Rural practice is challenging, yet few careers in medicine are as personally satisfying. Rural medicine is for those who enjoy the challenge of personal and intellectual growth. Rural physicians work closely with patients, staff, and peers. Rural physicians are active in school boards, health departments, and community organizations. Rural practice tests the limits of interpersonal, management, and clinical skills. Every physician has limits regarding time, resources, and knowledge, but rural practice seems to challenge these limits more thoroughly. Rural docs see the entire spectrum of disease from angina to Zollinger-Ellison syndrome. They see patients of all ages and in all stages of disease. Rural practitioners see 20 - 30% more patients a week. Rural patients are sicker. They don't come in for many routine illnesses. The end result is a demanding variety of diseases, conditions, and situations. Problem solving skills are tested and quality care involves more than simple prescriptions or routine hospitalization.

The Decision for Rural Practice is not an impossible dream. The rural practice situation is good and getting better. Few if any rural doctors in the future will be in towns of less than four physicians. Smaller rural towns will have satellites open only part of the week where one or more physicians, physician assistants, or nurse practitioners will deliver basic care. Few physicians will be alone unless they choose to be so. Once largely ignored, rural health currently enjoys a prominent position in legislation, in health reforms, in universal coverage, in improvements in reimbursement, and many other areas. The National Health Service Corps and most states have scholarships and loan repayments available for those interested in rural practice.

Call is the major concern of those considering rural practice. The call in rural locations in the future will be rarely more often than every fourth or fifth night. Current graduating residents are already writing this in to their contracts along with bonuses and guarantees. Hospitals and larger groups cover each other or hire locums doctors or residents to increase the local physician workforce. Rural physicians often choose to be on call for their own patients, but this choice is a personal one. Even in the past many rural physicians have opted to share call and have educated their patients to use other physicians who are on call for them. Time off to recharge the batteries is important to all physicians. The major determinant of the call is the location itself. If a location has not resolved its call problems, don't go there because you won't want to stay and other physicians will not stay either. The amount of time you spend in practice vs personal vs family vs community is primarily decided by you!

Money is not the main reason to choose rural practice. With debts and obligations you may be tempted to go for the biggest guarantee and bonus that you can. There will always be towns that are desparate enough to pay big bucks, but most doctors don't choose family practice for the money and fewer choose rural practice because of it. If you like the rural lifestyle, the closeness of rural communities, the broad variety of patients, and/or the feeling of making a difference, this will be enough. An average $100,000 to $120,000 will meet just about anyone's needs. This range is the current average for rural or urban family practice physicians. The key to personal financial success is not income but wealth and wealth is keeping more than you spend.

Other than the rural lifestyle, there are other reasons to choose rural. The variety of patients, the quality of the people, the desire to make a difference in the community, the opportunity to manage your own practice, and the potential to do more procedures are just some of the reasons for choosing rural practice. Students face many personal challenges when considering rural practice. Medical education takes its toll in time from family and debt. Those considering rural practice need to know about time for family, income, jobs for spouses, and debt repayment.

No location, urban or rural, meets all needs. The search for a practice is a "courtship" that ends up in a "marriage" to a practice and to a community that best fits your needs. Rural practices are no better or worse than urban. They do not lack culture or recreational opportunities. The opportunities are different and a matter of personal preference. The information about rural communities and practices is less available, making the search more difficult. In studies of family practice senior residents, residents invest just a few days to search for a location and a practice. After spending half a lifetime to train, such a minimal investment in the search process does not make sense, especially when the search process is such a growth experience.

The Challenge of Rural Medical Education At a time when rural communities are most in need of well-trained rural physicians, medical education is drifting in the opposite direction, away from rural preceptorships, procedural training, and allowing students and residents to have the direct responsibility for patients. Past medical education reforms, the drift toward subspecialization, and the difficult medico-legal situation have taken a toll. Only 47 of 125 medical schools have primary care in their mission statements and only 24 require some form of rural experience. It is easier for faculty to "do it themselves" or allow subspecialists and others to take control of patients. This has become far too common. It would be hard to imagine a worse situation for rural communities desparate for rural practitioners. Students are selected, trained, and socialized away from rural practice. Most schools have few rural faculty or programs. Students with rural interest are mostly on their own. Medical students who do not shape their own careers may find themselves following the influences of faculty, facilities, and fellow students instead of their own interests.

You must take charge of your career pathway 

so that you can best prepare for rural practice.

This pathway should include primary care and rural training experiences, top-notch medical education, procedural training, and rural faculty advisement. Career choices are not a single decision, but a whole series of decisions made during the seven years of training. One preceptorship, one faculty advisor, or one conference may not be enough. Students interested in rural health must pursue the advisement and experiences that will shape a career in rural health. The transition from the regular monthly predictable rhythm of medical school and residency to the unpredictability of the rural practice situation is tough enough without special preparation. Certain characteristics of residency training have been found to lead to a choice of rural practice. These include the location of the residency, the curriculum, the presence of faculty with rural practice experience, the number of months of obstetrical training, and the months of rural training. Some programs have rural practice preparation as their only mission. Others carefully select candidates based on their interest in a rural location.

For Those Leaning Toward Rural Practice Not all medical students know definitely that they want a rural practice, but many would like to keep their options open. The type of program that prepares for rural practice will also prepare residents for other locations or fellowships in obstetrics or other areas. One note of caution, programs that prepare for rural practice are likely to be more challenging as well. Candidates without proper training may not even consider a rural location. Even in a program widely regarded as excellent in rural preparation, 41% of graduates who ended up in urban locations noted that they really planned to choose a rural location. The type of training may be a major factor in this decision.

What Specialties Choose Rural Practice? About 25% of Family Practice residents will choose rural practice immediately after graduation. Interestingly in recent studies, about 25% can be found in rural practice at a later time as well. The numbers of rural physicians leaving practice tends to equal those choosing rural practice at a later date. The percentage of other specialties choosing rural practice is much lower. The reason for this is found in the population that is needed to support each type of practitioner. Family practice needs about 2500 patients, internal medicine and pediatricians each need 5000, surgery needs 25000, and other specialties need even more. A residency in medicine and pediatrics would provide a broader preparation, but additional orthopedics, surgery, and ob-gyn would be needed unless a larger rural town was desired. With the increase in the numbers of subspecialists, more are traveling out to rural communities two - four times a month to increase their support, but they will maintain an urban or suburban location.

The need for rural general surgeons may be greater than the need for family practice doctors and this need will increase. Programs to train specifically for rural general surgery are being formed. Many times rural general surgeons have spent time overseas in Christian missions. They have practiced an even broader range of practice and then opt for rural general surgery upon return to the states. These surgeons do a broad range of procedures, endoscopies, and sometimes C-sections and some orthopedics. Some family practice fellowships provide extra training in these areas through fellowships in rural, procedural, sports medicine, and obstetrics areas. Programs with fellowships often benefit residents as well as fellows. While these may not lead to board certification, they will allow family practitioners to do more procedures. Students who know where they want to practice should can assess the location and see what local services or needed and then tailor their training to the procedural needs of the rural community.

The timing of events and activities that will prepare you for rural practice is important. Your own medical school may have such a program. Most medical schools allow rural electives. These can be arranged through other medical schools if your request is not met. Rural student interest groups provide encouragement, information, rural projects such as health fairs, and career assistance to high school and college students. Other medical schools have specific rural rotations or tracks for those interested in rural practice such as Minnesota's 9 month rural track (RPAP - the Rural Physician Associate Program) or Nebraska's required two month rural preceptorship. Many schools have elective or required rural rotations. Often students rate these as some of their best medical education experiences. Students may also work with rural faculty to do summer primary care research projects such as studies on the recruitment and retention of rural practitioners, the management of a rural family practice, or common occupational illnesses in rural areas.

There are many special rural opportunities available to medical students. The Health Promotion and Disease Prevention project sponsored by the American Medical Student Association is a six to eight week elective for first or second year students. Students work with patients, rural physicians, Community Health Centers, and community leaders. The National Health Service Corps has a fellowship program in 36 states to train students for rural and underserved practices. Check with your state health department or medical school. The Appalachian Preceptorship at East Tennessee State University invites students at all levels to share a rich rural practice experience for a month. Twelve students meet with faculty to discuss the impact of culture on health, the doctor-patient relationship, the role of the rural physician in the community, and more. Students may choose to create electives by talking to clinician-faculty such as Sandral Hullett, M.D., at Eutaw, Alabama at one of several Community Health Center sites. This practice has trained medical students and students in five other disciplines. Students going to the site are impressed with the devotion of the physicians and staff. Role modeling is often a key component of a good rural experience. Students then can see the challenge and what it takes to meet that challenge. Rural Faculty Advisors are faculty who have been in rural practice or who direct rural programs. Talk to them regarding your career plans and possible residency locations. If there are no rural faculty at your location, call one of the STFM Rural Faculty for advice.

Don't rely on the interview alone. Make phone calls to residents and faculty at programs before and after the interview. Drop-in visits are OK, too. Remember, it's your life and your career! Residencies also have an interest in matching well with you.

Go to the AAFP student-resident meeting. This annual meeting of the family practice students and residents in Kansas City each August is an excellent opportunity to examine rural programs and talk to rural faculty.

Prior to your interview, make a checklist of items to examine that are important to your rural career. Some items to consider are:

1. The amount of training in rural locations. How many months are required in rural locations? What do residents say about this training? It should be highly valued by them. Does the program have a special rural track and if so, how do you get in?

2. The degree of "Hands-On" training that is present. In order to prepare for rural practice, programs and residents must have a "hands-on" attitude toward training. Those who invest more in their training will receive more rewards such as comfort caring for sicker patients, skills in doing procedures, etc. Students and residents that learn the art of successfully lobbying (elbowing out) others to be able to do procedures will prepare themselves best. A common misconception is that only community-based programs have this attitude. There are important exceptions in some urban locations where indigent hospitals or Veterans Hospitals allow much decision-making and procedures. You need faculty and residents who will invest time in you, allowing you to work within your zone of comfort, pushing you beyond it over time with good supervision, and constantly giving feedback and advice. Another vehicle used by university-based and other more urban programs is the rural training track which often has one year locally and two years of trainin in a rural location.

3. The presence of rural faculty advisors. A rural faculty advisor can be a major help for those planning a rural career. A good advisor will track your progress each few months and see if you are doing the electives, procedures, moonlighting, and other activities that will best prepare you for rural practice.

4. A track record of residents doing procedures such as C-sections, colposcopy, treadmills, endoscopy, setting fractures, handling trauma, etc. Programs with four or months of obstetrics tend to attract and produce the most rural physicians.

5. Are there extra-curriculur rural opportunities such as rural or procedural fellowships, rural moonlighting, etc.?

What do you want to do? Will this program get you where you want to go?

No program is perfect, the question is which one is best for you!

The STFM Group on Rural Health has a listing of 300 programs together with their track record of rural graduation. Although the information is a few years old, the basic mission and rural qualities of the programs have not changed.  

Dr. Bowman is the Director of Rural Health Education and Research at the Department of Family Practice at the University of Nebraska Medical Center at Omaha, NE. He is the Co-Chair of the Group on Rural Health of the Society of Teachers of Family Medicine, a Public Health Service Health Policy Fellow, and a member of the National Rural Health Association. rbowman@unmc.edu