“I never really pictured myself in a larger city or elsewhere,” says Adam Swisher, D.O., family medicine specialist with UnityPoint Clinic in Fort Dodge, Iowa, and regional medical director of UnityPoint Hospice.
A child of two medical professionals, Swisher grew up in Belmond, Iowa, a community of about 2,500. He knew that a rural, small-town lifestyle was what he wanted as an adult.
Similarly, Christopher Menzel, M.D., assistant professor of clinical surgery with Vanderbilt University Medical Center, spent much of his childhood in a small community in and around Hilton Head, South Carolina.
He also had family members in medicine, including both grandfathers and two uncles. He watched how one of his grandfathers served his community as a family practice physician, often accepting unconventional forms of payment from families who gave whatever they could.
Menzel knew he wanted to practice that kind of medicine. He craved personal connections with patients, something that can feel almost impossible today in larger cities and practices. Today, he serves at the Vanderbilt Wilson County Hospital, about 45 minutes outside of Nashville, as the only physician in his local practice.
Linda Zambrana, M.D., shared a similar motivation. After finishing medical school in Nicaragua, she moved to Miami and began looking for a community where she could make the biggest impact. She accepted a role in Homestead, Florida, as a family medicine physician with Community Health of South Florida, Inc. “I decided to look for a place where I could be most effective at helping people,” she says.
Going where the need is greatest
Choosing to practice rural medicine makes these physicians members of an important but small minority of health care professionals.
In 2019, the American Hospital Association reported that although 20 percent of Americans live in rural communities, less than 10 percent of physicians practice there. And as of 2018, two-thirds of the country’s 6,941 primary care health professional shortage areas were in rural or partially rural areas.
“You have a much higher concentration of physicians who prefer to be in or near the metro areas, and far fewer who are specifically looking to be in rural areas,” says Steve Look, principal and founder of Paradigm Search Group in Dallas.
“Not only are there just not enough doctors all the way around, but they tend to be more heavily concentrated or interested in working in metro and suburban areas.”
The result is hospital closures and declining access to medical treatment.
The Chartis Group reported in 2021 that 135 rural hospitals have closed in the past decade and that more than another 400 are at risk of closure. On top of that, 166 rural hospitals have stopped providing obstetric care, and 252 have ended chemotherapy services. The same study reported that 62 percent of rural hospitals do not have any intensive care unit beds.
With limited access to health care, rural death rates are climbing. A 2019 article in Health Affairs reported that patients in rural areas have a 23 percent higher death rate and a 40 percent higher rate of preventable hospitalizations than their urban counterparts.
Rural towns desperately need trained physicians. For many residents, it’s a matter of life and death. And for doctors, it’s an opportunity to make a huge impact. Small towns need you now more than ever.
Practicing full-spectrum medicine
Swisher opted to practice in rural Iowa to make a difference there. He also did it to practice the full-spectrum medicine he trained for.
“I wanted to be able to utilize what I learned,” he says. “I wanted to deliver babies. I wanted to work in the emergency room and in the hospital setting, as well as in family medicine. I wanted to be a full-spectrum family physician versus just a clinician.”
When Swisher started his practice in 2011, his clinic was in Gowrie, but he worked with UnityPoint Health affiliate Stewart Memorial Community Hospital. This allowed him to work in other nearby areas as well.
“I would take a call in Lake City, Iowa, and there I delivered babies, worked in the ER and the hospital when I was on call, but then I would also do clinic in Gowrie,” he explains.
By working in a smaller community, Swisher got to experience many different aspects of medicine. In larger cities, it’s much the opposite. Specialists are responsible for areas like pediatrics, obstetrics/gynecology, geriatric medicine or palliative care.
“In smaller towns, you often become the specialist, and you get to utilize that whole breadth of knowledge that you have,” Swisher explains. “In a smaller hospital in a smaller community, you’re treating all aspects of life, from birth until death.”
This allows physicians to apply more of the skills they developed in medical school and residency.
Plus, Swisher says, “You’re able to continuously learn.” At a satellite hospital within a larger health system, he found that affiliate practices shared knowledge with each other. He also says there was “the opportunity for personal growth and development, as well as for career advancement or even relocation if you wanted to move to a different UnityPoint area.”
And working in a rural area doesn’t mean you can’t refer patients to specialists.
“The benefit of being in a small town but working for a larger organization is that you have improved access to specialty care,” explains Swisher. He can transfer patients into an emergency room or hospital stay with shorter wait times, which helps improve patient care.
Sometimes, there’s a misperception that smaller rural hospitals practice an older, less evidence-based style of medicine. But Menzel says that’s not the case.
“My experience has been anything but that,” he says. “Physicians, nurses, administration and most other health care workers at my hospital have welcomed my practice with open arms.”
Forming patient relationships
Providing a wider spectrum of care in smaller towns allows physicians to develop a closer bond with patients. In many cases, the physician treats the entire family, giving them a more comprehensive picture of the family dynamics, habits and relationships.
“I know how they live, where they work, what they do,” explains Zambrana. “I know the grandfather, the grandma, the mother, the child.” These connections build trust and encourage her patients to share information that can help her diagnose and treat illnesses.
Menzel finds this bond inspiring. It’s why he chose to work in a rural setting like his grandfather. He say he develops familiarity with his patients by just being available to hear about what’s going on with them—whether that’s through direct contact in the office or running into them around town.
As his hospital’s only bariatric surgeon, Menzel can be more involved with each patient’s surgery. He sees them through the entire process—meeting with them in advance, answering questions, performing the actual surgery and being there afterward.
“I think a lot of physicians have this deep concern for their patients, that you want to make sure they’re treated like a family member,” he says. After all, patients in a smaller community often do begin to feel like family.
“In larger training centers, residents do a lot of the work and a lot of the patient care,” explains Menzel. “But when I went into medicine, I knew I wanted to have a direct role in the care of my patients. I didn’t want others making decisions without me knowing what was going on. The ability to have that personalized control and really take responsibility for your patients is something I truly value.”
Bonding with colleagues
Menzel says his days in the operating room are just like the old TV show “Cheers”: everybody knows your name.
In a small town at a small practice with a small staff, he says, “You know everybody, and everybody knows you.” His schedule might vary from week to week, but he sees the same staff regularly. “And that’s a good thing,” he adds.
“In the OR, that really lends itself to efficiency and success. Then everybody you work with, you know them professionally, and then you’ll see them at the store or at kids’ activities, at church. Getting to know people on that level, just like with patients, adds that extra layer of depth to your relationship. It creates a sense of community that is difficult to replicate in very busy urban centers,” he explains. “That is a huge plus.”
Swisher’s perspective on work relationships is similar. “Your relationship to your colleagues is much closer, so you’re more comfortable approaching your peers,” he says. “As a group, collectively you realize the important roles that you play together and how that improves positive patient outcomes.”
Negotiating attractive compensation
Because more physicians apply for jobs in major cities, Look says, “Rural recruiting becomes much more challenging.” That gives doctors a fair amount of negotiating power in rural areas, depending on the situation. As a result, the compensation and benefits are often (though not always) quite attractive.
Emily Davidson, physician recruiter with Holzer Health System in Gallipolis, Ohio, explains that Holzer is “able to be a little bit more flexible with our salary offers, our bonuses, our loan repayment—all of those things—because we are not a teaching hospital.” Combine an above-average compensation package with a lower cost of living, and she says, “Your dollar goes a lot farther.”
Menzel cites cost of living as one reason he and his family don’t expect to leave their small town anytime soon. They love the space, the size of their home’s lot, the fresh air and the great view. The value for the money can be incredible in rural areas, making the compensation seem even more generous.
On top of that, many rural job offers include some form of student loan repayment. “Most U.S.-trained physicians have around $150,000 in loan debt,” Look says.
To help entice applicants, some rural employers offer loan repayment over the course of several years. Sign-on bonuses are also more common in rural areas, Look says. Physicians can use the upfront payment to buy a house and put down roots, which in turn improves retention.
Enjoying better work/life balance
Not all the benefits are monetary, of course. Jobs in rural communities often offer a flexible schedule.
Look says four-day workweeks are common, as are three-day workweeks and block scheduling with one week on and one week off. If you want to spend time elsewhere on your days off, these schedules are incredibly helpful. Even more conveniently, smaller facilities can often design schedules to meet a candidate’s unique preferences.
Designing a schedule around their lifestyles is a big draw for physicians. So is a shorter commute.
In her recruiting pitches, Davidson says, “We really emphasize no commute time and easy access. You’re within five minutes to work, but you don’t live on top of each other in a big skyscraper.” Good schools and an affordable cost of living are also big selling points.
Quality of life is a huge advantage, too. “I love sports, and I love being out in the community—helping the community,” Swisher explains.
He and his wife, a nurse practitioner in nephrology, have four active children. When he’s not seeing patients, Swisher is usually coaching his children’s many sport teams or watching them compete. His position gives him the time and freedom to do that.
Experiencing provider-led organization
One reason smaller organizations can offer so much scheduling flexibility? Provider-led management teams. This structure gives doctors a much larger say in how things are done.
“In smaller hospitals, you collaborate better,” Swisher explains. “You lead together. You make changes together. You often have an organization that’s more provider-led. … As a provider, you feel like you have a voice in what is said and done versus in a larger organization where you might feel like you’re just a number.”
In larger cities and practices, Swisher says, “People get used to just doing a job versus helping them make decisions or make improvements in organizations.” He believes physician-led facilities improve the quality of patient care.
Building your practice faster
For specialists considering a move, Look often points out that it can be easier to build a practice quickly in a rural area. “There’s minimal competition frequently,” he says.
Being one of the only specialists in the area can be appealing, especially at the start of your career. For a surgical specialist, he explains that can mean “walking into a pretty significant surgical volume” right off the bat.
That’s exactly what Menzel has experienced. In just a year, he says “the volume [of patients] has really picked up.” He’s already finding that new consults frequently fill his clinic template.
Participating in leadership early
In addition to seeing patients, Swisher also jumped into several leadership roles early in his career, from chairing the diabetic center, to being the medical director for a couple of the nursing homes.
Menzel has also taken on leadership roles early. Within his first year out of fellowship, he’s already become the medical director of bariatric and metabolic surgery. Having that level of responsibility so early in his career has allowed him to grow his reputation and his program faster than he might have in a larger town.
Treating underserved populations
The main reason that Zambrana elected to work in a rural community was that she felt she could do the most good there. For her, one of the most satisfying parts of the job is educating her patients and seeing their health improve as a result.
However, lack of community education can also make her job more challenging. Sometimes patients need assistance and don’t know that it’s available or how to request it.
Other times, extra paperwork can mean patients in underserved communities end up waiting longer for care. Even so, Zambrana feels a deep sense of fulfillment when her efforts pay off.
As a recruitment manager at The Primary Health Network in Sharon, Pennsylvania, Jessie Miller helps let potential new hires know what to expect on the job.
“There are experiences we can offer that physicians and mid-level providers might not even realize that we have and which can definitely be attractive,” Miller explains.
These include the chance to serve one of the state’s large resettlement populations. There is a large Nepalese community in Erie, Pennsylvania, as well as a large Spanish-speaking resettlement population in central Pennsylvania.
So when Miller spoke with a candidate interested in Doctors Without Borders, she explained it was possible to work within an underserved population “and not be so far from their family in Erie, Pennsylvania.”
Choosing rural life
Physicians are critical in rural areas. Swisher says, “They’re more than just doctors. They’re teachers. They’re examples. Having those providers in [rural areas] allows care. If they didn’t have them in some of these smaller areas, patients would be forced to drive.”
While many younger doctors gravitate towards big cities, those who are willing to try rural practice often end up staying.
“It happens regularly,” says Look. Rural practice “really can provide physicians a much better lifestyle. Less stress, less headaches and more time with family—and ultimately, a more robust practice. They really can thrive in the rural and midsize areas.”