physicians per capita throughout the country has climbed higher since the time of the Country Life Commission, the number of doctors in rural areas has declined relative to total population. A century ago, roughly 41 percent of the nation’s physicians lived in communities of 2,500 or less.[5] At that time, according to the US Census Bureau, about 60 percent of the US population resided in rural areas.[6] Today, rural physicians make up 9 percent of the physician population, amidst 20 percent of the population.[7] While the increasing disparity in physicians per capita between urban and rural is undisputed, the effect of this change on the provision of health care is less clear.[8] The general consensus seems to be that the increasing shortage of physicians in rural areas over the last 100 years has had negative health consequences.[9]

Politics, Per Capita, and the Quality of Care

Nonetheless, there are some conflicting claims as to whether there is a crisis or even a shortage of physicians in rural areas, and this underscores the difficulties of measuring health care outcomes. The best measure of rural health care is surely the quality of care provided. But despite wide-ranging efforts from academics, insurance companies, activists, and government agencies, measures of quality are notoriously difficult to define.[10] Quality measures are severely hampered by the fact that tradeoffs between outcomes such as quality of life versus length of life are matters of individual preference.[11] As a result, the purely empirical assessment of numbers of physicians per capita remains the primary research measure of access to health care.

Data on the number of physicians per capita goes back to the mid-1800s, so this is also a crucial measure for historical comparison.[12] Emphasizing national figures of doctors per capita, however, misses two fundamentally important points; that increases in physician supply are not distributed equally and that doctors per capita may not be an accurate measure of the quality of care available. Thus, it has been reasonably suggested that different metrics need to be applied in a rural setting, where environmental conditions, spatial barriers to access, and differential exposure to disease and occupational hazards all affect the provision of health care.[13] Determining whether rural areas are underserved by doctors, however, is a complicated task, compounded by the fact that even simply defining “rural” involves choosing among a number of complicated, competing, and often politically motivated definitions.[14] Still, numerous studies have shown a correlation between the quality of health care in rural areas and per capita measures, not only between rural and urban areas, but also between geographically diverse rural areas.[15] But how many doctors are enough?

The Politics of Physician Supply

The first great intervention in physician supply was a reduction in the number of physicians following the 1910 publication of the Flexner Report. Commissioned by the Carnegie Foundation at the request of the American Medical Association (AMA), the Flexner Report examined medical education in America and called for stricter accreditation standards, to be enforced by the AMA.[16] This came to pass, and as a result, the number of accredited medical schools in the United States fell from 162 in 1906 to 69 in 1944.[17] Because every state licensing board required graduation from an AMA accredited medical school to practice, the supply of physicians declined significantly from roughly 1910 to 1930.[18] As shown below, the supply of physicians then held relatively steady from the 1930s through 1960, rising steadily thereafter (Figure 1).[19]

Reproduction of a graph produced in Medical Education Futures Study, The George Washington University School of Public Health and Health Services, October 2008.[20]

Beginning in the 1960s, physician supply increased dramatically following the passage of the Kerr-Mills Act of 1960, which financed medical care for the elderly and the poor. These programs evolved shortly into Medicare and Medicaid, producing greater demand for doctors and federal subsidies for graduate medical education.[21] This led the AMA to declare a physician “shortages” in the 1960s and to call for increasing physician supply.[22] That trend continues today, as evidenced by a recent major report from the Association of American Medical Colleges calling for a 30 percent increase in enrollment, citing an increasing disparity between physician demand and supply.[23]

No doubt medical colleges and the AMA itself value the provision of quality care above all else, but for as long as the AMA has been charged with both maintaining the quality of care and the incomes of its members, the AMA’s tinkering with physician supply has also been criticized as conflict of interest.[24]

Government measures of physician “shortage” are harldy an improvement. They also try to satisfy multiple constituencies, and are often more qualitative than quantitative. Three of the most widely used measures of access to primary care are Health Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs), and Medically Underserved Populations (MUPs), all of which were developed by the Department of Health and Human Services. HPSAs, for example, must have either a population to physician ratio greater than 3500:1, or a ratio of greater than 3,000:1 with an “unusually high need or insufficient capacity”.[25] While the validity of choosing those exact numbers is debatable, the medical literature seems to have taken a looming shortage as a given[26] (much as twenty years ago it took a looming surplus as given[27]), apart from a few who despair over the general state of physician workforce research.[28] These strictly defined terms belie the widespread belief in shortages, as evidenced by the maps of shortage areas they generate which show that most of the country qualifies.[29] For example, in the HPSA map, additional counties may qualify as a shortage area by geography (if all or portions of a county or adjoining counties are underserved) or by population (if specific populations within a county are underserved).[30] The definitions of MUPs and MUAs are even broader, allowing state governors to unilaterally declare that an area qualifies based on “unusual local conditions and barriers to accessing personal health services”.[31]

Each of these designations are used by state, county, and local governments to access federal funds, so it is not surprising that each casts a wide net, with qualifications available for geographic, demographic (such as low-income residents, migrant farmworkers, or non-English speakers), or institutional (facility-based) reasons.[32] One example of how these areas dictate policy is through the National Health Service Corps, a long-standing program run by the Department of Health and Human Services which provides scholarships and loan repayment services to physicians who commit to working in HPSA areas.[33] As a result of the attractiveness of these designations, almost every county in Utah, Nevada, Idaho, Montana, New Mexico, and Washington qualify as an HPSA. According to the Government Accountability Office, the expansive definition of an HPSA reduces its usefulness in determining how to allocate resources, clouding over the areas of greatest concern and blurring the difference between urban and rural care.[34] And as the maps below demonstrate, the difference between urban and rural can be significant, especially in the West.

The Rural West: From 1909 to 2009

The interactive visualization[35] associated with this essay and the maps below track changes in physicians per capita without any additional qualitative criteria. The maps below show the number of doctors per capita at the county level in the eleven most Western states in 1909 and 2009, showing both a broad, general increase in the numbers of doctors per capita and significant geographic diversity across the West.[36]

 

One unsurprising explanation for the geographic imbalance in physician increase is the rise of specialty practices that require access to a large population to be viable. The fact that many areas in the West have seen little change over the last one hundred years is surprising, and underscores the persistent remoteness of the rural West. It also underscores the importance of improving physician access in the rural West.

Much of the increase in physicians occurred in the latter part of the 20th Century, as shown below in maps of the change in physician density over the last 30 years.

Despite a steady rise in the number of physicians during this time, counties with few or no physicians still exist throughout the country. Combining this information with satellite imagery identifying urban and suburban development clearly shows that the white spaces (signifying low or no-density physician areas in the East) all lie in close proximity to more densely populated areas, whereas in much of the rural West they do not, confirming that the rural West is the epicenter of remoteness.[37]

Looking Beyond Physicians for Primary Care in Rural America

The story of geographic discrepancy in the numbers of physicians in the West between 1909 and 2009, and even between 1980 and 2009, would be incomplete without an exploration of alternatives to physician care. For the provision of primary care, it is often assumed that as the number of rural physicians per capita has lagged behind urban/suburban physicians, other professionals, especially nurse practitioners (NPs) and physician assistants (PAs), have increasingly provided primary care in rural areas.[38] Over a recent ten-year period for the United States as a whole, the average annual per capita increase in primary care providers was 1.17 percent/year for physicians, 3.89 percent/year for physician assistants, and 9.44 percent/year for nurse practitioners.[39] Other recent studies showed that over a range of hospitals around the country, and in rural Washington state and California in particular, the influence of NPs and PAs is greater in rural areas than elsewhere.[40] Hospitals are only a portion of primary care, however.

Data on recent changes in practicing physicians, nurse practitioners, and physician assistants is difficult to come by, especially at a finer grain of detail than the county level. Data provided by the Utah Medical Education Council[41], however, allows for a graphic test of the hypothesis that NPs and PAs are making up for physician shortages in rural areas of Utah. The maps below illustrate the relative change per capita from 1998 to 2003 in physicians and an amalgamation of NPs and PAs in Utah by zip code tabulation area. For Utah at least, the increase in physicians generally outpaces the increase in NPs and PAs (dark green indicates areas where physician increases outpace NP and PA increases, light green is the opposite, yellow is no change, white indicates neither physicians nor NPs and PAs are present, and red indicates a decrease in both physicians and PAs and NPs).

 

Imposing the nighttime satellite-based urban/suburban overlay blocks out a number of areas where the increase in physicians outpaced the increase in PAs and NPs. But even in rural areas physician growth generally outpaces NP and PA growth. Of course Utah is not the whole country. Utah's Department of Health has an office devoted to primary care and rural health and a dominant and successful institutional health care provider in Intermountain Health. Clearly, more research needs to be done around the rural West.[42] But at least for the state of Utah, it appears that the influence of physicians on primary care is only increasing, and that physicians per capita remains the most important measure of access to health care in that state.

 

 

The Future of Health Care in the Rural West

One hundred years ago, Teddy Roosevelt and the Country Life Commission worried about how to attract and keep doctors in rural areas. Those same concerns exist today, and as the maps above show, access to health care should be a particularly relevant policy topic in the rural West, where remoteness is more of a factor than anywhere else in the country.[43] With the passage of health care reform legislation in 2010, it appears there will be an opportunity to reshape the provision of health care in the rural West. A number of hurdles to reform remain, however. One of those hurdles is the current politicization of definitions of “rural” and of what constitutes a “shortage” of doctors. The satellite data used to define urban/suburban in the maps above is far from perfect, but it does cut out political and geographic biases. A straightforward, empirical definition of physician shortages is more difficult, but as our preliminary research in Utah has shown, simple numbers of doctors per capita is still a significant measure. Surely there is little point in qualifying the vast majority of U.S. counties; more empirical definitions should be employed and used by federal agencies.

It is also plausible that the dearth of doctors in some areas of the West may be a holdover from the Flexner Report’s effect on medical schools. While there are 133 accredited medical schools in the United States today, only 15 of those are located in the eleven most Western states.[44] Of those, California is the only state with more than one accredited medical school (it has eight), and three states, Idaho, Montana, and Wyoming, have no none.[45]

In Utah, the University of Utah School Of Medicine will graduate about 85 physicians annually in the coming year, down from the previous average of 100 after recent budget cuts. And the state of Utah has a number of programs to encourage rural practice, including a Health Department office devoted to primary and rural health, a Rural Hospital Program, and financial assistance programs aimed specifically at the provision of rural health care.[46] On the downside in Utah, a program that previously subsidized rural physicians was cut in 2009, so it remains to be seen what effect that will have on the number of doctors per capita in the future. Also the University of Utah Medical School does not recruit specifically from rural areas, and studies have shown that medical students tend to return to their roots.[47]

While Montana has an Office of Rural Health at Montana State University, Idaho has a Rural Health Institute at Idaho State University, and Wyoming has a state Office of Rural Health, none of these states have an accredited home-state medical school to tap into. More research is necessary, but it would seem likely that this has an effect on the number of physicians willing to take up a rural practice in those states.

As the maps in this essay illustrate, more attention should be paid to health care provision in the rural West. With so much money at stake in coming years, accurately identifying areas of health care shortage will be essential to addressing the problem, and we hope that the empirical data we have highlighted will foment a discussion on the development of more quantitative measures for determining where the problem of physician access is most acute.  



 


Notes and References

[1] Report of the Country Life Commission (Washington, DC: Government Printing Office, 1909), pp. 45-46.

[2] Michael De Alessi, “The Rural West: Jovial No More?” in The Expansion and Contraction of the Rural West, web-published by the Bill Lane Center for the American West (April 2010).

[3] Report of the Country Life Commission (Washington, DC: Government Printing Office, 1909), pp. 45-46.

[4] Report of the Country Life Commission (Washington, DC: Government Printing Office, 1909), p. 16.

[5] Roger Irving Lee and Lewis Webster Jones, The fundamentals of good medical care: an outline of the fundamentals of good medical care and an estimate of the service required to supply the medical needs of the United States, (Chicago: The University of Chicago Press, 1933), cited in Thomas C. Ricketts, “The Changing Nature of Rural Health Care,” (Annu. Rev. Public Health, 2000), 21: 639–57, and Jack M. Colwill and James M. Cultice, “The Future Supply Of Family Physicians: Implications For Rural America,” (Health Affairs, 2003), 22(1): 190-198.

[6] United States Census Bureau, “United States: 1790 to 1990”, downloaded February 15, 2010 from Selected Historical Decennial Census Urban and Rural Definitions and Data.

[7] See Roger A. Rosenblatt and L. Gary Hart, “Physicians and Rural America,” (Western Medicine Journal, 2000), 173(5): 348-351, and John P. Geyman, L. Gary Hart, Thomas E. Norris, John B. Coombs, and Denise M. Lishner, “Educating Generalist Physicians for Rural Practice: How Are We Doing?” (Journal of Rural Health, 2008), 16(1).

[8] See Edward Salsberg and Gaetano Forte, “Trends in the Physician Workforce, 1980-2000,” (Health Affairs, 2000), 21(5): 165-173, and Ira Moscovice and Roger Rosenblatt, “Quality-of-care challenges for rural health,” (Journal of Rural Health, 2000), 16(2): 168-176. 

[9] See Roger A. Rosenblatt and L. Gary Hart, “Physicians and Rural America,” (Western Medicine Journal, 2000), 173(5): 348-351, and David Hartley, “Rural Health Disparities, Population Health, and Rural Culture,” (American Journal of Public Health, October 2004), 94(10): 1675-1678. For a counterargument, see: James D. Reschovsky and Andrea B. Staiti, “Access And Quality: Does Rural America Lag Behind?” (Health Affairs, 2005), 24(4): 1128-1139. These different conclusions can be explained largely by two factors – the difficulty in measuring the quality of care, and the politics involved in designating physician shortage areas — which we examine here.

[10] See, for example, the six part series in the New England Journal of Medicine (1996) on “The Quality of Health Care” beginning with David Blumenthal, “Part I: Quality of Care, What is it?” (New England Journal of Medicine, 1996), 335(12): 891-894 and ending with David Blumenthal and Arnold Epstein, “Part 6: The Role of Physicians in the Future of Quality Management,” (New England Journal of Medicine, 1996), 335(17): 1329-1331.

[11] See David Blumenthal (ed.), “The Quality of Care: Parts One Through Six”, (New England Journal of Medicine, September 19 to October 24, 1996), Bert A. Loftman, “Series on the Quality of Health Care,” (New England Journal of Medicine, 1997) 336 (11): 804>, and Robert H. Brook, Elizabeth A. McGlynn, and Paul Shekelle, “Defining and Measuring Quality of Care: a perspective from US researchers,” (International Journal for Quality in Health Care, 2000), 12(4): 281-295.

[12] Kevin Grumbach, “Fighting Hand to Hand Over Physician Workforce Policy,” (Health Affairs, 2002), 21(5): 13-27.

[13] Ira Moscovice and Roger Rosenblatt, “Quality-of-care challenges for rural health,” (Journal of Rural Health, 2000), 16(2): 168-176. 

[14] Rebecca LaGrandeur and Michael De Alessi, "What Is Rural?" from Visualizing the Rural West, April 2010, Bill Lane Center for the American West, Stanford University, http://ruralwest.stanford.edu/cgi-bin/web/WhatIsRural.php.

[15] David Hartley, “Rural Health Disparities, Population Health, and Rural Culture,” (American Journal of Public Health, October 2004), 94(10): 1675-1678.

[16] See D.R. Hyde, P. Wolff, Anne Gross, and E.L. Hoffman, “The American Medical Association: Power, Purpose, and Politics in Organized Medicine,” (The Yale Law Journal, May 1954), 63(7): 937-1022; Andrew H. Beck, “The Flexner Report and the Standardization of American Medical Education,” (Journal of the American Medical Association, 2004). 291(17): 2139-2140; and Molly Cooke, David M. Irby, William Sullivan, and Kenneth M. Ludmerer, “American Medical Education 100 Years After the Flexner Report,” (New England Journal of Medicine, 2006), 355(13): 1339- 1344.  

[17] Reuben Kessel, “The A.M.A. and the Supply of Physicians,” (Law and Contemporary Problems, 1970), 35(2): 267-272.

[18] Monica Noether, “The Growing Supply of Physicians: Has the Marketplace Become More Competitive?” (Journal of Labor Economics, 1986), 4(4): 503-537 and Medical Education Futures Study, The George Washington University School of Public Health and Health Services, October 2008, online at http://www.medicaleducationfutures.org/uploads/PhysicianSupplyFollowsFederalPolicyALessonFromHistory.pdf

[19] David Blumenthal, “New Steam from an Old Cauldron: The Physician Supply Debate,” (New England Journal of Medicine, 2004), 350(17): 1780-1787, and Leo F. Schnore, “Statistical Indicators of Medical Care: A Historical Note,” (Journal of Health and Human Behavior, 1962): 133-135.

[21] Sidney Fine, “The Kerr-Mills Act: Medical Care for the Indigent in Michigan, 1960-1965,” (Journal of the History of Medicine and Applied Sciences, 1998), 53(3): 285-316.

[22] Reuben Kessel, “The A.M.A. and the Supply of Physicians,” (Law and Contemporary Problems, 1970), 35(2): 267-272.

[23] Michael Dill and Edward Salsberg, “The Complexities of Physician Supply and Demand: Projections Through 2025,” American Association of Medical Colleges Center for Workforce Studies, November 2008.

[24] Reuben Kessel, “The A.M.A. and the Supply of Physicians,” (Law and Contemporary Problems, 1970), 35(2): 267-272.

[25] US Department of Health and Human Services, Health Resources and Services Division, “Shortage Designation: Health Professional Shortage Areas (HPSAs),” downloaded from http://bhpr.hrsa.gov/Shortage/hpsacritpcm.htm

[26] Richard A. Cooper, Thomas E. Getzen, Heather J. McKee, and Prakash Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” (Health Affairs, 2002), 21(1): 140-154.

[27] See William A. Rushing, “The Supply of Physicians and Expenditures for Health Services with Implications for the Coming Physician Surplus,” (Journal of Health and Social Behavior, 1985), 26(4): 297-311, and Richard Cooper, “Weighing the Evidence for Expanding Physician Supply,” (Annals of Internal Medicine, 2004), 141(9): 705-714.

[28] David Goodwin, “Do We Need More Physicians?” (Health Affairs, February 4, 2004), W4: 67-69.

[29] Map Sources: Rural Assistance Center, using data from the Health Resources Service Administration, “Health Professional Shortage Areas” Map. January 6, 2010, http://www.raconline.org/maps/mapfiles/hpsa_primarytype.png, and Health Resources Service Administration, “Health Professional Shortage Areas” Map. April 4, 2010, http://www.raconline.org/maps/mapfiles/mua_muptype.png.

[30] Rural Assistance Center, using data from the Health Resources and Services Administration (HRSA), Bureau of Health Professionals, January 6, 2010.    available at http://www.raconline.org/maps/.

[31]  Rural Assistance Center, using data from the Health Resources and Services Administration (HRSA), Bureau of Health Professionals, April 4, 2010.    available at http://www.raconline.org/maps/.

[32] US Department of Health and Human Services, Health Resources and Services Division, “Shortage Designation: HPSAs, MUAs & MUPs,” downloaded from http://bhpr.hrsa.gov/shortage/

[33] David A. Kindig and Thomas C. Ricketts, “Determining Adequacy of Physicians and Nurses for Rural Populations: Background and Strategy,” (Journal of Rural Health, 1991) 7(4): 313-326. See also Department of Health and Human Services, “National Heath Service Corps,” http://nhsc.hrsa.gov/.

[34] Government Accountability Office (GAO), “Health Professional Shortage Areas: Problems Remain with Primary Care Shortage Area Designation System,” GAO-07-84 (October 2006)

[36] American Medical Association, 1909 Directory of Physicians and 2009 Directory of Physicians.

[37] See Paul Sutton, “Modeling Population Density using Nighttime Satellite Imagery and GIS” Computers, Environment and Urban Systems (1997), 21(3/4): 227-244, Paul Sutton, Dar Roberts, Chir Elvidge, and Henk Meij, “A Comparison of Nighttime Satellite Imagery and Population Density for the Continental United States.” Photogrammetric Engineering and Remote Sensing (1997), 63 (11):  1303-1313, and for an explanation of how this imagery was incorporated into the accompanying visualization, see Rebecca LaGrandeur and Michael De Alessi, "What Is Rural?" from Visualizing the Rural West, April 2010, Bill Lane Center for the American West, Stanford University, http://ruralwest.stanford.edu/cgi-bin/web/WhatIsRural.php.

[38] L.D. Baer and L.M. Smith, “Nonphysician professionals and rural America,” In: Ricketts TC, ed. Rural Health in the United States. (New York, NY: Oxford University Press Inc, 1999), 52–60.

[39] Government Accountability Office, “Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services,” GAO-08-472T (February 2008).

[40] Eric H. Larson, Lorella Palazzo, Bobbi Berkowitz, Michael J. Pirani, and L. Gary Hart, “The Contribution of Nurse Practitioners and Physician Assistants to Generalist Care in Washington State,” (Health Services Research, August 2003), 38(4): 1033-1050; Donna M. Anderson and Mary B. Hampton, “Physician Assistants and Nurse Practitioners: Rural-Urban Settings and Reimbursement for Services,” (Journal of Rural Health, 1999), 15(2): 252-263; Walter A. Morgan and Nancy D. Sullivan, “Nurse Practitioner and Physician’s Assistant Clinics in Rural California” (Western Journal of Medicine, 1980), 132(2): 171-178.

[41] Utah Medical Education Council, 230 South 500 East Suite 210, Salt Lake City, UT 84102-2062, http://www.utahmec.org/.

[42] One immediate research question based on the Utah data would be to ask whether nearby states such as Idaho and Montana, which do not have accredited state medical schools, have experienced similar trends in relative increases in physicians and NPs and PAs.

[43] See Michael De Alessi, “The Rural West: Jovial No More?” in The Expansion and Contraction of the Rural West, web-published by the Bill Lane Center for the American West (April 2010).

[44] American Association of Medical Colleges (AAMC), “Medical Schools” downloaded from http://www.aamc.org/medicalschools.htmAugust 13, 2010.

[45] The only other states without an accredited medical school are Maine and Alaska.

[46] One major program, the Utah Health Care Workforce Financial Assistance Program>, was eliminated in the 2009 state legislative session. See http://health.utah.gov/primarycare/scholarloanmenu.html

[47] Numerous studies have shown that physicians are more likely to practice in rural areas if they grew up in rural areas. See, for example, Zina Daniels, Betsy J. VanLeit, Betty J. Skipper, Margaret L. Sanders, and Robert L. Rhyne, “Factors in Recruiting and Retaining Health Professionals for Rural Practice”, (The Journal of Rural Health, 2007), 23(1): 62-71.

Last modified Tue, 5 Jul, 2011 at 6:12