Calidad de vida en las plazas

The practice of medicine in North Carolina (and nationally) has undergone dramatic change in the past twenty years. Fee-for-service and private insurance arrangements have declined while health maintenance organizations (HMOs) and public insurance plans (i.e. Medicaid and Medicare) have grown. Lengths-of- stay in hospitals have dropped dramatically and many medical procedures that formerly required inpatient stays are now performed on an out-patient basis. Health care has become more regional and less local. Procedures that once were performed by a primary care physician or general surgeon in a rural area are now referred to tertiary care settings in urban areas. Practice arrangements for physicians have also changed. Fewer physicians practice in traditional self-

employed practitioner offices and more are salaried in group practices.

Physicians are increasingly specializing and fewer medical students are opting for careers in primary care.

Despite the fact that these changes in the context of medical practice are fairly obvious and well-documented, a review of the literature reveals that almost without exception, physician workforce analyses fail to employ birth cohort

analyses to explore the importance of historical change on physician practice behaviors [30]. The vast majority of workforce analyses are cross-sectional or longitudinal with few observation periods. Those studies that are longitudinal analyses have generally failed to investigate the dynamic interaction over time of the physician’s developing career trajectory and the changing practice

environment.

The importance of studying the interrelated changes in two research units— the individual and the surrounding structures—is a recurring theme of life course research and was demonstrated by Streib (1993) in a study of retirement

communities. Streib found that “the characteristics and experiences of residents in these communities depended not only on the residents but also on the

‘adaptability, vitality, and long range survival’ of the community itself….just as residents grow older over time and new cohorts are recruited, structures also move through ‘stages’—social, economic and physical”. (quotation marks in the original) [7].

Recognizing the importance of context to decisions about where to practice, Cutchin (1994) proposed that the physician’s “socio-cultural integration” in the

rural community was a predictor of retention [31]. Cutchin proposed a theoretical model of retention called “experiential place integration” that suggested that “each physician’s pathway of integration is an outcome of the combination of unique personal history and self with a specific situation and time” [32]. This dissertation builds on, and extends, Cutchin’s beginning formulations of a more dynamic theory that incorporates the interplay of the physician’s developing career and the changing rural practice environment. However, instead of investigating retention in rural areas, this analysis focuses on the physician’s decision to move into a rural area. Further, because the dataset used in this dissertation has many more observations than were in Cutchin’s analysis and because it contains data on the physician and the rural practice environment over a longer period of time, it allows for a richer comparison of career transitions into rural areas between different cohorts of physicians who practiced in different historical periods.

A temporal version of Bronfenbrenner’s ecology of human development provides one way to conceptualize the complex interaction of the physician’s unfolding career and his or her changing practice context. Bronfenbrenner

proposed that “[t]the characteristics of the person at a given time in his or her life are a joint function of the characteristics of the person and of the environment” and he suggested that this interaction occurs at three levels: a micro-, meso- and macro-level [33]. While Bronfenbrenner’s conceptualization of the ecology of human development does not consider how temporal factors such as age and historical time influence life transitions, his typology provides a useful way to

structure an investigation into the way in which physician’s career decisions are influenced by the rural practice environment.

Micro-level influences might be exerted by the norms of the particular specialty in which the physician practices. Physician specialties exert a strong socializing force upon their members and the professional culture of surgery is very different than that of family medicine. Meso-level structuring might occur at the level of employment setting. Hospitals in rural areas may open or close. Physician practice settings have changed. More physicians are employed in group practice settings while solo-practitioner offices used to be more of the norm in rural areas. Increasingly, large tertiary medical centers are buying small rural practices. The availability of jobs in certain practice settings, as well as collegiality and competition from other providers is likely to affect rural physician career decisions.

Examples of macro contextual factors likely to influence the entry decisions of rural physicians include the proportion of the population on

Medicaid; changes in population size and the economic growth or decline of their community; and the presence of service sector industries that contribute to physicians’ quality of life (i.e. availability of shopping and entertainment centers). At the broadest macro-level, changes in societal expectations about female physicians’ roles as mothers and doctors also need to be considered.

The strength of basing this analysis on life course theory is that the theory provides a new lens through which to view physician careers. The life course framework suggests an approach that first identifies the major changes that have

occurred in the rural and medical practice over time and then investigates how these effects may have influenced the decision to enter rural practice for

successive birth cohorts of male and female physicians who encountered these changes at different ages and stages of their medical careers.

2.2. Cohort Effects: The Changing Context of Medical Practice