Book Review: Caring for the Country

Physician shortages in rural areas is not news; whereas 20% of the U.S. population lives in rural counties, only 9% of physicians practice in the same areas. Howard Rabinowitz cites these statistics in Caring for the Country: Family Doctors in Small Rural Towns, although the disproportion between rural healthcare needs and rural physicians have maintained a similar imbalance over the past half-century.

In Caring for the Country,Dr. Rabinowitz profiles ten physician graduates from the Jefferson Medical College's Physician Shortage Area Program (PSAP). This program was designed to recruit and train medical students in rural medicine, with a goal of encouraging graduates of the program to practice in rural areas. Dr. Rabinowitz has published a number of studies on factors relating to medical students' likelihood of establishing rural medical practice, and the two leading factors are having lived or grown up in a rural area and matching into family practice. The PSAP emphasizes both factors by recruiting college students from rural districts and having their participants rotate in rural family practice during the third and fourth years of med school.

In his book, Dr. Rabinowitz profiles ten graduates of the PSAP. All trained in family practice and are based in rural health professions shortage areas (HPSAs). The majority have returned to their hometowns to work, or stayed near their residency hospital. Some see inpatients, some deliver babies, one does C-sections, and one does endoscopies. All provide primary care for their communities. As a group, therefore, they are a fairly representative selection of rural family physicians, although Dr. Rabinowitz admits they represent the most successful of the PSAP's graduates, as the program usually retains 79% (not 100%, as in the book) of their graduates in rural areas.

Each PSAP physician is the subject of an individual chapter describing, in their own words, their upbringing, education, residency training, practice style and procedures, workweek, home life, hobbies, and patient panels. Dr. Rabinowitz style in this book is accessible to a lay reader; in fact, the overall tone is journalistic rather than academic, which goes greatly in its favor. Much of the book is reported in the physicians' own words, especially in those sections in which Dr. Rabinowitz reports their interactions with patients.

Common experiences among the physicians binds the separate narratives together. Almost all of the physicians report a great deal of career satisfaction, a difficult balance between home and work life (usually resolved successfully), and a top-tercile standard of living within their communities. They also discuss some tensions of living in small communities which are familiar to me, such as the dreaded supermarket encounter and lack of access to decent ethnic food. Overall, Dr. Rabinowitz's sample of rural physicians is content to be where they are. There are moments in the book in which the reportage begins to slip into the language of the recruitment flyer, especially when discussing income expectations for rural doctors. Most of the interviewees admit that they earn less than their urban counterparts, but all say that this is offset by the quality of life and lower cost of living in a rural town. I have discussed the fallacy of such an assumption, at least in California, and with rising gas prices disproportionately affecting rural regions, it may be that the cost of living in non-metropolitan areas may increase beyond the benefit reported by Dr. Rabinowitz's PSAP graduates.

Still, Caring for the Country captures an accurate slice of rural doctors at work and play. I find it heartening to see the success of rural medical training programs such as the PSAP, and to see more and more rural training programs being launched, such as this one in Kentucky and even the slapdash attempt of one osteopathic medical school to create a rural track for their osteopathic medical students in Rural, CA.

I recommend Caring for the Country to all readers--medical professionals and laypersons alike--who are interested in small-town medicine and narrative journalism in general.

Caring for the Country: Family Doctors in Small Rural Towns, by Howard K. Rabinowitz, M.D. New York: Springer-Verlag, 2004.