updates also at Status of Rural Health and Rural Medical Education
Postings so far, most of them from rural folks on the AAFP rural list serve and passed on to those on our list serve not on this list.
My questions - Finally what is going on in rural communities? At the local level do we tend to project an image that all is OK while giving a different story at state and national meetings? Will we ever gain the support necessary for what we feel are needed changes if we do not keep our communities informed as to what is going on? What is your opinion?
Robert C. Bowman, M.D., Co-Chairman
Email: rbowman@unmc.edu
http://www.ruralmedicaleducation.org
Robert C Bowman
09/25/2002 09:49 A
It's interesting that you write this now. I just finished going through the evaluations/readings for our rural medicine elective we teach to M-2s at Louisville, and I'm preparing some "rural" notes for our presentations to the premed groups at our regional colleges. Except for first person narratives, it's really hard to find articles/books that don't give a negative view of rural practice, but our audience is overwhelmingly positive. I wonder if in our zeal to convince policymakers that rural practice needs special consideration that sometimes we fail to "accentuate the positive" enough. Thanks.
Bill Crump, M.D. "BCrump" bcrump@wko.com
Associate Dean, UL/Trover Foundation Campus at Madisonville, KY
Bob-
I've just gotten through debriefing the 87 second year students of ours who participated in our RUOP(Rural/Urban Under-served Opportunities Program) this summer-most went to quite small rural towns throughout WWAMI. I'd say that 95% of them had a fabulous time, often a life-changing event intheir words. Although they see all the problems of practicing medicine, they mostly came back enthusiastic, and open to the possiblity of rural practice.
One trend: it seemed pretty clear that those in Community Health Centers saw their preceptors as more satisfied, less frazzled, and more optimistic. It also seemed pretty clear that the CHCs had a richer menu of services and staff, in general. An interesting switch from times past.
Roger A. Rosenblatt MD, MPH
Professor and Vice Chair, Department of Family Medicine
RUOP Director - School of Medicine
Box 354696 - University of Washington School of Medicine
Seattle, WA 98195
RUOP Phone - 206-543-9425; Research Phone - 206-685-1361; Fax-206-616-4768
e-mail: rosenb@u.washington.edu
I have had a similar experience in working with students in the "med scholars' program here in Madison. These are students selected out of high school to enter medical school provided they successfully complete their pre med program. They too felt that the health care in the rural areas of the Wisconsin was good. Our challenge is to provide an image of opportunity continue improving a rural health system that is in the process of improving. As we work with current providers we focus on the short comings and often do not fully celebrate the successes and improvements. As I drive around rural Wisconsin, I am truly impressed with the quality of the facilities and the compassion of the providers. That said, we need to increase the numbers of these compassionate providers and work to change health policy that serves as barriers to further enhance the quality of rural health.
Byron Crouse, MD Byron Crouse bjcrouse@facstaff.wisc.edu
Bob,
I don't have a comprehensive answer for you, but I do have a couple of comments.
1)Rural health care needs are complex, and each community and its players are unique. The students might not see any problem accessing health care because a couple of NP staffed rural health clinics run by regional institutions might be within thirty miles, while the local hospital is dying on the vine because there are only two physicians to take ER call. The services that are in short supply might not be the ones a healthy 22 year old uses and hence "invisible".
2)If one looks at the patterns of care of a community, the single biggest change in the past thirty years is the improvement of rural roads. I live in a town of 17,000 souls with a 100 bed hospital, yet at least 20% of our citizens get ALL of their care in a University Community 90 miles down the road because the care is perceived to be better. The tragedy for the smaller communities is that it is the patients with automobiles, gas money, and health insurance that are able to travel. I stay busy partly because the patients from smaller towns within forty miles of here don't support their local doctors either.
Arthur Freeland
Kirksville Missouri
Bob:
Your informal quiz with those young students reaffirms our 10-year old contention that "things" are certainly better and still improving in rural Iowa and elsewhere in the Midwest. Ninety-nine percent of our state's residents who live in towns without primary care physicians or reside in rural townships are within 15 minutes of the nearest physician. That statistic doesn't even take into account part-time primary care satellite clinics of which we have more than 130 across rural Iowa.
Iowa's FP per 100,000 population ratio is already at the AAFP 2015 goal of 43/100K. We have more than 30 inactive FPs who are "between jobs" as a result of our abundant supply. We just finished our annual statewide demand study. We work only with a 100% response rate. We survey all employers of physicians---every address where at least one physician is employed. We survey nonrespondents two times after the initial mailing then go to the phone to reach 100%. We currently have only 83 jobs for FPs in private practice. In addition there are some FP jobs with the VA and in emergency medicine. In 1988, we had 383 jobs for FPs in private practice. Quite a decline is depicted when we chart our progress on a line graph.
We have an increasing number of towns with populations under 2000 that have full-time physicians.
Visiting medical and surgical consultants conduct outpatient clinics in 124 rural Iowa towns 2 to 8 times per month. Most of that activity is based in rural hospitals, each having between 10 and 20 different visiting consultant arrangements. While this pattern doesn't do much (except by coincidence) for urgent and emergent problems, imagine the typical community with regular visits by cardiologists, pulmonologists, medical oncologists, orthods, urologists, etc. Most of the visiting consultant arrangements rely on referrals from FPs in the area of the outpatient clinic.
I could go on with a few more supporting facts, but you get the point. There is a very good chance that circumstances are much better than many of us typically portray. I believe damage is done by repeatedly describing the condition of the "rural Titanic." It is becoming a self-fulfilling prophesy. We are so convincing in describing the disaster that no one would want to "get on board." This includes all of the hyperbole relating to the prospects of rural hospital closures. Look at the annual AHA statistics. They are not consistent with the 25 years of shouting about the "forthcoming closures."
Why not focus on the positive accomplishments, the gains, the models, the vision? That has been our theme in this office for many years....rt
Roger Tracy Assistant Dean/Director
Office of Statewide Clinical Education Programs UI College of Medicine
(319) 335-8618 (319) 335-8034 (fax)
I think you are correct about physicians and hospitals in rural areas not presenting a true picture about the difficulties of rural practice. I am struggling to practice in a small town making "bricks without straw" yet if I complain my fellow neighbors seem to have it as bad or worse than I do. The paper mill, our main source of employment, is laying off many and the mill who now has stock at an all time low is not beginning any new projects.
The teachers are swamped with paperwork and demands for low pay in adverse conditions. Our state agencies are unproductive due to government bureaucratic demands. Houses are forsale everywhere. As I listen they seem to have it worse than I do.
All my neighbors in this day and time have the same difficulties, yet I live in a larger house. It is difficult to complain while my standard of living in still much higher without drawing attention and criticism to that fact. They do not see the losses on paper, my two months behind on accounts payable, etc.
We had our congressman here last year. We had just built a new hospital three years before his arrival. It really looked nice for his visit. Of course when we complained he said it is difficult to listen to our complaints when we had such nice pictures on the walls, such an elaborate entranceway, and such a fine appearing facility on the exterior. He was right. Until it looks bad and physicians and hospitals appear to live worse than our neighbors they will not listen to our complaints. However we keep up the image so our locals think all is well.
In my opinion this facade will cause rural medicine to fall apart rapidly almost overnight when it goes. I took a large pay cut this year and put my house up for sale. Sadly no one in our town can afford it now even with lower interest rates. No new car since 1996. My fellow colleagues built a new building before HMO\PPO and balanced budget cuts in reimbursement. They have no credit with vendors due to bad cash flow. They also have let all experienced help go to hire new people with little experience so as payrolls will be smaller. However if you were to ask them they would tell you all is better than ever. They have to keep up the image for pride sake in the community.
The death of rural medicine will be like the frog in slow heating water. We will boil to death all the while ignoring the water's temperature increase around us.
Legislative and community support will take more than complaining. We must visibly demonstrate the crisis for others to believe there really is one.
William W. Henry Jr. MD
Hamburg, AR
I had a fabulous education in Rural Health politics while Directing the Office of Rural Health U of Nevada in the mid 80's. The issues have not significantly changed including such as rural OB, Malpractice insurance and locals abandoning their LMD's for "City Specialists" And finally, the legislators (most of whom were from metropolitan areas) had little interest in small towns. I offer the following observations/suggestions:
1. When talking w legislators i reminded them of what neglect of small towns meant--a population movement to big cities. I reminded them that they had a duty to their smaller brethren to help them survive--I'm not sure but what it went in one ear and out the other.
2. Many rural folks noted that their doctors were not always available and continuity of Dr:Pt was not always as real as we present. They felt somewhat like their LMD was akin to a 7-11 store-- handy when you had an acute problem but for "real problems" they felt better at the hands of a "City Specialist"
I come away today feeling that too many FP's have become too detached from their patients via insurance, and life-style conflict with significant bonding. And patients have taken that to mean that there isn't something significant with a full relationship w the LMD. Therein lies my indictment of current FP (OK, I know you don't do this) practice--too focused on time off, too focused on reimbursement issues (that's important too but not to patients who are REALLY struggling) and not focusing on insurance that patients are receiving the best care no matter where.
Where are the rural practitioners who take on the role of patient advocate, collate all their specialty care, and make themselves indispensable to their local patient population? You should tell folks what you do to keep your patients (and therefore your hospital) business at home rather than away somewhere. And don't embellish! Remember, the Mayo Brothers started in a Small town! (editor's comment - so did managed care!)
Pat Crow, MD, ABFP, Ret Harold Crow hecrow@pol.net
Good to hear your comments,they are right on target. Roy Gerard M.D.
My interpretation is that it's the doctors that are hurting -- not their patients. I generally do not complain to patients or community members because in our current culture it would be interpreted as very self-serving. And, frankly, wage-wise I'm still doing better than anyone else in my church - although perhaps not on a per hour basis!
I do take every opportunity to point up how difficult it is to recruit doctors, and explain in some detail why the wait at the office is 2 months for a routine appointment, why 4 family physicians just left the county north of us (already a HPSA), why no one in town is taking new patients (We can't take care of the patients we have!), ...and why I initiated a rural residency program, hoping to increase the perceived value of the residency program to the community.
--
Randall Longenecker MD
Associate Rural Program Director
Mad River Family Practice: The Ohio State University Rural Program
"A Rural Practice with a Residency"
4879 US Route 68 South, West Liberty, Ohio 43357
Email: rll.mrfp@logan.net
Phone: 937-599-1411 (MRFP) or 937-465-0080 (Residency #)
Website: http://www.logan.net/users/mrfp/
Bob,
Thanks for the opportunity. This one strikes a cord for me.
I've long been ambivalent about the strategy used by us (well, certainly by me and I know some others). The "underdog" and "poor me" strategy, or more appropriately belief, has some short term influence with, say, "funders" but not much with students. There ARE some who will go and say rural because it's a calling, but most do that because they LIKE rural. So, when we communicate how BAD things are, reasonable-minded people may say "Why would I go there -even the advocates think it's awful." Although I lack proof, I'm of the opinion that generation X and Y students will produce fewer martyrs that us boomers. I think they are likely to see their possibilities more clearly and make decisions based on opportunity - and they should.
SO, as I tell legislators and educators how much is needed, I'll tell students and residents about the rewards that await them.
"Williamson Jr, Harold A." WilliamsonH@health.missouri.edu
I have no education in "rural health politics" and do not sit in ivory towers that produce the residents who are to go to rural practice. I don't have one study or statistic to back up what I have to say. I have no "expert qualifications" except for the fact I believe I actually practice as Dr. Crow expounds. I see who the Lord sends as best I can. We take care of today's sick today as best we can. We advocate for the patient in every circumstance for his\her best interest regardless of insurance refusing to see no one, even those with debt when really sick. I nicely on collection letters tell patients if they will let me know we will assist with payment options under true adverse circumstances. We collate all the specialty care explaining and coordinating the total patient care for more than 5000 in a town of 3000 and county of 25,000 at least one hour from any specialty center. We still make long distance phone calls, fax records, talk with specialists for advice on care and workup, answer pages, and listen when needed. I am on call twenty-four hours a day seven days a week. It takes me
twenty minutes to get across Walmart and I have even been drug by patients to the blood pressure machine as I entered the door. I give advice freely to at least ten people every service at church as I live with the people I serve. My patients in the waiting area defend me when one complains about being seen late for an appointment telling the critic to sit down and be quiet because on their turn they will all the time they need. I gain weight because of pies, cakes and special delicacies. I had one five-day vacation
in each of the last two years. Serving the people I have come to love is not the problem that endangers what I do, what I feel called to do by the powers that created me.
While I cannot pay the cost of the medicine I think Dr. Crow attempts to describe I know One who can. Therefore I keep going toward the "Red Sea" looking for the dry ground I know will be there. It may mean less pay, a smaller house, older cars, and to say the least less compliance with all the bureaucratic requirements - but I will attempt to be loyal to the people I serve and seek wisdom to make a difference for the glory of the One I serve most.
The question I have is: HOW MANY ON THIS EMAIL ARE REALLY IN THE KIND OF RURAL PRACTICE DR. CROW DESCRIBES? HOW MANY ARE REALLY IN THE RURAL TRENCHES ON THE FRONT LINES IN OLD STYLE PRACTICE WITHOUT OUTSIDE (HOSPITAL OR OTHER) ASSISTANCE?
I would be more interested in their story. No disrespect for the educators and retired is meant.
P.S. My wife on reading this told me the docs in the trenches are to busy seeing patients to read this and tell their story. My problem is I just happened to have a rare slow afternoon. William W. Henry Jr. MD "William Henry Jr. MD" williamhenry@cei.net
I applaud Dr Henry as a true selfless, God loving man.
I have been "on my own" for less than a year, and the way finances run, will be out of business by the end of the year. In order to attempt to stop the hemorrhage of finances, we have an LVN in the clinic only 1/2-1 day per week to give immunizations, we have greatly restricted Medicaid and "indigent" visits, and have eliminated one insurer that paid less than Medicare (in addition, it consistently denied payments for removing simple skin lesions - saying this was out of the "scope of practice" for a Primary Care person). This merely slowed the hemorrhage, and I fear it is too little too late. We were assured when we started that the "there are grants out there to help" -these so called called grants turned out to be only for not-for-profit rural health clinics which require mountains of paperwork and hiring a PA/NP at least 20 hrs/week (and then Medicare denies payment for other things b/c it's "included" in the additional payment) - so still a losing situation. And no, no "help" was forthcoming, despite multiple promises. My husband is extremely frustrated - he's my office manager, and the two of us together are now making less than I did as a resident. The people rarely make it any better, it seems like any time I bend over backward for anyone, I just get kicked in the teeth. So, I'm ready to throw in the towel and leave rural health care to the PA's and NP's, who don't have the additional overhead of $100,000 in Medical School debt to add to the mortgage.
Frustrated and Ready to give in
-Carolyn Eaton, MD
ceaton30@netscape.net
Dr Henry,
Wonderful! I congratulate you for knowing your purpose and delivering on it. I admire you. As educators we need to get more of you into and through medical school with values intact. There in lies the reason we keep doing what we do in the "ivory towers". But, every once in a while, to hear your story is to remind us why we do what we do. I hope you had a great afternoon.
Tom
Tom Rosenthal trosenth@acsu.buffalo.edu
I've been solo BC FP in southern Idaho for 17 years. I believe things have gone from bad to much, much worse in the financial and regulatory arenas. We are getting all kinds of red tape on top of the struggle to provide low income people with some semblance of quality care by US standards.
In February I jumped through the hoops to become a Rural Health Clinic (RHC). I'm the only doctor in a county of 1200 square miles and about 4,600 people. Many of my patients come from surrounding counties that have a shortage of primary care access. My children have trust funds for college or
I would never have been able to justify staying in my current practice with the relatively low income I've had. Yes, I get beef, pork, eggs, produce, baked goods from time to time. That doesn't directly pay my creditors but it is appreciated. To a point. Like I said, those gifts wouldn't put the kids through college and they don't fund a retirement.
Sadly, I could not recommend solo rural practice to anyone starting out in
2002. Maybe things will be better next year!
"Keith E. Davis, MD" docdavis@shoshone.net
Dr. Bowman,
I agree with many of the replies so far. Maybe we do sugar coat our problems when those around us have it tough or tougher. I don't do that when I have high school students following me around or with my board members as I want them to know what rural providers face in providing health care.
I have practiced in rural western Kansas for 14 years. I was a local who went off to medical school and paid for the scholarship by returning to my hometown. I replaced a physician who had been here 35 years when he retired. We have built the practice, with assistance from my hospital and community, up to three physician, two mid-levels and a primary behavioral health specialist and have a clinic in a neighboring community that has no hospital.
I sold out to my hospital as the AR began to lag the AP and now they have the headache of talking to vendors about past due debts.
The health care of the community should be a community interest and that is what I have tried to do along with my partners; make the community decide what they want for local health care and to make sure it's available, whether they have insurance or not. We have tried to be frugal and don't do elaborate procedures or services that we haven't felt appropriate for this small 18 bed hospital. We capture over 90% of the local market, 35% from our neighboring county where we have a clinic and continue to get more patients from the other two surrounding communities because they don't have a stable healthcare provider system.
We avoided EACH/PEACH when it meant removing surgery and c-sections as we were trying to expand services. Now with fewer restrictions CAH status is going to draw us in as we can't survive at the current rate with such poor reimbursement to rural facilities and providers. We are 3 years out from a new nursing home, ER and clinic. The cost overruns and architect errors left the hospital board with no reserves. We see marginal facilities, that can't keep providers, operating in the black and we will soon have to go to the community and ask for no-fund warrants to get out of the AP hole we find ourselves in.
Believe me; my community knows the struggles of a rural health care system but I'm sure there will be those who see the house I have and my car and wonder why they have to pay more to keep the facilities going. Yet I'm like most rural providers who don't leave their practice when they close the door at night. We only change the location and situation when patients approach us at every civic event and local business. Most appreciate the efforts the providers put forth to have health care services locally. Fortunately, the closest specialty-oriented community is 90 miles away and not a direct competitor. Emphasis by editor
We must actively involve the rural community and make them take a vested interest in their health care system. The hospital board should be volunteer, folks who share this interest and actively promote it rather than those who seek an elected post with hidden agendas or motives outside the interest of the community as a whole. If we don't educate our patients about the vagaries of Medicare, Medicaid and third-party reimbursement programs, or the difficulties we face operating a rural health care system then we will die on the vine as our voices alone are not loud enough to draw the attention of elected officials. It's very effective getting 4-5 seniors at the local senior center to write letters addressing "our" concerns. Get the local community involved before you have to lock the doors and close the health care system!
Bob Moser, MD kurpm2md@sunflowertelco.com
Tribune, KS
I appreciate all the responses so far and in no way want to close this off, but I wanted to be sure that all took a note of these words just posted by
Bob Moser:
"Believe me; my community knows the struggles of a rural health care system but I'm sure there will be those who see the house I have and my car and wonder why they have to pay more to keep the facilities going. Yet I'm like most rural providers who don't leave their practice when they close the door at night. We only change the location and situation when patients approach us at every civic event and local business." "Robert Moser" kurpm2md@sunflowertelco.com
I will add this and others to my collection and continue to share it because it captures the service ethic that I find so lacking in many of my colleagues since leaving rural practice years ago. Some others of similar relevance from the past:
"I may be naïve, but I still think that a career in rural family medicine offers the best opportunity for the best doctors to be at their very best and have fun doing it and find those moments where you too will be dear and glorious." Robert Boyer, M.D. reference to Taylor Caldwell's book about Luke, the physician in the Bible who wrote Luke and Acts
"Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance." Rosenblatt and Moscovice, 1982
It is interesting that Roger Rosenblatt, quoted above in 1982, just mentioned in 2002 that the federally supported docs seemed to be doing better. Others were doing well by working with or for their hospital. Perhaps the solution to some of the problems noted above is summed up by previous physicians. Docs must work together, with their hospitals, and with their community, using whatever federal and state and local resources necessary to keep their patients served and them reasonably accommodated for their efforts. Perhaps we still think within a framework of solo or group docs when the character of rural practice has changed. Rural hospitals have turned things around by working with each other, perhaps rural docs need to take note. I know that our rural doc networks in Nebraska seem to be addressing many of the challenges expressed previously.
My fear as a rural medical educator has always been that I not encourage an enthusiastic, well trained, rural motivated resident to go to a place that does not support them. We cannot afford to waste their efforts when they stay only a few years when the right situation might have them stay for life. Contrary to other FP graduates, rural graduates, really do want for things to work out for the long term for them and for their community. This seems to be one of the reasons that they are interested in rural practice.
Rural health takes the combined efforts of community, hospital, and physicians. All most work with each other for rural health to do well. If we can keep most of our rural physicians in practice only a few years longer, they will be better docs for their community, and we will go much farther toward economic stability in rural communities, retention and expansion of health services, improvements in the quality of life of rural communities, and decreasing the need for excess physicians for the nation.
My favorite group in rural practice was the Ministerial Alliance, followed by the underserved group we formed with our Medicaid office people, and then the Chamber of Commerce. My least favorite was the hospital staff and hospital board. I think this had to do with the former group being people out to serve the community, and the latter group people who wanted to take from the Community. It sounds like many of you are fortunate to have people involved in health that work together.
I could share with you the challenges of urban underserved practice yesterday. It seemed that there is little justice left in this nation for the poor, the sick, or victims of domestic violence, the one success story actually turned sour again. I could add to it the personal dimensions of raising challenging teens, but yesterday combined with the reflections of some of the rural postings just help me identify again that I am not in control, I just have to trust the Lord and let Him guide me and take away my burdens.
Robert C. Bowman, M.D. Rural Medical Educator, Facilitator, Father,
Servant rbowman@unmc.edu
Just talked with one of our most frequent rural visitors. He noted that there are good and bad situations scattered. We reviewed some of the emails from earlier. I talked about some of the pictures from a mission team just returned from Kenya. We talked about how those with material wealth were spiritually bankrupt and vice versa. He noted that he was just happy to have a job and a window to open, which was better than many making $300000 or more. I noted, tongue in cheek, that they were afraid to give them windows for fear they would jump out. He reflected that one of the psychiatrists at the Medical Center just noted that losing investments from recent financial crises was like losing a close relative. Then he went on to note how he was recently out on several days of rural visits, including a stop at a church in south central Nebraska where much of the land looks like it has been blowtorched. He did not hear one complaint from the farmers about their problems during this time.
Robert C. Bowman, M.D. Rural faculty rbowman@unmc.edu
I am always optimistic and positive when I am with medical students, for reasons we all know well. When I served on a rural physician lifestyle panel recently at the medical school, I asked the moderator if, for a change, we could discuss some of the more
problem issues instead of telling warm fuzzy stories. He didn't respond until the day of the panel, then said he was sorry he didn't get back to me.
When my mountain village practice of 30 years was going to close within months if the hoped-for Community Health Clinic grant didn't come through, I went to the community with a description of the current-era difficulties of rural health care. They were very responsive. Their understanding may have been merely, "if we don't do something we will lose our doctor." But they made a big stink that helped accomplish the rest of the process of becoming a CHC.
We will soon have a community board for the first time. I hope that will activate people in taking responsibility for the medical care of the area. I agree that low income people simply have a lot to worry about, and are glad to leave this responsibility to someone who cares about them. They can give their energy to coping with bosses (pt told me a few hours ago that she has just worked factory 31 days without a day off!), family responsibilities and making ends meet.
I do the 24/7. I live in a double wide trailer and, at age 57, haven't yet owned a new car. My kids made it in college with scholarships, thank goodness. Personal sacrifice was not the issue with having to give up owner-operator medicine this year: we were running out of sutures, medicines, x-ray film, even the waiting room chairs were busting and couldn't be replaced. Creditors wouldn't do it any more despite decades of paying my bills. HIPPA was looming. Gosh.
The community members really never seemed to notice that my lifestyle was kind of low for a doctor. Don't worry about it. They will be there if you need them, if you've been loyal to them. I have no problem with my situation so far.
Dr. Eaton: You came in at the (Hopefully) bottom of the pendulum swing. I hate it for you. I couldn't do it now. New starts have not worked around here the last 5 years. We need to get the word out about that. Believe me, it's not you.
Dr. Rosenthal: I wish my teachers could know that I did this. Need all of you. Thanks.
Dr. Bowman: We are so rural that there is no local government, no community forum. We organize through the rescue squad, the churches and crises. That's why the future CHC community board is important for a developing a voice and perspective on their precarious situation. I look forward to working with that. Thanks for bringing up a great subject.
Dr.Henry: I don't think that new docs who aren't making it in rural communities are short on faith any more than I think that when someone gets a bad disease it's God' punishment. I know that isn't what you mean; but I think there's a plague upon us!!
"Janice F. Gable" jangable@email.com
There are many inequities for doctors in
rural practice, not the least of
which is lack of easy access to consultants. And for this we get less pay.
The bonus was a effort to get docs to rural areas, but I am still just
barely making it and while I kept the same front office person for 23 years
and a NA for 15, both have left for various reasons and replacing is very
difficult. In an environment of suspecting doctors of fraud and yet having
all the people making money off of our fear of coding incorrectly and even
the legal system telling the billers they are financially liable is making
it hard. Yet I am working more hours, doing less care than ever and am
uneasy about my status after 27 years of practice in the same town. My
husband does my disbursals and he now suggests for the first time that a
salary would be better. I have a good reputation, one suit settled due to
not wanting to get tied up in court (unattached smoker with GI bleeding,
atrial fibrillation and ischemic bowel). I have a feeling I am suffering
from post-traumatic stress only the stress is still on. I love my
work--continue to make changes all the time. Even tried EMR but couldn't
get past the EULA so am tied up trying to get released from the lease. My
patients have alot of problems too. Many can't pay and I refuse to get them
on cards that charge 18 % interest. How can I share this with them? I'm
not even sure I can share it with my own peers. (one of them has the same
EMR sitting idle in his office.) List serves are the closest thing to
sharing of these matters for me at this time. C
"Carolyn McCormick" <cbmfp27@bellsouth.net>
I'm late jumping in on this since I don't
have a ton of time to check my
email, but I am one of the guys in the trenches... town of 3000; county of
10,000; 1600 square miles.
I just had a heartbreaker this year when my malpractice bill showed up... a
53% increase in rates because I do OB. Plus a $5000 mandatory contribution
to the "cash pool" for the physician run company. And I've never had a
claim... not one! Well, the only other doc in town doing OB quit on the
spot, and now I'm being forced to quit too, since my OB population is too
small and too Medicaid-heavy to support the rate hike.
THIS IS NOT WHAT I SIGNED ON FOR!!!
As my OB panel slowly shrinks (I'm down to seven ladies to deliver) it makes
me sad to think of all of the kids (I've delivered about 200 since I came
here) who won't have a chance to be born at our little hospital, where they
get the kind of one-on-one LDRP care that just isn't given at the big city
hospital 45-60 minutes away.
This goes a long way to say that there are those of us that receive no
stipend from anyone to be out here. I am a solo practitioner and have to pay
my help and the bills before I take home a dime, and now I've been forced to
abandon something I love (OB) because it's financially not acceptable to
continue. (Not to mention the fact that I lost my back-up for the same
reason).
WHAT"S WRONG WITH THIS PICTURE?
J. Robert Parkey, MD
Henrietta, Texas
"J. Robert Parkey, MD LP" <jrparkey@wf.net>
Bob,
We have an annual event where we invite communities and residents to meet
and discuss practice opportunities. This year we decided to put together a
panel of rural practicing physicians to tell the residents what to expect.
It was all very positive.
My impression of the theme (if any) was. Freedom to practice medicine the
way you want and the joy that comes with that. Quality of family life.
We had many volunteers to come to Austin and give a week-end the make these
presentations. There are a lot of positives out there.
Mike Easley
512-936-6709
measley@orca.state.tx.us
Yesterday was a good day for rural health and rural medical
education. I
traveled to the other end of the state to recruit small town students to
rural practice. The Chadron State Rural Health Career Fair includes about
230 high school students and about 70 parents and advisors and another 40
of us facilitators at the college and health profession school level.
Students come from 4 states. It also gets me a chance to see what is going
on in rural areas in the region. I would encourage you to work with rural
student interest groups and others to have such fairs, especially on small
college campuses. They are important to helping rural kids learn the ropes
about getting to college and also to professional training. It helps them
keep their dreams alive. We also have one at Omaha, but my preference is a
rural college campus by far! We encourage the students and help them learn
the next steps and try to get them to work with someone as a mentor or
advisor for the long haul. We advise them to work with local docs as much
as they can to get shadowing and service projects, etc. More on this at
http://www.unmc.edu/Community/ruralmeded/preprofessional.htm Be sure
to
pass this on to any rural teachers, parents of any kids interested in rural
practice, etc.
Such programs can help reverse the centralization process that is killing
small towns. Small colleges are indeed the breeding grounds of young rural
professionals, and are on the endangered species list along with the rest
of us.
http://www.unmc.edu/Community/ruralmeded/fedstloc/centraliza.htm
I always enjoy talking with the dental, and PA, and OT and Rad Tech folks
that travel with us. Dental is facing many of the same problems. Pharmacy
cannot find enough people and the smaller pharmacies are closing for lack
of someone to take over. Sometimes hospitals and communities are stepping
in. All of us have a higher and higher percentage of females that are even
showing interest in health careers, same with college where female
percentages continue to rise. Veterinary medicine has only a handful of
students interested in large animal vet in the entire nation. Some vet
schools are 70+ percent female. Some states play fair when training
professionals from other states, and other states seem to attempt to
extract the last penny, knowing full well that building a full scale
professional school is costly for only a few graduates. Nebraska tends to
be a loser in these situations.
The impact of West Nile on one community for the death of a special horse
was greater than in many areas, since the horse was a champ destined for
glory with its rider.
Had interesting conversations with rural media regarding situations such as
coverage of traumatic events, centralization of state resources, Medicaid
cuts, etc. Talked to a rural teacher in her mid 40's that is now uninsured.
Seems that a late hiring forced her to miss open enrollment period (school
or insurance policy?) and just pray that she does not get ill while she
scrambles. If she does, it will not only be her that suffers. Her family,
her hospital, and her doctor will likely lose out also. More about such
patients in my practice who are abused by the system at
http://www.unmc.edu/Community/ruralmeded/poorer_health_in_the_process.htm
Senator Hagel sent me a letter today stating that he is read to overhaul
the whole health care system. He will need lots of support to balance out
the huge war chests built up by the insurance companies.
The other teachers at the career fair had long discussions about how hard
it is to get certification in plains states, the very ones who send
recruiters across the nation. My wife has had the same lost forms,
duplication, and delays as they have had. Nebraska, Colorado, and South
Dakota seemed to have ridiculous and burdensome requirements for paperwork
and courses and documentation. One teacher of 40 years experience said that
this was her last year, she was tired of all of the paperwork, sound
familiar?
The plane flight was better than most. The governor stole our plane at the
last minute, but because the state planes are not as much in demand, we
were bumped up to a new King Air 9 passenger with only 160 air hours. It
was smooth, quick, and much much quieter. Oh, and their insurance increased
at a rate equal to 15 cents per plane mile even though they have only had
one claim ever. My buddy in pest control in the Houston area now has only 2
competitors instead of 4, seems insurance costs have driven the others out
of business.
The fact that the state planes are not used as much to ferry people around
the state is a direct measure of hard times. It also means that personal
contacts from various state people at all levels will be decreased.
Government people will more and more be guessing what to do unless we step
in and tell them what is really going on. It appears that they won't be
coming out to see us as much. Centralization strikes again.
More about Rural Visits to Preceptors at
http://www.unmc.edu/Community/ruralmeded/facil/research/authors/Hobbs_Invisible.htm
Robert C. Bowman, M.D.
rbowman@unmc.edu
Academic Impacts on Family Physicians