1. Factors Influencing
Physicians’Choice to
Practice inUnderserved
Areas
Lana Nassif

2. Important?
Higher concentrations of physicians, particularly primary healthcare
physicians:
Lower overall mortality
Improved outcomes in multiple health-related parameters
References (1-6)

3. Reality
Shortage Designations :
• Medically Underserved Areas (MUAs)
• Medically Underserved Populations (MUPs)
• Health Professional Shortage Areas (HPSA)

4. How Big ?
 82 million living in Health Professional Shortage Areas
 14 million living in Medically Underserved Areas
 4 million being designated as Medically underserved populations
(Health Resources & Services Administration, 2020)

5. Federal
Programs
State
Programs
Educational
Programs

6. PICOTQuestion
How do financial incentives, demographic factors, and educational
programs characteristics’ compare in their ability to influence
physician’s choice to practice in medically underserved areas?
P: Physicians
I: financial incentives, demographic factors, and educational programs
characteristics’
C: absence of positive factors
O: choice of medically underserved areas as a area of practice
T: not determined

7. Databases
• Pubmed
• Cochrane Library
• Cinahl

8. Pubmed
 “Medically underserved area” AND “professional practice
location”:
508 papers
 Meta-analysis, systematic reviews and RCTs:
4 relevant articles

9. Cochrane
“Medically Underserved Area”:
 2 results, with only one study being relevant.

10. Cinahl
 “Medically underserved areas” AND “Healthcare Professionals“
 44 results
 Only 4 relevant

11. Review
Process
 Reviewed abstracts of 10: chose 5 (relevance and level of
evidence)
 Full-text analysis of articles
 3 articles (level of evidence, relatedness to PICOT question,
publication year, and sample size).

12. Study #1
 Metanalysis and systematic review
 Whether medical student clinical education experiences in rural
areas, MUAs, and HPSAs influence their ultimate practice location
and specialty
 Meta-analysis: Level I
 Systematic review: Level 2a (systematic review of cohorts)
(RaymondGuilbault andVinson, 2017)

13. Study #1:
Results
 “ Undergraduate medical students training in rural or underserved
areas are about three times as likely to practice in those areas as
their peers (RR = 2.94; 95% CI = 2.17, 4.00” (p. 150)
 Characteristics that make one training program more successful
than another need further studying

14. Study #2
 Systematic review
 Factors associated with providers’ choice of geographic area of
practice (rural underserved vs other locations)
 Success rate of training programs attempting to recruit rural
providers.
 Level of evidence: 2a -3a (heterogenous observational)
MacQueen, Maggard-Gibbons,Capra, Raaen, Ulloa, Shekelle,
Miake-Lye, Beroes, and Hempel, 2018)

15. Study #2:
Results
 Provider characteristics rural training experience, financial
aspects, and training-based interventions
 Inconsistent/weak evidence, including financial factors
 Strongest: background of being raised in a rural area.

16. Study #3
 Systematic review
 Factors most strongly associated with primary care
physicians (PCPs) choice of underserved areas as
practice location
 Level of evidence: 2a -3a (heterogenous observational)
(Goodfellow, Ulloa, Dowling,Talamantes,Chheda, Bone,
and Moreno, 2016)

17. Study #3:
Results
 Personal characteristics and background, financial factors, medical
school curricula, and GME programs
 Background, ethnic-identification and language matching
increased the likelihood of practice in such an area.
 Exposure of students has a positive influence on practice location
(true over a long period of time –decades)
 Financial factors: inconclusive

18. ClinicalDecisionfor PracticeChange
Financial Factors:
- Evidence was contradicting
- Loan repayment programs demonstrated the highest
retention rate
- Health professional education financing models rather than
incentives
•

19. ClinicalDecisionfor PracticeChange
Educational Exposure:
-Varying positive effect
- Factors affecting the success rates are poorly understood
-Variable applicability, but relatively more achievable

20. ClinicalDecisionfor PracticeChange
Background Characteristics:
- Contradicting results for some factors
- Race, ethnicity, and language
- personal ties to underserved areas

21. Conclusion

22. References
1. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health.The
Milbank quarterly, 83(3), 457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
2. Shi, L., Macinko, J., Starfield, B., Xu, J., Regan, J., Politzer, R., &Wulu, J. (2004). Primary care, infant
mortality, and low birth weight in the states of the USA. Journal of epidemiology and community health,
58(5), 374–380. https://doi.org/10.1136/jech.2003.013078
3. Emery, J. D., Shaw, K.,Williams, B., Mazza, D., Fallon-Ferguson, J.,Varlow, M., &Trevena, L. J. (2014).The
role of primary care in early detection and follow-up of cancer. Nature reviews. Clinical oncology, 11(1),
38–48. https://doi.org/10.1038/nrclinonc.2013.212
4. Friedberg, M.W., Hussey, P. S., & Schneider, E. C. (2010). Primary care: a critical review of the evidence on
quality and costs of health care. Health affairs (Project Hope), 29(5), 766–772.
https://doi.org/10.1377/hlthaff.2010.0025
5. Shi, L., Starfield, B., Politzer, R., & Regan, J. (2002). Primary care, self-rated health, and reductions in
social disparities in health. Health services research, 37(3), 529–550. https://doi.org/10.1111/1475-6773.t01-
1-00036

23. References
6. Ferrante, J. M., Lee, J. H., McCarthy, E. P., Fisher, K. J., Chen, R., Gonzalez, E. C., Love-Jackson, K., &
Roetzheim, R. G. (2013). Primary care utilization and colorectal cancer incidence and mortality among
Medicare beneficiaries: a population-based, case-control study. Annals of internal medicine, 159(7), 437–446.
https://doi.org/10.7326/0003-4819-159-7-201310010-00003
7. Health Resources and Services Administration. (December, 2020). Retrieved from:
https://data.hrsa.gov/topics/health-workforce/shortage-areas
8. Raymond Guilbault, R.W., &Vinson, J. A. (2017). Clinical medical education in rural and underserved areas
and eventual practice outcomes: A systematic review and meta-analysis. Education for health (Abingdon,
England), 30(2), 146–155. https://doi.org/10.4103/efh.EfH_226_16
9. MacQueen, I.T., Maggard-Gibbons, M.,Capra,G., Raaen, L., Ulloa, J. G., Shekelle, P. G., Miake-Lye, I.,
Beroes, J. M., & Hempel, S. (2018). Recruiting Rural Healthcare ProvidersToday: a Systematic Review of
Training Program Success and Determinants of GeographicChoices. Journal of general internal medicine,
33(2), 191–199. https://doi.org/10.1007/s11606-017-4210-z
10. Goodfellow,A., Ulloa, J. G., Dowling, P.T.,Talamantes, E., Chheda, S., Bone, C., & Moreno,G. (2016).
Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United
States: A Systematic Literature Review. Academic medicine : journal of the Association of American Medical
Colleges, 91(9), 1313–1321. https://doi.org/10.1097/ACM.0000000000001203