Becoming a Rural Doctor, Part 2: The Generalist's Mind

When I think of rural doctors, I think of family practice. Part of this is training bias, because I am a family doctor, but this bias is supported by surveys which demonstrate that a significant number of rural communities would be medically underserved if it were not for the presence of family physicians:

"A recent study from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care indicated that, if family physicians were removed from the 1,548 rural U.S. counties that are not Primary Care Health Personnel Shortage Areas (PCHPSAs), 67.8 percent of those counties would become PCHPSAs. On the other hand, removing all general internists would make only 2.1 percent of the counties PCHPSAs, and only 0.5 percent would become PCHPSAs without pediatricians or without ob/gyns." (Fryer et al., 2001, cited by an AAFP Position Paper)

In this post series, I will emphasize the family practice model of medical training as an approach to preparation for rural practice. I do not mean to imply that other primary care specialties--such as internal medicine, pediatrics or OB/GYN--have no place in rural communities. Quite the opposite, in fact. My job in Rural, CA. would be so much more difficult if I did not have the support of the other primary care specialties. I hope this post series will be useful to medical students and residents who are training in those specialties as well, even if the content tends to veer towards family practice. I will argue that it is the generalist's mind, rather than the specialty, which will suit a doctor for rural practice.

Consider three rural scenarios:

1. Rural county (population density 35 people per square mile) with one large hospital and three smaller hospitals, a community healthcare network, and most medical/surgical specialties represented. However, there is no neurosurgery, neonatology, or perinatology available in the county.
2. Rural town located with one local hospital but limited medical services available (OB, general surgery, general inpatient medicine). Most specialty care requires travel over difficult roads to the county seat twenty miles away; some specialty care (including perinatology, cardiology and nephrology) requires travel to the next county south.
3. Extremely remote rural county (population density 0.4 people per square mile). Basic hospital services only; patients requiring ICU care or surgical services are airlifted to the nearest full service hospital. No permanent medical staff in the usual sense; physicians do one-month blocks of time to staff hospital ER/OR/L&D and attached clinic.

Obviously, the remoteness of a community and the availability of medical services varies greatly in rural settings. The kind of medicine a doctor practices will vary as well. Family doctors are particularly well-trained to adapt to different practice scenarios. A popular definition of the specialty's scope is an ability to diagnose and treat 90% of all patient problems. This includes ordinary childhood illnesses and chronic diseases of the very old, acute injuries, normal pregnancies, and common conditions requiring hospitalization. Some medical students worry that the specialty is too broad, that you need to be an internist, pediatrician, and obstetrician all in one. Family physicians would disagree. Instead of rolling three specialties into one, family practice trains doctors to master the most common issues and diseases across a spectrum of specialties.

Although family doctors will refer patients with very complicated medical conditions to consultants, if specialty care is not easily available, they might absorb complicated care into their scope of practice. Scenario #1 describes Rural, CA. pretty well. Because there is no perinatology available within 180 miles of Rural, our prenatal practice manages gestational diabetes and autoimmune illnesses such as multiple sclerosis and Crohn's disease during pregnancy. We rely on online references such as UpToDate and telephone consultations with UCSF perinatologists to guide us, but formal referrals are not pursued if the patient is doing well. This is very different from my residency experience in which all high-risk women went to perinatology clinic. Similarly, in my hospitalist job, both family doctors and internists provide critical care, whereas in a larger hospital an ICU might be staffed with intensivists. Our community also supports family physicians who have limited surgical privileges for C-sections, D&Cs and postpartum tubal ligations. In very remote communities, such as Scenario #3, family doctors might also obtain appendectomy privileges as well, although this is less common.

Ultimately, the success of family practice in adapting to the wide variety of rural settings lies within its generalist approach. We begin with a wide base of common illnesses across the lifespan, and this serves as a base from which to develop competence in more specialized topics. The generalist education prepares us to meet problems we've never seen before, research them, seek help when necessary, or initiate a work-up on our own. This is an approach which has served me extremely well during my first years in Rural, when I had to begin practicing in a community very different from the one I knew well during residency.

This generalist mind-set is not unique to family doctors, of course. Our local pediatricians are more generalist in their practice than their urban counterparts, since neonatology falls onto their shoulders rather than to the subspecialists. Our most beloved pediatrician also assists surgeries and, when he worked in remote Alaska, was known to catch a few babies here and there as well. He remembers this experience fondly.

Components of the generalist mind-set:

• An understanding that no problem is inaccessible to the generalist.
• An independent cast of thought, an ability to keep your own counsel.
• An organized approach to clinical problems--i.e., developing differential diagnoses, ordering selective tests to narrow the differential, anticipating a management plan based on test results and patient needs/resources.
• An intellectual curiosity that overpowers inertia. Investigating the unknown takes time and energy.
• An ability to set a reasonable threshold for consultation, i.e. avoiding knee-jerk consultations but not delaying appropriate referral.
• A tolerance for uncertainty. Complex clinical problems rarely have immediate or simple solutions, and when they do, the process of finding them is not simple. You have to be comfortable with the fact that you don't know how things are going to turn out.

The point of all this discussion is this: the generalist mind is the single most important element in a rural doctor's education. Anyone interested in working in a rural community--whether well-staffed as in Scenario #1 or very remote such as Scenario #3--will be well advised to remember to think like a generalist as they go through their training.

References:

Fryer GE, Green LA, Dovey SM, et al: The United States relies on family physicians unlike any other specialty. AAFP 2001; 63(9):1669.

Comments

[Baggas]

Batguano - sounds like you have quite a challenging existence. I would say Australian rural general practice is quite similar, but without the tropical medicine stuff. Our rural GPs generally provide 100% of the services in their areas, with perhaps the occaisional visit by a surgeon once or twice a month in some of the larger towns. There are virtually no medical specialists of any sort outside the cities and big towns. Many of the remote towns are dependant on the flying doctor service to get their patients transferred when they are seriously unwell or injured.

They do run a quite thorough rural training fellowship course which is actually undersubscribed as very few graduates want to work in the country, but I guess that is a problem everywere.

[Batguano101]

Family Practice specialty fits with rural practice.
Rural practice does not necessarily fit with family practice specialists.

There is a Latin American model to rural practice that differs from the US.

The infrastructure is different.

You have less diagnostic choices, have to learn which of those to actually trust and to what degree.
Referrals are moving mountains to find and plug in patients who do not have the money to pay for private specialists.
There is no back up, you are on your own.
Sleep deprivation is the single largest obstacle to rural practice in Latin America.
Depending on the site, anything that walks in the door- you are it, if you do not do it, it does not get done, as much for the lack of income of the population as the location.

For intellectual challenge, no university, no teaching hospital on earth can top rural practice in remote locations- what ever you have you dig into, and this is constant, on going, ever changing.

The down side to finally getting a particular patient into a suitable hospital for specific specialty or sub-specialty care, is it is almost impossible to get feed back on what happened form there.

Tropical medicine is part of your differential diagnosis for every patient, and general practice in the tropics without the laboratory to nail the diagnosis is a time tested diagnosis by exclusion and empirical treatment, based on history and physicals, which is learned from other doctors, not in university hospitals.
Suros, Spain, and Degowin and Degowin, USA, physical diagnosis are more important day to day in the most minute detail, than all the lab references on earth.
You cannot rely on quick fix references, that spit out the tests to run in outline form.
The more heavy references with the whole pathophysiology and complete disease process from start to finish, with all the variations of presentation, the better, because that is the only way you can increase your identification of people's problems.
Repeated history and complete physical on a patient is not just a line in a text, you read and automatically skip, it is the single most important tool you have.

US grand wazhoo doctors come down to rural Latin America and the Caribbean on visiting firemen trips. Some do surgery of patients already accumulated by local doctors, a superb service. Others, particularly those of a certain elk specialized into the US system to the nth degree, are lost as a goose, and react with arrogance and anger that all the services they are accustomed to are not to be found, doing little good and irritating all concerned by their presence.

Rural tropical medicine is very different from US family practice in what goes through your mind as a working list, how to approach it, what is important and what is not. It is a different breed of cat, and it is General Practice, not USA Family Practice.

I never had the means to take the Australian courses and degrees for rural doctors, but always wish I had.
It would be terrific to see what they have put together there.

The US Medical System does not appear very well adapted to rural USA, much less other rural areas.
But this may be my impression based on unpleasant aspects of exclusion and disagreeable doctors.

[Theresa]

Hi Baggas,

Thanks for cruising by. I liked hearing about your birthing rush on Twitter!

Family practice is everywhere, not just rural areas. However, the full spectrum of FP that I describe in my community is more of a rural phenomenon. Urban FPs do perform deliveries, but it is more limited. In San Francisco, FP residents and their attendings do deliveries at the General Hospital, but not in the big tertiary care hospital. Furthermore, there are some regional differences. FPs on the Western side of the country are more likely to provide obstetrical services, whereas they are less likely to on the East coast.

USMLE? Not fun for sure....

[Baggas]

Interesting post. As a family doctor (= General Practitioner) from Australia it is interesting to hear about family medicine in the USA. The picture we usually get here of US medicine is that of a super-specialized landscape and it is difficult to see where family practice fits.

In particular, as a GP who practises obstetrics I find this (and all your stuff) very interesting. GP obstetrics is a slowly dying field here as fewer GPs have the training, experience, or inclination to deliver babies and we face a hospital system that is trying to push us out in favour of a specialist Obstetrician and midwifery model. I had imagined that in America the role of family doctors in obstetrics would be even more limited so it is nice to see this is not totally the case.

Couple of questions : is family practice an increasingly rural specialty there or is there still a healthy role for it in urban areas? Secondly is the family doctor performing deliveries something you would see only in the country or is this an option in the cities also?

Has long been a dream of mine to move my family to live and work in North America for a few years so these are valuable insights for me. Still can't face the thought of that USMLE though :P