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Health Services Research & Development

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HSR&D In Progress

December 2021

In This Issue: HSR&D Advances Research in Providing Healthcare for Veterans in Rural Settings
» Table of Contents

Identifying Approaches to Strengthening the VA Physician Workforce in Rural Settings

Feature Article

Takeaway: This study will provide data-driven insights for informing the development of effective strategies to successfully recruit and retain high-quality primary care physicians. A fully staffed and highly skilled physician workforce is one essential element to delivering world-class care to Veterans and their families.

Primary care physician (PCP) shortages are a significant and growing problem confronting the US healthcare system. In addition, rural communities often face challenges in recruiting and maintaining an adequate healthcare workforce, making it difficult to provide patient care. An overall shortage of up to 53,000 PCPs is projected by 2025, and a shortage of PCPs in VA has recently come under increased focus due to the emphasis on improving Veterans' access to high-quality and timely healthcare. Moreover, nearly five million Veterans live in rural settings. Prior research on physician workforce has not examined several important individual, economic, job and system-level factors associated with the recruitment and retention of PCPs by health systems, including components of pay and compensation, academic affiliation, elements of the patient-centered medical home model, and workplace climate. In addition, no prior research has examined the relative importance of these factors in explaining PCP recruitment and retention.

The objectives of this ongoing study (March 2018 – February 2022) are to:

  • Identify and prioritize individual, job, economic, and system-level factors associated with the choice of VA for employment—and the selection of rural practice (i.e., recruitment); and
  • Identify and prioritize individual, job, economic, and system-level factors associated with long-term retention of primary care physicians within VA and in rural VA clinics.


To measure factors associated with VA recruitment and physicians’ selection of a rural practice setting, investigators will conduct structured interviews with current internal medicine residents trained in VA settings, as well as new primary care physicians with a permanent VA position. Utilizing information from these interviews, they will develop and administer a new survey to compare influential factors identified by residents and new PCPs. Multivariable analyses will then be used to identify factors that are significantly associated with consideration of VA employment and rural practice among internal medicine residents. Using VA data, investigators also will track VA PCPs’ employment status over the long-term. They also will work to identify all full-time equivalent PCPs assigned to a panel of primary care patients at any time between 2003 and 2016 – and will assess the influence of factors on quarterly retention probabilities and PCPs' expected duration of VA employment. Parallel analyses will assess PCP retention in rural VA facilities. Investigators expect to examine approximately 10,000 PCPs in retrospective analyses of retention, 3,000-6,000 survey responses, and 30-60 interviews.


This research has identified several key contributors to satisfaction with training and working in VA. Notably, participants reflected on the importance of VA culture including service-oriented values, and work-life balance. Residents who were interviewed noted that VA gets unfair media attention and suggested that VA improve advertising and recruitment through exposure. For example, “… training at the [city] VA has really changed my perception of the VA in general, and I am really proud of the care that we deliver, where I think beforehand, I had heard some mixed messages about VAs….”

Residents also noted the need for streamlining and modernizing hiring processes, which was perceived as “very slow” and “piecemeal.” For example, “…I still don’t have a formal offer [months later], and I’m not quite sure why the VA policy is that you can’t give a formal offer contingent on passing credentialing… that puts a lot of stress on the applicant…” Lack of communication from HR was perceived as the biggest barrier.

For more information, see the archived Cyberseminar titled “Best Kept Secret and Red Tape – Resident and Physician Perspectives on Working for the VA,” which is available 24/7.

Anticipated Impact

This study will help VA – and other health systems – identify and prioritize key factors associated with primary care physicians’ employment choices, as well as strategic recruitment of PCPs and the development of evidence-based strategies to retain high-quality physicians. This will ensure appropriate capacity to deliver world-class healthcare services to Veterans and their families.

Principal Investigator

Edwin Wong, PhD is an investigator with HSR&D’s Denver/Seattle Center of Innovation for Veteran-Centered & Value-Driven Care.


Sterling R, Rinne S, Reddy A, Moldestad M, Kaboli P, Helfrich C, Henrikson N, Nelson K, Kaminetzky C, and Wong E. Identifying and prioritizing workplace climate predictors of burnout among VHA primary care physicians. Journal of General Internal Medicine. July 29, 2021; online ahead of print.

View study abstract

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