The Front Lines of Rural Medicine

{Every now and again, I have to “get out of my system” something that has been bothering me. I know the time has come because when, instead of just clearing the deck and writing a post about it, it starts slipping into whatever else I am talking or writing about. This will involve things of a somewhat personal nature, though I am trying to avoid it being a whinefest about our particular situation. The thing is that I think this has ramifications above and beyond our current circumstances and it speaks to some larger issues talked about round these parts.}

When people discuss the “doctor shortage,” there are few places it is felt more keenly than family practice and primary care in rural America. There is a shortage of primary care physicians in general. Because of this, primary care physicians have a lot more flexibility in where to live and where to practice than do a lot of people in a lot of other professions. With those options, comparatively few choose to serve rural places. In that regard, my wife is an exception. She specifically chose rural medicine as her focus and had dreams of running a full-spectrum practice in rural America.

This week, over Thanksgiving, my wife and I are due to have a discussion about what the future holds. We’ve termed it the “exit strategy” from her current job, which – on paper – was almost everything that she wanted.

Now, it’s difficult to entirely disentangle which of the problems we have are specific to this job, and which are intrinsic to the career focus that she chose and the state of modern rural medicine more generally. On the former score, there is a coldness between Clancy and her employer. There’s just no other way to put it. I’m not going to chew everybody’s ear off exposing all of the dirty details, but I do feel the need to mention it for context because we’ve past the point where we can sit down and work things out and the question is “rural medicine somewhere else” or “something else somewhere else”. Ultimately, however, while it’s hard for either side to remember it, everybody is in the same boat here. And that boat is on tumultuous waters.

The long and short of it is that I miss the days of residency, when we actually got time together. When it required less fingers and toes to count the days when she was on call rather than having a night “off”. When having only an hour to spend catching up with one another didn’t constitute “a good day.” When we actually got to watch television together. When we got to go beyond a 10-mile radius together because she wasn’t either on call or having to work either the day or early the next morning or on paperwork throughout. When it didn’t recall calling in ten favors so that she can go out of town and see a specialist. When more than one weekend a month was free or when the weekends that were free weren’t spent going through mountains of accumulated paperwork. When I didn’t feel guilty for telling her about my day or something interesting I read about because I was keeping her from said paperwork (or the brief unwinding between arrival and paperwork, assuming she’s not working at the office). When, from one year to the next, pay was going up slightly and work was constant or going down instead of pay going down and work going up. It’s been a hard couple of months, and last week we were informed that it’s about to get worse.

Whatever I will say about her employer, they’re not doing it to be mean or because they have stockholders to answer to. It wouldn’t surprise me if they were really doing the best they possibly can, under the circumstances. There aren’t enough doctors. The doctors that are around limit their scope of care because of malpractice liability, exhaustion, or (in one case) tax brackets. The doctors that haven’t limited their scope want to. My wife wants to do it all, but not all the time.

As far as small towns go, the town we live in is a pretty good one. It’s notably educated, within driving distance of great hunting and fishing (ahem, if you can find the time). The local schools are good. When we were originally looking for a place to land, it stood out as a place – though smaller than I would like – that I might be able to settle down in. I mention all of this because it should make this an easier place to recruit and retain doctors, as far as rural places go. There were other opportunities in less desirable places (hours and hours from the nearest town of any real size, less educated, less affluent) and I have to wonder if they will ever be filled.

A lot of people talk blithely about how “the medical establishment” (if they don’t know what they are talking about, they will say “the AMA”) artificially limits the number of doctors and limit what non-doctors can do in order to drive up salaries. Yet, when the rubber hits the road in the places of greater shortages, the supply-demand curve doesn’t work. The hospital can’t tell my wife or any of the other doctors “We need you, so we will pay you double what you could get in a more desirable place to live,” because the structure of payment schedules are determined by non-market forces (the government and the insurance oligopoly), it’s set up according to training and not according to need, and the market itself might not even suffer a hospital here to begin with. Those other places I refer to that are “less desirable” that we would need a massive pay bump to even consider? They pay less than her current job does. And in a more market-based system, a lot of these places simply wouldn’t be able to afford doctors at all unless there were such a glut of primary care physicians that they had to move out to the boondocks just to have a place to make a living. Even then, I am not sure it would work as advertised. On the other hand, having enough doctors out there might make the job more tolerable.

We can also talk about the medical cartel and their preventing of nurses and mid-level providers from doing the things a doctor can, but that itself doesn’t really apply out here. First, our area does make extensive use of MLPs. The problem is that even when an MLP is present, you still need doctors around (so they can’t go to out of town doctor appointments, or Walmart, for that matter). Also, MLPs themselves are hard to recruit to this area because they, too, have other options. So are nurses (my wife doesn’t have a nurse, for instance, she has a medical assistant). One invariable problem of being in rural America is that people who come here for jobs are often only one half of two-income households. Since my wife is a doctor, we can get by on one income, but it’s tougher for nurses and not easy for medical professionals to find other work for their spouses. Sitting around with the husbands of the rural-track doctors, most of us knew we were leaving our IT and engineering careers behind.

Here’s the part where I say, “What we need to do is…” but I am truly at a loss. A truly free-market system would likely result in the hospital being shuttered which would be disastrous for a an area larger than New Jersey. Government involvement as it has existed, on the other hand, has created a number of the problems it’s facing. This could be part of a greater commentary that the model of the remote small town is fatally flawed and would need to be abandoned, if it came to that, because they can’t easily support themselves and/or attract the people they need. Or we can just shrug and say “if it takes them two hours to get to the nearest emergency room and they die along the way, that’s the choice they made when they chose not to become city-dwellers.”

I am tempted to say “more doctors, more doctors, more doctors (pronto)”. I fear even “flood the market until they move out to the sticks” might not work because at some point doctors will create niches in the city rather than resign themselves to life out here or they will forgo medicine altogether and use their training for other pursuits (I’ve found myself wondering what my wife could do with her bio-chem degree and medical training outside of medicine, though she’s still committed to being a doctor). But if it did work it might lighten the burden and make the job more tolerable. It would also be costly and perhaps economically inefficient. Cutting down on the paperwork and making it more efficient would help (70% of her struggles to keep up involve paperwork) and so EMR, once implemented, could prove to be a godsend.

You can also try to tip the payscales. The PPACA actually works towards this end (as well as increasing residency slots for primary care docs). The state we live in also has an incentive program. But this is as much as anything biting around the edges. Even with the incentives, some city jobs would offer 50% more money (some over double, but we those are money factories that she doesn’t want any part of) and a lighter call schedule. The incentives in place don’t come anywhere near counter-balancing the overall income differential. Never mind the work schedule, which is the much bigger problem (at least for us – no complaints about the salary). So bribery is also out, unless we start really throwing money at it. Nationalize rural hospitals? The former libertarian in me shudders at the thought, but the Indian Health Service was never like this.

It’s also possible that most places aren’t this bad and that a lot of the problems involve mismanagement. This thought is tempting, given the cool relationship my wife has with her employer, but I’m really not sure it’s true.

One a personal level, my wife would work more “efficiently.” Instead of spending hours and hours monitoring a labor, she could just declare “c-section!” and be home in time for supper or to catch a little rest. She refuses to give in to that temptation (I do not exaggerate when I say that she is a model of integrity), but she’s anti-interventionist compared to most obstetrics. Other doctors, seeing more gray, might (and I suspect do) approach the situation differently. She does need to improve her paperwork processing skills, but it takes time to speed up and it’s hard to strategize when you’re exhausted all the time and when you’re stuck in a perpetual state of reaction.

Ultimately, though, the solution for us is the exit strategy and therefore likely becoming a part of the problem. She’s not going to give up medicine. It’s possible that we will even give rural medicine another go, if at the end we determine that it’s just a particularly bad fit with her employer. We don’t know when it’s going to happen. She doesn’t have time to read my blog, much less look for work or follow the potential leads we already have. We also have a five-figure exit penalty to account for. More than that, though, we don’t want to leave the hospital in the lurch. We don’t want to make the problems of her fellow doctors even worse. She wants to do the responsible thing, but the most responsible thing is never to leave and we’ve past the point where that’s even possible. All we can do is figure out the least-worst time to give notice and (months later) depart. And what happens after that.

But the problems we leave behind aren’t going to get any better.

Will Truman

Will Truman is the Editor-in-Chief of Ordinary Times. He is also on Twitter.


  1. Excellent post, which I feel chagrined saying due to the circumstances which inspired it. I am tempted to just say “have her come practice in Portland,” but I admit much of that has to do with the fact that it would be cool to have beers. (Not the best reason to uproot.)

    I have an actual constructive if odd thought, but maybe I’ll shoot it to you in email.

    • Thanks.

      Oregon (though not Portland) is on our radar. I’d love western Oregon, though I think she is more fond of eastern. We both have family connections in that state and a part of the history of us involves a band originally from that state.

      It’s really a shame we didn’t get to know one another when I lived in the Northwest.

  2. Great post. A lot to chew on. Here in AK we have similar problems on huge scale. In Anch we have the majority of all the hospital beds in the state and almost all the specialists. People have to fly in from all over the state or move to Anch for treatment for many problems. There are a handful of smaller hospitals in the other “cities” but most people get by with medical clinics and are lucky to have a nurse. We have an IHS hospital which serves most of the Alaska Natives. It has a middling reputation although i know that have a couple national level specialists and programs.

    Since i’m a lib i’m forced to believe that the only way to solve this is to pump money in to incentives, subsidize primary care doc education and public clinics. But i can’t see any other way to get at this. Other than that there are always going to be places that people have to be willing to make some sacrifices to live in and hope to appreciate the rewards of those places.

    • Thanks.

      Yeah, Alaska is what I am talking about writ-large. The funny thing is that some degree of shortage is helpful to us because places with too many specialists mean that she can’t get to do what she wants to do. But too much of a shortage and we run into what we have here. Times 100 for Alaska.

      My wife worked for the IHS for a while. It was a real mixed bag, from a doctor’s perspective. But a lot more tolerable than this.

    • I’d think you could attract doctors from the lower 48 with the promise of cute helicopter pilots.

  3. This seems so topsy-turvy to me.

    Your wife is providing a service and alleviating the problem. It’s like saying that someone who opens a Dairy Queen is responsible for making sure that people don’t go hungry (and, therefore, has an obligation to be open longer and longer hours).


  4. Looks like we’ve had a spam attack here. Will, I’ve banninated this particular spammer from my posts after repeated prior offenses. Shall I do the same with yours?

    • At least his comments were on-target this time. His tone and demeanor, however, are antagonistic and not remotely constructive. So it depends on where you want to set the parameters on speech vs. dialogue.

    • How courageous. Protecting Will from an Insane Clown Posse. I’m quite sure Will would be more than capable of hitting the delete button on his own without your help. How disappointing that even you could exhibit such shameful, petty behavior in reflexively shutting down and out ideas you don’t want to hear.

      The rules have been explained to you many times. And my track record of tolerating ideas with which I disagree speaks for itself.

      • To add to this, when I signed on I specifically said that I wanted Burt to take the lead on setting parameters. If anything, I am inclined towards a smaller range of acceptable discourse. But since he was here first, I didn’t want anything changing on my account and I trust his judgment on such matters.

  5. This is, as ever, a well-written and thought provoking piece. One naive question from the outside: it seems that a significant chunk of your wife’s time problems come from an abundance of paper work. Is it possible to outsource that problem – hire more administrative assistants that work directly for the physicians? Such assistants would be less costly than hiring more physicians, due to the lack of intensive training costs. Might also provide an additional source of income for the one-income households.

    Again, this isn’t my field, so it might not be a feasible notion, but it seems that there must be a way to off-load some of the admin burden.

  6. Stuck in Logan trying to wrangle a toddler, so I can’t comment at much length. Great post, Will, and a compelling argument for subsidization. And any time you find yourself for the glory days of residency, a change must be made.

    I’ll write more when we’ve arrived.

    • “The long and short of it is that I miss the days of residency, when we actually got time together.”

      Yeah, I read that and all sorts of warning bells went off.

      If you want to approximate rural doctoring, it may be possible to live in a mixed community setting. Portland is an actual city, but many of the local communities within 40 miles are rural. Timesharing of a sort? Not sure.

      You could also look for something like Flagstaff, AZ?

      Man, I feel like I’m offering worthless advice to a situation that is all suck.

  7. In Canada we also struggle with the ability to provide excellent primary, secondary and tertiary (where necessary, roads closed, no ambulance, no nurse to go in the ambulance etc) care in rural settings. We train physicians in rural settings so they have the clinical courage and skills to work there, and then they settle in urban areas because their spouse can’t find rural work. Perhaps this is less an issue in Rural America. If one is fortunate enough to be able to practice in a rural setting, the lifestyle issues you’ve mentioned are very real. I work as a locum tenens in three remote rural and northern areas, and my colleagues in these areas spend not insignificant portions of their time on recruitment of colleagues. Still, I would suggest to your wife to be cautious about choosing an urban setting where she would no doubt give up the breadth and scope of practice she has come to enjoy. Can she recruit a partner/find someone to share her practice? Can she reduce her office hours recognizing how much other time she contributes to the cause? Can she ask her community if they’d rather lose an entire doctor than sacrifice a few hours of her time per week to keep her? Sometimes we forget that retaining a trained and settled physician is WAY easier than recruiting and accommodating a new one. Kindest regards – from one rural doc to another rural doc’s spouse!

  8. I wanted to thank everyone for their sympathy and advice. Rather than go one-by-one, I will say that we will be investigating all possible options and have already discussed and thought about many of the things suggested here. We will figure something out, even if it means that she has to go back to train to do something else.

  9. So, just a quick follow-up comment.

    First of all, you should jettison any guilt you or your wife feel about leaving. I know it’s so easy for me to say, and the only reason I say it is because I have at least some understanding of what it is to be in your position. From what you describe, your situation is simply and undeniably unsustainable. Your wife cannot continue with the demands of this job and continue to deliver the care that she knows they deserve. She’s human, and humans have breaking points. Leaving before she passes hers is no shame to her.

    And I don’t know how anyone can read what you write (and let me just chime in that I don’t doubt the veracity of a single word you posted) and question the need to subsidize medical care in rural and underserved communities. The free market simply won’t provide the incentives necessary to draw providers to these areas. If there is a more clear-cut situation that calls for governmental intervention, I would love to know about it.

    • Thanks, doc. It’s a tough dilemma to leave a place because they need you* so much. Or need so much from you (her). We use the word “unsustainable” a lot and felt that way even before the last few turns for the worse. We remained hopeful for the longest time that things would change. But everyone had different ideas of what “change” meant (and that’s excluding the unforeseeable changes for the worse that nobody wanted).

      It’s kind of ironic that for all of our complaints, money really isn’t one of them. But I do wonder if money isn’t the solution. You can’t pay my wife enough to endure this much longer, but you might be able to pay enough to bring more doctors in so that she doesn’t have to. Or, if not money, something to bring more people out here. A liability shield? Foreign doctors without full American credentials? I don’t know.

  10. Will,

    With a sig. other in her first year of law school I can relate to the problem of having to balance the desire to maintain closeness while giving a person the room they need to be who they are, though it’s not nearly as extreme a situation as it sounds like you two face. My thoughts are with you.

    This isn’t any kind of real consolation, but sometimes I do find it helps to keep in mind that so many families are separated by various kinds of work, including but not limited to soldiering, at the holidays and for months or a year or more at a stretch. Nevertheless, I very much relate. Sadly, I have absolutely no good ideas about how to start to address what, from all I have read, is becoming a medical crisis for small and especially isolated communities. I hope you and the good doc are finding some time to be together this holiday. Happy Thanksgiving!

  11. Wil wrote,
    Or we can just shrug and say “if it takes them two hours to get to the nearest emergency room and they die along the way, that’s the choice they made when they chose not to become city-dwellers.”

    Russell wrote,
    And I don’t know how anyone can read what you write (and let me just chime in that I don’t doubt the veracity of a single word you posted) and question the need to subsidize medical care in rural and underserved communities.

    Wil describes the alternative in the bluntest possible way, but in fact it’s not an unquestionable policy. When people choose where to live they have to accept tradeoffs. Once upon a time the government mandated airline fares that made it as cheap to small out of small-city airports as big-city airports, so small-city folk didn’t have to accept the full cost of their choice of where to live. But of course that meant it was the big-city folk who had to subsidize them. We did away with that policy–now it’s hard to get a good flight out of a small city–but now people in smaller communities have a better realization of the cost of their choice.

    It is not necessary to have so many people living in rural America, and it is questionable whether a social policy that encourages them to do so by subsidizing their choices is a wise policy.

    I’m not arguing for any particular outcome here, just saying that we can legitimately question whether we should subsidize doctors in rural areas. By doing so we obscure the full cost of living there (pushing that cost onto others who didn’t choose to do so). And whenever we hide the real costs of something we get more of it than is efficient.

    To some extent efficiency is at battle with notions of justice here. But also to some extent notions of justice are at battle with other notions of justice.

    • There’s am ex-neighbor of ours who was my kids’ pediatrician when they were younger. He was terrific — really liked kids, listened to them, cared about their health, took time to explain their issues to us. He’s now a plastic surgeon, because it’s so much more lucrative, and the hours are much more reasonable.

      It would of course be wrong to address these perverse incentives by subsidizing pediatric care, because there is no a priori reason to value children above women dissatisfied with their bust size.,

      • So, Mike, you’re saying that people “choose” to be kids? That’s an interesting concept, but I can’t say I agree.

    • James, I think we can both agree that currently, there are more subsidies in place to support urban living than rural. So…

      > It is not necessary to have so many people living
      > in rural America, and it is questionable whether
      > a social policy that encourages them to do so by
      > subsidizing their choices is a wise policy.

      … we can easily sub in “urban” there and your argument stands.

      Now, of course, one can argue that it is better to cut subsidies to urban living in order to make *them* realize the true cost, so that *they’ll* be more likely to choose rural living, but unfortunately the first thing to go won’t be all the infrastructural subsidies, but the exception subsidies. Roads will still get paved, but earthquake retrofits won’t occur.

      During normal times, nobody will much notice the difference. During the exception scenarios, lots more people will die.

      • Patrick,

        Actually, I have a post going up tomorrow on my blog asking this question, whether there are similar subsidies to urban areas. Two subsidiary questions are: a) Who’s subsidizing who more heavily (which depends not just on size of subsidies, but on relative numbers of urban vs. rural folks and their tax rates), and b) if all these subsidies were eliminated, how would that affect living patterns (which is more dependent on subsidies? And I think we’d need to throw suburbs in there as a third category.).

        • Look forward to it.

          And I’d guess I’d argue (with lots of handwaving) that suburbs aren’t so much an entity of their own as an offspring of urban subsidies, but I’m hardly a city planner.

        • I look forward to it, too. I am pretty sure that if you remove suburbs from the equation (and even if you keep them), you’re quite right that urban subsidizes rural more than the other way around. I think the picture is more complicated, though, than a lot of people make it out to be. I think the gains (particularly of economic boosts) of moving people to the cities are likely to be somewhat less than the statistics might suggest. And I think a lot of the “who is subsidizing whom and how much” depends on how you do your accounting (my main problem with the donor/beneficiary map).

          • > And I think a lot of the “who is subsidizing
            > whom and how much” depends on how
            > you do your accounting.

            Such is the way of these things, generally.

            There’s also the question of self-referential subsidies. City taxes and city bonds are collected to pay for city functions. So they’re decoupled from urban subsidies; how much do you count those? Is free parking a subsidy? Well, in one sense it is as it’s moving money from the mass transit people to the drivers and local shop owners, but they’re all city dwellers so how much of this is skin off the rural folks’ nose?

          • so how much of this is skin off the rural folks’ nose

            I think that’s my real question. Granted that there are lots of subsidies in urban life (such as mass transit), how much of that is a within-group transfer (urban dweller to urban dweller) and how much a between-group transfer (rural dweller to urban dweller). And, of course, how much the reverse is true for rural subsidies.

            I’ve no particular axe to grind here. I prefer relatively rural life myself and don’t want to live in a city even as big as the puny one (20k) I live in now.

  12. yes, the sound of birds’ footprints on the sky is the essense of flight!
    I’m sure the original comment is going bye-bye, but I had to preserve this gem; a triumph of bad poetry over careful observation.

    • There is a degree of inadvertent poetry in some of Heidegger’s rantings (under whatever name he chooses to use on any given day). And he’s right to love classical music, which is so often so beautiful. But that is hardly the point. And if he wants to get back in my good graces and earn commenting privileges back, calling me “a thoroughly awful, bloodless, joyless human being” is not a good way to do it. Abiding by the site’s comments policy, and staying on topic in comments, would be.

      • I’m fully in support of you deleting those comments, Burt. I just wanted to preserve that one line, and I appreciate you allowing it.

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