Significance. International Medical Graduates (IMGs) comprise 26% of the physician workforce in the United States and 18% of the physician workforce in Iowa. IMGs fill gaps in health professional shortage areas (HPSAs) in the United States and are significant contributors to the medical community. The State Conrad 30 Program allows states to recruit IMGs to HPSAs. Physicians supported under the Conrad 30 Program are obligated to work in HPSAs for three years. Although an important subset of the physician population, little is known about the experiences of Conrad 30 Program participants, or the factors associated with recruiting and retaining this sector of the physician workforce.
Purpose. This dissertation described the characteristics and experiences of IMGs practicing in the Iowa Conrad 30 Program, examined retention intention and actual retention of these physicians, and analyzed factors associated with retention of four or more years.
Methods. This dissertation utilized a mixed methods approach. Study 1 examined the characteristics of 410 IMGs participating in the Iowa State Conrad 30 Program between 1996 and 2012, using existing data. Logistical regression was used to compare the characteristics of physicians who were retained for four or more years with those who were retained less than four years, controlling for covariates. Study 2 explored the experiences of nine physicians using in-depth qualitative interviews. Inductive content analysis was used to identify themes related to site selection and retention. Study 3 used a physician survey to analyze physician attitudes and subjective norms on 33 practice factors. ANOVA and linear regression was used to analyze the difference in attitudes and subjective norms by physicians’ intent to remain practicing in Iowa long term and actual retention.
Results. Study 1: Of 410 physicians, 378 (92%) met the 3-year program obligation to practice at the original practice site and 280 physicians (68%) were retained four or more years. The average length of retention was 6 years and 4 months (SD = 4 years, 1 month). Male physicians had 2.7 greater odds of being retained four or more years than female physicians (95% CI = 1.39, 5.19). Physicians with a region of origin of the Americas had 0.25 lower odds of being retained four or more years compared to physicians with other regions of origin (95% CI = 0.06, 0.98). Marital status, having children at the time of hire, training in the Midwest, practice specialty, and salary were not significantly associated with odds of being retained four or more years. Study 2: Nine physicians completed semi-structured interviews. Themes from the interviews included: Physicians’ visa obligation requirements drove the initial site selection. Physicians had minimal knowledge about the state prior to selecting a practice site and had little intent to remain practicing in Iowa long term when making the initial practice site selection. Visa-related issues and the physician’s perception of mistreatment due to the visa status influenced the retention decision. The practice setting and personal motivators influenced the retention decision through the practice model, community attributes, influence of salient others, career motivators, and a sense of place. Study 3: Fifty-one physicians completed a survey regarding their retention intention when initially selecting the practice site, and their attitudes and subjective norms towards the practice and community. The perception of the beliefs of residency/fellowship faculty (subjective norms) were significant (p = 0.01) for those physicians intending to remain at the practice site for their careers. Attitudes towards the community were significantly more positive (p = 0.03) for physicians intending to remain at the practice site for their careers. Positive subjective norms of significant others (p = 0.02) and residency/fellowship faculty (p = 0.04) were significantly associated with actual retention of four or more years. Positive attitudes towards the practice site and employment factors were significantly associated with longer retention in months (p = 0.02, p = 0.03, respectively). The positive subjective norms of significant others and residency/fellowship faculty were significantly related to longer retention in months (p = 0.0002, p = 0.02).
Conclusions: The findings of this study provide important empirical data on the factors influencing site selection and retention of IMGs that participated in the Iowa Conrad 30 Program. The findings suggest a modification may be needed for the existing theoretical model, which was based upon the Theory of Reasoned Action. Improving retention of physicians could help improve quality of care and reduce overall costs for physician practices. Understanding why Conrad 30 Program participants may elect to practice in rural and underserved areas, and the factors influencing retention of physicians in these areas can assist employers, program administrators, and policymakers to aid in improving the retention of International Medical Graduates.