The pros and cons of practicing medicine in a rural setting

This article is sponsored by Careers by KevinMD.com.

Wide open spaces. Fresh, clean air. No people for miles around.

The advantages of rural living are plentiful, but there are disadvantages, too, especially when it comes to health care; being way out in the country likely means the choices for doctors, clinics and hospitals are severely limited.

According to the National Rural Health Association (NRHA), more than 25 percent of the U.S. population lives in rural areas, yet less than 10 percent of the country’s doctors practice there. This could be because of the many obstacles that doctors in a rural setting face, including a lack of access to resources and medical technology, the absence of a defined work schedule and possibly a lower salary than their urban counterparts.

But the same factors that draw residents to a rural area (and keep them there) are the same ones that might entice a doctor to practice there — like the slower pace, feeling of safety, lack of traffic and pollution, short (or no) commute and lower cost of living.

The challenges are many, but so are the rewards, says Stephen Kliewer, M.S., MDiv, DMin, a rural mental health therapist who practices at Winding Waters Clinic in Enterprise, Oregon, a tiny town of fewer than 2,000 people in a county of fewer than 7,200. Kliewer and other doctors from Winding Waters Clinic were featured in the not-for-profit 2018 documentary The New Country Doctor: Living and Practicing in Rural America, produced and directed by Carl Davis.

“Being in rural medicine takes the best of the best,” Kliewer says in the film. “The scope of what you’re being asked to do is wider, and the depth of knowledge you need to have is deeper.”

We recently chatted with Kliewer and asked him to tell us more about the pros and cons of practicing medicine in a rural setting. He’s the son of a rural doctor, several of his other relatives are rural doctors, and he conducted extensive research into the dynamics of rural medicine during his more than ten years teaching in the Department of Family Medicine at Oregon Health Sciences University. If you’re thinking of accepting any health care position in an isolated area — or if you’ve already said “yes” and are preparing to relocate — read on for Kliewer’s tips for happiness and success. Although these tips are directed at doctors, they apply to all health care professionals working in a rural area, including PAs, nurses, therapists, and dentists.

1. Be willing to go out on a limb. When you’re the only doctor for miles, you have to be ready to address the full spectrum of medicine — from pediatrics and obstetrics to cardiology, oncology, and triage. “You’ll be expected to know a fairly good amount about almost every aspect of medicine,” Kliewer says. You’re also likely to see injuries in the country that you’d rarely see in the city, like those caused by farming equipment or encounters with wildlife.

2. Adopt a new set of professional rules. Country life is quite different than city life, Kliewer cautions. “You will be friends with your patients. You will run into them in the grocery store, at social events, on the street, at church.” The key, he says, is to learn to be comfortable seeing your patients in those settings, and be ready to have people casually mention an issue they are having. “You have to respond, but you can’t over-respond,” he says. Try dealing with the comments gently, like, “That sounds like something we should look into. Let’s get you on my schedule.”

3. Draw personal boundaries — and stick to them whenever possible. Unlike with a medical practice in the city, it won’t always be possible to make a “clean break” from your designated work hours, but Kliewer advises rural doctors to at least try. “If you have a good backup in place, and you go hiking, don’t answer your phone.” There may be exceptions, though, when you really want to stay in the loop.

4. Be flexible. Rural patients — with fewer health care options, little or no insurance and sunup-to-sundown farm chores — might not always obey doctor’s orders regarding follow-up appointments, medications, post-op instructions, and home care. Be innovative in finding alternative ways to treat certain patients, like offering evening or weekend appointments or making an occasional house call.

5. Preach preventive care. See above. During an illness or after an injury, rural patients might wait longer to seek medical attention. When you do get them into the office, gently remind them about preventive measures they can take to help avoid illnesses.

6. Advocate for technology. Funds may be tight at a rural practice, but be ready to insist on at least the basics, like the ability to teleconference with specialists when you need advice or testing equipment that will help patients avoid hours-long drives to far-flung facilities.

7. Connect with community resources. “In our county, a primary care physician needs to be close with mental health resources, the domestic violence program, community connections for housing, transportation, and food, the VA program, and local veterans’ programs,” Kliewer says. Be ready to assist vulnerable patients who may need help getting a ride to an appointment or who may have significant housing or family issues.

8. Connect with medical resources, too. Establish a network of medical professionals you can call on when you need advice. Rely on medical-school friends and mentors, and physicians at the nearest hospital or clinic, and don’t be afraid to ask for help when you need it.

9. Keep studying and learning. “Getting out of the area, going to where you connect, discuss and vent with other doctors, is gold,” says Kliewer. “You’ll gain important encouragement and perspective.” Travel to conferences and workshops whenever possible to improve your skill set and keep up on the newest information and technology. Online education is good, too, he adds.

10. Support your spouse/partner. In a recent study on rural retention conducted by the Robert Wood Johnson Foundation and the Harvard School of Public Health, it was reported that one of the most important factors for a physician who wants to succeed in a rural setting is to pay attention to establishing a new work and social life for your spouse or partner. “Help them find meaningful work, either volunteer or paid,” Kliewer advises.

11. Don’t neglect your own social network. “Find friends who do things that you like to do,” says Kliewer. “Look in a church community, a music community, wherever. It doesn’t matter where.”

Lisa Truesdale is a writer, Careers by KevinMD.com.

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