Ralph Riley, MD, Bought his practice in Saluda, South Carolina, after a 15-minute phone conversation and a handshake. "Nothing was ever signed; I bought the entire building and practice," he says. While lawyers and practice management advisors would frown on such loose business practices, it fit Riley’s unique situation. He was coming home to his rural roots.
Riley was from Saluda, a town of about 3,000 people in central South Carolina. In the nearly 25 years since the handshake, Riley Family Practice Associates has grown with the addition of two full-time and two part-time nurse practitioners. A few years ago, he hired an additional physician. He knows that one of the challenges of rural practice is keeping the workload at a manageable level, but he wouldn’t trade it. "It was always my dream to go into family medicine and come back to Saluda," Riley says.
In Houston, Missouri, Tricia Benoist, MD, is also living her dream. She works as a family practitioner with obstetrics for St. John’s Clinic and is on the staff at Texas County Memorial Hospital. Benoist has only been in Houston (population 1,995 according to 2004 census data) since September 2008, but word has already spread about the "only female who delivers babies" within a one-hour radius. Benoist has two young children and her parents live in St. Louis, which is about two and a half hours away. She could have stayed there to practice, but it’s not what she wanted, even from the time she entered medical school at Rosalind Franklin University of Medicine and Science in Chicago. "I always wanted to do the small town thing; that was always my dream," she says.
Unfortunately, not every resident dreams of rural practice. According to the American Academy of Family Physicians (AAFP), 25 percent of the nation’s population resides in rural areas, but only about 10 percent of physicians practice there. The disparity is striking and can create a vicious circle of overworked physicians and an increasingly unhealthy patient base. Even defining what’s "rural" is difficult. The U.S. Census Bureau still uses a population definition of 2,500 or fewer people to define rural, but depending on the government agency or service measured, municipal boundaries or economic factors may be used. These varying definitions create an estimate of a rural population that ranges from 17 to 49 percent of Americans.
It’s no less complicated for health care. Medicare definitions may be used to designate a community hospital and rural health clinics. Medicare uses the medically underserved population formula for clinics and health professional shortage area designations, which include ratios of the number of physicians per 1,000 people in a given area. For the people who live in rural areas, however, rural is a feeling, a way of life.
Maybe that’s why Riley is more typical of the physician who chooses rural practice - he grew up in a rural area. Even so, there are transplanted physicians who choose topractice and live in rural areas and thrive there. Many people involved in rural health policy and physician recruitment, as well as the physicians, believe more medical students simply need exposure to rural medicine so they can make their own assessments instead of relying on hearsay and ever-growing myths about the practice. "We need to continue to emphasize training programs in rural areas," says Tim Skinner, the executive director of the National Rural Recruitment and Retention Network (3RNet), based in LaCrosse, Wisconsin.
Martin Clements, MD, is an example of an urban transplant who chose rural practice after exposure to the small-town lifestyle. Clements, who now works as a family practitioner, who also does high-risk obstetrics for Lake Chelan Clinic in Chelan, Washington, grew up in Louisville, Kentucky, but went to a small college in one of Kentucky’s small towns - Danville. "It was a school of less than 1,000 students and a town of about 15,000. I started shadowing some of the family practice and internal medicine physicians doing hospital rounds and working in their clinics. That was just the kind of medicine I wanted to do," he says.
The choices that Clements and Benoist made are more the exception than the rule. Aside from the issue of graduates not selecting rural care, many medical schools are not encouraging medical students to enter primary care fields. A study from the AAFP-affiliated Robert Graham Center, reported that less than one-fifth of medical students are interested in primary care as a specialty. "In medical school, too often students hear that the money’s not there for primary care, it’s too challenging, you have a tough call schedule, do extra work," says Stacey Day, the director of recruitment for the South Carolina Office of Rural Health. "Medical schools want students to be successful; it’s not intentional, but they’re highlighting specialties," she says.
Day works with students in medical schools in South Carolina to encourage them to think about primary care and rural practice as options. Part of her work is debunking myths students have about rural medicine. One of the most common concerns she hears about is social and professional isolation. Thomas Dean, MD, has been a family practice physician in his hometown of Wessington Springs, South Dakota, since 1978. He says isolation can be a legitimate issue, "but I think it is much less of an issue than it was 20 or 30 years ago," he says. Dean says that rural physicians have many ways to deal with isolation today.
Day agrees, saying rural physicians usually have a colleague or another physician in the community to talk with. "And you can pick up the phone," she says. Rural physicians can also pick up a mouse, cell phone, or employ other technology. According to Skinner, physicians in rural practice stay in touch with other doctors through the Internet and teleconferencing. Rural areas were among the early adopters of telemedicine; networks range from simple 24-hour teleradiology to complex networks that offer interactive specialist services.
Skinner says that many medical students choose specialties because they know they’re going to leave medical school with high debt. "If a specialist can start practice making about $400,000 a year and has $200,000 in debt, then students are forced to make decisions based on money," he says. Specialty salaries are higher than primary care salaries and many rural medicine advocates hope features of healthcare reform will even this disparity. The latest data from the Medical Group Management Association (MGMA) show an average 2008 salary for specialists of nearly $340,000 and an average family practice (without OB) salary of $179,000 across all demographic locations.
However, the assumption that salaries are lower in rural areas is not always based in truth. The MGMA compensation salary also shows that family practice average salary in onmetropolitan areas (fewer than 50,000 people) was between $177,670 and $198,742 for those who also do OB. "I make more money than a lot of my peers in urban areas," says Benoist. She attributes part of that to her practice’s affiliation with a large healthcare network. Benoist also received complete loan repayment when she moved to Houston
Larry Lyons, MD, the medical director of Santa Fe, New Mexico-based Presbyterian Medical Services, emphasizes loan repayment when he’s recruiting physicians to Presbyterian’s 82 primary care sites in 32 New Mexico communities. "Many physicians don’t realize that they may be able to pay off their loans by doing family practice in a rural area," he says.
Dean says that a heavier workload than their urban counterparts is another myth that scares off many younger physicians. "They hear about being on call all of the time, and the phone rings constantly, and you work yourself to death," he says. "Some of it is based on fact, but the environment has changed significantly, and most of it is simply not true."
Lyons says that many rural hospitals in New Mexico have gone to hospitalist programs, which means family practice physicians interested in rural areas can practice "without having to gear up for call every fourth night." In a town like Saluda, there is no hospital, just a skilled nursing facility and hospice, so if Riley has admitted a patient, he turns him over to the hospitalist at one of the facilities within about 30 minutes. Physicians who still want to do inpatient care can find a rural area where that’s possible. Benoist delivers babies and sees inpatients at her local 60-bed hospital, which is across the street from her office. She shares call with five family practice physicians in town who deliver babies and perform C-sections.
Of course, there is an essence of truth to some drawbacks of rural practice. It’s true that some rural areas lag behind in adoption of technology such as electronic health records. Riley has had EHRs for nearly three years. "I do believe we need them and I do believe they’re better," but he says the technology decreased his practice’s efficiency by 20 to 30 percent in the first two years.
Lyons has received grants to add EHRs in his centers beginning this year. Skinner says the American Recovery and Reinvestment Act (ARRA) should help stimulate EHR funding and adoption, which may attract more young physicians.
Isolation sometimes is more of an issue for a physician’s spouse and family. Benoist’s husband is a stay-at-home dad for their two children. "It’s an adjustment for him, staying at home and also trying to meet people," she says. The town has a golf course and a drive-in theater, so the family manages, "but it definitely was an adjustment for him getting used to life around here."
Rural medicine is on the healthcare reform radar. Although the specific details are unknown, change is coming. "The dynamic really is going to play out over the next couple of years in Washington," says Larry Lyons, MD, the medical director of a large community health center system in rural New Mexico. Like many others who stay abreast of the healthcare reform debate and who practice in rural regions of the country, he knows reform must address more than coverage for the uninsured and underinsured.
Alan Morgan, the chief executive officer of the National Rural Health Association (NHRA) in Kansas City, Missouri, agrees. He recently discussed the problems of rural medicine with members of a delegation from Latin America, where insurance alone hasn’t solved the problem. Morgan says that even though some of the countries’ governments fund health coverage for their citizens, "they don’t have clinicians in rural areas. Obviously, we need health insurance, but it has no bearing if you can’t get clinicians out there to practice," he says.
Lyons and Morgan say that in addition to addressing disparities in coverage for rural residents, healthcare reform must also include support efforts to encourage primary care physicians to practice in rural areas. "It basically means more loans, scholarships, support of the National Service Corps, and training primary care physicians," says Lyons.
Organizations such as the NRHA and the National Organization of State Offices of Rural Health have published policy statements advocating for a number of measures to stabilize and increase the rural physician workforce. The NRHA’s suggested legislative solutions include improving and expanding the National Health Service Corps, creating incentives for programs and students to increase rural primary care physician ranks, and implementation of medical school rural training tracks created by Congress in 1999. The Center for Medicare Services (CMS) never approved the start of this program because it claimed it didn’t have an appropriate definition of "rural training track," according to Morgan. Congress has only to require that CMS adopt a definition in order for the program to be implemented, and Morgan hopes this issue will be addressed in current reform legislation.
That’s always been the trade-off when moving to a rural area - isolation and inconvenience in exchange for a lifestyle that many urban physicians dream about. It may be the reason why small-town natives are more likely to choose rural medicine in the first place. It’s easier for a physician who comes from a small town to adjust when moving there to practice medicine. Clements says one of the drawbacks to his Washington practice is adapting to the fact that the specialists and services his patients need aren’t right there in the hospital. "Now it’s, ’they need something; do I send them to Wenatchee or to Seattle and can we get them over the passes to get them there?’ It’s more about how to get things done and where do you go to do it?" he says. Some of his patients have to take a ferry trip that can last up to four hours and turn into a stay of several days in the winter, when the ferry doesn’t run daily.
However, he says, "I get to live where other people vacation."
Even though the nearest shopping, Starbucks, or large hospital may be three hours away, many rural physicians are right next to fishing, skiing, and other activities.
Maybe it’s the size of the communities that adds to the benefit physicians cite most - relationships. "I think I’m not unlike most primary care physicians we’re relationship people," says Riley. "People in small towns are relationship people, too. I have a very large second family," he says. When people who have left Saluda return to the smaller town to get their health care from Riley, it must be a strong relationship.
Clements sees similar effects across the country in Chelan. "I feel like some of the people here have an option of getting care elsewhere but they would much rather come to our clinic." He says in the local clinic, patients and physicians feel connected. "It’s not like a factory just moving patients through," he says.
Wanting to feel connected is what draws physicians to rural medicine, according to Alan Morgan, the chief executive officer of the National Rural Health Association (NHRA) in Kansas City, Missouri. "They know their patient base and their families’ histories and there is community support for the physician," he says. That support is another benefit that Day discusses with medical students in her recruitment efforts. "I tell them that you can truly be a community leader, caring for generations of families," she says.
Benoist says she also enjoys the camaraderie in her small hospital. "I know every single nurse; I know everybody who works at the hospital," she says. "The CEO walks down the hall and asks how I’m doing every morning."
Despite the many positives, the results of the 2009 National Residency Matching program show that student interest in family medicine in general continues to decline. Fewer positions were filled in family medicine residency programs in 2009 than in 2008. When the pool of family practitioners is smaller each year and the myths of rural practice are added to the equation, it’s not a promising outlook unless small towns continue to "grow their own." Studies support the notion that rural physicians tend to come from similar environments. In particular, more than half of female physicians who practice in rural areas were raised in a town of fewer than 25,000 people, according to a 2001 study in the Journal of Rural Health.
Rural Healthy People 2010 lists access to insurance and physicians as two of its top objectives. In a companion document to Healthy People 2010, the authors state that 20 percentof people living in nonmetropolitan areas are likely to be uninsured, compared with 17 percent in metropolitan areas. The uninsured ranks rise in the smallest communities, as do the underinsured. Dean, in South Dakota, who is the past president of the NRHA and is an active member of the Medicare Payment Advisory Commission (MedPAC), says providing coverage for the entire population is essential. "Employer-based insurance is less common in rural areas. Most of our people work for small businesses and we know those businesses’ ability to provide health insurance has been hurt in the current market," he says. "The employees either have policies that aren’t very good or they’re paying way more for their policies than if they were working for a big national employer. We also have a lot of people who are self-employed, and they really get hammered," says Dean.
What’s more, there is a higher proportion of older Americans living in rural areas. According to the Center for Rural Affairs, in 2007 about 15 percent of rural residents were 65 or older, compared to roughly 11 percent for the rest of the country. According to center data, rural Americans also tend to have more chronic and mental disease yet receive comparable or less preventive care, such as regular medical checkups, mammograms, and blood pressure and cholesterol checks. Part of the reason is access to care (see "Health Reform More than Insurance Reform," page 29). The inadequate number of primary care physicians and distance from specialty care mean less health care for rural populations, and the workforce shortage is not expected to improve the situation. The Center for Rural Affairs says the average rural physician is 48 years old. In South Carolina, Riley sees this as a big problem, but he thinks some older physicians would practice "well into their 70s if they’re healthy because they love it." The problem, he says, is frustration with the time spent jumping through hoops and recent moves in insurance. This time interferes with physician-patient relationships and may force some physicians into retirement, Riley says.
[Rural] physicians believe more medical students simply need exposure to rural medicine so they can make their own assessments instead of relying on hearsay and ever-growing myths about the practice.
Health associations and communities aren’t waiting for healthcare reform to solve all of the issues surrounding rural medicine. After all, it hasn’t been easy to recruit to rural areas for some time. Initiatives such as the National Health Service Corps help bring physicians to underserved communities. The 1995 creation of 3RNet in 1995 by various state and federal organizations that recruit physicians to rural areas was intended to serve as a resource for both communities and physicians. Rural communities also band together to attract and retain physicians. "Often, the local hospital is the driving force," says Morgan.
With 50 million people living in areas where there are too few providers to meet their basic primary care needs, however, everyone in the industry agrees more must be done. The NRHA has set health reform priorities for rural America that include abating the workforce shortage crisis, gaining equity in reimbursement, and eliminating health disparities and protecting vulnerable populations. Morgan says that regardless of the final outcome of the health reform debate, two tracks should emerge. "One is improving health coverage," he says. "If physicians know they will receive payment, that’s a good thing for rural practice." The second issue is access and improvement of the workforce. He realizes that all of the NRHA’s suggested solutions may not occur, but he is encouraged that they’re being considered.
Dean is tackling another front. MedPAC is going to address medical education this year, he says. "Medicare data show that we know Medicare enrollees need a primary care base and yet we’re clearly not going to have that as the baby boomers come in." According to Dean, research supports patients’ preference for the medical home approach and the patient-centered relationship it affords. For physicians both personally and professionally, the positive aspects of small-town practice outweigh the negative, which he says get a lot more attention, he says.
It’s a good thing that physicians like Benoist and Clements ignored the negative talk. "I thoroughly love being where I am and thoroughly enjoy what I’m doing," Clements says. "It gets lost in training. Students kind of forget they’re in this to be with patients and to be part of a group. It’s something I think everybody should have the opportunity to check out to see just how nice it is," he says.
Teresa Odle is a regular contributor to PracticeLink’s Unique Opportunities.