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Are you cut out to be a country doc?


If you can thrive on a high-stimulus career and low-stimulus lifestyle, you may be happiest living and practicing in the country.


Your Career Guide
Surveying the landscape

Are you cut out to be a country doc?

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Choose article section...The big step: Starting a small-town practice

If you can thrive on a high-stimulus career and low-stimulus lifestyle, you may be happiest living and practicing in the country.

By Marc A. Ringel, MD
Family Physician/Greeley, CO

It's a beautiful, clear summer morning in eastern Colorado. I ride my bike to town, where hospital rounds await. On my way, I wave to neighbors and admire the latest explosion of wildflowers in the ditches.

As I arrive, my pager goes off. It's an emergency. I hop off my bike, leaving it unlocked at the ER entrance, dig the stethoscope out of my saddlebag, and run in. A young man lies on a gurney; ambulance attendants and hospital personnel are doing CPR.

The patient, fit and in his early 20s, looks perfect except for a small burn on his hand and another on his foot. But he's not breathing. While helping his uncle move some farm equipment, he was walking alongside an implement hitched behind a tractor. A boom he held accidentally touched an overhead power line, and he was electrocuted. If this patient was ever salvageable, the time it took the ambulance crew to get to the accident site, far out in the country, probably doomed him.

Our feverish efforts are not enough to start his heart, and he dies. I inform the waiting family, many of whom are my patients. They are devastated—especially the uncle, who blames himself for the tragedy.

I still have to see a few inpatients before crossing the street to my office. Then I will immerse myself in caring for 25 or more outpatients and respond to the constant staccato of phone calls from the hospital and nursing home. Despite these distractions, visions of the dead young man and sobbing uncle will haunt me throughout the day.

This incident, drawn from thousands I've stored in my memory over 20 years, encapsulates much of what is good, and bad, about rural practice. The good: country living, bicycle commutes, familiar neighbors, trust, and close teamwork among professionals. The bad: challenging situations at unpredictable intervals, delays in critical care, and having to deliver dreadful news to people you're close to.

Today, I practice two days a week and one weekend a month in Brush, a town of 6,000. I stay overnight when I'm on call, but otherwise I live in a larger community 60 miles away. It took me years to figure out that rural family practice is too hard for me to do full time. Would it be the right choice for you? Based on my experiences, here's how to tell if you are one of those fairly unique physicians who can thrive amid the demands of rural practice.

Some people seem to be born craving lots of sensation. As kids they love to be tickled and tossed in the air. As adults they like roller coasters, loud music, bright colors, spicy foods, and vacations in new places. They value novelty and challenge in their careers. Low-stimulus people, on the other hand, tend to stick with familiar places and foods and to choose quieter music and decor. They prefer their work to be predictable.

What kind of person thrives in rural practice? One who likes both a high-stimulus career and a low-stimulus lifestyle. Rural living is marked by the slow, predictable change of seasons, few strangers, and a lack of restaurants that serve hot curries. But rural practice, in virtually any specialty, also means higher stimulus than you would get from urban medicine.

A rural family doctor may practice higher-risk obstetrics, including cesarean sections; perform other major surgeries; provide emergency care, including fracture reductions and tendon repairs; and handle intensive care patients, complete with ventilator management. General internists may pass all sorts of scopes and poke all sorts of organs that, in the city, would be the turf of subspecialist colleagues.

Not only is the breadth of practice potentially greater in rural settings, so is the level of responsibility. Rural practitioners tend to work longer hours than their city cousins while getting paid less, mostly because of lower reimbursement rates. But despite the vagaries of life in an agriculture-driven economy, collections are generally better there. People are more likely to pay someone they know, and old-fashioned values, like meeting one's financial obligations, endure in the heartland. If savvy country docs work hard, do more procedures than their city counterparts, and stay out of the clutches of managed care, they can sometimes reap big financial rewards.

Some areas that are truly "frontier" may support only one or two generalists, who shoulder 24/7 responsibility for the community's medical needs. Bigger towns may provide a larger contingent of primary care doctors who share call. But the internist, general surgeon, obstetrician, or orthopedist may be all alone. And being all alone can take its toll.

Even so, professional isolation is less severe than it was when I started out as one of two doctors in a town of under 2,000. I was on call every other night and weekend, and the telephone was my sole connection to the outside world of medicine. I cultivated a group of distant consultants I could call at any time; they were a great source of information and support.

Now we have e-mail, teleradiology, and even interactive video consultation. Over the next decade or so, rural doctors can look forward to ever-increasing technological support as a bulwark against isolation. Still, the buck stops with the doctor on the front line—at a bare minimum, it stops for as long as it takes to stabilize and ship a gravely ill patient.

The day-to-day grind may take a bigger toll than the scary emergency. If I stopped by the market for a carton of milk on the way home from work, I could count on seeing somebody I knew, including a patient or two who had, at some time, bared soul and body to me. I'd have to stop and chat, even if all I wanted was to get home and take off my shoes. I'd invariably have to field questions about a child's cold, the results of a serum cholesterol check, or a bill from my office. When I wasn't on call, I could finally stop being a doctor only when I crossed the threshold of my house, sometimes too late to have dinner with my wife or tuck in my kids.

The upside: As an important person to the community, I've been able to have a real impact—on the financial health of the hospital, the injury rate at the canning factory, the local teen pregnancy rate. If we rural doctors wish to venture outside of medicine, a slot on the school board or a regular newspaper column is usually ours for the asking.

But a strong public persona may not leave much for your private self. It's hard to keep track of who you really are if you're always addressed as "Doc."

Even if you're universally beloved, it can do weird things to your head never to see yourself truly reflected in the eyes of those who surround you. Instead, you're the object of all the strong feelings about health, illness, and doctors that people project onto you. Local celebrity brings a small-town physician the same risks to self, marriage, and family that hitting the big time brings a Hollywood actor.

On the other hand, being so intimate with so many people is one of the gifts of rural practice. There is no replacing the insight I've been able to acquire by knowing the family history of a patient (if I didn't know it, my receptionist or nurse did) or the joy I've felt at a party where I'd delivered all the children present.

If you're contemplating life as a country doctor, consider this homemade list of traits. The more they apply to you, the better suited you are to rural practice:

• You—and your spouse—like the countryside and small-town life. This should be based on actual experience in rural living, not on reading or fantasy.

• You want to provide as wide a range of services as you can within your specialty.

• You favor high-touch over high-tech.

• You want to work hard.

• Making money is not your primary goal.

• You want to have an impact on your community and its health system.

• You're not afraid to make decisions on your own.

• You're good at getting support from colleagues who are far away.

• Being your friends' doctor doesn't make you too uncomfortable.

• You don't mind being in the public eye.

• If exotic food is important to you, someone in your household knows how to cook it.

The big step: Starting a small-town practice

By Gary Burchfield

A major late-winter blizzard hit Rawlins, WY, last April, forcing dozens of travelers off I-80 and into local motels. One young couple had just checked into their motel room when the wife, 30 weeks pregnant, went into labor.

Realizing he had no backup physician and only limited nursing support at the local hospital, family physician Wayne Couch II got his patient into an ambulance and, trailing it in his pickup truck, headed for the next available hospital, 100 miles away.

A few miles east of Rawlins, a semi-trailer carrying hazardous cargo jackknifed and shut down the highway. The ambulance driver turned around and headed back to Rawlins. Couch got the young mother to the local hospital and delivered her premature baby. Next morning, the weather cleared enough to fly mother and infant to Salt Lake City, where both were doing fine by that evening.

"Practicing medicine in a small town and rural area is a high-responsibility, high-work situation," says Couch. "Sometimes, it is extremely intense. But it also can be very rewarding. Your patients tend to be more friendly and more appreciative."

Couch had several offers when he finished his residency at the University of Wyoming in Casper. He even had a chance to return to his home state of Texas, where he'd gone to medical school.

Instead, the young physician opted to strike out on his own and start a solo practice. He picked a place many of his associates believed was too remote—a community of some 9,000 on the windswept plains between the Red Desert and the Snowy Range Mountains of southern Wyoming.

Memorial Hospital of Carbon County, a 35-bed hospital, was actively recruiting physicians to reopen the OB ward, which hadn't seen a delivery in seven years. None of Rawlins' physicians did OB; expectant mothers had to travel two or three hours to Casper or Laramie.

Couch had a special interest in obstetrics and had completed two special rotations at hospitals serving high-risk OB patients. One of them was an elective two-month stay at a hospital in Pakistan. There, he assisted with many high-risk pregnancies and performed about 100 C-sections.

Those experiences further increased his interest in OB care. So, when the hospital in Rawlins came calling, Couch listened. Working with the hospital administrator, he arranged to share office facilities with an orthopedist. He established his new practice, Rawlins Family Medical, in June 1997. Five months later, he set up a satellite prenatal clinic in another doctor's office in Saratoga, 40 miles away. He works closely with that doctor and spends one morning there every other week.

Besides the hospital, major employers in the Rawlins area include a state penitentiary, an oil refinery, and district offices of the US Forest Service. By the end of his first year, Couch was averaging almost 25 patients a day. He's had a steady increase in obstetrics cases, and the hospital OB ward is again busy. All told, there are some 15 other practitioners in Rawlins, but only Couch and one other new doctor are doing obstetrics.

"In an urban or suburban clinic," he says, "I might be discouraged from doing obstetrics. Here, I'm able to provide comprehensive OB services."

Couch's wife Jill, an occupational therapist, is currently busy full time raising their three young children. She's also working on a master's degree through Colorado State University and is president of Wyoming's occupational therapy association.

"We enjoy the Rocky Mountain outdoors," Couch says, "and spend what little free time is available elk hunting, fly fishing, back country skiing, hiking, and rafting. I am currently seeking a dynamic partner so we can have more time for these pursuits."

There's room for that dynamic partner in the 5,000-square-foot clinic Couch moved into last summer, a new log structure that fits perfectly with the landscape of this rugged country. The building, in fact, is designed for up to three additional physicians.

The biggest advantages of small-town practice, says Couch, are "independence, being your own boss, and having plenty of space to hunt and fish."

The author is a freelance writer based in Lincoln, NE.


Marc Ringel. Are you cut out to be a country doc?. Medical Economics 2001;1:35.

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