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Implications for Planned Expansion

Roger A. Rosenblatt, MD, MPH; C. Holly A. Andrilla, MS; Thomas Curtin, MD; L. Gary Hart, PhD

JAMA. 2006;295:1042-1049.

Context  The US government is expanding the capacity of community health centers (CHCs) to provide care to underserved populations.

Objective  To examine the status of workforce shortages that may limit CHC expansion.

Design and Setting  Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia, conducted between May and September 2004. Questionnaires were completed by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative.

Main Outcome Measures  Staffing patterns and vacancies for major clinical disciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment.

Results  Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equivalents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty filling positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities.

Conclusions  CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.

Author Affiliations: WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Research Center, Department of Family Medicine, University of Washington, Seattle (Drs Rosenblatt and Hart and Ms Andrilla); and National Association of Community Health Centers, Bethesda, Md (Dr Curtin).

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