Many assume that there is so much need for physicians in small towns that new physicians can go right in a establish a practice. Building a practice is far more complex. Physicians choose a practice location by examining many different characteristics. A key determinant is the practice itself. In urban practices, one location may have a choice of several different hospitals, employers, and home locations. In rural practice there is usually one hospital, one or two clinics, and only a few physicians to choose from to share call and other duties. This in itself requires quite an adjustment on the part of the physician.
The following is adapted from research interviews of established and new rural doctors in towns of less than 5000. The quotes are directly from rural physicians regarding getting started in practice.
The initiation of a practice is a difficult process. New physicians have deferred gratification for many years and may be extremely susceptible to certain guarantees or promises. Those choosing rural practices deal with much change in the practice, professional, and personal aspects.
Studies of rural physicians reveal some basic differences in their selection and training. About half of rural physicians come from rural backgrounds and half from urban. Attrition from marriage to urban spouses is likely the major reason for the decline in rural interest over the years of college, medical school, and residency.
All of the physicians noted great difficulty for themselves and others when starting a rural practice. They had to choose between the conflicting dimensions of practice, person, family, and community.
"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
"I think for the most part physicians who go to rural areas in the first place have already pretty well made up their mind that that is what suits them, small town living and so on. Once in awhile you may find somebody who is truly kind of an urban kind of person basically who tries it in a small town to see how they like it and of course it usually has to be a joint thing between the physician and his spouse and if you find that one side or the other isn't suited to small town living then it easily doesn't last. And so most of the people who go to small towns to practice in the first place have already, they are from that kind of a setting or they have already adapted to small town living and liked that kind of life style and so that part usually kind of solves itself."
"They (new physicians) are going to have to accept what life style is here within some limits."
Of course many of them chose rural practice because they looked forward to the type of lifestyle present in rural communities. This is often missed by urban people who don't consider this a possibility.
"Those that leave rural practice do not find things that stimulate them and they quit having fun in their practice and they don't keep up and add new skills to their practice like they should. I have a lot of fun in my practice"
"Well I think that a person probably does better in a rural practice if he can somewhat isolate himself from some of the, you have a tendency to do a lot of things but on the other hand you may not want to know your patients always as well as you get to know them in rural areas. There are pros and cons to that. That is individual and it depends on the person I would say.
(regarding time for family/recreation) "That is the big loss in a rural area because if your not with a lot of coverage because it isn't a lot of fun to go out for dinner and get called out twice during a meal or fun to go out and try to hunt or fish and be beeped off your hunting grounds or fishing area or take your family out for a picnic and have you beep you off the picnic. That always happens when your getting ready to eat.
(privacy issues) "That is no problem here and that depends on the person and what they want people to do, I mean how much they want to let people in their lives and that is very depending on the wife and that is where you get into the fall down is probably with the wife more than the doctor.
Rural physicians themselves often note the need for more physicians, but are less willing to encourage competition. The competition for building a practice vs the cooperation needed to share call and have reasonable lives was a real dilemma. One of the adjustments noted in towns with four or more physicians was training patients to accept whoever was on call. This seemed to be difficult for some of the physicians as they took care of their patients personally even when they had partners.
From the physician perspective, building a practice can conflict with having enough physicians for a rural health systems are challenging and dynamic. Potential remedies often have other consequences.
May best be viewed as an unstable environment with endangered species - hospitals and doctors.
The smaller the system the increased need for fit, the less total providers, the less resources for support, the more likelihood of overload if a provider is lost, the more critical the timing of additional providers, the more difficult it is to get established doctors to recruit others.
New doctors are not as efficient. It takes time to learn the resources. Also it takes time for less complicated patients to come in to your practice. The more challenging patients will check you out first, having been rejected or discouraged by the other physicians. Students noted that the older rural physicians often knew the diagnosis and situation before they went in the room. When pressed, the doctor confessed that he had knowledge gained from the community or previous contact with the patient. There is some degree of maturation of patient care skills also
Group practices may help but groups also have more physicians. Some of the rural physicians noted that they were impressed with a situation where there was something established or something that was building and had direction. Others seemed to want a situation were they could make a contribution. Groups add colleageality and the potential for support and advice in dealing with the new situation.
Implications for retention
Others may ask how they can help rural physicians. Many seem comfortable with their situation. Previous locums studies show little use by rural physicians. The competition, the closeness with patients, the high expectations of care, and other factors may keep rural doctors from using locums. Those who are "established" or completely solo without competition may utilize the services more. Many noted the difficulty of scheduling locums far in advance. Organized locums programs also run the danger of taking established rural physicians out of practice for higher paying locums work. This would not help the workforce in the long run.
Call - by far the most challenging part of practice. Doctors have to decide when they will be "off". To do this they have to be able to trust the other providers to care for their patients appropriately and get their patients back to them. Some situations work out well, others... Some hospitals pay for physicians to be on call.
Community responsibilities - some physicians hide, others are active, some can say no, others can't. Some communities have been trained not to bother docs, others haven't.There is a wide variation in workload.
There is less willingness of docs to own practices, buy in, or do call more than 1 in 4. Often the training is not as broad in procedures. More docs want their free time or time with family, or both. Many blame the younger generation, but all of us have gotten more comfortable with more things to have and things to do.
The leadership roles are also a challenge. Communities need young leaders to step up in health care and many areas.
There must be a balance between too many (also getting there at same time) to build practice and too few to share call. Recruitment needs to be a constant.
The smallest existing rural health systems involve two to six doctors and a local hospital. In rural states such as Nebraska, this involves 25% of the counties. These systems have the greatest difficulty getting and keeping physicians. There are who could support four physicians with surrounding populations of 10000. there are others who could support four with reasonable help from the area (assistance). Support eases the dilemma of competition, and may encourage cooperation
The need to build a practice is more than just physician patient ratios and local economics. There is a complex interweaving of many factors - dealing with a challenging job, dealing with one's own personality and needs, balancing the competing areas of short term income and practice and patient needs with long term personal needs of recreation, family, quality of care that can be best met by shared call and coverage.
Communities can turn around some dangerous situations that would run off physicians and their families:
"Well here in our particular setting because even though we are rural we have attracted several physicians and we have carefully trained the patients over the years to accept any one of us on an on call or emergency situation. Here we have fairly good isolation in terms of privacy in as much as the patients understand, they go to the hospital on nights and weekends and whoever is there is the one that takes care of them. Prior to having recruited several physicians to our community the privacy thing was a big factor and is a big factor in a lot of other small rural settings where there may only be one or two physicians covering a fairly large patient load. Patients are not at all shy about coming to your house or calling you any time of day and night or in social settings you know, although there is a lot of jokes made about it it still is very irritating when people want advise on the street corner or in the theatre or at some party or some kind of thing or come over to your house while your trying to have some private life and just walk in and want some kind of medical attention. We had those things here but we have kind of managed to evolve to a safe distance beyond that here Patients can be educated and some times some physicians have a great deal of difficulty saying no or educating the patients you know towards respecting their privacy.
I: What did they expect you to do there?
R: Well they didn't know what to do but they were never adequately trained or told. The doctor before me told me that how to do that is you get two lines in your home, you put an answering machine on one of them and if your sick call the nurse at the hospital and they can get a hold of me and if you have an emergency go to the hospital.
Better understanding of the ebb and flow of rural physicians could result in less ebb and more flow. Interventions could be utilized to increase the retention of each physician in a global fashion. In some cases physicians could be counseled to pick a better situation for them, interact differently with patients or the community, or focus on more long term goals. Communities could anticipate problems and deal with them with more understanding and effectiveness.
Dealing effectively with one's own personality was also important. "If you can't tell people no, you probably shouldn't be in a small community because they will have you do everything if you will" "You have to kind of be flexible and be able to roll with the punches and laugh about some of the things"
For some rural physicians, patients were obviously their top priority. Not even a partner could help some doctors. This puts an added strain on physicians to be available to patients even on off call days. This blur of the boundaries was noted to strain physician-physician relationships and family relationships as well.
The relationship between rural physicians and their patients is a close one. "In some communities the patients trust the doctors and the doctors can do almost anything. New doctors may not have this trust at the start and patients may ask (or get) other opinions." Many physicians noted that their devotion to patient care impeded relations with family and friends. "(My Practice is) Kind of like the tiger once you got a hold of the tail it is hard to let go."
Many doctors personalized their lack of building a practice. They were noted to take the lack of patients as a sign that people doubted their ability.
"In some communities the patients trust the doctors and the doctors can do almost anything. New doctors may not have this trust at the start and patients may ask (or get) other opinions"
Often new physicians have not realized how hard practice is, regardless of location. Some go through a first year guarantee and can not support themselves.
"In order to make a go of it they are going to have to work like hell either here or where ever they are at and so once they make that realization, then they will stay in a place"
Few would doubt the challenge of rural practice. Rural people often delay chronic conditions until they are life threatening (Reilly, B Legge, J Reilly M 1980 A rural health perspective: Principles for rural health policy Inquiry 17 120-127, Scharff 1987 The nature and scope of rural nursing: Distinctive characteristics masters thesis at Montana State). Rural people do have less health insurance as well. Another study noted that rural physicians dealt with the broadest array of service conditions and patient situations. (Waller 1987)
Health seeking behavior by rural peoples has been studied. , Weinert C and Long KA 1987 Understanding the health care needs of rural families Family Relations 36 450-455). Some studies note that frontier people (pop density < 6/sq mi) turn to formal health resources less often. This may be related to the lack of resources and the "self-reliance" characteristic of many rural populations. (Weinert C 1988 Social Support: Families living with long-term illness unpublished ) Rural providers wishing to blend in need to identity and work with the informal health resources to be able to build a practice (Weinert and Long 1987) Most would agree that there are major differences in the characteristics of the smallest rural practices as opposed to those with many physicians and consultants.
Rural workforce studies consider all rural practices to be homogeneous. A recent article noted that a cohort of family physicians who graduated from a Colorado residency considered rural to be nonurban population centers of less than 25,000 population, suggesting that this become the standard for rurality. There is a wide variation in rural practice. Those wishing to examine workforce issues must consider subcategorization by the type of rural physician environment so that they may best determine the impact of various factors. Studies note that there is not a homogeneous Rural America and it is reasonable to expect variations in health behaviors which would lead to differences in rural practices Miller MK Stokes CS Clifford WB 1987 A comparison of the rural-urban mortality differential for deaths from all causes The Journal of Rural Health 3 23-34