Becoming a Rural Doctor, Part 8: Welcome to Your Rural Community

In the last post in this series about becoming a rural physician, I'm going to discuss joining your new community. By this point in your training, you've already explored the rural experience in medical school and residency, and you've also found a job in a rural community you like. But once you get there, how do you start life and medical practice?

A young professional can find dozens of how-to guides on how to hire movers and pack boxes, how and when to cancel utilities at your old home and install them in your new one, and how to forward your mail. But there's more to moving than relocating your coffee maker, your garden gnomes and your lava lamp collection. You have to become a part of a new community, and for a new doctor, there are some special tasks to complete and considerations to make.

1. Notifying the medical board in your state of your new address. There are penalties for failing to notify the board of a change in address. This is easy to forget when you've spent hours filling out credentialing forms for your new job, but don't be fooled into thinking your new HR department will notify the board--only you can change your address of record.

2. Finding a place to live. In addition to the usual considerations of renting vs. buying, school districts, etc., a new doctor in a rural community must consider the following elements of a new home:

• Distance from the hospital: members of hospital medical staff usually have to live within a certain driving distance from the hospital at which they take call. When calculating distance, consider quality of roads between your house and the hospital, likelihood of driving delays due to local industrial activity, and weather patterns in your area. What looks like a ten-minute drive on a map can easily become thirty-five minutes on a stormy night or when logging trucks are inching along a winding dirt road.
• Privacy vs. visibility within the community. If you are a gregarious person, you might be attracted to a family neighborhood with closely-spaced houses, but take a moment to consider what it will be like to leave you house in the morning in full view of people who will very likely be your patients. This doesn't bother some people, but it made me uncomfortable, so I looked for a house off the main road.
• Instruct the phone company to make your home number private, or list it in your spouse's name. Trust me on this one.

3. Becoming a part of your new clinic. As the newest member of a practice, you'll have the largest number of openings. Your clinic may advertise your arrival and your new patients will be curious about you. If you're a newly-minted doctor, you're going to be faced with a whole slew of new patients and problems, as well as confronting local practice styles which might be very different from those you knew during residency. A few suggestions:

• Don't feel compelled to take on every complex or demanding patient who walks into your exam room. In communities of all sizes, a subset of patients will move back and forth between doctors. The reasons for doing this are many, and some reasons may be quite legitimate, but to build a new practice panel from dissatisfied patients is not a good way to begin a new practice. Trust me on this one, too.
• Define your clinical boundaries. You can expect to test your knowledge base and your previous clinical comfort zone when you start a new job. I believe testing your comfort zone in supportive clinic environment is a healthy thing for a young doctor to do, but I don't think you should take on any complex situation in order to prove yourself. Do not be afraid to consult with your colleagues about local practice standards.
• Ask your clinic to permit extra time to review medical records, especially during your first few months. All of the patients you're seeing are new to you, and you need time to take in their medical history in order to be effective.

4. Becoming part of your new hospital. This is fish-out-of-water time, more so than the new clinic because you'll be so ingrained in the way you used to do things. Hospitals are similar across the country, but each one has a certain unique stamp. Give yourself time to find your way around, not only the physical layout of the place (where is the doctor's lounge? where are the scrubs in my size?) but also the psychosocial map. A few questions:

• What is the nursing culture within the hospital like? I've worked at many hospitals, and I've found nursing staffs to vary greatly in experience and morale. I've worked with wonderful nurses who've watched my back, taught me how do take care of patients, and become good friends--and I've worked with nurses who tried to sabotage the plans I've made for patients, without ever communicating their concerns with me. The single most important step for you to take after joining a hospital is to develop a strong collaborative relationship with the staff nurses. This is even more important than forging collaborations with the other medical staff, believe it or not.
• What is the relationship between the doctors like? At first, you're learning names and specialties, then you get a feel for what the consultant is like when you call at two in the morning. The subtle underbelly of being a member of the medical staff is learning the political battles already existing at your hospital--and having the wisdom not to get entrenched in them. Be neutral, but learn where the battle lines are drawn.
• What is the administration's reputation among medical and allied staff? I'm sorry to say I've never worked for a hospital which had the respect of its entire staff. I've written about some of the difficulties I recently faced at my current hospital, so you might have already (correctly) gathered how disillusioned I am with administration. However, there are some good examples, and if you are lucky to work with a good one, learn from them. If you work with a bad one, learn from them as well. True success lies in enduring through lean times.

5. Setting social boundaries. I've written about the problem of exposure when you practice in a small town before. You will inevitably run into patients in the supermarket and other public places. Most people will respect your down-time and limit their conversation to small talk, but there will be some who want to corner you in the canned good aisle and ask about their Cardiolite stress test or that nagging suprapubic pain you worked up three months ago. If you adopt an open-access policy, it is very difficult to pull back later on. I recommend deciding on how far you will let the conversation veer before pulling back to everyday affairs. I also recommend having some polite evasions/redirective phrases handy, such as:

• "You know, that's a really good question. Why don't you call the office and make an appointment so we can talk about it privately?"
• "I can see you're concerned about this issue, but I honestly can't remember all the details of our last discussion. It would be better to tackle this subject during an appointment, when I have your medical record."
• "Good question. The thing is, I'm here with my family/in a rush/pressed for time right now and can't really go into depth about it right now."
  

If you adopt a straightforward tone, people take these redirections very well, and they will respect your professional demeanor.

These were the major issues I struggled with during my first year in practice. As you stay longer in your rural community, you may encounter other professional issues: isolation from like-minded colleagues, longing to form collaborations with others who share a common interest, rediscovery of a long-lost dream of writing. What do you do then? What I did: start a blog, and share your rural experiences.

Comments

[doctorjen]

The social boundary issue was the hardest one for me. I practice in a town of 14,000. I have 4 children, and am involved in my church, the kids' schools, some community activities, and I now know an awful lot of people. Of course, I then have acquired patients who met me first socially, and also patients who have become acquaintances and friends. I also am someone who tends to become emotionally involved. I have finally reached a point of comfort - I think it's okay to have some emotional attachment/involvement as long as you are aware of it and are careful with it, but if it clouds your clinical judgement it's better to refer the patient on. Knowing and caring about my patients is the thing I like best about rural practice, and the thing my clients like best about my practice is the chance to know their physician well.
Sometimes it is so tiring, though, to have very few friends in the "outside world." I have found some outlet in online community, and maintain some outside friendships, but those real life outside friends require a lot of planning to meet up with since I live in the middle of nowhere now!
Absolutely excellent advice about not taking on every dissatisfied difficult patient - wish I'd read that one early on! My partners straight out of residency encouraged me to take on these difficult patients and what a hassle to have your whole day filled with patients you don't really want to see and don't know what to do with!
On the other hand, knowing my clients well makes it harder sometimes to give bad news. I need to call someone right now and tell her she needs a breast biopsy, and she also had a very sad and traumatic ruptured ectopic pregnancy this year and I'm really dreading having to make the call (I also attended her healthy 2 year old's birth, and care for her husband as well, so these are folks I know well.) Sometimes, it was easier in residency with patients I had much more emotional distance from.
Sometimes I daydream about academic medicine - I miss having more academic focus, and more intellectual/academic colleagues. I did a medical ethics fellowship prior to residency and early this year I returned to their case conference and it was so nice to spend an academic day - I think I have to do more of that in the future.

[rlbates]

Some good advice.