Who still wants to be a country doctor?
■ There is still need for physicians in rural areas, but interest is declining. One solution: Improve work-life balance to attract and keep doctors.
By Victoria Stagg Elliott — Posted Oct. 22, 2012
J. Matt Byrd, MD, a family physician in Ogallala, Neb., population 5,000, starts his workday with a 15-minute drive to his office. He’s usually home by 6 p.m., and after dinner with his family, he might go out to his backyard with his 11-year-old daughter to hunt deer, pheasants, doves and grouse. Or they might go for walks, ride bikes or fish in nearby Lake McConaughy, Nebraska’s largest.
“There’s a life balance to be had in a rural area,” Dr. Byrd said.
With more doctors, in any location, placing a premium on work-life balance, organizations trying to reduce an acute shortage of physicians in rural areas say lifestyle issues are likely to play a more prominent role in attracting physicians to remote cities and towns — and keeping them there. “Identifying and understanding personal needs can be as important as meeting practice needs in retaining rural health care providers,” said a 2012 report funded by the Veterans Administration Office of Rural Health. Twenty-five percent of the population lives in rural areas, but only 9% of physicians practice there, according to the National Rural Health Assn.
One barrier to attracting doctors has been the traditional view of the rural practice: one doctor, alone, always at work, always on call. But that is changing as rural areas and hospitals recognize physicians’ desire to be employed and have time to enjoy their families and surroundings without having their time filled with a large amount of call and administrative work that could come with a solo or small practice.
“If a community is trying to recruit somebody who is going to own his or her own practice and run his or her own practice, that’s probably not going to work,” said Brock Slabach, MPH, senior vice president for member services of the National Rural Health Assn. “Work-life balance is very important, and physicians are not interested in 70- to 80-hour weeks. It’s not something people are going to be attracted to.”
Even for a doctor with deep rural roots like Dr. Byrd, who did his residency in Grand Island, Neb. (population 48,000), the idea of working outside a large city gave him pause. He knew firsthand of the country doctor’s experience of seemingly never-ending days. “My grandfather was a rural physician in solo practice,” Dr. Byrd said. “My dad was a rural physician who was solo. I grew up in a rural area. I knew I wanted to live in a rural area, but I wanted to focus on medicine, not billing.”
It turned out that Ogallala, 3½ hours east of Denver, worked for Dr. Byrd. There, he could be employed with Banner Medical Group, which provides medical services to Banner Health, a nonprofit health system with 23 acute care facilities in seven states.
Recruiters say rural facilities, like their counterparts in urban areas, are responding to physicians’ desire for work-life balance by creating more employed positions. A survey of 302 residents, both urban and rural, released Oct. 5, 2011, by Merritt Hawkins found that 32% would be most open to hospital employment. This was true for only 3% in 2001.
Still, it’s not easy for many rural hospitals offering employment because they don’t have enough physicians or financial resources to make sure there are plenty of doctors to cover all shifts and call, said Mike Shimmens, executive director of 3RNet — the National Rural Recruitment and Retention Network — an organization made up of agencies that recruit doctors to rural locations.
Ashland Health Center, an independent critical access hospital in Ashland, Kan., population 867, does not have the patient population to keep two physicians occupied. But the town recruited one full-time doctor and another who splits hours between Ashland and Laverne, Okla., another rural town an hour away that also needs a medical professional.
Doctors cannot practice all alone, said Brianne Clark, DO, the family physician who works part time in Ashland and in Laverne. “Call has to be manageable, and doctors need to be able to have a life if the situation is going to last long term.”
Keeping rural doctors home
The rule of thumb continues to be that doctors with a rural background are most likely to consider rural practice. A survey by Merritt Hawkins & Associates, a physician search firm based in Irving, Texas, found that residents want positions with work-life balance, but fewer than 1% want to practice in a community of less than 10,000 people. “Out of every 100 primary care physicians [who] call or write me, it’s just a handful that say, ‘Give me rural, or give me death,’ ” said Randy Munson, manager of the New Physicians for Wisconsin Program of the Wisconsin Office of Rural Health. It’s also a rule of thumb that the spouses of those doctors, if they’re married, need be happy in a rural area, too, and many hospitals and locations sell themselves just as hard to them as they do the physicians.
Recruiters’ typical sales pitches are less geared toward changing the minds of most urban doctors who are unlikely to consider practicing in a rural environment. It’s about doing more to keep physicians with rural roots, or the few who might consider establishing them, from planting themselves somewhere more urban. That’s why retaining rural physicians is becoming just as big an issue as recruitment, said 3RNet’s Shimmens.
If call and hours can be managed, rural locations at least can take a shot at selling their benefits to physicians who are just out of residency, or those nearing retirement — two key demographics for recruitment. Doctors who practice in rural areas say what they like most is the time a lack of commute and other urban hassles gives them to spend with their families, or on activities they enjoy. For example, a survey of 711 rural physicians released in June 2012 by the Colorado Health Institute found that 70% in that state rated recreational and leisure activities as very important reasons they stayed. Fifty-five percent said the idea that rural areas were good places to raise children also was very important.
“My commute is about three minutes, eight if I stop for a latte,” said Aaron Knudson, DO, a father of three and a pediatrician and internist who works four days a week with Banner Medical Group in Page, Ariz., a town of around 7,000 that serves as the entryway to the Glen Canyon National Recreation Area, near Lake Powell and the Colorado River. “The commute times are short enough that I can get away to school activities. On a slow day, I usually have lunch with my wife and our 2-year-old.” Dr. Knudson said he left working in urban areas because he wanted someplace with better schools and less crime.
Some facilities are getting especially creative in selling personal and professional flexibility. Ashland Health Center had been without a doctor for months before it started offering physicians jobs with eight weeks off a year. The intention was to attract those who wanted extra time off for missions to less-developed countries, although the vacation time can be used for any purpose. Executives at Ashland believe that doctors who want to care for underserved populations outside the U.S. also want to do the same for those inside the country.
“They can use the time at their discretion,” said Benjamin Anderson, Ashland’s CEO. “But the physicians we have recruited work in Haiti and parts of Africa, really all over the world. And if they can practice in Africa and don’t need access to a Starbucks or a Nordstrom, they are more willing to practice here.”
Beyond the sales pitch
For at least 40 years, there have been local, state and federal efforts to find ways to attract more doctors to rural areas. Minnesota and West Virginia, for example, have attained success with programs that identify potential doctors with rural roots and put them through medical school training that includes months spent alongside a preceptor in a rural practice. (Dr. Byrd serves such a role for the University of Nebraska’s rural medicine program.) Success is measured generally by a small but steady increase in the number of students from the schools who eventually practice in rural locations — and stay there.
Meanwhile, there continues to be programs such as medical school loan forgiveness and other financial incentives for doctors willing to stay in a rural practice a certain amount of time, as well as J-1 visa programs that bring international medical graduates to rural areas. The Affordable Care Act greatly expanded programs to attract physicians to rural areas. Advocates for rural practice say that with improvements in technology, physicians can connect more quickly and frequently with colleagues and specialists elsewhere, making them feel less professionally isolated.
However, whatever the financial support or the level of work-life balance, there are worries. There may not be enough new physicians to take over when other doctors retire. With call such a big issue, there is a question of whether there will be enough doctors to fill the expanding number that will be needed as a result. Or a small, rural hospital system might not have the financial means to attract and pay them.
Shimmens said there are nine new rural-track programs this year at medical schools that will produce about 50 physicians. But they won’t be in place for about five years, and some may decide before then that they would rather go to an urban area.
Still, those recruiting doctors to rural areas, and doctors in rural areas, say being in the country has a lot to offer, personally and professionally. “I could not imagine being in a town of half a million people or more,” Dr. Clark said. “I like the quiet. I like seeing the stars at night. There’s more respect for doctors, and there’s more of a pull to really be a part of the community.”