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Introduction

The study aimed to quantify the preferences of young physicians for different attributes relevant to practice establishment in Germany.

Methods

Qualitative in-depth interviews of 22 physicians were conducted to identify relevant practice attributes. Based on this information, a questionnaire was developed containing a discrete choice experiment comprised of a “best–worst scaling” (BWS) task. It was mailed to a representative sample of 14,939 young physicians who were close to making a decision regarding practice establishment. Regression analysis was used to estimate utility weights quantifying physicians' preferences for practice attributes.

Results

Qualitative interviews identified six attributes: “professional cooperation,”“income,”“career opportunities of the partner,”“availability of child care,”“leisure activities,” and “on-call duties.” For the BWS task, 5,026 returned questionnaires were analyzed. Results indicated that a change in income led to the largest utility change compared with changes in other attributes. Additional net income to compensate the disutility of a rural practice as compared with an urban practice was 9,044€/months (U.S.$ 11,938). Yet, nonmonetary attributes such as on-site availability of childcare and fewer on-call duties would decrease the additional income required to compensate the disutility of a rural practice.

Discussion

The results offer quantifiable information about young physicians' preferences in establishing a practice. It can assist health policy makers in developing tailored incentive-based interventions addressing urban–rural inequalities in physician coverage.

Qualitative in-depth interviews of 22 physicians were conducted to identify relevant practice attributes. Based on this information, a questionnaire was developed containing a discrete choice experiment comprised of a “best–worst scaling” (BWS) task. It was mailed to a representative sample of 14,939 young physicians who were close to making a decision regarding practice establishment. Regression analysis was used to estimate utility weights quantifying physicians' preferences for practice attributes.

Results

Qualitative interviews identified six attributes: “professional cooperation,”“income,”“career opportunities of the partner,”“availability of child care,”“leisure activities,” and “on-call duties.” For the BWS task, 5,026 returned questionnaires were analyzed. Results indicated that a change in income led to the largest utility change compared with changes in other attributes. Additional net income to compensate the disutility of a rural practice as compared with an urban practice was 9,044€/months (U.S.$ 11,938). Yet, nonmonetary attributes such as on-site availability of childcare and fewer on-call duties would decrease the additional income required to compensate the disutility of a rural practice.

Discussion

The results offer quantifiable information about young physicians' preferences in establishing a practice. It can assist health policy makers in developing tailored incentive-based interventions addressing urban–rural inequalities in physician coverage.

Keywords: Physician shortage, stated preferences, discrete choice experiment
In Germany the looming shortage of physicians has been an important health policy issue in recent years. The German Federal Medical Association (GFMA), the joint association of the 17 state chambers of physicians in Germany, reports residents in some rural areas—particularly in eastern Germany—to be considered medically underserved (Kopetsch 2006). The GFMA expects a rising physician shortage, since 19 percent of the practicing physicians will retire within 5 years, and some study results show fewer medical school graduates intending to work in clinical medicine (Rieser 2005; Gensch 2007; Kopetsch 2008. Several studies describe physicians' job satisfaction as presumably a key factor influencing remaining in the medical workforce. For example, “the level of remuneration,”“the general workload,”“the extent of administrative work,”“the collaboration with colleagues,”“the balance of work and family,”“the extent of responsibility in the decision making process,” and “continuing education” seem to impact job satisfaction (Gensch 2007; Janus et al. 2007, 2008; Laubach and Fischbeck 2007; Brähler, Alfermann, and Stiller 2008).

Concerning the physician shortage's effect on health care, the Association of Health Insurance Physicians (AHIP) of the federal state of Saxony-Anhalt, a less densely populated state in Eastern Germany, described rural areas with five general practitioners per 10,000 inhabitants, with 33 percent aged 60 or above (Kassenärztliche Vereinigung Sachsen-Anhalt 2009). Another indicator of limited health care access is waiting time for consultations, with up to 33 days on average in some rural areas of Eastern Germany compared with 12 days in urban areas of Berlin (Betriebskrankenkassen Ost 2008). Particularly in Eastern Germany the state AHIPs reported that patients' traveling distances for medical care and the use of nonphysician services like nurse practitioners has increased. In conclusion, the AHIPs have questioned whether ambulatory care can be secured in the future. Yet studies about whether, for example, nurse practitioners are a cost-effective alternative to physicians for treating simpler medical conditions and how much such nonphysician services affect the quality of care are still missing.

In contrast to these indications of physician shortage, the Organization for Economic Cooperation and Development (OECD) reported the total number of physicians per capita in Germany increased in the last years, averaging 3.4 practicing physicians per 1,000 population, compared with a 3.0 average in OECD countries (Simoens and Hurst 2004). Considering this, one could assume that the problem of physician shortage in Germany is not necessarily due to a lack of physicians in general but to an unequal distribution (Klose, Uhlemann, and Gutschmidt 2003; Simoens and Hurst 2004. This means physicians tend to practice in urban or affluent rural areas, whereas other areas have difficulties attracting enough physicians to provide high-quality health care to the residents. This “maldistribution” of physicians is perceived in many countries, including the United States, the United Kingdom, Australia, and Canada (Joyce, McNeil, and Stoelwinder 2004; Rosenthal, Zaslavsky, and Newhouse 2005; Robertson et al. 2007.

In Germany health policy makers have addressed the “maldistribution” of physicians with many interventions, tending to improve the diffusion of physicians either by regulation or by incentive-based programs. Monetary incentive-based programs were implemented, including improved remuneration plans or the donation of seed capital for practice establishment. Little evidence in the literature favors the long-term success of such programs (Sempowski 2004), and health policy makers are thinking about programs focusing more on physician life-style concerns, for example, the number of on-call duties. To date very few studies have explored the role of monetary and nonmonetary attributes in practice establishment. The present study aimed to provide information for health policy makers about the importance of different attributes and their combinations related to practice establishment.

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METHODS
The study used a preference-based approach to derive information about attributes relevant for practice establishment: in a hypothetical scenario a practice alternative is described by several attributes at different levels, and respondents choose the most and the least preferred attributes at a respective level (see Figure 1). This choice task is repeated according to an experimental design plan for a set of practice alternatives and is called “best worst scaling” (BWS) (Finn and Louviere 1992; Flynn et al. 2007.