Association Between Having a Highly Educated Spouse and Physician Practice in Rural Underserved Areas

Physician undersupply in rural areas remains a problem, despite efforts to improve the workforce distribution.¹ Rural origin, age, and sex have been linked to physician choice of rural settings.² An additional factor may be that many physicians have highly educated spouses with independent careers, which may constrain their ability to locate in rural areas.³ We investigated the prevalence of physicians with highly educated spouses and whether having such a spouse was associated with working in rural underserved areas.

The Dartmouth institutional review board determined that the study did not involve human participants. We studied a 1% sample of all employed physicians aged 25 to 70 years working in the United States every 10 years from 1960 to 2000 (n = 19 668) obtained from the Decennial Census, and every year from 2005 to 2011 (n = 55 381) from the American Community Survey.⁴ Both surveys used comparable questions, included all household members, and had response rates of more than 95%. We identified spouses reporting 6 or more years of college (before 1990) or a master’s degree or higher (1990 and later).

Comparable information on primary place of work was available for 2005 to 2011. Using the Health Resources and Services Administration’s Geospatial Data Warehouse, we determined whether each rural census block was in a (geographically defined) primary care Health Professional Shortage Area (HPSA).⁵ Physicians who worked in prespecified groups of census blocks with more than half the rural population in a shortage area were classified as working in a rural HPSA.

The proportion of married physicians with highly educated spouses was calculated for each year and plotted, along with a linear trend estimated by simple linear regression. Sampling weights were provided by the census.

For 2005 through 2011, we estimated logistic regression models of the likelihood of working in a rural HPSA comparing physicians married to a highly educated spouse with other married physicians (reference group) and single physicians. Odds ratios (ORs) were estimated adjusting for physician age, race/ethnicity, and sex. Tests were based on 2-tailed t tests using a P value of less than .05 for significance, and accounted for use of sampling weights and clustering of observations within households. Analyses were performed using Stata (StataCorp), version 13.1.

The proportion of married physicians with highly educated spouses increased from 8.8% in 1960 (95% CI, 7.3%-10.2%) to 54.1% in 2010 (95% CI, 52.6%-55.6%; P for trend <.001) (Figure). In every year, approximately one-third of spouses with graduate degrees were also physicians. Women were an increasing fraction of married physicians (4% in 1960 and 31% in 2010) and more likely than men to be married to a spouse with a graduate degree (68% for women vs 48% for men), but even among men, the proportion of married physicians whose spouse held a graduate degree increased from 7% in 1960 to 48% in 2010.

Overall, 5.3% (95% CI, 5.0%-5.5%) of physicians worked in a rural HPSA between 2005 and 2011 (Table), whereas 10.88% (95% CI, 10.85%-10.91%) of the US population lived in these areas. Compared with other married physicians, physicians with a highly educated spouse were significantly less likely to work in a rural HPSA (4.2% for married physicians with highly educated spouses vs 7.2% for married physicians without highly educated spouses; difference, 2.9% [95% CI, 2.4%-3.4%]; adjusted OR, 0.62 [95% CI, 0.56-0.69]; P < .001). Single physicians were also less likely to work in a rural HPSA (4.1% for single physicians vs 7.2% for married physicians without highly educated spouses; difference 3.0% [95% CI, 2.4%-3.6%]; adjusted OR, 0.69 [95% CI, 0.61-0.79]; P < .001), as were physicians who were young, women, black, or Hispanic.

By 2010 more than half of married physicians had a highly educated spouse, which was associated with a reduced odds of working in rural underserved areas. However, the absolute difference between those with and without highly educated spouses was only 2.9%, and the proportion of both groups locating in rural underserved areas was small relative to the population. Limitations include the lack of information on physician specialty and possible misclassification of rural shortage areas. Incentives to encourage physicians to practice in rural areas⁶ are needed, but policies that target job opportunities for spouses may not improve undersupply greatly. Other approaches, such as allowing provision of health care without requiring physicians to locate in rural areas (ie, through telemedicine), should be investigated.

Corresponding Author: Douglas O. Staiger, PhD, Department of Economics, Dartmouth College, 6106 Rockefeller Hall, Hanover, NH 03755 (doug.staiger@dartmouth.edu).

Author Contributions: Dr Staiger had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Staiger, Marshall, Auerbach, Buerhaus.

Acquisition, analysis, or interpretation of data: Staiger, Marshall, Goodman, Auerbach.

Drafting of the manuscript: Staiger, Auerbach, Buerhaus.

Critical revision of the manuscript for important intellectual content: Marshall, Goodman, Auerbach,

Statistical analysis: Staiger, Marshall.

Obtained funding: Buerhaus.

Administrative, technical, or material support: Staiger, Auerbach, Buerhaus.

Study supervision: Staiger.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Staiger reports personal fees from and holding stock in ArborMetrix. Dr Auerbach reports consulting for Johnson & Johnson. Dr Buerhaus reports receiving personal fees from various universities and institutions for lectures. Dr Marshall reports receiving travel accommodations from the Federal Reserve Bank of Richmond. No other disclosures were reported.

Funding/Support: The Gordon and Betty Moore Foundation provided grant support.

Role of the Funder/Sponsor: The funder played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.