Becoming a Rural Doctor, Part 1: The Rural Landscape

I've been reading the blogs of medical students and residents with some interest lately.  Their stories about the trials and tribulations of learning to stay awake night and day and how to deal with cranky attendings and even crankier patients take me back to the bad old days of my own residency. I've also had a few glimpses of the osteopathic medical students (OMS) who are rotating in Rural, CA. as they assume their new roles as clinical learners. Hearing about and witnessing these experiences makes me reflect on my own training and the steps I took to become a doctor in a rural community. This new post series is going to examine these steps in more detail, and I hope it will be helpful to trainees who are considering a career in rural healthcare.

This is going to seem obvious but it bears repeating: Rural communities are different than metropolitan or suburban communities. Any survey of economic or political demographics of the US will highlight various aspects of the distinction, but the differences that I encounter most frequently in healthcare are these:

• Poverty: Every corner of the world feels the impact of poverty. I do not mean to minimize the magnitude of the problem in urban or global communities, but I am particularly concerned with the problem of poverty in the rural U.S. There are various definitions of poverty, but the face of the poor looks different in the country than it does in the city. For example, the rural poor are a bit more likely to live in a broken-down fifth-wheel trailer than a building project, and that fifth-wheel is often parked off a country road and has no telephone or electricity attached to it. Pay-as-you-go cell phones, which have provided a lot of low-income adults with reliable communication, are not a solution for the remote rural poor who live beyond cell tower range.
• Distance: Policymakers often refer to distance as a barrier to accessing health care. The distances rural citizens must travel to obtain basic care in our community range from 5 to 60 miles. Some of the roads leading into town are treacherous in winter--windy, covered with black ice, often closed down due to mudslides or--this summer--due to wildfires. It is important to remember that distance comprises more than mere miles or kilometers. And, in this era of high fuel costs, even 10 miles may be too far for a cash-strapped patient to travel for care.  Unlike urban communities, public transportation is spotty and infrequent; people must often hitch-hike just to get to a bus depot in some communities in Rural.
• Industry-specific impact: Not all rural economies are alike. In my community, the major industries are construction, lumber, hospitality, commercial agriculture, and fisheries. In the past 10-20 years, lumber and fisheries have dwindled and haven't been replaced by any new industries, so unemployment is a persistent problem. Young people usually leave the area when looking for work, which creates a demographic shift common to many rural communities. Furthermore, some of the more dangerous occupations--construction, lumber mills, industrial fishing--means that a certain significant percentage of mid-life adults are living with sequelae from industrial injuries. My impression of the local 40-50 male population is that at least 20% of them are missing fingers from these types of accidents, and that's only considering one limb. A related problem, the impact of which we haven't fully grasped, is the disproportionate military recruitment from rural communities. As young people return from Iraq with injuries and stress-related illnesses, these will inevitably change the face of rural healthcare.
• Few doctors means breadth of practice: Because doctors are few and far between in rural communities, the breadth of practice is greater for doctors, especially among primary-care specialties. For example, a beloved local pediatrician regularly assists surgeries, family physicians and their midwife colleagues provide most of the maternity care, and primary care internists perform colonoscopies. Many of these services would be provided by specialists and subspecialists in metropolitan areas.
• Few specialists means even more breadth of practice: Not to sound redundant, but when there are fewer specialists and fewer doctors in general, there is more need for existing community doctors to shoulder a greater range of medical care. Rural, CA. does not have a perinatologist so the family doctors manage gestational diabetes, autoimmune illnesses, and multiple gestations in their practice (the latter get referred to obstetricians in the 3rd trimester). There are only two critical care doctors in the area, and they cover both hospitals, so both primary care internists and family doctors assume critical care responsibilities in the hospitals.
• Magnification of local politics: I have written about some of the tensions between the two local hospitals in a previous post. Politicking is not unique to rural communities--I used to live in the big city, I know--but in a small community, the disagreements tend to color every interaction with hospital administrators and medical staff who straddle the divide.

Obviously, the commonalities between urban and non-urban medicine outweigh the differences, but I would argue it takes a certain kind of doctor to thrive in a practice environment such as the one I've described above. In subsequent posts in this series, I will discuss a number of elements in such a doctor's training, including:

• Specializing for rural practice
• Evaluating medical schools
• Approach to medical school curricula
• Personal attributes of a rural doctor
• Useful procedures
• Residency training
• Job-seeking
• Joining a rural community
• Online resources for physicians in remote locations

Ultimately I hope this series will be helpful to students and residents who are considering work in a rural community. Your input about other topics not listed above is valuable to me--please don't hesitate to comment.

Comments

[Angela]

I'm a 31 year old single female going to back school to become a rural doctor/ophthalmologist and I'm having difficulty finding finacial aid to finish my undergrad. I work as a certified ophthalmic technician and make good money. The federal finacial aid doesn't seem to understand I will be attending full time and will not have any income so they are not giving me much to work with. Any information would be greatly appreciated and if you could e-mail me at astebbins77@yahoo.com. Thanks everyone!

[mountainsister]

What you describe in rural California is not much different from rural West Virginia. I retired to this area from DC and what a shock.
There's not one xray machine within 40 miles.
Your description of black ice on the dirt roads on the ridgetops matches what runs in front of my house. The internet has allowed me to protect myself from some rural practitioners who seem to get much of their medical information from drug reps. However there are some who manage to stay well informed.

[Beth]

My medical school has a program called RMED. For 9 months during the third and fourth years, students who apply for and are accepted in the program are placed in rural spots all over New York (Ogdensburg up by the Canadian border to Hamilton and all points in between). The students complete a few required clerkships (peds, medicine, ob/gyn) prior to departure. While at their RMED sites, they are exposed to everything - family practice, general surgery and subspecialties, ortho...you name it. They've been doing this for over 10 years now and they've had a lot of success with students in the program entering practice (general and subspecialty) in rural communities. As part of the admissions committee, we look at students from rural areas who are interested in going back to practice in those communities heavily and are considering tracking those students right into the RMED program upon acceptance.

[Hilary]

I forwarded this to the president of our rural med club at our med school. I will be reading, too!

[Theresa]

Hi everyone,

I've heard both glowing reviews AND horror stories about NHSC loan repayment/scholarship placements. My own NHSC loan repayment was not bad at all, but I got to qualify as an FP who does OB, which only obligated me to be in clinic 21+ hours per week and therefore permitted me to take OB call and round on inpatients.

If you do take a loan repayment/scholarship option, you should read the fine print carefully (everyone should do this) and question your site director carefully about the responsibilities you'll be expected to take on. I'll cover some of the questions you should ask later in this series.

Thanks for the input, Dr. Mary. Sorry you had a bad NHSC experience. As I said, mine wasn't bad but it is important for the young folks to get a range of what to expect.

[Dr. Mary Johnson]

Before any of you younguns dive into a rural community or a public service gig, you might want to take a look at a blog the mighty Kevin won't link: http://www.drjshousecalls.blogspot.com

The short story is in the profile - the long story is in a link directly under it.

I was burned and burned badly by my hometown hospital - as I completed a service obligation to the National Health Service Corps (NHSC) - AND the NC Department of Rural Health.

These state & federal programs do not protect their doctors. They do not honor their contracts or their promises. The doctor is a warm body - a wheel in a cog.

You are likely not going to hear these kinds of stories from your residency directors - or the "in" blogs (that are corporately sponsored).

[Cait]

I am a prospective med student, interested in going into OB/GYN in my rural state. Therefore, I'm going to pretend you're writing this series for me, specifically. :)

Your blog is fantastic- thank you so much for the resource you provide.

[Theresa]

Hi Beach Bum, Hi jsebooth:

Thanks for commenting. I'll be addressing med school electives and applying for residency later in the series. I hope it will be helpful to share my own training experiences.

[jsebooth]

I'm a 4th yr med student. Rural med is something I've considered, but I've only heard from very bias big city physicians. I'm excited to read the rest of the series!

[Beach Bum]

I went into medical school planning on Rural Family Practice. I'm willing to have my mind changed, but don't expect it. I'm almost finished my first two years, and am starting to look forward to my clinical work. I'd be interested in your thoughts on clerkship electives that might be useful, as well as thoughts on how to land a rural family practice residency.