The Realities of Rural Medicine

Back in April, the Journal of Rural Medicine published an article that spelled out some of the ways in which rural medicine is a tough gig: Rural primary care physicians “tend to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients” than urban physicians. Worse still, “[a]fter adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practice in rural settings made $9,585 (5%) less than their urban counterparts."

So being a doctor in a rural region means less pay, longer hours (anywhere from 4 to 10 percent longer per week than urban doctors), and more Medicaid patients—none of which is particularly appealing to doctors.  (As I noted last year, reimbursement rates for Medicaid are abysmally low across the nation). At this point you may be thinking that this sounds like a warning to anyone even thinking about becoming a rural doctor.

Income

Not so fast. According to the Center for Studying Health System Change, the notion that the average rural doctor earns less is, well, what you might call an urban myth. While the Journal of Rural Medicine (JRM) looked only at primary care physicians and concluded that they make 5 percent less than their urban counterparts, CSHSC’s study of all physicians in rural practice tells a slightly different story.

CSHSC found that urban docs make, on average, $218,000 a year, while country doctors took home an average a $204,000 (a difference that’s comparable to JRM's calculation--and one that CSHSC says isn’t even statistically significant). But adjust for cost of living, and the numbers change. It costs more to live in a city than it does in the country. As a result, notes The Physician’s Money Digest in its contribution to CSHSC’s work, tweaking the numbers for differences in buying power in effect raises the average rural doctor's income to $225,000—while the average income for an urban practitioner drops to $199,000. Among primary care doctors, the difference is even more dramatic: rural primary care physicians have a real income of about $199,000 after cost-of-living adjustments; for urban PCPs, the average income is a measly $145,000. In other words, it’s not just about how much doctors make; it’s about where they make it.

More Patients

While rural doctors’ dollars go further than those of their urban counterparts, CSHSC does acknowledge that rural doctors work harder, “adding about 5 hours to the typical work week.” This is no doubt due to the higher doctor-patient ratio found in the countryside. Despite the fact that 20 percent of Americans live in rural areas (i.e. counties that do not contain a town of at least 10,000 people) only 9 percent of physicians reside in these regions.

Indeed, in the U.S., physician distribution is all over the map—both literally and figuratively. The University of Washington reports that in 2005, “the ratio of physicians to 100,000 population…varied from 209.6 in urban locations to 52.3 in the most isolated rural areas.” In other words, there are some cities where people have access to four times as many doctors as in the countryside.

But those are the extremes. If you look at averages, CSHSC points out that “rural areas have 53 primary care doctors (i.e. internists, family/general practitioners, and pediatricians) and 54 specialists for every 100,000 people who live there. In contrast, urban areas have 78 primary care physicians and 134 specialists for every 1000 residents.” This is still a noteworthy difference, but nowhere near the factor of four noted above.

Ubiquitous Patients

Still, the distribution of physicians in rural communities brings with it some pretty unique situations for country doctors. There are plenty of doctors in cities who feel stressed because of long hours, low pay, and un-profitable patients (especially with rumblings about Medicare pay cuts); but few feel as though they are the only doctor in town. But in rural areas, this is much more likely to be the case. You're not just a doctor, you're the doctor--and, if you’re working in a rural area, be ready to run into your patients pretty much everywhere.

As Dr. Robert Boyer, a retired rural physician, has put it, rural doctors “live in a glass house.” They’re exposed to their patients—and the full spectrum of their patients’ lives—in ways that urban doctors are not. A physician in Manhattan has an 8 million person buffer between him and his patients; many of his patients are commuters, in the doctor’s neighborhood only through work hours and then far away for the rest of the day. In other words, doctor and patient have what is primarily a professional relationship. They see each other in structured medical settings and probably nowhere else. Further, because there are so many doctors in New York, different people see different doctors, so no one doctor feels like the entire community is resting on his or her shoulders.

But if you’re a doctor in, say, Loving County, Texas—which had a population of 67 in 2000—it’s a very different ballgame. The social distance between doctor and patient is nil. The guy you saw about his sniffles on Monday is fixing your car on Wednesday; the lady you operated on last week owns your local convenience store. And because there are so few other doctors around, everyone in your community turns to you for medical advice. You are it.

Depending on how you look at it, this is either a special burden or a special opportunity. On the one hand, you can see how a rural practice could become stressful: when a doctors runs into her patients regularly outside of the office, and she’s their only resource, it can start to feel like a physician is on-call 24/7, even at the grocery store.

Consider an anecdote related by Theresa Chan, a hospitalist in rural Northern California, on her blog Rural Doctoring. While shopping for groceries at the local Safeway supermarket, Chan ran into a patient who was also her neighbor. The two exchanged pleasantries (“…I was pleased to hear your early peas are already flowering…”) and parted ways—that is, until the patient caught Chan at the check-out line. At this point, the patient asked her "What do you think about all this stuff they're saying about Fosamax? Should I stop taking it?" 

Chan notes that “I was unprepared for such a question” because, “when I go to Safeway, I go not as a family doctor, but as an ordinary citizen…At the supermarket, I do not bring the analytic mind that accompanies me to the hospital or to the clinic, but the harried householder's mind, concerned about bank balances and the dire possibility of running out of orange juice before the weekend.

“In other words, I do not like to be asked medical questions when I am conducting my everyday errands.  I do not like to be cornered in the supermarket, or at the coffee stand, or when I am out to dinner on a rare night off…”

This seems like a reasonable complaint. No one, regardless of their job, wants to feel like they are constantly ‘on,’ especially people who work as hard as rural doctors. Chan feels so strongly about this that “dread of running into patients at the supermarket is one of the major reasons why I occasionally consider moving back to a more populous area, where I could walk into a shoe store and try on some sneakers without having” a patient “sit down next to me and ask whether [he] could be doing more to take care of his diabetes.”

Chan is so sick of being everyone’s doctor, all of the time, that she “feel[s] compelled to drive several hundred miles out of town to have my hair trimmed, and even when seated in the barber's chair at some distant SuperCuts, I lie about my profession.”

Chan’s colorful post speaks to how the physician shortage in rural America isn’t just an issue of patient welfare, but of physician lifestyle. 

Of course, there are other, more positive ways to look at this dynamic. Boyer, for one, views the ubiquity of doctor-patient relations as an opportunity to provide better care. “Patients don't always tell you the truth” when it comes to their lifestyle or habits, Boyer told Family Practice News. "But by watching them and being observant in their habitat, which is your habitat, you can be smart about figuring our things about them.” For example, if a doctor comes across a patient who swore he was eating healthy at his last check-up but has a shopping cart full of Twinkies, that’s useful information.

The doctor-patient rapport also has much to gain from a more communal interaction. Boyer notes that “he was just as apt to take time in the grocery store and other public places to approach his patients with questions like: ‘How are you doing since we changed your antibiotic? How is your mom?’” because, in his words, “people like that sort of initiative from their doctors." Communication and connection is nothing to scoff at in medicine; and it seems that rural medicine offers a unique opportunity to maximize both.

As we think about how to address the shortage of physicians in rural America, it would be helpful to keep in mind what’s special about practicing rural medicine in a community rather than a metropolis. That means looking beyond how rural and urban medicine compare in terms of professional metrics (pay, hours, etc.) and looking at the surrounding social universe—the stuff that isn’t easy to measure. As CSHSC points out, for example, “rural practice frequently offers a less abrasive lifestyle.”  Patients aren’t in as much of a hurry—and, presumably, neither are the doctors. In the end, rural doctors might feel a unique anxiety about running into their patients after hours; but there are other anxieties—those of city life—that they don’t need to worry about. 

The day-to-day experience of being a rural doctor might not be for everybody. Some may resent the constant imposition of their patients into their lives; but others may well relish the opportunity to be a pillar of a small, tightly-knight community. Either way, if we want to be smart about attracting rural doctors—and we need to be—we need to do a better job of helping docs-in-training understand what it’s really like being a country doctor, not just in the office, but also in the community. Communicating these realities—even if only through, say, regular guest lectures by rural docs in top med schools--could go a long way.

Comments

[Acountrydoctorwrites]

Hello. I am a country doctor at a Federally Qualified Health Center. We get a favorable, fixed rate from Medicare and Medicaid. I work hard 5 days a week, but I go home for a 1 hour + lunch every day. Things are pretty good here.

[Niko Karvounis]

Thanks for the comments, all.

Chris--That's an interesting point. The pace of life is definitely very different, as is the schedule. I would tend to think that urban areas are much more adherent to a 9-5 workday schedule, which means that physicians are more likely to be stuck with a steady stream of obligations throughout the day (since all patients are trying to cram in their appointments during work hours). In rural areas, where there may be less rigid structure to the workday, doctors may work longer hours, yes, but as you say--they probably have more time to make their own here and there throughout the day.

Anon--You're right, the rural community is close-knit across occupations, not just with doctors, and I wouldn't be surprised if a similar sort of interaction happened with many different professions. My hunch is that physicians might get this treatment the most though, since there are few things more valuable and ever-relevant than health. But, being a city boy, I wouldn't claim to be certain about that fact.

Theresa-

Welcome! Thanks for giving me some great material to work with. You bring up ANOTHER good point regarding rural communities: basic geography. When we talk about rural communities, I think often we tend to think of a small, intimate town, where everyone lives within walking distance of each other. But you're right, one of the big issues with rural communities is distance--stuff can be really far apart and geography is much more variable than in the concrete jungle. It's hard to, say, go home for lunch when you have to travel 12 miles or cross mountain range to do so!

Barry--

Good catch, thanks. And I think you're very right that we have to consider the origin of doctors when looking at the urban/rural divide. There are many people raised here in NYC that wouldn't go to a rural community for a million dollars, and there are folks raised in Iowa who think NYC is hell on Earth.

That being said, I don't think that these preferences are universal or unchangeable. You can imagine that, with a greater peer support network--like say, regional chapters that get together regularly, or plan trips, or soemsuch--being a rural physician could be more amenable to people who worry that trekking to the countryside is akin to being a castaway.

Sure, you'll never be able to perfectly duplicate what you get in cities in the countryside, and vice versa. But I do think there are probably some creative ways to bridge the distance between the two.

Howard,

You certainly bring up some points that I hadn't considered. But, allligators and celibacy aside, it's true that (1) sevices in rural areas are more sparse and (2) physicians are fewer, which means that our standards to how we demand care is diffused across a community (i.e. no self-referrals) should probably be adjusted in such contexts.

There is a possibility for virtual medicine to make an impact here, of course. For some cases, the problem of travel time and isolation can be dampened by online communication, which allows a visual consultation.

[HCBerkowitz]

I've often wondered about the relevance of some well-meant rules when applied to rural physicians, especially in truly remote areas. For example, reimbursement rules may say that a physician can't self-refer for lab or imaging studies. I remember the frustration of breaking my ankle on the way to my primary physician in suburban DC, and not being able to get it X-rayed and set in his office, but sent to an approved radiology department 45 ninutes away. When the service is 8 hours or more away, it's much worse.

The rules about no sexual relationships with current or potential patients made one physician friend leave a remote area he loved and where they loved him, as he had not taken a vow of celibacy.

Another problem is finding some way to extend time-critical interventions. Thrombolysis can reverse cardiac damage within 6 hours of an MI--will there be enough diagnostic equipment? It's worse for stroke intervention--there's about a 3 hour window for thrombolysis, and the odds are that it's a clot, not a bleed. If it's a bleed and there's no invasive radiology, even remote, the outcome of thrombolysis is death.

A friend ran an ER in rural Louisiana, which he explained was like a third world country, without the efficiency. We had been debating antibiotic use, and I commented that most hospitals where I had worked allowed IV vancomycin only if an infectious disease specialist signed off. He mentioned that if a phone consult would do, that was one thing, but, otherwise, it was 12 hours or more to the nearest ID specialist. I never knew whether to believe him when he said that any emergency transport involved fighting off alligators.

[Theresa Chan]

Thank you for the link to my post. The interaction I describe is not rare but happens infrequently enough to be a shock when it happens. I don't fault patients for wanting to ask their medical questions when they see me in public, but I find it personally stressful.

Some rural doctors practice in a small town, where they might live a few steps away from their office and can take a nap after lunch--something I long to do. Unfortunately, I live in a rural area which is agricultural, so my home is 12 miles from my office and I never get to go home for a nap. Even if I wanted to make the drive, I would have to spend most lunch hours doing primary care paperwork.

We need more primary care doctors in rural areas. I recently gave up my primary care reponsibilities but I would like to go back to them some day, although perhaps in a different rural community.

[Barry Carol]

Niko,

I certainly agree that it is important to reflect cost of living differentials (especially for housing) when comparing incomes between urban and rural areas. I always say that it’s not the income in dollars that counts but the standard of living that the income can support.

I think a more fundamental problem in attracting doctors to rural areas is one of culture. Since doctors are generally smart, sophisticated people, attend medical school in an urban setting and probably do their residency in an urban setting as well, at least for the most part, they may be more attracted to the cultural and other lifestyle opportunities that are found in or near large cities but not in rural areas. Physician spouses may feel the same way as well. The exception may be doctors who grew up in a rural environment, liked it, and want to practice in similar surroundings. Short of paying them much more money than they could make in an urban locale, I don’t know what the answer is other than, perhaps, importing doctors to rural areas for short stints on a rotating basis to supplement those who practice there full time.

By the way, I think your reference to the number of doctors per 1,000 residents should have read: per 100,000 residents.

[Anon]

Doctors are not the only ones who get pestered with professional questions outside the office or place of work. Just talk to the local vet, accountant, lawyer, even the mechanic. Or the local computer geek, me. I understand talking about a computer virus is a lot easier than talking about a patient's virus, but the closeness of a rural community it is part of who we are and how we like to live. I also volunteer at the local state park and have had my gynocologist's kids take part in the nature walks I give. I wouldn't have it any other way. If a doctor is uncomfortable running into his or her patients locally, maybe he should think of practicing elsewhere.

[Chris Johnson]

Rural practice has other perks. My father, who was such a doc, came home every day for lunch, after which he took a brief NAP before going back to work. This was not considered unusual. The whole pace of things was slower. When your patients know you socially, they're less likely to pester you unnecessarily.