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Sustaining Family Physicians in Urban Underserved Settings

Anne Getzin, MD; Bonnie L. Bobot, MD; Deborah Simpson, PhD

Objective: Our objective was to identify factors that sustain family physicians practicing in Milwaukee’s underserved urban areas.

Methods: Family physicians with clinical careers in Milwaukee’s urban, underserved communities were identified and invited to participate in a 45–60 minute interview using a literature-based semi-structured protocol. Each interview was transcribed and de-identified prior to independent analysis using a grounded theory qualitative approach by two authors to yield sustaining themes. The project was determined not human subjects research per Aurora Health Care IRB.

Results: Sixteen family physicians were identified; six of 11 who met inclusion criteria agreed to interview. Four general domains central to sustaining family physicians working with underserved populations were identified: (1) cognitive traits and qualities (trouble shooting, resilience, flexibility), (2) core values (medicine as mechanism to address social justice), (3) skills (self-care, communication, clinical management), and (4) support systems (supportive family/employer, job flexibility, leadership opportunities, staff function as team). The formation of these personal attributes and skills was partly shaped by experiences (from childhood to medical training to work experience) and by personal drivers that varied by individual. Common was that the challenges of providing care in urban underserved settings was seen as rewarding in and of itself and aligned with these physicians’ values and skills.

conclusions: Family physicians working with underserved populations described possessing a combination of values, cognitive qualities, skill sets, and support systems. While family physicians face complex challenges in quality care goals in urban underserved settings, training in the personal and professional skill sets identified by participants may improve physician retention in such communities.

(Fam Med 2016;48(10):809-13.)

Underserved communities, in rural and urban areas, have an acute, unmet need for primary care physicians. Milwaukee’s central city exemplifies that national shortage with 57 unfilled primary care positions needed to provide an adequate physician to population ratio.1 Barriers limiting primary care physician recruitment and retention include salary disparities, debt load,2 and concern for physician burnout.3 Approaches to address these barriers are heightened in underserved settings and range from societal-level strategies (eg, federal physician financial incentives, public health service placement) to the individual physician level (eg, recruitment and training of individuals motivated to care for underserved).

Recent literature has focused on increasing the numbers of newly graduated physicians working in primary care4,5 with less focus on retention. A few small studies have addressed retention and elements of a successful practice in urban settings.6,7 Several qualitative studies have addressed physician retention in rural areas.8-10 However, factors sustaining family physicians working in underserved settings remain undefined, particularly in urban areas. Identifying factors key to sustaining family physicians could be utilized in medical education to enhance physician retention in underserved areas.

Our objective was to identify the factors that sustain family physicians practicing in a large, underserved urban community.



A grounded theory, qualitative in-depth participant interview approach was used to identify and elucidate sustaining factors and to develop authentic descriptions of the phenomena we studied.11,12 The study setting was Milwaukee County, WI, the largest metropolitan area in the state, ranking 71st among Wisconsin’s 72 counties in health outcomes and health determinants.13 The project protocol was approved as not human subjects research by the Aurora Health Care IRB

Participant Population

Participants were recruited through a multi-step process elucidated in Figure 1. Family physicians meeting the criteria were contacted by an e-mailed letter with an e-mail follow-up to nonrespondents. We sought a small sample (five to eight) for detailed authentic descriptions allowing us to identify preliminary factors and verify categories through a phased, iterative data analysis




Semi-Structured Interviews

All interviews were performed by the first author to maintain consistency, using a semi-structured interview protocol that remained constant throughout the study (Table 1). Interviews lasted 45–60 minutes. Participants selected a method (in person or phone), location (physician office, local cafes), and time convenient to them. Participants received a copy of interview questions in advance. Verbal informed consent was obtained with approval for field notes and audio recording. Anonymity was protected by de-identifying the demographic information, and transcript identifiers were disassociated with interviewee name and contact information and stored in separate, secure files.



Thematic Analysis

The first and second authors independently read each transcription of the audio recordings noting key elements using a memoing process.14,15 Authors convened, clustering memos from each interview. Analysis of these memo clusters yielded common cross-cutting themes and categories between interviews with consensus reached through discussion. This analysis process occurred in three phases, applying a constant comparative methodology (Figure 1). Utilizing an affinity diagram, reviewers explored subthemes and relationships to larger categories to ultimately develop a narrative.6,13 The third author independently reviewed the transcriptions and participated in thematic analysis discussions. The preliminary findings and subsequent refinements were presented at academic faculty sessions attended by physicians who work with underserved populations for feedback and validation.16,17



Sixteen family physicians were referred to the project, and six of 11 family physicians meeting inclusion criteria agreed to interview (Figure 1). A common thread across all interviews was that the challenges of providing care in urban underserved settings were intrinsically rewarding and aligned with these physicians’ values and skills. To support this thread, four emerging domains with associated themes central to sustaining family physicians working with underserved populations were identified and graphically presented in Figure 2. Illustrative quotes from family physician interviewees for each of the four themes are provided in Table 2.




Theme #1: Brain—Cognitive Traits and Qualities

Interviewees identified cognitive traits and qualities that contributed to sustaining their work with underserved populations: troubleshooting, resilience, flexibility, and coping strategies in the face of challenges. These traits appeared to create a tendency toward reframing challenges as rewarding. The interviewees reported being drawn to the complexity inherent in caring for populations with high health needs.


Theme #2: Heart—Core Values

Interviewees consistently identified working toward health equity and social justice as a major driving force in their careers and medicine as the mechanism by which they could fulfill a need for disadvantaged populations. This driving force was what brought them to, and sustained their work in, medicine.

Theme #3: Utilizing the Skill Box—Skillset for Complex Challenges

Multiple skills were identified as important in managing challenges working with high need, low health literacy populations including:

  • Clinical diagnosis and management in settings with limited resources for evaluation and specialty services.
  • Communicate and establish rapport with communities that face challenges with trust and the health care system.
  • Patient education in the context of low health literacy and time, cost barriers.
  • Self-care while working in high pressure settings

Theme #4: Foundation of Support

Physicians identified “two legs” of external support as vital—professional and personal. Key elements in the professional realm include job flexibility and opportunities for leadership or growth, supportive administration, and effective support staff, sharing a common vision. In their personal lives, a supportive family and work/life balance were identified as important.



Family physicians working with urban underserved populations face complex challenges in achieving quality care goals and sustaining their careers. This early study reveals that family physicians who have sustained careers working in these settings possess a specific combination of cognitive traits, personal qualities, core values, skills, and support systems.

Study findings are limited by sample size and single urban area. However, themes identified may be relevant to larger populations as family physicians interviewed practiced at HRSA/HPSA designations, providing a common context for their clinical work. While a single interviewer established consistency between interviews, interviewer bias is possible.

Next steps include further exploration of the identified themes with additional family physicians and other primary care providers within and beyond Milwaukee’s urban underserved regions. Applying these findings to residency training may improve physician recruitment and/or retention in such communities.

Acknowledgments: This paper was a poster presentation at Aurora Health Care Scientific Day, Milwaukee, WI, May 20, 2015, and was presented at a Scholarly Roundtable at the 2016 Society of Teachers of Family Medicine Annual Spring Conference, Minneapolis, MN.

Corresponding Author: Address correspondence to Dr Getzin, Aurora St. Luke’s Family Medicine Residency Program, Aurora Health Center-Midtown, 5818 W. Capitol Drive, Milwaukee, WI 53216. 414-449-2114.



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From the Department of Family and Community Medicine, Aurora Health Care, University of Wisconsin, Madison.

Copyright 2018 by Society of Teachers of Family Medicine