Questions Asked By Journalists

Questions Asked About Rural Practice

in draft form for list serve members and students

What draws physicians to rural health?

Wanting to make a difference in people’s lives
Wanting to have a respected position where you care for a town and the town cares for your
The opportunity to lead and make decisions – in practice, in the hospital, in the community
Opportunities for family for rural living – rural is not better or worse, just different. Rural is also as diverse across the country as you can find by driving 10 blocks in any direction in a large city, particularly recreational opportunities, personal interaction vs anonymity of urban living,

What types of doctors are best suited to this type of practice?

Physicians who are oriented more toward services than intellectual pursuits. Unfortunately medical schools put a priority on intellect far more than service. It is no wonder that only 400 of 16000 medical school graduates each year are interested in towns of less than 10000 people (study by me of AAMC data).
Physicians who have had better than the usual training. Medical schools and residencies have not been able to prepare as well. They do not let training physicians make decisions. Medical schools have lost access to indigent patients and hospitals. Physicians in the cities do not know their patients and do not let students or residents do much. Rural practice is about making decisions. It demands training programs where residents get to actually do procedures and practice the full range of medicine.
Physicians who are willing to learn, from patients, from town leaders, and from each others. Despite the best training programs and lots of procedures, physicians still have much to learn. In the city, especially without such emphasis on managed care, physicians can send a patient to just about anyone. Rural docs do not have this luxury if they want to take the best care of their patients.
Mature physicians who can adjust and who have good emotional intelligence, the ability to delegate, negotiate, keep in balance, work with others well
Physicians with spouses who are willing to adjust, have good emotional intelligence…

What specialists are most in demand?

Family practice physicians are the best match for the smaller towns, they can see the broad range of patients, they can best share call and support one another, they have the training closest to rural practice demands.
Data from AMA Marketing and the states indicates that family practitioners are in the greatest need nationwide, despite the decline in managed care.

What are employment prospects

In the larger rural towns, there is the need to recruit physicians because of growing populations. The demand for physicians for the medium and smaller size towns is great and growing because of ongoing needs and continued presence of shortage areas. This is about to get much worse.
In the next 2 years we will lose over 2500 physicians in these areas due to Homeland Security measures. Foreign doctors used to be able to do service in underserved areas in order to qualify for the J-1 VISA program and stay in the US. This program was abruptly terminated. Even if the program is restored, the security measures will reduce the flow from this source to a trickle. Training programs only graduate about 700 rural family physicians a year. Over the past 30 years this has not changed. Massive increases in the number of primary care and family practice residents have not changed this figure. This level of output did not keep up with retirements and those leaving practice. Also rural populations are growing again, fueling even more demand. It is important to remember that the most dependable source of rural physicians is admitting students who come from small towns themselves. Medical schools are not admitting any more of these students, so there have been no increases in the number choosing small towns.
Salaries for rural family physicians continue to stay strong and are at the higher end of family physician salaries nationwide.

What role does debt forgiveness pay - translated, what factors in medical education impact on the graduation of doctors for rural communities

The easy answer is that debt forgiveness does not really matter that much. Almost every state and several federal programs provide funding for debt. The real problem is that the spiraling cost of medical school keeps the right students from getting in. Students from lower socioeconomic and rural backgrounds are far more likely to choose underserved locations. They often have the most disadvantaged education. Admission committees often do not want to take a risk on such students. It is easy to take the students with intellectual qualifications because they are easy to teach and will do well regardless of the training. These intellectual students are easy to assess with MCAT scores and GPA alone. They also tend to do research and subspecialize and this will bring more recognition and money to the medical school. The students with service-orientation and more challenging backgrounds often struggle to be able to pass medical training. Of course these are the ones that are more comfortable with working on long term problems with patients and populations of people. It is far more difficult for admissions committees to look through their applications and judge their ability to make it through medical school. Being on the admissions committee takes the most time of any medical school position already. It is also easy to rationalize not taking the risky students because they will be stuck with huge debts and no ability to pay them back if they do not graduate.
Students who truly want to choose rural practice do so because of who they are. They are the ones that resist the environment and faculty of medical schools who often tell them they are wasting their lives as primary care or rural doctors.
Medical schools who want to get the right students can take the time to select them. My research demonstrates that medical schools graduating rural doctors are in the more rural states, they do more Family Medicine, and they have rural leaders on campus. In other words their medical students choose family medicine and they have invested in rural medical education. They have a mission for rural health and rural faculty and rural curricula. They also work with rural communities, rural colleges, rural high schools, and rural health networks to improve rural education, rural health care, rural economies, and rural leadership.

What are some of the drawbacks of rural medicine (call coverage, lack of backup)?

This depends on the ratio of doctors to the population served as well as the past and current attitudes of the community and doctors. Many towns also attempt to staff and emergency room.
In towns without an emergency room or with fewer numbers of patients, the call is often not bad.
In towns with 4 doctors and around 10,000 people in the population served, it can be busy but not overwhelming, as long as the doctors truly share call.
In towns with over 6 physicians trying to all share call it can be a real headache on the weekends that you have call.
Lack of surgical and other backup is a concern, but the need arises rarely in the smallest towns and the larger towns tend to have some surgical and other arrangements.
If doctors do not share call well, or if doctors are competing heavily for patients, then the call can be constant. In a few communities, the past physicians have come in for every patient at all hours and this expectation makes it difficult for more reasonable physicians to come into town and practice. In these situations it is important to set boundaries and assure reliable and shared coverage. Many of these situations have already closed the town health services over the years, a natural effect of poor cooperation and poor leadership.
Some doctors do enjoy constant contact with patients, but these are rare and it is difficult for them to find partners and replacements.

What role does technology play in letting physicians practice in rural settings?

Physicians have always practiced in rural settings, with or without technology. Access to technology, especially to the kind of technology needed for primary care, has become universal. Many have great hopes for medical care delivered over great distances through technology and this may indeed impact some people, but medical care in rural areas is very personal. This is what rural patients expect and this is what rural doctors deliver. This kind of personal care does not translate well electronically. Also distance technology has not arisen out of primary care offices and practitioners, it has arisen out of distant urban centers and larger hospitals and subspecialists. Even the area of mental health is mentioned as a key area, because of the lack of such services in rural areas. Much better programs have flown psychologists out to rural areas once or twice a month, with good results and the personal contact that is needed.
It is important that physicians practice in rural settings because of who they are and what they want to become, the technology is not a factor in attracting them or holding them to an area.
Having well-trained physicians who are able to do a wider range of services is important to rural practices and rural communities. This means being able to do treadmills, scopes, minor surgical procedures, deliver babies, etc. This means that more people can choose to use local services and keep their health care dollars at home. Even a town of 2000 people means some 6 million dollars in health care expenditures with a good portion of that staying locally.
Practicing in rural areas is a matter of economics, learning how to keep market share, continuing to provide a wide range of services, learning how to keep physicians in practice longer in rural areas, learning how to work together, physician and hospital, to practice high quality and efficient medicine.