Q&A with Tim Skinner, Executive Director of the National Rural Recruitment and Retention Network (3RNet)

By Laura Trude, HWIC Information Specialist

The lure of entertainment, convenience, and being where things are happening draws many health professionals to jobs in cities and their suburbs. The slower pace of a small town far away from shopping centers and major businesses makes health personnel shortages a chronic problem for rural communities. Yet some people prefer that pace of life. The not-for-profit National Rural Recruitment and Retention Network (3RNet) members help connect health professionals who want to work in rural and underserved areas with the communities who need them. Tim Skinner helps oversee this network as its executive director. Here, he shares his insights on rural health workforce recruitment and retention, trends, and success stories.

Given your hands-on role working with providers and communities, what are some things you see that someone looking at workforce data might miss?

While working with rural and urban underserved communities, one of the biggest things we see is the importance of involving the community in the recruitment and retention of medical professionals. If they don’t have a shortage today, they probably will in a couple of years. How are they planning for that? What is their strategic plan for the medical facility and the community combined? They need to assess their community’s medical and health care needs, look at how the community currently responds to them, and identify the strengths of their community so that they can respond to the issues at the local level.

One of the things we know is that recruiting a physician or pharmacist not only meets the health care access needs of the community, it brings additional dollars into the local community. People come to see patients and they go to the restaurant, they use the other stores in town, and they hire people to work for them, adding salary into the community. Rural Health Works studies show that family physicians may bring in another million dollars a year into the community in addition to what happens in the hospital and the clinic. That’s a community development issue that needs to be tied into recruitment and retention of medical professionals.

The other thing that most people don’t realize, but which people working in the field have known since 1952, is that rural communities have chronic shortages of physicians and other health care providers. In 1952 there was a Presidential commission on the health needs of the nation and they found “There are not enough general physicians and most of those we have are so busy they cannot give the patient the time and sympathetic care the old family doctor could give.” While people have suddenly become very concerned about a shortage of providers this last four or five years, as a nation, we’ve known about this for a long time. It’s not a new issue; it’s just one that we have failed to address. And I hope now, it looks like we are finally addressing it.

The other thing that people looking at workforce data see is a slight uptick in medical school enrollment. More medical schools are being developed with a community and/or rural focus. In the most recent Match for family medicine, in March 2010, they matched more medical students to family medicine residency programs. On the other hand, even though we are seeing more medical schools, more community programs, and an increase in the number of students choosing family medicine, medical schools still need to admit more students from rural communities. They may not achieve the highest MCAT scores, but they’ve got the personality and the grades and the brains to be very, very good physicians. We need to concentrate on getting more and more students interested in health care and medicine in rural communities. And the AHECs [Area Health Education Centers] are doing a great job with that and so we need to support them.

While we are seeing more medical students choosing family medicine, it wasn’t a big surge. They filled up 98 more spots than 2009. On the flip side, very, very few people going into internal medicine, like two percent, go into general medicine as a profession. Most of them are going on to subspecialty training or are taking jobs as hospitalists. It’s shift work, there’s no call – they’re either on duty or they are off work. It’s a lifestyle issue.

The other thing people looking at data may or may not find is that graduating providers have a whole list of things they look at: time away from family; call schedule; debt and debt reduction possibilities; colleagues of similar age who are friendly and professional; compensation; quality facilities; access to specialists even if it’s through telemedicine; time spent on the business side of medicine; ability to have a voice in the clinic and hospital; opportunities for CME; participation in teaching or academic activities; opportunities for research; a welcoming community that is safe and family-oriented; the feeling that they can make a difference in the community; availability of adequate housing; access to places of worship; a stable local economy; recreational activities; employment opportunities for spouse/significant other; educational facilities for children; proximity to relatives (or not); and access to cultural, entertainment, and sporting events. They are choosing a lifestyle when they determine where they are going and what they will practice. If people can practice where there is no call schedule or call schedule is one in twelve, they are going to choose that over a rural community with a call schedule of one in two or three. NPs and PAs are doing the same thing, choosing specialty work to avoid that. It’s something we have to keep working on and is a serious challenge in small practices.

People probably realize that we have this huge bulge of baby boomers in the health care population that are at retirement age or very close and we’ve got that same bulge in the general population that needs more medical and health care. A lot of people are concerned that when the economy completely turns around, which it’s starting to do, we are going to see a huge rash of retirements. It’s going to be interesting to see whether we can be flexible and coax older workers to stay, particularly physicians. Can we give them part-time work? Can we arrange locum tenens situations for them? Can we be flexible and keep them around to see patients and yet give them a break and some lifestyle relaxation?

If you compare the United States with other countries, our physician to population ratio is low, but the more significant concern is that we have more specialists serving the population than primary care providers. That’s an issue we need to keep addressing.

What health workforce trends have you noticed in the past year in your role as director of the National Rural Recruitment and Retention Network?

In the past couple of years, we have had more collaboration between national organizations that work in rural communities and support rural health care like the National Rural Health Association, Agency for Healthcare Research and Quality, AgriSafe, National Organization of State Offices of Rural Health, National Cooperative of Health Networks Association, 3RNet, and Western Interstate Commission for Higher Education. We have pulled together and collaborated on various issues as they relate to rural. I think we are going to see more of that at the state level. State budgets are in such bad shape right now that state-based agencies and private non-profit agencies are forced to collaborate and partner because they need to share their resources – both personnel and budgetary resources – in order to serve their state.

As an example, say an office of rural health loses most of its state budget. Perhaps the state primary care association has a budget and maybe the rural health office has personnel resources for recruitment, so they decide to collaborate and form a partnership. In the past, state organizations tended to, not always, but tended to have turf battles about who is running the show. We are going to see more and more collaboration, which is a good thing that needs to happen.

How do you anticipate the rural health workforce landscape will change in the next decade?

We will see more electronic communications like clinical health records. Broadband will really open things up for rural areas, which is going to be a real plus because we are training people right now in health care on all of the electronic equipment. People have handhelds, laptops, iPads, PDAs – if rural communities are not able to provide access through that technology, younger people are not going to be interested. This generation grew up with and trained in medicine to use electronic resources heavily to work with patients and to meet the needs of their patients by accessing information and other health care professionals for referrals and consults, etc. I cannot imagine anyone in the millennial generation considering going out to practice without that, it’s such a part of their lives. As we extend broadband and electronic medical records, it will really help rural America with some of their workforce issues.

The other thing is that the millennial generation is constantly connected. If they cannot do that at work, it is going to be a problem. They also work differently than I do. I am a baby boomer; give me a project and I go off into my little corner and work on it, maybe collaborate on it and get it done. Give the same project to a millennial, they get a couple or three people together and whip it out in two hours and then they say, “Okay, time to play now, I want to go on the internet.” We have got to recognize that and deal with it.

Part of that changing landscape is teaching Baby Boomers and Generation-X’ers and Millennials how to work together. A lot of that is going to rely on the baby boomers being flexible. That’s a two-way street, too. The Millennials need to look to that older generation and say, ”Hey that’s not right,” when needed. Baby-boomers also can’t automatically assume they will be mentors to new people coming in. Many of them will be good mentors, but you can’t force mentorship onto people; it has got to be a mutual decision. Unfortunately, there is still some of that negative mentoring going on.

How do you expect health reform and particularly the National Health Service Corps trust fund will affect 3RNet and the ability of rural communities to attract and retain health care providers?

The National Health Service Corps and 3RNet have been partners going back three or four years now. That relationship continues to grow. 3RNet has done some large training sessions with the NHSC on how to do recruitment and retention around the country and those have been very well received. We are also working with the Corps on manuals, surveys, and other things and I think we will continue to do various projects for the Corps. The NHSC has been very well-funded recently with the ARRA money; I am concerned what is going to happen when that runs out. That has been a real boon for rural communities.

Our relationship continues to get stronger probably because the Corps recognizes that 3RNet members are doing much of the recruitment for NHSC sites and they also know that 3RNet members in general are well schooled in recruitment, retention, and other health workforce issues. It’s a good, solid, and fun relationship.

As for health care reform, that’s a really tough one right now. I hardly know what to say to that one, because I don’t know what is going to happen with health care reform. If it continues as envisioned, that will strengthen the Corps, 3RNet, the rural health clinics, the critical access hospitals, and not just the community health centers. With what’s going on with health care reform right now, who knows?

If 3RNet had unlimited funding, what would they do?

I love that question. Actually, we are in the process right now of updating and improving our website. Our website is complicated because candidates can register and select states of interest or specific jobs and change their preferences. Then we have this huge database of candidates in the background that’s not accessible to anyone other than members, so it’s a fairly complicated site. If we had unlimited funding right now, we would push pretty hard to make some changes and develop our new website and connect it with practice sites.

We would also add staff and provide a lot more technical assistance than we are able to do right now like workshops, presentations, and webinars. We would also be more available for consultations when communities have issues that affect their access to health care and their recruitment and retention of medical professionals. All of those issues take more people. We currently have three full-time equivalents for 3RNet which are held by four people, as the Co-Director Tom Tucker and I job share. Our members do quite a bit and offer presentations and speakers, but they have jobs too. It would be nice if we had the funding to do more and offer more.

Tell me about some of your success stories.

Since the National Research Center started evaluating 3RNet in 2004, 90% of all placements made by 3RNet members have been to designated shortage areas. I think that says more about 3RNet and our members than anything.

Although we saw a slight decrease in the number of opportunities that were posted last year, in spite of the recession, we’ve continued to see real increases in the number of applicants who were interested in looking at rural and underserved locations. Even last year that number went up again. I have preliminary figures for 2010: 5,418 postings; 20,748 applications; and 1,255 placements.

Some people ask why we don’t base our evaluations on placement alone. I can’t influence placement. Our members can’t influence placement. Who makes the placement decision? That’s the health care facility and the candidate. We don’t push placements; we give people the information so they can make a good decision. I always tell candidates that my job is to help them make a good decision and I’d rather have them do that and go elsewhere than make a bad decision and join our group.

Individually, there are some examples that 3RNet members have sent us. I think a lot of people are familiar with the TV show Deadliest Catch; there is a little health clinic in Dutch Harbor where the fishing boats launch from. They found their PAs and NPs on 3RNet. You can’t get much more rural than Dutch Harbor, so that was a treat to see.

Occasionally we’ll get a note from a resident or a nurse practitioner or a PA or a nurse or a pharmacist that is quite positive. There’s one from Alaska where one of the clinics was thanking our Alaskan member, who said, “The credit goes to 3RNet for forwarding all of the good candidates!” Those are the kinds of things we like to see.

A PA candidate commented on how wonderful this organization has been as a resource for exploring states in the western US and New England. She was particularly amazed at how willing 3RNet members were to share information about other states whereas other recruiters, particularly recruitment firms, won’t do that. I appreciate that we can help each other out: if a candidate talks to somebody in one part of the country and decides it’s not quite for them, that candidate can be connected right away to somebody on the other side of the country.

Recruitment firms charge a placement fee that can approach $50,000. We would much rather see communities keep that money in their community and in their health care facilities, using it to improve access. When you look at 1,200 placements a year for the last couple of years and multiply that even by a conservative $30,000, that’s the amount of money being saved that those communities can keep in their communities. It’s really pretty substantial.

Is there anything else you would like to add?

I love my job. I’ve got the greatest job in the world because I feel like I’m doing good deeds and helping people all over the United States. That’s why I’m not retiring.

Tim Skinner can be reached at 608.782.0660 or skinner@3rnet.org. For a list of 3RNet members by state, see https://www.3rnet.org/about/all-members.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.