© 2006 National Rural Health Association 294 Vol. 22, No. 4
providers have presented the rural patient and health
care system with a unique yet interrelated set of
challenges. 5-7 Research into these challenges has tended
to focus on the recruitment and retention of primary
care physicians (PCPs); less well explored has been
how specialty services might be made more accessible
to rural residents.
iffi culties involved in delivering health
care to rural communities have been well
documented. 1-5 Sparsely settled
populations, geographical isolation, low
rates of health insurance coverage, a
higher proportion of elderly, and too few health care
To generate a patient base, specialty care is typically
concentrated in urban metropolitan communities. This
leaves rural dwellers facing the problem of poor access
to a broad range of medical services and the rural
community hospital falling short of its goals of offering
a full spectrum of care and generating adequate
revenue. Moreover, the rural PCP is stymied in his/her
desire for access to convenient specialty consultations,
as well as more streamlined referrals and professional
networking opportunities. While numerous suggestions
have been made regarding system changes aimed at
meeting the needs of rural residents and providers, 3,8-13
only a few of these approaches have included the
addition of the visiting specialist model of care. 1,14-17
A visiting specialist is a non-PCP who maintains a
rural ancillary practice in addition to an urban/suburban
primary base practice. 1 In effect, the visiting specialist
model brings at least some of the services more
commonly found in urban areas to the rural patient, the
community hospital, and the PCP. In the past decade, the
prevalence of this type of practice arrangement has been
described in a few Midwestern states. It has been
described in only a very limited way in New England. 1
The goal of this study was to characterize the
visiting specialist care delivery model in Massachusetts.
ABSTRACT : Context: Hospitals in rural communities
may seek to increase specialty care access by establishing
clinics staffed by visiting specialists. Purpose: To
examine the visiting specialist care delivery model in
Massachusetts, including reasons specialists develop
secondary rural practices and distances they travel, as
well as their degree of satisfaction and intention to
continue the visiting arrangement. Methods: Visiting
specialists at 11 rural hospitals were asked to complete a
mailed survey. Findings: Visiting specialists were almost
evenly split between the medical (54%) and surgical
(46%) specialties, with ophthalmology, nephrology, and
obstetrics/gynecology the most common specialties
reported. A higher proportion of visiting specialists than
specialists statewide were male (P = .001). Supplementing
their patient base and income were the most important
reasons visiting specialists reported for having initiated
an ancillary clinic. There was a signifi cant negative
correlation between a hospital ’ s number of staffed beds
and the total number of visiting specialists it hosted
(r = − 0.573, P = .032); study hospitals ranged in bed size
from 15 to 129. Conclusions: The goal of matching
supply of health care services with demand has been
elusive. Visiting specialist clinics may represent an
element of a market structure that expands access to
needed services in rural areas. They should be included in
any enumeration of physician availability.
1 University of Massachusetts Medical School, Worcester, Mass.
2 Department of Family Medicine and Community Health,
University of Massachusetts Medical School, Worcester, Mass.
This work was supported in part by the University of Massachusetts
Medical School Offi ce of Medical Education, Medical Student
Summer Research Fellowship Program. The authors acknowledge
the following people for their assistance in carrying out this study:
the physicians and hospital administrators who responded to the
questions; the Massachusetts Statewide Network Area Health
Education Center, particularly Joanne Dombrowski and Linda Cragin;
the Massachusetts Offi ce of Rural Health; and several anonymous
reviewers. For further information, contact: Jacob Drew, BA, Mailbox
0270, University of Massachusetts Medical School, 55 Lake Avenue
North, Worcester, MA 01655; e-mail JMDrew29@capecod.com.
The Visiting Specialist Model of Rural Health Care
Delivery: A Survey in Massachusetts
Jacob Drew , BA ; 1 Suzanne B . Cashman , ScD ; 2 Judith A . Savageau , MPH ; 2 and Joseph Stenger , MD 2
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Drew, Cashman, Savageau and Stenger 295 Fall 2006
A relatively small state known primarily for its large,
urban medical centers, Massachusetts has numerous
underserved rural and small town communities,
concentrated mainly in the Lower Cape Cod and mid
and western areas of the state. To maintain and
supplement limited medical resources, these smaller
communities employ a variety of creative strategies
including telemedicine, health care networks, service
specialization, and even critical access status for small
community hospitals. Among these more publicized
options, the visiting specialist model is a further
adaptation — one that has attracted little attention but
that is aimed at ensuring that a moderately complete
range of medical options is available in rural areas. This
study describes the extent of the visiting specialist
practice modality as well as reasons for and satisfaction
with a secondary rural practice.
In June 2004, the Offi ce of Rural Health in the
Massachusetts Department of Public Health provided
the researchers with a list of the 15 nonspecialty
hospitals located in rural areas of the state. A
municipality in Massachusetts is considered rural if it
meets at least 1 of 4 federal rural defi nitions — Census,
rural-urban commuting area codes, Offi ce of
Management and Budget nonmetropolitan areas, or the
Beale/rural-urban continuum codes — and/or it has a
population less than 10,000 people and a population
density below 500 people per square mile (personal
communication, Massachusetts State Department of
Public Health ’ s State Offi ce of Rural Health, June 7,
2004). The researchers contacted the chief administrative
offi cer of the 15 hospitals, explaining the intent of the
study and requesting a list of all the visiting specialists
who had maintained an ancillary practice affi liated with
the hospital within the previous 12 months. One of the
15 hospitals did not respond and 3 did not have any
visiting specialists, leaving 11 participating hospitals.
Physician lists were compared and consolidated so
that visiting specialists who were affi liated with more
than 1 hospital would receive only 1 initial contact.
This produced a list of 199 visiting specialists.
Using information from previous studies of visiting
specialists, 14-16 a 47-item questionnaire was developed
and mailed to each of the study physicians. The
questionnaire asked providers about their reasons for
maintaining a visiting specialist clinic, characteristics of
their base practice and their visiting specialist clinic,
satisfaction with selected aspects of their practice, and
the likelihood of continuing this arrangement.
Guided by Dillman ’ s 18 total design method, if the
questionnaire was not returned within 10 days, a
telephone call was made to the physician ’ s offi ce,
encouraging him/her to complete it. As an incentive,
physicians who returned the survey within 1 month
were eligible to win 1 of 3 $50 bookstore gift
certifi cates. If a completed survey had not been
received within 3 weeks from the date of the fi rst
mailing, a second survey packet was sent. Addresses
marked “ undeliverable ” were checked with the state
Board of Registration ’ s database to obtain more
accurate and current addresses when available.
Three main sources of secondary data were used.
They included (1) the Massachusetts Health Data
Consortium ’ s Massachusetts Physician ’ s License
Database 19 for physician demographic and educational
information, (2) The Dartmouth Atlas of Health Care: The
New England States 20 to describe hospital referral regions
and distances from major medical centers, and (3) the
American Hospital Directory 21 and hospital Web sites to
describe individual hospitals. The study was approved
by the University of Massachusetts Institutional Review
Board ’ s Human Subjects Committee.
Data were analyzed using SPSS/PC statistical
software (V11.5, 2002; SPSS, Inc., Chicago, Ill). Univariate
and bivariate statistics were the primary means of
analysis. Frequency and percentile distributions, means,
and medians were used to describe characteristics of the
visiting specialists, as well as the participating hospitals.
Depending on the categorical or continuous nature of
the data, chi-square and t tests were used to assess
signifi cance at the .05 level; as appropriate, Mann-
Whitney U tests were used to compare ranks.
Questionnaires were mailed to all visiting
specialists (N = 199). Twenty-seven were subsequently
excluded because they had left their practice, did not fi t
our defi nition of a visiting specialist, or could not be
contacted. Of the remaining 172 eligible visiting
specialists, 99 completed and returned the survey (58%
With respect to location of medical school attended,
no statistically signifi cant differences were found
between respondents and Massachusetts specialists,
nor between respondents and all Massachusetts
physicians. Additionally, there was no statistically
signifi cant difference between respondents ’ and
nonrespondents ’ gender, medical school location, or
specialty category. Respondents were, however, more
likely than Massachusetts specialists ( ? 2 = 4.46, P = .03)
and all Massachusetts physicians ( ? 2 = 10.94, P < .001)
to be male ( Table 1). This was also true for the study ’ s
universe of visiting specialists ( ? 2 = 10.66, P = .001 and
? 2 = 23.32, P < .001, respectively).
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The Journal of Rural Health 296 Vol. 22, No. 4
Respondents were almost evenly split between
those practicing medical (54%) versus surgical
specialties (46%) ( Table 1 ). Ophthalmology, nephrology,
and obstetrics/gynecology were the most common
specialties practiced; in descending order, hematology/
oncology, otolaryngology, and cardiology were the next
most common specialties. Based on state licensing data
and the numbers of visiting specialists identifi ed by
hospitals responding to our initial survey, 1.7% of
Massachusetts surgical specialists and 0.6% of medical
specialists have ancillary practices in rural hospitals.
The mean number of hospital clinics staffed by the
medical specialists, however, was slightly higher than
that of surgical specialists (1.98 and 1.73, respectively).
The study hospitals ranged in size from critical
access hospitals with only 15 beds to hospitals with 129
beds. On average, these community hospitals were
located 47.7 miles (range: 20-102 miles) from the
nearest major medical center, with an estimated
transportation time of 73 minutes (range: 24-282
minutes). The hospitals were affi liated with an average
of 14 visiting specialists. Three of the 14 responding
hospitals did not report any visiting specialists, while
the remaining 11 reported affi liations with between
1 and 52. There was a signifi cant negative correlation
between the number of staffed beds and the total
number of visiting specialists hosted by a hospital
( r = − 0.573, P = .032). There was no statistically
signifi cant relationship between distance from the
nearest major medical center and number of beds nor
distance from the nearest major medical center and
number of visiting specialists.
Respondents identifi ed the opportunities they had
to supplement their patient base and augment their
income as the most important factors contributing to
their initial decision to become a visiting specialist as
well as their reason to travel to a rural area. These top 2
reasons were reaffi rmed in response to an open-ended
question about establishing the visiting specialist clinic;
28% of respondents mentioned a desire to increase their
patient base/income as their prime motivating reason.
Interestingly, 2 additional reasons — “ opportunity to
deliver care to underserved patients ” (27%) and
“ added convenience for rural patients ” (23%) — were
mentioned by approximately one quarter of the
respondents and refl ected motivators that had not been
included in the closed-ended question.
In addition to being the 2 most important factors
infl uencing their initial decision to establish a clinic and
travel to a rural area, visiting specialists cited
supplementation of patient base (25%) and income
(20%) as the 2 most important factors infl uencing their
Table 1. Sociodemographic Characteristics of Massachusetts ’ Visiting Specialists and
All Physicians in Massachusetts *
Massachusetts Visiting Specialists †
n = 99 (%) n = 73 (%)
n = 19,542 (%)
All Massachusetts Physicians
N = 31,620 (%)
Nonrespondents All Surveyed
n = 172 (%)
Younger than 45
Older than 55
Medical school §
Medical Specialists ¶
Surgical Specialists ¶
* All Massachusetts specialist/physician data as well as all age data are from the Massachusetts Health Data Consortium, Database of
Licensed Physicians. Columns may not total 100% due to sporadically missing data. Response rates by hospital site ranged from
38% to 100%.
† Visiting specialists identifi ed by participating hospitals.
‡ NA indicates not available.
§ Gender/medical school data and nonrespondent/all surveyed data are from the Massachusetts Board of Registration in Medicine.
¶ Medical specialties include nephrology, cardiology, anesthesia, hematology/oncology, etc. Surgical specialties include ophthalmology,
obstetrics and gynecology, otolaryngology, urology, general surgery, etc.
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Drew, Cashman, Savageau and Stenger 297 Fall 2006
decision to remain a visiting specialist; contractual
arrangements ranked as the third most important factor.
Responding to a 5-point Likert scale, with 1 indicating
“ very satisfi ed ” and 5 indicating “ not at all satisfi ed, ”
visiting specialists reported greatest satisfaction with
their base practice ( M = 1.64) and their practice situation
overall ( M = 1.83) (all locations); they were generally less
satisfi ed with their satellite practice ( M = 2.27) and least
satisfi ed with their overall workload ( M = 2.67).
When asked to predict the likelihood of changes in
their practices in the next 5 years, almost three quarters
of visiting specialists reported that they anticipated
remaining committed to their current professional
arrangement (72%). While most thought it unlikely that
they would discontinue their satellite practices (65%),
only about one quarter expected to expand or direct
additional resources toward those clinics (26%).
A majority of respondents (71%) noted that they
visit their rural hospital clinic more than twice per
month ( Table 2). Almost all (96%) reported seeing 5 or
more patients per visit. Statistically signifi cant
differences by gender appeared only for length of time
at base practice and travel time between visiting
specialist clinic and base practice. Although the number
of medical specialty clinics in the study hospitals was at
least equal to but in most cases greater than the number
of surgical specialty clinics, surgical specialists were
more likely than medical specialists to see more than 15
patients at each visit (58% vs 39%, respectively, although
this was not statistically signifi cant). For the majority of
respondents, the clinic was one they had been visiting
for more than 5 years (64%), with round-trip travel time
between visiting specialist clinic and home as well as
between visiting specialist clinic and base practice less
than 2 hours. Very few (11%) indicated that they were
willing to travel more than 1 hour to their clinic.
While hospitals were statistically signifi cantly
more likely to provide staffi ng ( P = .03) and equipment
( P = .02) for the medical than the surgical specialists, in
most cases, the rural base hospital provided
equipment, staffi ng, and supplies for a visiting
specialist clinic. Patient scheduling was handled either
by the hospital or by the offi ce of the visiting specialist.
The visiting specialist physician model of
workforce distribution has been described as refl ecting
the dynamics of supply and demand. 15 Our study ’ s
results support this assertion. In a state such as
Massachusetts, known for its urban medical centers
and physicians, competition for patients can be strong.
Faced with a smaller-than-desired urban patient base, it
appears that specialists are looking elsewhere to
supplement their patient base and income. By making
regular visits to communities needing a specialist ’ s
care, these physicians are able to add to an existing,
albeit insuffi cient, base practice patient population.
The primary motivation for establishing a visiting
specialist clinic, therefore, appears to be driven by
factors directly related to the physician ’ s professional
needs for patients and income. Secondary motivations
important for continuing to maintain an already
established visiting specialist clinic appear more
altruistic in nature. Obligations to the needs of patients,
the rural medical community, and contractual
arrangements are more compelling reasons to retain a
visiting specialist service than to initiate one. This
mirrors the research that has shown techniques used to
recruit physicians to rural areas should differ from ones
that are effective in retaining them 11,22,23 and indicates
that when a rural area has been successful in recruiting
a visiting specialist to supplement existing services, it
would be wise to reinforce these altruistic motivators.
Our fi nding that visiting specialists are
disproportionately male refl ects results of a similar
study of visiting specialists done in Missouri. 15 That
study also found that physicians with second offi ces
tended to be younger than the state ’ s other physicians.
With a greater proportion of the Massachusetts visiting
specialists older than the age of 55, our study did not
confi rm that result. As this population of older visiting
specialists nears retirement age, these physicians and
their services will need to be replaced; this presents
a challenge that is heightened by the increasing
proportion of physicians who are female. Moreover,
women in our study were more likely than men to
have shorter drive times between their base and their
Previous studies of visiting specialists have
described these physicians as urban- and/or suburban-
based professionals who maintain a secondary offi ce in
a rural or small town area. 15,16 If one were to consider
only urban areas as sources of visiting specialists,
however, this would place signifi cant restrictions on
the available pool of visiting specialists. In
Massachusetts, a portion of the state ’ s visiting
specialists do not originate from urban medical centers
but rather from another rural location. This raises
questions about the assertion that it is intense urban
competition that is driving specialists into rural areas
to supplement their patient base, but continues to
support the theory of supply and demand: a specialist
in a rural setting has a small patient population from
which to draw and therefore must expand into other
rural areas that have unmet demand in order to
supplement that patient base.
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The Journal of Rural Health 298 Vol. 22, No. 4
In past studies, it has been diffi cult to identify
characteristics of the host hospitals that correlate well
with the number of affi liated visiting specialists. 15,16
The strong negative correlation found in our study
between number of hospital beds and total number of
visiting specialists hosted refl ects a logical relationship
between size and need for specialists, with the larger
hospitals not needing to engage in a visiting
Specialties such as ophthalmology, nephrology, and
otolaryngology that may be expected to draw from a
relatively limited pool of patients were among the most
common practiced by visiting specialists present in
our sample. Interestingly, when compared to the
Table 2. Characteristics of Visiting Specialists ’ Clinics by Gender and Subspecialty Type
n = 83 (%)
n = 16 (%)
n = 53 (%)
n = 46 (%)
All Visiting Specialists
N = 99 (%)
Number of visits to respondent ’ s
visiting specialist clinic per month
Number of patients seen on a typical
day at visiting specialist clinic
Length of time at visiting
Less than 1 y
More than 5 y
Round-trip time between visiting
specialist clinic and home
Less than 1 h
Round-trip time between visiting
specialist clinic and base practice *
Less than 1 h
Maximum time willing to travel
1 way to visiting specialist clinic
Length of time at current base
Less than 2 y
More than 10 y
Percentage of staffi ng provided by
the host hospital †
Less than 25%
More than 75%
Percentage of medical equipment
provided by the host hospital †
Less than 25%
More than 75%
* P ≤ .05 for male versus female differences.
† P ≤ .05 for medical versus surgical specialty differences.
. . . . . Workforce Issues . . . . . Download full-text
Drew, Cashman, Savageau and Stenger 299 Fall 2006
distribution of specialist practices in Massachusetts, we
found a disproportionately high percentage of visiting
specialists reporting that they were practicing a surgical
specialty. This is noteworthy as it is not uncommon for
rural hospitals to lack the level of skilled staff support
required to ensure high-quality postoperative care.
Nevertheless, that host hospitals were more commonly
providing equipment and staffi ng for medical than
surgical specialists was unexpected.
The visiting specialists investigated in this study
seem to refl ect a state of stasis. Most have had their
satellite clinic arrangement for at least 5 years, and few
anticipate making changes to their clinics in the
foreseeable future. Hospital administrators view
visiting specialists as a growing trend, and many are
actively recruiting more to fi ll additional niches in their
community health care systems. This suggests that
while the visiting specialists in our sample are not
interested in expanding the capacity of their satellite
clinics, the demand for specialist services in these
communities has not yet reached saturation. Moreover,
given the average age of this study ’ s physicians, the
host hospitals will need to recruit new physicians and
possibly tailor their recruitment efforts to the needs of
female physicians if they are to maintain (and possibly
grow) their specialty clinics.
There are several limitations to our study. First,
the visiting specialists included in our survey do not
represent the total number of visiting specialists in
Massachusetts. No master list of physicians in such
practice arrangements is available, so we relied on
hospitals in rural areas to provide names of physicians
who were functioning in this capacity. In addition,
physicians who visit rural clinics not connected to
a hospital were omitted. A next step in developing
a comprehensive assessment of this modality of
practice would require developing such a physician
list. Second, while our fi ndings generally support
similar research conducted in 2 Midwestern and thus
very different states, our results cannot be generalized
to other states. Finally, the issue of quality of care is
an important one that this study did not attempt
The goal of matching the supply of health care
services with their demand has long been an elusive
one for policy makers, administrators, and community
leaders. Numerous studies have computed area
physician/population ratios and concluded that either
a provider oversupply or undersupply exists. Based on
the fi ndings of recent studies — including this one in a
relatively small New England state — visiting specialist
clinics represent a model that supports practice
elements within a market structure 3 and should be
included in any enumeration of physician availability.
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