The pitfalls and opportunities of rural health care

My medical school is located in Harrogate, Tennessee, a town of 4,000. That’s considered rural. My residency is located in Casper, Wyoming, a city of 60,000. There were some community attendings there that considered that rural. I live and practice in a town of 200. The closest hospitals to me are 40 minutes to one hour away. The roads are dangerous and frequently close in the winter, and winter lasts for nine months. This is rural. Some have even called this “frontier.”

The short answer to why I am practicing where I am and why I chose to go to medical school and residency where I did is that I grew up in the suburbs and hated them. I always preferred to be where the big open spaces were. But beyond that, it’s always intrigued me how much rural areas get forgotten about in medicine. Our health care system is based around the hospitals and all the other marvels of modern medicine. As technology advanced, as the population of the United States and the world became increasingly urbanized, medicine became increasingly complex. The number of specialties ballooned, and many of them center around a particular marvel or other. Cardiologists have their cath labs. Nephrologists have their dialysis. Surgeons of all kinds have their surgical suites. Two-hundred years ago, there were any number of congenital and genetic disorders considered debilitating or fatal that are quite manageable today. With our modern medical marvels, we can help people with these disorders lead full healthy lives. This is an extraordinary thing. The only problem is that those modern medical marvels require a certain critical mass — of population and of resources — to justify their existence.

So what would happen if that critical mass didn’t exist? How would medicine be practiced if we didn’t have all these marvels so easily accessible? How would we practice medicine, how would we help our patients achieve optimum health if we only had our head, our hands and a few durable tools (i.e., stethoscope, otoscope) at our disposal? During training, I asked myself these questions often but never got a satisfying answer. On the whole, training largely consisted of learning what tests to order, what medications to prescribe and how to do procedures. Quite limiting, actually. To their credit, my medical school and residency both tried to instill a broader perspective by requiring at least one rural medicine rotation. I don’t know how universal that is. These rotations did a lot to teach me to consider the value of this or that intervention carefully. Does a patient really need to drive two, four hours for a specialist, test or procedure? Sometimes they do. The extra time, energy, and expense are actually worth it. Sometimes not. Either way, this is a very helpful exercise, even in preparation for practice in a more populated area.

What this training didn’t do was teach how to practice medicine and thrive as a doctor in a rural area. This is evidenced by the rapid turnover in rural areas and by the number of physicians who commute from the cities to practice in rural clinics. Amongst my colleagues, as well as my professors, preceptors, and attendings during training, I sense a fear of existing outside the hospital-centric paradigm. I sense that most doctors feel their identity is dependent on this paradigm. In fact, I’ve been told more than once that my plan to practice rural medicine was “brave.” I’ve also been told that sustainable rural medicine can’t be done. It’s a good thing I’m stubborn. Medicine is context-dependent, and as long as our mentality continues to be wholly hospital dependent, rural communities will continue to suffer, health-wise.

What I’ve discovered after a year in my current practice is that the dysfunction of the health care system is more honest in rural areas. The medical histories I hear from my patients and neighbors are both shocking and sad. There are intense feelings of abandonment as a result of the absence of providers and rapid provider turnover. Many times, accessing secondary and tertiary care is prohibitively expensive or time-consuming; expectations of what modern health care can do, which we are responsible for promoting, sometimes conflict with reality. Disruption of care, i.e., being lost to follow up, often results in a worsening of health when a plan of care is abandoned. And yes, the opioid crisis definitely exists here, too. As a result of these abuses, distrust of doctors and the health care system runs deep, even as our prestige is honored and admired. In a rural area such as this, it’s not possible to sugarcoat these harsh realities. It’s just not possible here to pretend all the problems in the health care system can be solved with the right EMR, wellness program or building renovation. While all this may painful to witness, it’s better than ignoring it — or worse, not realizing that it exists at all.

Rural medicine presents both a challenge and an opportunity. The challenge, as I see it, is to create a standard of care that takes advantage of all these modern marvels of medicine without creating a dependency on them. Concurrent challenges are to create a lifestyle that is both appealing and satisfying and to repair the reputation of the health care system amongst rural dwellers. Through addressing these challenges, I hope that what other rural doctors and I discover can be applied to the health care system as a whole. For we are only strongest as the weakest link. And if there’s one thing we know, it’s that the future is uncertain. In rural areas such as these, the pace of life is slower. There is space and time here to innovate, study, research and experiment with ways to practice medicine and deliver care. All that’s needed, I guess, is a dose of healthy dose of bravery and stubbornness.

Liz Hills is a family physician who blogs at Heal Thyself.

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