Study: physicians with service commitments are generally more satisfied with their careers

By DAVID WILLIAMSON
UNC News Services

CHAPEL HILL -- Programs designed to boost health care in medically underserved areas by paying doctors’ educational expenses in exchange for service commitments appear to work well, a new national study concludes.

Perhaps surprisingly, physicians fulfilling obligations to various states were more satisfied in their careers overall than physicians without such obligations, the University of North Carolina at Chapel Hill research showed. The former were more likely to practice in needier areas, and they took care of more Medicaid and uninsured patients. Nine of 10 said that if they had it to do over again, they would still enroll in the government programs.

"There’s been a perception that practicing in a shortage area under a service commitment is a noble and important thing for a young physician to do but also an unpleasant thing," said Dr. Donald E. Pathman, senior fellow at UNC’s Cecil G. Sheps Center for Health Services Research. "This study should dispel the latter notion."

A report on the research appears in the June issue of the journal Medical Care. Besides Pathman, authors are Drs. Thomas R. Konrad of the Sheps Center; Tonya S. King of Pennsylvania State University’s health evaluation sciences department; Donald H. Taylor of Duke University’s Terry Sanford Institute of Public Policy Studies; and Gary G. Koch of the UNC School of Public Health’s biostatistics department.

"States, as well as the federal government, continue to be concerned about the geographic maldistribution of physicians, nurses and other health professionals and continue to search for the most effective ways of attracting practitioners to areas of scarcity," Pathman said. "Among the most common efforts, pursued by four out of five states, are scholarship programs, which pay students' educational expenses if they later work in shortage areas. Loan repayment programs, which repay the educational loans of recently trained practitioners if they move to shortage areas, also are common."

The past dozen years have witnessed a significant growth in the number and size of those initiatives, he said. New programs also have emerged.

"To date, it hasn't been clear which types work best," Pathman said. "Some believe that programs that recruit practitioners after their training work better because that’s the point in young professionals' lives when they are able to judge career paths that fit them and their families and knowledgeably weigh specific practice site options."

Government-funded scholarships, which obligate students years in advance of their required service, have remained popular, however, he said.

The new study assessed outcomes of the various programs with data on primary-care physicians from most state-run programs nationally.

"We found that overall, these programs were quite successful," Pathman said. "Their physicians work in clearly needy and typically rural areas and take care of patients of whom nearly half are uninsured or covered under Medicaid." 

State-obligated physicians are also generally well pleased with their work lives, he said.  "In fact, these young physicians are more satisfied as a group than are other young physicians with no service obligations," Pathman said.

Programs that obligated physicians after their training generally had better outcomes than programs for younger students, he said. About half the students participating in state programs bought out of their obligations rather than serve.

Programs that recruit students therefore often must levy financial penalties to help curtail buy-outs, but this leads to lower physician satisfaction and to physicians leaving their service sites earlier, Pathman said. Programs that committed physicians after training averaged a 93 percent service completion rate, even though most had minimal or no buy-out penalties.

"Physicians in these programs were more satisfied in a couple key ways than participants in programs that committed physicians earlier when they were students," he said.

"Doctors in loan repayment programs also remained longer in their service sites. They even remained longer than physicians who were under no service obligations and who generally worked in non-needy areas."

Pathman said the findings were important because they will show state health officials and legislators how better to entice physicians and other health professionals to work in underserved areas.

"These efforts have generally worked well, particularly those that recruit physicians after they have completed their training," he said "The National Health Service Corps, the federal version of these state programs, recently shifted nearly 90 percent of its program dollars to its loan repayment program and now commits less money to scholarships. What we found suggests it will get better results that way."

The Agency for Healthcare Research and Quality supported the UNC research. Pathman also is associate professor of family medicine at the UNC School of Medicine.

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Note: Pathman can be reached at (919) 966-4270 or don_pathman@unc.edu

Contact: David Williamson, (919) 962-8596