Becoming a Rural Doctor, Part 4: Residency for the Rural Doctor

Late in the third year of medical school, most students begin to contemplate the Match--the baroque hoop-jumping performance students need to complete in order to enter residency in the specialty of their choice. I am not going to describe the Match process here--they've probably computerized it more effectively since I matched--and I am not going to go into the strategic variations between matching in, say, Internal Medicine vs. OB/GYN. Instead this post will concern itself with planning a residency experience to prepare oneself for rural practice.

Whereas medical school is a time for experimentation with bits and pieces of different specialties, residency is an apprenticeship within a the specialty of your choice. During the 3+ years of residency, a doctor learns the depth of their field and lays a foundation for their first independent job. A few things to keep in mind:

• No residency, no matter how good, can teach you everything you need to know about your specialty.
• If you know which elements you like best within your specialty, choose a residency strong in these elements and make the most of the offerings.
• Choose a residency location similar to the one you'd like to practice in, or which offers electives in such locations.

Some specialty-specific tips for prospective rural doctors in the following fields:

• Family Doctors
• • Give serious consideration to choosing a rural family practice residency. Living in a small community and becoming a temporary part of its health care system will give you good preparation for rural practice.
  • If you attend an urban or suburban residency, look for opportunities to do elective rotations in rural areas.
  • I strongly recommend attending a program where FP residents are the only ones running the hospital and clinics (i.e. "unopposed").
  • During medical school, honestly assess your desire to practice obstetrics. This will help narrow the list of residencies to consider. Some FP residencies offer the chance to get few (<50), some (51-100), or many (>100) deliveries. Others, like mine, are renowned for very heavy OB volumes. If you plan to practice remotely, OB skills are usually sought-after and I personally think you need 200+ deliveries to feel comfortable doing deliveries autonomously.
  • Conduct a similar assessment of your desire to obtain advanced privileges in C-sections.
  • If you are planning to maintain inpatient privileges and perhaps do some hospitalist work, work hard on your critical care skills. This is the single area in which I have learned/gained experience since leaving residency.
• Pediatricians
• • Rural pediatricians are truly general pediatricians.
  • Plan to be on call and be the first-line person called for neonatal resuscitation, even if you are an adolescent specialist.
  • In some communities, such as Rural, having basic surgical assist skills is very helpful, since you will be attending C-sections anyway.
  • Develop a basic idea of how OB/GYNs think, even if you don't agree. You'll have a closer relationship with OBs in a rural community where the medical staff roster is smaller.
• Internists
• • Fellowship-trained specialists may be few and far between in your rural community.
  • Commit yourself to working up patients as though your were the consultant. This is much appreciated when you finally do call them on a case.
• OB/GYNs
• • In many teaching hospitals, OB residents run Labor & Delivery, with FP residents and midwives taking a very limited role.
  • Embrace a more collaborative model. In rural areas, FPs practice obstetrics with greater autonomy than they do in urban areas.
  • Opt for an elective in rural perinatology consultation to get a feel for the range of pregnancies handled by FPs and midwives in smaller communities.

For all specialties, I think the single most useful thing you can learn during residency is how wide-ranging the scope of practice can be in rural areas. New graduates tend to arrive in rural communities with the preconceptions of their residency experience. For example, if you are an OB/GYN who trained at a mid-sized suburban residency, you might be surprised to meet midwives who do pudendal blocks or FPs who do D&Cs. The surprise is not a problem, but any attitude that would restrict an able practitioner outside your field from practicing to the full scope of his abilities would become a problem. Emerging from residency with a strong collaborative model in mind is the best preparation for rural practice.

Comments

[ENT doctor]

There are a lot of rural community that needs a doctor.

-Kaylee

[DrCris]

You obviously can't talk about the other side of the fence, but some suggestions for surgeons thinking about rural:

- Make sure you can do the general stuff --> it is not good if your hospital only lets colorectal trainees do bowel resections. You need to be able to do most procedures, so ensure you arrange a broad experience.

- It is important to have seen and understand the rare and intimidating. The community I have worked in routinely has general surgeons doing or assisting at emergency ruptured AAA operations. If you are the only person to help a dying person, you need to be able to try something,

- Accept any opportunity --> There is no reason a rural surgeon shouldn't learn how to do a LUSCs or a hysterectomy. They might be vital skills in a spot.

- Focus on testing your own ability. The urban experience sometimes ecourages us to refer everything. But most people can learn basic ENT, Opthalmology etc. Those skills might be vital in a regional area with visiting specialists.

Some of my suggestions may be Aus-centric, but hopefully they will help some of your readers.