Care in the Country: A Historical Case Study of Long-Term Sustainability in 4 Rural Health Centers

Abstract

From 1978 to 1983, researchers at the University of North Carolina conducted a National Evaluation of Rural Primary Care Programs. Thirty years later, many of the programs they studied have closed, but the challenges of providing rural health care have persisted. I explored the histories of 4 surviving rural primary care programs and identified factors that contributed to their sustainability. These included physician advocates, innovative practices, organizational flexibility, and community integration. As rural health programs look ahead, identifying future generations of physician advocates is a crucial next step in developing the rural primary care workforce. It is also important for these programs to find ways to cope with high rates of staff turnover.

The health care system in the rural United States faces many challenges. Compared with urban populations, rural residents are more likely to be low income, uninsured, and in poor health.¹ Per capita federal spending on rural health, despite an arguably greater need for services, is not quite half that for health care nationally.² Limited resources impose financial constraints on rural primary care programs that provide a large amount of uncompensated care, which in turn threatens organizational sustainability. Rural primary care programs are the sole source of health care in many communities; thus their survival is vitally important.

From 1978 to 1983, researchers at the Health Services Research Center (now the Cecil G. Sheps Center for Health Services Research) at the University of North Carolina at Chapel Hill undertook a comprehensive study of rural primary care programs. At the time, there was a major push by government, advocates, and health services researchers to expand primary care programs in rural areas but uncertainty about the best way to do so. The National Evaluation of Rural Primary Care Programs (hereafter, National Evaluation) sought to categorize rural primary care programs and assess their relative effectiveness.

The National Evaluation identified and contacted 998 organizations—all externally supported rural primary care programs existing in the United States as of 1979. Of those, 640 responded and met inclusion criteria, and 467 programs in operation for more than a year were selected for further study. Five types of organization were identified: comprehensive health centers, group practices, institutional extension practices, free-standing primary care centers, and solo physician practices. Stratified random samples were drawn to ensure representation of each program type in subsequent parts of the National Evaluation. The researchers conducted site visits for 40 programs. Their methods are discussed more fully elsewhere.^3–6

The National Evaluation found that the majority of programs had difficulty covering their expenses. Financial instability threatened the long-term sustainability of many programs, and roughly 1 in 4 programs reported difficulty recruiting and retaining clinical staff.³ In the 25 years since the original evaluation, 10 of the 40 programs have ceased to operate. A sizable literature, including an entire issue of Health Services Research, has reported on factors leading to such facility and program closures.^7–11 Shi et al. followed up the original study with a quantitative examination of rural primary care program survival in 1978 to 1987.¹²

I documented the history of 4 of the 30 programs that participated in the original evaluation and are still in operation and explored the factors that allowed these programs to continue operating in the face of financial and other barriers that threatened their long-term sustainability. I employed qualitative methods and recent data to better understand the phenomenon of sustainability.

METHODS

I used a multicase design to identify factors associated with long-term sustainability in rural primary care programs. First, I reviewed all of the National Evaluation files, which included information on the 40 programs selected for site visits. I identified the 30 programs still in operation, by an Internet search and review of Health Resources and Services Administration records. From these 30, I used information-oriented sampling to identify the 4 programs that had the largest and most comprehensive files from the National Evaluation and the most detail in their site visit reports. This purposive sampling ensured that enough material was available to construct a thorough organizational history. Geographic representation was a secondary consideration in the selection of cases.

I reviewed the files for each program in depth to construct its full history. I selected keywords from the National Evaluation files to facilitate an Internet search for current program information. I combined all the information to develop chronologically ordered program narratives. I reviewed and coded primary and secondary resources, which comprised historical records, newspaper articles, interviewer notes, clinician surveys, and other documents belonging to the original National Evaluation files. Quotations given without citation in this report were taken from unidentified interviewers' field notes from these files.

A literature review on health care organization survival and sustainability suggested 8 broad coding themes: program origins, community demographics, community perceptions of and attitudes toward the program, program interaction within the community environment (e.g., collaboration with a hospital), clinician recruitment and retention, clinicians' perceptions of and attitudes toward the community, revenues and funding, and actions taken to sustain the program when faced with the possibility of closure. I derived the language of the themes from a synthesis of various recurrent themes found throughout the literature. Many of the themes are described by the 6 domains of sustainability (political, institutional, financial, economic, client, and workforce) in primary care as delineated by Sibthorpe et al.¹³ I used these themes as a framework for open coding (a method that allows the addition of new codes suggested by the material) the documents in each file to identify emergent themes within the broader concepts. I then analyzed the coded historical narratives to identify common themes related to long-term sustainability occurring across programs.

RESULTS

The Laurel Fork and Clear Fork Health Centers

The Clear Fork Health Center, located in Clairfield, Tennessee (population 1108), was, at its founding in 1969, the first community health center in Tennessee. Soon thereafter, the Laurel Fork Clinic opened in nearby Frakes, Kentucky. These clinics served the mostly White residents of a geographically isolated, low-income Appalachian coal-mining community along the Tennessee–Kentucky border. Travel through the mountains was slow and frequently dangerous, especially in the winter, and there was (and is) no public transportation.

Jesse Walker, MD, who had moved to Clairfield in the 1950s to work for the United Mine Workers, joined the Clear Fork staff in 1972. Walker, who had a rural upbringing and was highly involved in the community, began to oversee activity at both the Clear Fork and Laurel Fork clinics. Walker spent 1 day a week at each site; most cases were handled by nurse practitioners and physician assistants, allowing the clinics to treat many more patients than they otherwise could have.

Nationally, the use of such new health professionals was strongly opposed by the medical establishment, which perceived them as a threat to physicians' scope of practice.¹⁴ At the time, Medicare and Medicaid did not reimburse nonphysician providers unless a doctor was also present in the exam room. Walker worked with Representative John Duncan and the Appalachian Regional Commission to testify before Congress in support of “physician extenders” and the Rural Health Clinic Services Act.^15,16

In 1976, an umbrella organization, Laurel Fork–Clear Fork Health Centers, Inc, was formed, with Walker as its medical director.¹⁷ By 1980, the program was sufficiently established to pursue expansion. The clinics hoped to expand from 1 physician on staff to 5, and the Clear Fork clinic was expanded by 200 square feet to handle a larger patient load. Kentucky and Tennessee now had 2 clinics each. However, during the 1980s the Reagan administration drastically reduced funding for many domestic federal programs, including health centers, and the Laurel Fork Clinic was closed.¹⁸

According to the study files, this sacrifice enabled the remaining clinics to weather the storm of recession and cutbacks while the number of patients treated climbed—from 6487 patients in 1981 to more than 11 000 patients in 1987—as the national uninsured rate grew. For his efforts, Walker was named Rural Health Practitioner of the Year in 1985 by the National Rural Health Care Association.

In February 1998, the program was reorganized into the Dayspring Family Health Center, Inc. The Clear Fork Clinic remains operational as a satellite site, along with the Cumberland River Clinic (Williamsburg, KY) and the Indian Mountain Clinic (Jellico, TN). Today, 6 physicians, 2 nurse practitioners, and 3 physician assistants serve the 3 sites. These clinics handle 44 000 patient encounters per year, generating $3.5 million in annual patient revenue.

The Dayspring center is affiliated with Jellico Community Hospital and received a $1.7 million federal grant in fiscal year 2002. It plans to implement a progressive health information technology program, to be completed between 2008 and 2010, that will equip each examination room with wireless access to electronic medical records to facilitate both electronic prescription and access to immunization and medication histories.¹⁹

The Teche Action Clinic

When the Teche Action Clinic opened its doors in 1974 in the bayou town of Franklin, Louisiana (population 7822), it was the first community health center in the state and had already faced down strong racially motivated opposition from the medical establishment and the local power structure. Nationally, the health center movement sought to empower vulnerable populations and had direct links to the civil rights movement; locally, it drew substantial White opposition, particularly from the Franklin Foundation Hospital and the owners of large sugar plantations, many of whom sat on the hospital board. The majority of the area's residents were low-income Blacks whose sole source of income was the sugar plantations: they were paid annually and threatened with loss of their jobs if they sought additional employment during the off-season.

The clinic was created by a human relations council led by local residents Rose and Bernard Broussard that had been formed to address the racial tension. Teche's mandate was to provide primary care to the predominantly Black farmworkers who did not qualify for Medicaid. The program was initially funded by a federal migrant health grant, because the target population was seasonally employed. By 1978, the clinic was receiving community health center funding.

Members of the board break ground for Teche Action Clinic's new facility, 1989. Image courtesy of Alfreida Edwards of the Teche Action Clinic. Used with permission.

The clinic overcame community opposition when a local physician got involved in the program, bridging the gap between the fledgling clinic and the medical establishment. According to an interviewer's field notes, this “cooled much of the opposition” and allowed the clinic to gain a foothold in the community. Still, some physicians opposed to the clinic encouraged the hospital to submit a competitive grant application claiming that the hospital and private physicians could provide the same services less expensively. Clinic supporters worried that this competition would force the clinic to close, because providers at the clinic were already feeling financial pressures (e.g., the head physician made < $40 000 a year in 1981). Ultimately, however, the hospital never applied for the grant.

Grudging acceptance of the clinic by the local medical community enabled Teche to survive in the early years. By the time of a 1981 site visit, investigators reported that

this clinic is now mature and has conquered its organizational problems of a clinical program under client sponsorship and control. Stability of personnel and funding are crucial to its future. The black farmer now, for the first time, has a health program with which he or she can identify and one which they help to develop.

Like the Clear Fork Clinic, Teche led the way with midlevel providers, becoming the first program in Louisiana to employ a nurse practitioner and a diabetes educator. The program continues to employ such professionals. Today, the clinic is the health care home for more than 8000 patients. The Franklin clinic has satellites in Edgard, Dulac, and Houma, Louisiana. Together, the 4 sites employ 5 physicians, 3 dentists, 1 physician assistant, 6 nurse practitioners, 1 pharmacist, and 2 social workers. Some 40% of the budget comes from federal grants and 60% from generated income.

Patients wait to be seen at the Teche Action Clinic, 1980. Image courtesy of Alfreida Edwards of the Teche Action Clinic. Used with permission.

Members of the community attribute the continued growth and success of Teche to Gary Wiltz, MD. Wiltz, became the clinic's medical director in 1982 while a member of the National Health Service Corps (NHSC), a federal program that trains clinicians and offers them financial incentives to work in underserved areas. Wiltz was named chief executive officer of the clinic in 2003. His commitment to the community was invaluable in the late summer of 2005, when Hurricane Katrina hit New Orleans and the surrounding community was called upon to help handle the influx of evacuees. Two of Teche's sites closed temporarily after Katrina because of power outages, but Teche managed to respond to many evacuees' health care needs. In March 2007, Wiltz testified before Congress:

My family personally housed 19 family members for many months after the disaster hit…. As of May [2006], Teche Action Clinic has cared for hundreds of Katrina evacuees, added two displaced providers, and by the end of August will be employing five evacuees on its staff.²⁰

Wiltz also told the representatives about his background:

My roots run deep in New Orleans. I can trace my ancestry back for over 4 generations. I was born at Charity Hospital in 1953 on the “colored” ward section of the then-segregated hospital. I grew up and attended the public school system in New Orleans, earned a scholarship to Tulane University, and later attended Tulane Medical School where I was fortunate enough to earn a National Health Service Corps scholarship while in medical school… . Upon completion of my residency, I was assigned to Teche Action Clinic in Franklin, to serve my 3 year service pay-back obligation; 25 years later, I am still practicing medicine at that same site.²⁰

Franklin's population had declined in recent years, and even more residents fled the area after Hurricane Katrina. The town's population dropped from 9004 in 2000 to 7879 in 2006. Teche is a well-established operation, but at some point a shrinking population base may no longer sustain the clinic, necessitating retrenchment, which could take a variety of forms: reducing services offered, reducing staff, or closing a satellite clinic.

La Clinica del Pueblo de Rio Arriba

The early history of Rio Arriba County, New Mexico, is one of ethnic conflict between indigenous occupants and US settlers. In 1848, the US government gave a land grant (the Treaty of Guadalupe Hidalgo) to the indigenous community of Tierra Amarilla (population 750), but there was some ambiguity over whether this grant was to the community or to one Manuel Martinez, as later claimed by his descendant Francisco Martinez and confirmed by Congress in 1860.²¹ After the congressional decision, Martinez sold the land to Thomas B. Catron. This denial of ownership to the original grantees of the lands of Tierra Amarilla was typical of tactics used by English settlers to move American Indians off their land.

The indigenous residents of Tierra Amarilla established a farm co-op through La Clinica. Image courtesy of La Clinica del Pueblo de Rio Arriba (available at: http://www.laclinicadelpuebloderioarriba.com/history.htm). Used with permission.

It was from this history of conflict that the clinic at Tierra Amarilla arose. Indigenous people founded La Clinica del Pueblo de Rio Arriba in 1969 as an outgrowth of a major confrontation in the community that took place in 1967, when a group of land grant activists known as Alianza (Alliance) conducted an armed raid of the local courthouse in an attempt to make a citizens' arrest of the district attorney. Elected officials, bankers, and landowners all opposed the clinic, which they viewed as an extension of the long-standing land grant dispute. Notes by a National Evaluation investigator who conducted a site visit described the community conflicts:

The “haves” (bankers, landowners, and elected politicians) have been virtually at war with the “have nots” who run the clinic. The latter stormed the courthouse in 1967. The former developed a competing clinic in Chama, 12 miles north. When the Chama clinic opened, the Tierra Amarilla clinic mysteriously burned to the ground. Antonio Devargas, Administrator at Tierra Amarilla, blames the Chama supporters.

For the next 20 years, hampered by geographic and cultural isolation, La Clinica barely survived and never developed into a self-sufficient—or even expanding—rural health clinic. The nearest hospital was 68 miles away, geographic factors posed transportation barriers, and community attitudes toward the program were strongly divided. Although the clinic enjoyed the loyalty of the local indigenous population, 75% of whom lived below the federal poverty line, the only organized support for the clinic came from the Chicano political organization La Raza Unida [The United Race]. In discussing when this program “took off,” the interviewers wrote, “It hasn't and it won't. It has probably gone as far as it will go. It's inevitably limited by its philosophy which results in refusing to solicit any government funds other than NHSC.”

A look at the La Clinica examination facilities, circa 1980. Image courtesy of La Clinica del Pueblo de Rio Arriba (available at: http://www.laclinicadelpuebloderioarriba.com/history.htm). Used with permission.

For more than 2 decades, La Clinica continued to operate with 1 physician, 2 nurses, and 2 promotoras [promoters], but, as the investigators predicted, with little growth. The turning point came in 1992 when the clinic's board of directors successfully applied for federal funding and community health center status.²² La Clinica now participates in the Health Resources and Services Administration's Diabetes Health Disparities Collaborative, an effort to integrate the work of health centers with the resources of national, state, and local health care organizations to implement evidence-based best practices and reduce health disparities.

La Clinica has partnerships with the New Mexico Department of Health Diabetes Prevention and Control Program, various pharmaceutical companies, the New Mexico State University Cooperative Extension Office, Rio West Medical Roadrunner Footwear for Foot Care, and the Con Alma Foundation. La Clinica also serves as a rotation site for psychiatry and behavioral health students from the University of New Mexico Health Sciences Center.²³ The infusion of federal funds has bolstered La Clinica, but it remains to be seen whether these affiliations will open the organization up to more resources, added stability, and future growth.

The Yuba Feather Communities Health Program

The Yuba Feather Communities Health Program was started in Brownsville, California (population 1069), in 1974 by local resident Robert Kearney, a retiree who took it upon himself to submit the first NHSC funding grant for Intermountain Communities Services, Inc, and continued to serve as the project director until at least 1989.

Brownsville is located in northern California in the foothills of the Sierras, where forestry is the dominant industry. During the late 1970s and early 1980s there was an in-migration of predominantly White, young, urban exiles, many of whom lived in trailer parks and mobile homes and were described in an investigator's notes as “very free-spirited activist-types who shun[ned] government intervention in daily life.” Traversing the mountains was dangerous, especially in winter. Many people therefore went without preventive care, and when the Yuba Feather clinic first opened, late-stage cancer, uncontrolled diabetes, and hypertension were prevalent.

From the clinic's inception, medical director William Hoffman, MD, has been instrumental in the program's success. One investigator described Hoffman as a workaholic who focused solely on medical issues. He sought to treat one patient at a time rather than try to change the community or solve its problems. The investigator described Hoffman's goals:

to provide 24-hour, comprehensive family practice that includes hospital care, out calls, and emergency care. That philosophy has been assumed by the organization and for anyone to function within it they must accept that.

In 1976, John Rose, MD, joined the clinic staff and fit in well with Hoffman's model. Although he came to Yuba Feather to fulfill his NHSC obligation, he planned to stay indefinitely, as both he and Hoffman have done. Both doctors describe themselves as being highly involved in community activities, highly committed to remaining in the community, and highly satisfied with their practice.

A satellite site was opened in the late 1970s in Feather Falls, but as early as 1981, investigators noted that it was in danger of closing because it was only 30% self-sufficient (i.e., revenues equaled only 30% of the clinic's total budget). At the same time, the Brownsville site was fully self-sufficient. Indeed, the Feather Falls site closed the same year.

By the end of the decade and into the early 1990s, the Brownsville site also experienced financial difficulties, precipitated by a changing patient mix with a greater proportion of low-income individuals, both publicly insured and uninsured (70% of patients had Medi-Cal or Medicare). The clinic affiliated with Sutter North Medical Foundation in 1993 and secured federal funding in 2002 from the Rural Health Initiative (RHI), which brought higher reimbursement from Medi-Cal and Medicare. Hoffman described the benefits of the new arrangements:

Given our high percentage of low income and uninsured patients, we wouldn't be able to continue without the RHI funding and support from Sutter North. Being part of a larger medical group has made it easier for us to meet the administrative demands necessary to run a small practice and given us access to technologies we couldn't afford on our own. Our patients also get access to specialists, hospital care, home health and other services available through Sutter North and Sutter Health. Just because you live in the country, doesn't mean you shouldn't have access to the same services as people in a big city.²⁴

Yuba Feather celebrated its 30th anniversary in 2004 with the same 2 doctors at the helm. The clinic, which started in 2 log cabins belonging to the forestry service in 1974 and served just 2000 people annually by 1986, has grown into a 7000-square-foot medical facility serving some 10 000 people.²⁴ Hoffman, who remains the chief medical officer, noted,

I've known many of my patients for 20 or 30 years and treated their children and grandchildren. I love the people and challenges of practicing in a small rural area where I can take care of patients of all ages, no matter their ability to pay. I may earn less than I would in a big city, but the satisfaction I get from my job is priceless.²⁴

In a 1980 interview with Time Magazine, Rose, the board's vice president, said, “I could be making more money in the valley, but what else could I want? I think I'm just a hick at heart.”²⁵

DISCUSSION

Together, these cases suggest that long-term organizational sustainability is the result of a complex combination of structures and processes present both inside and outside the organization. Foremost among these is the presence of dedicated, tireless physician advocates. With the exception of La Clinica, each of the programs had at least 1 prominent physician who was highly committed to and involved with the community and who provided leadership, continuity, and stability to the program in addition to his clinical role.

With the exception of Yuba Feather, each of the programs encountered strong opposition during its inception. In some cases the medical establishment opposed the programs, viewing both the clinics and their use of so-called physician extenders (nonphysician providers) as threats to physicians' scope of practice. In other cases, the clinics were the target of racist opposition. In the face of both types of challenge, a physician acting simultaneously as advocate and member of the entrenched power structure was able to bridge the gap between the program and the opponents in the community by mollifying influential stakeholders. Physician advocates represent a critical element of political sustainability by not only championing their programs but also neutralizing threats to sustainability that arise when the status quo is challenged.¹³

Another major success factor I observed was the willingness of programs to employ innovative solutions to problems. For example, the use of alternative kinds of providers (e.g., nurse practitioners and physician assistants) by all of the clinics was revolutionary at the beginning and met with opposition from the medical community. But it allowed more patients to be treated efficiently, a crucial consideration in understaffed rural areas. Today, analogous efforts exist in the form of care management programs (e.g., Kentucky's Skycap Program), culturally sensitive outreach efforts (e.g., the promotoras [promoters] model), and transdisciplinary health care teams (e.g., dentists cross-training pediatricians to apply dental sealants).²⁶ Programs with limited resources are often forced to think creatively and find new and better ways to accomplish their mission.

Organizational flexibility was another characteristic of successful programs. If clinic leaders remained more committed to the mission of caring for the underserved than to the clinic building, specific geographic location, foundation name, or other concerns, then the program—although it might be modified—persisted. The Yuba Feather and Clear Fork clinics were excellent examples of this quality, and the experience of the Tierra Amarilla Clinic illustrated how rigidity can retard the growth of a program.

For Yuba Feather, organizational flexibility appeared to be crucial to survival. Had the program tried to hang on to the Feather Falls site despite all indications of its failure to thrive, it was entirely possible for the Brownsville location to be taken down with it. By recognizing that it was a financial liability and closing the Feather Falls site, organization leaders were able to preserve the Brownsville location and allow it to flourish. Similarly, closure of the Laurel Fork clinic enabled the Clear Fork clinic to survive funding cuts.

Conversely, the strong commitment of Tierra Amarilla's indigenous people to each other and the land, although noble, also made them rigid. This rigidity prevented the clinic from enjoying many of the opportunities open to similar providers—including financial support—for more than 2 decades. Tierra Amarilla's supporters and patients were unwilling to compromise their values regarding certain deep-seated conflicts with their White neighbors over land, even if it meant improving their health services. Now that the organization has decided to accept federal funding, it may experience more growth.

A final major success factor was how well a clinic integrated with the local community. Sibthorpe et al. cite such interorganizational networks as facilitators of institutional sustainability.¹³ Ultimately, long-term sustainability depends on clinics becoming financially self-sufficient, but this will be difficult for all of the programs I studied, because they serve populations with large proportions of persons who are uninsured, of low income, and in poor health.¹ This problem has worsened over time as the number of uninsured has risen, reducing revenues. These case studies show, however, that affiliating with other organizations, such as a nearby hospital, can help to strengthen a clinic's financial position.

As noted by the National Evaluation,

A close relationship between rural primary care clinics and hospitals clearly favors the self-sufficiency of the clinic, mostly through the overall reduction of costs, especially laboratory, community service, and administrative service costs.⁶

The Laurel Fork Clinic's affiliation with the hospital in Jellico and Yuba Feather's affiliation with Sutter North are evidence of this. Conversely, the early tension between the Teche Action Clinic and Franklin Hospital demonstrates the competitive threat a hospital can pose to a clinic when no mutually beneficial arrangement exists.

It is also important to note the role that federal funding plays in the sustainability of rural primary care programs. Given that these organizations serve a patient mix that is disproportionately of low income and uninsured, financial self-sufficiency may simply be an unattainable goal. Ongoing support of these programs through federal grants is essential to their continued viability. However, federal funding for these programs varies from year to year, often for political reasons. Thus, rural primary care programs must develop the capacity to adapt during downturns. Strong advocates, a willingness to innovate, organizational flexibility, and community integration are all vital to developing this capacity.

Limitations

This study had several limitations. Purposive sampling of centers on the basis of the availability of secondary data may have biased the results, because it is likely that centers yielding more information during the previous study were systematically different from centers from which less information was obtained. The direction of this bias is unclear, although I suspect that centers with a greater volume of available data were strongly established centers, making it possible that I interpreted the association between the observed themes and organizational survival as being stronger than it really was.

I did not present any comparison cases of failed organizations from the National Evaluation. It is possible, even likely, that clinics that survived differed from clinics that failed in important ways. Thus, a comparative approach could identify factors associated with long-term organizational sustainability. Recent information on failed organizations, however, is rarely available, making such a comparative study unfeasible. By considering only surviving organizations, I identified similarities and differences among programs that may have been associated with their long-term sustainability.

My analysis relied solely on secondary sources. Consequently, some relevant information may have been excluded here because long-term organizational sustainability was not the focus of the National Evaluation for which the data were collected. For instance, it would be useful to know more about the dynamics of decision-making to better understand the deliberative process and other contextual factors that shaped organizational responses. Future studies might consider interviewing key clinical and administrative staff to gather this data; limited resources precluded my taking this approach.

My findings are likely to have only theoretical generality. Thus, similarly situated rural primary care programs that started out very small and in very low-income, sparsely populated areas could reasonably be expected to share similar experiences. Generalizing to other settings should be undertaken with caution. However, the programs presented here were worth studying precisely because they managed to persist despite unfavorable odds.

Finally, the themes I identified may or may not be causally related to the outcome of organizational sustainability. Some of the experiences of the programs described here may be instructive; others may be less relevant. The only certainty is that the future brings change, and how rural primary care programs respond to that change is vital to their continued existence.

Conclusions

The most pressing questions to emerge from this study are, What happens to these programs after those who championed them are gone? Are the clinics well enough established to survive under new leadership? Can comparable replacements be found to fill the role of physician advocate? Can clinics find a way to become less dependent on particular individuals for their success? How can clinics plan for a smooth leadership transition and organizational growth? Future studies should investigate the personal motivations clinicians have for both choosing to practice in rural settings initially and deciding to remain there and become invested in the communities they serve. Identifying and training health care administrators to operate these clinics is also important.

As the government seeks ways to recruit health care providers to underserved areas, it must move beyond financial incentives, whose effects are limited. Some NHSC scholars stay on after fulfilling their service obligations, but most report not feeling committed to or involved in the communities they serve, and they leave when their 2, 3, or 4 years are up.²⁷

Efforts should be made to identify and foster the motivations that drive physicians— such as the dedicated leaders of the clinics profiled here—who forge careers in rural medicine. If young doctors can be enticed into such programs and nurtured so that they remain, they might help to alleviate America's serious health workforce shortages in rural areas. The rural population of this country, roughly 60 million persons, sorely needs more clinics—and their clinician trailblazers—like those I studied.