Current Concerns of Rural Physicians
Link to rural physician lifestyle
The following is from a survey of rural physicians throughout the state of Nebraska. All comments are included for the free text question. These are some of the ongoing real concerns of rural physicians now, in the recent past, and for the foreseeable future.
"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
Quotes from Rural Physicians from the 1995 Statewide Survey
Followed by Summary and Comments
22. To the question, "Please feel free to comment on any issues you feel this survey has raised or overlooked:"
Fifty-nine (59) physicians provided the following comments. They are not listed in any particular order and have not been categorized. They are printed verbatim.
* The limited supply of Family Practitioners for rural areas plus the competition in recruiting for them has forced the finances involved out of the realm of the private physicians into the hands of 3rd parties (which have deep pockets) which I think is bad.
* Medicaid patients routinely suffer from hygienic arrest, arrogance and always model the veiled threat of legal action if they don't receive exactly what they demand. In addition, they show up in droves when their doctors' offices close -- 5 p.m. There needs to be some effort at disciplining these people.
* We need additional M.D.s - Not foreign medical graduates.
* I have a feeling that the Office of Rural Health is pushing for more primary care nurse practitioners and I feel this would not be in our state's best interest.
* I am no longer in private practice. I was for 35 years. I recently quit because of "burnout." Took time off and have resumed part-time practice as an employee - various places. Currently, am working for Social Services. I found I earn more money as an employee than I did as owner of a private practice.
* Family physicians tend not to be reimbursed for the work they perform. I am frustrated by the subspecialty mentality for medical care and think their reimbursements should be capitation-based if we are truly to provide cost-effective quality care.
* I'm a farm boy from rural Nebraska. Get more of us in to Medical school and back here to rural areas ASAP.
* Has the concept of Managed Care improved or made more difficult the practice of medicine. Answer = made worse.
* The feds. continue to invade the practice of medicine. The mandates for office lab etc. are very harmful.
* Generally, doctors' fees seem too high. Practitioners have provided care in many areas with satellite clinics. It could be expanded by more use of Nurse Practitioners. I haven't been impressed by the Physician Assistant program. I have heard complaints that patients often see the assistant - but are charged the usual office call fee. -- Drug companies prices are too high.
* Regulations (e.g., CLIA) have made things more difficult for MDs, their offices, and patients while "quality improvement" is theoretical/marginal. -- Good relationships/working relationships between PAs and MDs in rural areas while demands for independent practice for nurses deteriorate working relationships between providers. -- Rural health clinic status helps hospital networks but not solo/group practice. It indirectly encourages/stimulates hospitals into setting up satellite clinics --> increases availability but skyrocketing charges in rural areas.
* When rural doctors are compensated as well as city doctors, there would be no rural health provider problem.
* The practice of the art and science of medicine are great -- fulfilling, exciting, challenging. -- Medicine, however, is beleaguered by problems from "outside" and principally-centered around finances. Especially insurance, fed./state bureaucracies which seem to be growing in influence in a field in which they redistribute (to coin a political term) funds and provide no service. -- The upcoming fed. review and threat of fines etc. will push practitioners like me to withdraw from servicing medicare-financed clients.
* You might want to ask about how government control and Managed Care has affected medical practice. How many doctors are limiting or changing their practice.
* I feel that practicing Family Practice in a small community of 3000 is becoming increasingly difficult because of the need for referral specialists - especially in the hospital setting.
* The intrusion of other organizations into organized medicine is becoming overwhelming and making it extremely difficult to operate in a solo atmosphere. Doctors are losing their independence and they really don't seem to care. Times change. Practices change. It is difficult to adjust to all the new complicated rules and provider organizations.
* Primary care is not being sufficiently remunerated for their work and responsibility in comparison to procedural medicine. Why go into primary care, especially rural, where you don't get compensated for what you do and can't get away?
* The current turmoil of hospitals and outside interests sponsoring and subsidizing practitioners is very disruptive of our usual professional relationships.
* Don't see how capitation will work in rural areas where population density of 8 per square mile - no large employers. In other words, when the alphabet of care plans settle down, I hope there is someone, somewhere -- that realized that truly rural areas don't fit into most molds.
* I plan to leave rural practice this next year because my spouse plans to relocate for his job. I think its very hard to find job opportunities/satisfaction for physician's spouses in rural settings.
* Small towns are really taking a "hit." Its hard to keep auxiliary help (e.g., lab, x-ray, nurses etc.). Older MDs retire etc. The coverage by physicians (and hospital groups) from other towns just isn't resumed! Very rarely do they (the MDs) live close, e.g., Doniphan being covered by MDs from Grand Island. Also, the same group goes to Wood River.
* We are a merger clinic of 2 groups, now employed by our hospital. We have lost 2 doctors in 2 years. One to Texas for medical reasons, one to teach at the Lincoln Family Practice Residency. We have gained an itinerant doctor who doesn't take night ER call. We are recruiting, unsuccessfully recently. We need more doctors to timely treat our needy patients and to share ER call to avoid burnout. Our P.A. is pregnant and going to cut back on work. One partners wife has cancer. Throw all this together and I am not an optimist. It is nice to have Family Practitioners in such demand, but the down side is that it is very hard to compete salary-wise in rural Nebraska; versus about every other place in the nation.
* I get way too many stupid surveys to fill out!
* Under payment. Poor people have no money. High indigency. Lack of technology and supply. People are extremely nice.
* I'm lucky I've experience the joy of medicine that my father did and I can now retire and return to my previous profession. Ethics and philosophy of medicine has changed to the same concepts espoused by the marxists and the communists that medicine should be controlled by society - not the patient doctor relationship and that competition is bad. The government has used the cost shifting principle of capitalism against itself and has adapted the Keynesian principle of cost shifting to the future and the medical profession has acquiesced to the Socialist viewpoint.
* I live in a community of 3,500 and work in an emergency room in a town of 24,000. Local hospital has no out-of-town ER coverage. Flexibility of ER accounts for much of my satisfaction with job. Abuse of ER - especially by Medicaid is very frustrating, and COBRA ties our hands far more than any other single issue.
* The problem of care in rural Nebraska seems to be addressed by (1) surveys, and (2) newsletters. Perhaps its time for a more aggressive approach. The majority of grads from the residency programs in the state still go to larger cities although some are going to rural areas, which is better than a few years ago. Maybe a state-organized affordable locum tenens (program) would help. I have to pay the equivalent of 4 days salary for every day of locum coverage. As far as recruitment, the state says its the town's problem. The town people say its the doctor's problem. When you work 80 hours/week, its hard to become a recruiter.
* Respect for the medical profession by its own members appears to be deteriorating. By that I mean the way the younger generation dresses as well as personal appearance.
* Our medical schools are the source of the problems we have.
* If you truly want to increase the number of MDs in rural Nebraska, raise the rate of reimbursement higher for rural MDs than urban MDs. Then a greater shift in distribution might occur.
* Malpractice insurance. Fear of lawyers. Fed. and state regulations. Insurance demands.
* My practice is a suburban one -- not nearly as strained for the number of practitioners as a more rural practice. However, we still have a shortage of physicians. The PAs have been wonderful extenders of our practice but the need to be available for supervision lessens the time off one would desire.
* More and more medical practices are dictated by non-medical administrative "experts." The economic drive to medicine is at an obscene level. Health education in any meaningful sense in schools is a farce.
* There are no financial incentives to practice in a small community. Actually, the overhead per MD is greater. I'm the last solo practitioner in my area. It would be very difficult to advise a younger physician to pursue small town medicine as it currently plays.
* In our clinic, 2 primary care physicians have quit in the last 2 years -- too long hours, poor pay, lack of coverage. This can only worsen as Medicare regulations become more outrageous and Medicaid patients are shifted into Managed Care plans.
* Poor Medicare reimbursement is a critical issue for Family Practice physicians. Our Medicare population is high but the reimbursement is horrible. They are the most complex patients we take care of but are reimbursed barely above Medicaid rates.
* Encroachment of Managed Care into medicine today makes me fear for the likelihood that the enjoyment I get today from the practice of medicine will no longer be present. This is due to the development of adversarial relationships between patient and provider in the Managed Care approach to cost control.
* Have recently recruited a second physician originally from Iraq. Age 62.
* I think access is very good. People are willing to drive from 30-60 minutes across Omaha to medical care. Why is it difficult if people in rural areas drive 30-60 minutes. I'm more worried about physician oversupply than having a physician in every town.
* Major concern of siphoning effect of Managed Care in larger cities. Higher income in cities is a disruptive effect. Possible in mid-sized cities is continuity of care by Managed Care.
* Excessive redundant paperwork and forms. Increasing problem with payment on surgical assist.
* Appears to me fees charged for certain procedures (e.g., surgery, radiology, various tests, MRI, CT) are excessive. Why do insurance carriers and Medicare-Medicaid permit and pay excessive fees for such procedures but falls on quality time spent with patient? Are we pricing ourselves right out of the business? Inviting socialization?
* I have a growing discontent with the practice of medicine. It is not medicine but what it takes to run the business of medicine that is distressing. This is especially true for those of us in the rural setting. The fed. government basically penalizes us for practicing in the rural setting and certainly the State of Nebraska is of little help as well. I have found the State Health Department to be very obtrusive when it comes to helping us.
* Loan repayment for recruitment purposes.
* Relief from paperwork would be the most helpful thing that a regulatory body could offer.
* There seems to be an emphasis to place new physicians in rural areas with programs (on local or state level) to provide a signing bonus or school loan assistance -- but little to retain doctors. In fact, we just lost a potential physician recruit to another community because we couldn't give a big dollar signing bonus or pay off his loans. There needs to be more attention paid to retention of current rural physicians or it will be tempting to go to a state where school locum are assisted with etc. Annual small signing bonuses or something to help keep us around. It's tough to see someone come out of residency and get a lucrative contract elsewhere and feel like staying where you are!
* Liability remains a concern. Even with a "good" law, attorneys are likely to file suit rather than use the panel to settle disputes. Managed Care and federal programs (bureaucracies definitely making rural practice less enjoyable).
* Not happy with Managed Care.
* Excess paperwork.
* I have worked for the fed. government 21 out of 22 years that I've been in practice. Haven't a lot of material things to show for it but have managed to have a decent like, put 2 kids through MIT and USC, have adequate time to pursue an Army National Guard career, and be involved with veterans organizations such as the VFW and American Legion. I am in decent health and pass my treadmill every year (READ: Army PT test.) I am shooting for a 30 year federal career/pension, then I'll attempt the private sector.
* Survey should include concern about (1) malpractice reform. Need badly with ceilings. (2) Reimbursement of Medicare and Medicaid. (3) Increasing physicians ability to utilize physician extenders (mid-level practitioners) without excessive red-tape.
* Overall, we are satisfied and happy with our practice. Rural Health Clinic status should help reimbursement and income though there is a long delay in implementing this. And actually getting the money is reimbursement. Coverage is the issue. We would like one other physician and then we could be less dependent upon outside coverage. Also, as far as rural health, physicians that complete their service agreements to the state for medical student loans should all have their locum completely forgiven. They earn it!
* An increase in state and federal regulations have required an increasing amount of time and money for compliance and has not raised the quality or accessibility of medicine. 3rd party payment was and is a disaster for patients and doctors.
* I like living in a small town (4000) but I work in ER in a town of 25,000. It gives me the benefits of a small town but without the "call" burden and burden of government and insurance regulation. Best of both worlds.
* I feel the classification of RURAL should be reconsidered. True, Rural should be any county with a hospital ER staffed by local MDs. I've lost 2 good prospective MDs to 24 hour ER-covered hospitals. This seems to be the single most important factor in deciding where to practice. Some consideration should be made for hospitals where the local doctors cover 24 hour ER services. As this does impact Total Quality of life and time off.
* New physicians seem to want a "good quality" of life. Most are not interested in working.
* I believe mid-level practitioners can be helpful to many practices and communities. I believe we should continue to attempt to provide the problem with highly trained medical practitioners, i.e., MDs and I believe a continued effort to encourage increased independence of mid-level personnel is not in the best interests of the public.
* Profiles of rural practice.
* Local PHO lured my in-office physicians (2) and created a local monopoly -- financed entirely by the local hospital. Group ostensibly non-profit but used the PHO vehicle to raise sales substantially. Over regulation (state and national) and Medicare are making the practice of rural medicine less and less attractive.
Summary of comments by Robert Bowman, M.D.
13 noted third parties and managed care a problem
12 noted low reimbursements
9 federal interference
7 coverage of ER, practice when off or gone
6 loss of control of practice
6 Medicare problems
5 state interference
4 paperwork
3 subspecialty mentality of medicine in 1995
2 poor understanding of rural practice by leaders
chaotic/undisciplined Medicaid patients
malpractice
hospital invasion through PHO
1 potential oversupply
need for spouse job opportunities
too busy to recruit well
high cost of drugs
future oversupply of doctors
Health education concerns
3 not enough rural docs coming out of training,
3 worried about NPs
1 abuses of PAs
2 need for facilitation of extenders
2 benefit from extenders
1 new doctors too interested in quality of live
3 too many surveys, newsletters, etc.
Rural Doctor’s suggestions for improving the supply of practitioners
more farm boys to medical school, more pay for rural areas, locums coverage more accessible and affordable, more focus on retention efforts, signing bonuses, forgive loans completely for rural service