Obstetricians and gynecologists are notoriously difficult to recruit to rural areas, but offering the right candidates loan forgiveness, shortened work weeks, extra vacation time, and housing allowances can be effective.
Patients living in rural areas may be accustomed to having to travel for healthcare services, but few specialties have become as inaccessible as obstetrics and gynecology, says Katy Kozhimannil, PhD, MPA, assistant professor of health policy and management at the University of Minnesota School of Public Health.
"I'm speaking specifically to obstetrics and childbirth services, but in general, there are access issues and challenges to delivering services in rural areas," she says. Between 1985 and 2000, hospitals in rural areas providing obstetric services dropped by 23%—and that number is on the rise.
Traveling for OB/GYN care is not ideal. "Studies have shown that the farther expectant women have to travel for their prenatal care and delivery, the higher the rate of infant and maternal morbidity," Kozhimannil says.
Rural Life
Obstetricians and gynecologists are notoriously difficult to recruit to rural areas, says Kenneth Platou, president and CEO of Dignity Health Mercy Medical Center in Mount Shasta, CA, a rural city in the far northern part of the state with a population of approximately 3,500.
He says it's important to filter candidates carefully and make sure their lifestyles are compatible with remote regions. "It takes a special kind of physician to want to practice in rural settings," he says. "The biggest barrier is the lifestyle. You have to like small-town life. If you like opera and Nordstrom's, rural opportunities aren't going to appeal to you," he says.
As the town's current gynecologist is nearing retirement, Platou recently found himself in need of finding a replacement. After a rigorous search, a candidate was found, in neighboring Oregon. That means the specialist will have to be licensed to practice in California—a process which, he says, "can take months."
Interstate Medical Licensure Effort Gaining Ground
Mercy Medical Center sweetened the deal by offering a guaranteed income loan for the first year with the hospital—a loan which will be forgiven after and additional three years of service. It was worth the wait and inconvenience, Platou insists, to find a candidate he is convinced will be happy in a small town.
Realistic Recruiting
It's important to play up quality of life perks to candidates and incentivize them, says Tommy Bohannon, a senior recruiter with Merritt Hawkins. He has seen gynecologists and obstetricians offered student loan forgiveness, shortened work weeks, extra vacation time and housing allowances by rural hospitals.
"Whatever it takes to get them there," Bohannon says. "Women's Services is a hard service line to recruit and maintain," he adds, saying that competition for a good gynecologist can be fierce, even in urban centers.
Add in the element of a small town where people might feel distrustful to an unfamiliar clinician and the isolation an outsider might feel, and positions gain the potential to remain vacant for months, if not years.
Following Physician Compensation Trends? Read This First
Bohannon says he's seen many rural hospitals resort to contract labor to maintain gynecology as a service line, which he says should never be considered as a long-term solution. "It's not economically viable and, while passable for routine gynecological procedures, local women will not be comfortable starting their pregnancy with one obstetrician, then giving birth with another," Bohannon says.
He considers himself a realist regarding the situation many rural health systems find themselves in, and believes that maintaining women's services is not financially viable for all systems. "When making these decisions, [leadership] has to ask themselves: is the revenue we're getting worth doing this? Because often, it's not."
Appropriate Level of Care
Kozhimannil conducted a study of rural hospitals in nine states and found that a common strategy to cope with staffing shortages was to team up clinicians with different specialties in an attempt to cobble together the right combination of skills.
"Larger rural hospitals more likely to have an obstetrician or gynecologist and nurse Midwives together," she says, "while smaller facilities often have family physicians working with general surgeons."
She suggests that rural clinics evaluate each pregnancy and determine the proper care setting for that particular mother and her child. "Pregnancy is not an ailment. Most women need a lot of information, support, and some screening, but medical requirements are minimal for 70% of pregnancies." These are the pregnancies that are candidates to be handled in a rural hospital by a nurse midwife or family physician.
But the additional 30% might need a more advanced care setting, says Kozhimannil. "Watch those twins, anxiety disorders requiring meds during pregnancy, women who develop diabetes while pregnant… Those are the higher risks."
For all the obstacles of rural life, rural birth, and rural healthcare, Platou is optimistic about the future of his hospital and others like it. "I can't think where I'd rather [like] be to manage population and community health," he says, including bringing new lives in to this world. "I'd rather be here than in downtown Manhattan."
Lena J. Weiner is an associate editor at HealthLeaders Media.