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Friday Sep 26, 2014

The Doctor is Out: Retention Poses Major Challenge for CHCs

HHS announced Sept. 12(www.hhs.gov) that it is making nearly $300 million available to nearly 1,200 community health centers (CHCs) across the country. The funding is intended to help CHCs hire more than 4,700 new health care professionals and offer longer hours and expanded services, including oral health, behavioral health, pharmacy and vision.

The funding is expected to help CHCs reach about 1.5 million new patients.

Although the funding for additional staff is needed -- and welcome -- the change doesn't address one of the biggest problems CHCs face -- retention. Not only do these clinics need more physicians, they need the physicians already working in these settings to feel motivated to stay in communities where they are desperately needed.

© 2014 Casey Health Institute
My first job after residency was at a community health center, but I now work at an integrative primary care practice. Research has shown that family physicians at community health centers have lower rates of job satisfaction.

Federally qualified health centers (FQHCs) are a source of primary care for millions of uninsured and underinsured patients. They're also the place where many family physicians -- like me -- get their first "real" job outside of residency.

I spent my first four years out of residency at a CHC, and I loved it despite the challenges. I served a culturally and socioeconomically diverse population that was in need of good health care. I truly felt like I was living up to being the doctor I wrote about in my medical school personal statement.

In addition to the reward of serving a community desperate for medical care, many physicians are drawn to CHCs by offers of loan repayment -- either as part of a National Health Service Corps commitment or through state and local programs. Although many physicians enter these doors excited and eager to help the people they went to medical school to serve, too often, physicians are just as eager to leave after their loans are repaid.

Research tell us that family physicians at CHCs are less satisfied(www.jabfm.org) with their work situation than other physicians. The reasons are multifactorial, including low compensation(www.researchgate.net) and excessive workload. Isolation from cultural activities and limited career opportunities for physicians' spouses in rural areas also contribute to dissatisfaction.

I saw several colleagues come through, do their time, repay their loans, and move on. This is a common theme, because family physicians often feel burned out after just a few years at a CHC. Many went to an FQHC not just to get their loans paid off, but rather to make a difference and fulfill a personal mission to serve the underserved. One friend and colleague told me she planned to come back to an FQHC at some point in her career. But after five years of having worked in that setting, she felt that if she hadn't left when she did, she would never have wanted to go back.

More than half the states and the District of Columbia are expanding their Medicaid programs under provisions of the Patient Protection and Affordable Care Act. Many of these new Medicaid enrollees will be seen at CHCs because many private practices don't accept Medicaid. This could lead to an increase in patient visits -- and potential headaches -- at the centers, which often struggle to fill vacant positions for physicians and other clinicians. To make matters worse, the low retention often creates a burden for those who do stay.

My interest in CHCs started in high school because I had a mentor who worked in that setting. Later, I volunteered at CHCs during medical school, and I had no doubt where I wanted to go after residency.

When I left my first job at a CHC, it wasn't because I was burned out. I had an amazing opportunity to work as a White House Fellow and spent a year advising the U.S. Department of Agriculture on a range of issues related to nutrition. When my time there was up, I didn't go back to an FQHC. Although I don't miss the headaches, I do miss serving that population.

Today, I'm the medical director of an integrative primary care practice where we incorporate some of the features of an FQHC to ensure access to care, including a sliding payment scale for uninsured patients and a sliding scale for insured patients who seek services that may not be covered, such as chiropractic, acupuncture and massage therapies. At the same time we're trying to ensure access in the way FQHCs do, we're trying to avoid some of the pitfalls these centers face. We try to give our clinicians the time, space and support they need in order to be there for patients and to make them feel valued and respected.

So how do we get more CHCs to operate the same way and improve their recruitment and retention rates?

  • The Bureau of Primary Health Care (BPHC), a segment of HHS that funds health centers, should track physician retention at FQHCs and publish these data along with other quality measures. Ultimately, the goal would be to create a recommended standard for clinician retention that centers can be compared against.
  • Once a physician commits to a community for the long term, that community has a powerful advocate. The BPHC should encourage FQHCs to create strategies for physician recruitment and retention. The National Association of Community Health Centers has already done a lot of work in this area.
  • The AAFP recently established member interest groups to provide a forum for AAFP members with shared professional interests. A CHC member interest group would provide physicians who work in these settings to communicate with each other and develop relevant AAFP policy. If you are interested in starting a member interest group for family physicians in CHCs, you can find more details -- including information regarding the criteria and application process -- online.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Posted at 03:46PM Sep 26, 2014 by Kisha Davis, M.D.

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