Physician Careers in Rural Areas: Transitions and Trajectories

There is general consensus among health care policy makers on the need to reform and strengthen the primary care infrastructure. This is especially true in rural and underserved areas. Despite significant investment of federal and state dollars in programs to address physician maldistribution, policy interventions have had only limited success. One reason may be that current policies are based on research that does not investigate how the geographic preferences of male and female physicians in different birth cohorts may vary. This dissertation applies the conceptual framework of life course theory from sociology to explore whether the choice of rural practice location diverged for male and female physicians of the same age in different birth cohorts. Licensure data from the North Carolina Board of Medical Examiners were linked at two-year intervals between 1980 and 2005 to form 13 waves of physician-level location histories. Descriptive statistics, logistic regression and event history analyses were employed to compare the timing of transitions into rural practice in North Carolina for physicians in the Boomer 1 (born 1946-1954), Boomer 2 (born 1955-1964) and Generation X (born 1965-1979) birth cohorts. The most compelling finding was that while female physicians in earlier birth cohorts were significantly less likely than their male colleagues to choose rural practice settings, this gender effect was much smaller in the Generation X cohort. The study also found that both male and female physicians in the Generation X cohort were less likely than an earlier cohort to practice in rural counties and that physicians over the age of 50 were more likely to choose rural settings than younger physicians. Existing rural workforce polices are based on research which implicitly assumes that the effect of age and gender on physicians' decisions to enter rural areas is equivalent and fixed across birth cohorts. Findings from this dissertation demonstrate the presence of inter- and intra-cohort differences in rural location behaviors for physicians. The study suggests the need for more dynamic policy levers that are differentially targeted toward male and female physicians in different birth cohorts and are specifically designed to work across physicians' career trajectories