Recruiting enough physicians to rural communities can seem daunting, to say the least. One out of every five Americans lives in a rural region. Yet, only 11 percent of doctors practice there, according to a 2010 study in the journal Academic Medicine.

But the analysis, which looked at physician practice locations in 2005, also identified some glimmers of hope. Graduates of rural medicine residency programs were three times more likely to work in rural locations than those who had trained elsewhere. More recently, the Affordable Care Act incorporated some rural training initiatives that, if funded moving forward, could help, experts say. (For more detail, see "Location, Location, Location," in the January 2012 issue of Trustee.)

Still, hospital leaders must be innovative and always searching. "I use anybody that can bring me a doctor when I need it," quips Jim Platt, CEO at Fort Madison (Iowa) Community Hospital, when asked about his recruiting firm preference.

It used to be that subspecialty physicians were more difficult to hire, says Mike Farrell, CEO at 150-bed Somerset (Penn.) Hospital. "That's evened out," he says. "Primary care is as difficult to recruit for as orthopedics and general surgery, as some examples."

To stay ahead of the recruiting curve, hospital leaders apply a mix of strategies, from contracting with firms to growing their own and pursuing any personal connections that might land a talented doctor.

Hiring a Firm

For years, a small emergency physician group had staffed Ocean Beach Hospital, a 15-bed public facility perched on the scenic peninsula of Ilwaco, Wash.

But they were juggling administrative tasks, along with staffing the 24-hour emergency room, says Joe Devin, CEO of the public hospital. As the number of doctors shrank from four to two plus a part-timer, the strain became acute, he says. "Just by working the shifts, they were burning themselves out, much less trying to keep the business going on their side."

Once Devin decided not to continue the group's contract, he knew he had to be ready to get new doctors into the emergency room fast in the event the current physicians walked once he gave notice.

In the fall of 2010, he provided the group two months' notice and hired Dallas-based EmCare physician services to build a new emergency room team. The company, which develops and manages physician practices around the country, was given less than two months to recruit doctors and create a new group, including assuming billing and other administrative tasks.

"It was a faster-than-normal start," says Bill Yarbrough, CEO of EmCare. Ninety days is ideal, although the company has created groups in as few as 28 days or, at the extreme end, six days. "It's possible, but not recommended," he says.

Contracting with a practice management company eased the transition, Devin says. If hospital officials had to recruit directly, it would be difficult to handle all of the credentialing and other logistical work, as well as coordinate with the new doctors to start work at the same time.

Devin asked the company to be ready to get an emergency physician on-site within a few hours, if needed. "When you're planning, you need to be ready for the worst," he says. But the transition proved to be "pretty seamless," and last fall the hospital renewed its contract.

Training Pipelines

Convincing primary care doctors to move to Montana, never an easy task, has become even more stressful in recent years, says Lisa Benzel, who directs the South Central Montana Area Health Education Center in Dillon.

The national primary care shortage certainly doesn't help, she says. "I think it's much easier to work in a setting where you have more amenities and more co-workers, people to lean on," she says. "It's difficult to think of going to a rural area where you might be the only doctor with a mid-level or two."

Still, Benzel harbors some hope for the future, in part due to the establishment of the state's Targeted Rural and Underserved Tract, or TRUST, program in 2008. The initiative, developed through the Washington-Wyoming-Alaska-Montana-Idaho collaboration at Montana State University, is designed to encourage Montana students interested in primary care eventually to practice in the state.

The participating students, a handful each year, are matched with a Montana community and rural physician preceptor shortly before medical school starts. As they progress through school, they return to spend, sometimes, significant stretches of time, as long as several months, working in that same community.

"From what we've seen from the fourth-year med students, we've made some good selections," Benzel says. "Hopefully, we will see the benefit of that in the next three-plus years."

Burke Hansen, M.D., a Dillon family physician and TRUST preceptor, strives to show students the unique challenges and variety inherent in rural practice. Along with performing colonoscopies and tubal ligations, he might be called in the wee hours to deliver a baby.

It's not long before students notice how work and life meld in a small town, he says.

"[The student] starts to realize that the waiter who served her dinner last night — she has a pretty good chance of seeing him in the clinic the next day," he says. "Because that's just simply part of it and you have to feel comfortable with that."

Leveraging Personal Connections

At 50-bed Fort Madison Community Hospital, a new orthopedic surgeon started work last year. But the nonprofit facility's courtship dated back years, to his medical school days, says CEO Platt.

Since the surgeon had married the daughter of one of the hospital's board members at the time, the couple would be in town periodically, Platt says. "We used a lot of local ties to put pressure on him and get them to want to come back," he says, describing ongoing conversations with the couple.

The hospital provided the budding surgeon a small stipend during medical school and then during residency, contingent upon his returning to Fort Madison after training. It was an added bonus that he wanted to practice orthopedics, Platt says. "Orthopedic surgeons in rural areas are very, very difficult to come by." Now that the surgeon has joined the hospital, Fort Madison is paying off his remaining educational loans, Platt said.

This isn't the first time that Platt has taken advantage of local connections to pursue a talented physician. When Platt first was interviewed last fall, he believed that he was weeks away from finalizing the hire of a family practice resident, "a local boy who married a local girl," as Platt describes it.

The physician had completed a couple of training rotations at Fort Madison while studying at Des Moines University, a graduate health sciences university offering degree programs in osteopathic medicine and other areas, located in the state's capital. He returned last fall for a two-week preceptorship during his final residency year. "No pressure," Platt jokes. "We have him tied to a desk right now, and he's got to sign before he can leave."

Platt hoped to have sealed the deal before year's end. But at press time, he was still in negotiations.

Charlotte Huff is a writer in Fort Worth, Texas.