How long will you be staying, doctor?

The data presented in Kim's study can be applied at 3 levels: within the Navajo area, within the Indian Health Service (IHS) as a whole, and within all of rural America. There are important lessons to be learned at each level. The Navajos live in a large and beautiful, if barren, reservation encompassing parts of Arizona, New Mexico, and Utah. Partly for this reason, and partly because their ancestral culture is maintained more than in some other cultures of Indian country, recruiting to the Navajo area has been less difficult than to other parts of the IHS. Kim notes, however, that “if recruitment is excellent and retention is poor, a facility [or an area] can remain understaffed.” When I arrived in Gallup, New Mexico, at the edge of the Navajo Reservation, as a new general medical officer in 1970, I was asked not “Where were you trained?” or “What is your philosophy of care?” but “How long will you be staying, Doctor?” Despite having been served by a succession of well-trained, enthusiastic, and altruistic physicians, my patients were concerned about seeing another new entrant coming through the revolving door. Kim's data have important messages for the IHS and for the Navajo tribe before and after the tribe assumes control of its health care system. The IHS spends considerable money and effort in recruiting to Navajo facilities; it should spend considerable effort in retaining its many good providers. Where administrators are perceived as being unresponsive and unappreciative of the physicians in their facility and the needs of their families, the reality and the perception can be changed. The IHS could also make a strong effort to convince its providers that changeover to tribal control of the health system will be a positive experience, as has been the case in many other parts of the IHS—for example, in most of Alaska, in Chickasaw and Choctaw portions of Oklahoma, and in Warm Springs, Oregon (R Gollub and J Berner, oral communications, July 2000). The tribe could specifically address the issue of making health care available to its non-Indian employees, as it is empowered to do under PL 93-638. It is more difficult to see an easy solution to the “quality of schools” issue. Assuming that the Navajo tribe wishes to retain most of the physicians by whom it is served, it, too, could be more reassuring regarding its intentions to retain and to adequately compensate those physicians. It could signal its intentions even before its takeover of the health system by dealing with the severe housing problem at many of its facilities. Bolte studied questionnaire results from 283 of the approximately 800 IHS physicians across the country.1 Her findings are similar to Kim's in many respects (although dealing only with physicians). With respect to national IHS retention problems, Kim's and Bolte's findings are salient. Some factors are beyond easy IHS control, such as the availability of good schools and recreational and cultural activities. Some, however, could be given greater attention, such as housing, responsiveness of administrators to providers' concerns and family needs, adequate compensation, and professional education. Everling cites 10 scholarship or loan programs available to the IHS for the purpose of recruiting and retaining medical providers2; the only one having to do with providing continuing medical education funds has not been funded by Congress since 1978. Roemer catalogues other countries' methods of dealing with rural health needs.3 In the United States, problems with maldistribution of physicians (away from high-need areas such as rural regions) have been thoroughly discussed over the past decades. Programs such as the highly successful Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia have done well by specifically recruiting students from rural areas who express the desire to return there and by providing a substantial portion of their education in rural areas.4 The retention of PSAP graduates has also been good. The IHS similarly invests a large amount of effort and money in recruiting Native American students into medical fields, assuming that they, too, will return to serve their tribes.4 Burnett and colleagues note that family practice residency programs have in general been most successful at routing graduates to rural areas.5 Among the reasons they give is that “family practice residency programs often are structured specifically to prepare physicians in ambulatory settings in communities for which there are access barriers (geographic, social, or economic).” Other residency programs could make similar efforts to convince students and house staff of the benefits of a rural practice. This would aid recruitment. Employers recruiting physicians to rural communities will find lessons in Kim's data in how to retain them. While “I'm planning to stay forever!” might not be the answer always given to a rural resident, Native American or otherwise, such attention to the details of the life of rural medical providers would improve the chances that they would stay “a long time!”