Growing up in rural Minnesota, Joshua Crabtree, MD, thought he was going to be a football coach or biology teacher. Working for an ambulance service during college steered him toward medicine instead.
“It was such a thrill and something I enjoyed so much that I knew that I needed to change my career path and become a physician because I wanted to take care of people in rural areas,” said Dr. Crabtree, a family physician who has worked in the small community of Luverne, Minnesota, for nearly 18 years delivering babies and offering primary care services.
“Rural health care is very important to me. It's a passion of mine. I want people to be able to have access to high-quality care without having to drive hundreds of miles,” he said.
As the chief physician at Sanford Health, which serves communities across the Upper Midwest, Dr. Crabtree’s goal is to recruit and retain physicians who have this mindset. Sanford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Like all health care organizations, Sanford Health has various recruitment needs that change annually, depending on retirement or turnover. But the general approach is to recruit high-quality physicians who have a connection to Sanford Health’s communities and region.
While many recruits hail from the Midwest, others from outside the region “come here and don't realize what we have, and then they appreciate the quality of life it offers and stay,” said Dr. Crabtree.
Retaining staff is another key objective.
“We’ve got high-quality physicians, and we want to make sure—because there are opportunities all over the country—that they want to stay with us,” he added.
In an interview with the AMA, Dr. Crabtree discussed the challenges of recruiting in rural areas and how Sanford Health is growing its numbers through educational pathways and a unique locum tenens program.
Aging population, fewer doctor hours
Sanford Health has much to be proud of. In 2023, Sanford Health received gold-level recognition from the AMA Joy in Medicine™ Health System Recognition Program, which empowers health systems to reduce burnout and build well-being so that physicians and their patients can thrive. The health system was also named by Forbes as among America's best in-state employers and recognized by Becker's Healthcare as a top place to work.
Meanwhile, Sanford Health’s turnover rate is around 8%, which is better than the national average of 13%. Still, Dr. Crabtree added, “We need to not rest on our laurels. We want to be the premier rural health care system in the country.”
But several conflicting forces can make recruitment a difficult prospect.
The health system caters to an aging population. In North Dakota and South Dakota, for example, over one-third of the population will soon be older than 60 and will have more health care needs in the future. And many of these people live in smaller communities.
“Recruiting, especially primary care into those smaller communities, that's a huge priority,” said Dr. Crabtree. Minnesota, Wisconsin and other areas also have significant numbers of baby boomers.
Then there are the changing work-life preferences in the physician workforce.
“Differing lifestyle desires for our physicians don't necessarily meet what our traditional recruitment would have been,” said Dr. Crabtree. People may only want to work part-time. Or a two-physician couple may each want to work a 0.75 full-time equivalent.
“The challenge is we've got an aging population in a rural space that we don't have enough physicians for,” he summarized.
Expanding residency, fellowship programs
Sanford Health is proactively responding to the ongoing need for more physicians by expanding the reach of its residency and fellowship programs.
Thanks to a $300 million philanthropic gift from benefactor Denny Sanford, the health system is making an unprecedented expansion in graduate medical education (GME) offerings, which will grow from 15 to 27 residency and fellowship programs by 2027.
Between 40% and 50% of Sanford Health’s residents and fellows stay within 100 miles of their training location. If that ratio holds true, expanding GME means a huge influx of new physicians coming into local towns, cities and health care centers.
“Because some of these programs are relatively new, we're going to start to see the benefits of ‘growing our own’ come to fruition in the next three to five years,” noted Dr. Crabtree. Once these programs are up and running, he anticipates having 350 fully funded residency and fellowship slots annually.
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Partnering with schools to boost teams
Recruitment and retention are not just about the physicians in these communities. If support teams aren’t given a comfortable space to work in to take care of patients, they will seek work elsewhere. If they stay, they’re at risk for burnout and that makes practicing medicine harder for physicians, noted Dr. Crabtree.
Sanford Health has been partnering with universities and technical colleges in its region to ensure it has the allied health professionals needed to keep health systems and medical practices running. This includes surgical technicians, radiology technicians, respiratory therapists, physical therapists, occupational therapists and certified nurse anesthetists.
“We’re partnering with these universities and tech schools to make sure that we have larger class sizes for training those individuals,” he said. In his view, these partnerships are part of recruitment and retention.
“You can have the greatest physician in the world in one of your communities, but you're not going to be able to take care of many people without a cohesive team,” he said.
Focusing on greatest areas of need
Sanford Health also launched a Sons and Daughters scholarship and scholar loan program, which primarily serves physicians, certified nurse anesthetists and clinical psychology.
“These are some of our biggest clinical needs,” explained Dr. Crabtree. If a son, daughter, niece or nephew of a Sanford Health employee wants to train in any of these areas of medicine, the health system will provide financial support through a scholarship and give them access to the loan program.
Participants can also get advisory and educational resources to guide them through their training.
“Our team connects with each trainee on a regular basis as they’re moving through their training,” assisting with things such as handling student loans or creating a resume, said Dr. Crabtree. “We try to serve as a concierge for those individuals to help get them the information or the guidance they need.”
The aim is to keep these trainees connected to Sanford Health.
“Their family is literally part of our family, and we want to at least provide that opportunity for them to be part of our family,” he said. While there’s no guarantee of a job, the program at the very least provides intentional support during their training, he added.
Over the last year, Sanford Health has signed 25 Sons and Daughters participants to contracts within the health system’s footprint, a significant increase from 10 in the previous year, and four the year before that.
“I expect that going forward we'll probably be in that 20 to 25 bucket every year. So, it's exciting. It’s working,” said Dr. Crabtree.
Try before you buy
Another strategy Sanford Health has employed from a connectivity and recruitment standpoint, is its internal locum tenens agency, Solutions by Sanford.
This offers a “try it before you buy it scenario,” explained Dr. Crabtree.
Physicians who might be interested in Sanford Health but aren’t sure if they want to move their family to the area to pursue a career can work on a part-time or a fill-in basis to meet gap coverage. Many of these physicians come in and work a weekend or a week or do a long-term locum arrangement where they work one week out of every month.
Many times, these people will say, “I think I want to be done with this locum work. This is where I want to stay. This is where I want to settle,” said Dr. Crabtree.
Since launching the Solutions by Sanford program, 12 physicians decided to pursue and attain permanent employment.
Meanwhile, more than 100 physicians in the internal locum program were previously employed by Sanford but left the organization for family or other personal reasons.
These physicians “wanted to stay connected with Sanford somehow, and they have done this through Solutions by Sanford,” Dr. Crabtree said. “I believe this is an additional way to keep physicians connected with our organization, and a benefit to patients.
“These are really good, high-quality physicians that we would love to have return to our organization someday if their life and situation allow it,” he added.
