The changing country doctor

Small-town physicians now have big-town worries, but they wouldn't trade places for anything.

By Dorothy L. Pennachio
Senior Editor

There are more deer than people in Forest Hill, WV, and FP James Blume is the only physician in town. But his patient base numbers more than 7,000 because folks come to him from all over. At 46, he's the youngest ever to be named "Country Doctor of the Year," an award given him last year by Staff Care, a Texas-based locum tenens firm.

The stereotype of the rural doctor, the Norman Rockwell image, is elderly, kindly, and self-sacrificing, but without a clue when it comes to high-tech diagnostic or therapeutic procedures, not to mention the Internet.

"That doctor is long gone," says Blume. "But those guys were good. Without benefit of high-tech testing, they relied on a physical diagnosis and knew how to communicate effectively with their patients."

Board certified in family practice, Blume does just about everything his patients need—including making house calls, when there's time. "The only problem is, I have no one to share call," he says.

How does rural practice differ from urban practice?

"What's different is the scope," says Howard K. Rabinowitz, professor of family medicine at Jefferson Medical College in Philadelphia. "Many rural docs have to do OB, and they have to care for farm injuries."

They also build a different relationship with their patients, Rabinowitz adds. "They know a lot about them because they live in the same community and typically take care of multiple generations. They're also familiar with their patients' environment—their job situations, the schools, and so on."

"The irony is, we may not be as good as the old guys," says Thane Turner, who practices in Lock Haven, PA, population 9,000. His patients include newborns and 85-year-olds, and he provides comprehensive care ranging from suturing and casting to delivering babies and treating the flu.

"Some of my patients are on my case about not doing house calls. But with the shortage of doctors here, there's no way I could devote the time."

They have to be tech-savvy, too

Today's rural physicians have to worry about technology that their predecessors never even dreamed of. Among other things, they have to make sure they have access to high-tech services like CT and MRI.

"The old, low-tech country doctor has faded into the sunset," says Pat Harr, past president of the AAFP. Harr himself practices in Maryville, MO, population 10,600, and his office houses an MRI and a well-equipped lab. But for vascular surgery and most cardiology services, Harr refers out to hospitals in Kansas City or Omaha.

"Knowing when to refer and having good relationships with specialists are essential to rural practice," says Thane Turner. He adds that he's blessed to have Geisinger Medical Center just an hour away in Danville, PA. His ability to continue delivering babies is dependent upon relationships like the one he has with the medical center. "If I deliver a baby that needs to be in the Geisinger NICU, I can have the helicopter here in 12 minutes," he says.

Rup Nagala is another rural physician whose life sounds anything but simple. Nagala lives and practices in Oakes, ND, where he founded Southeast Medical Center 25 years ago. The three-physician, six-PA group practice is far from the stereotypical rural practice. "We offer X-ray, stress tests, pulmonary function tests, colonoscopies, CTs, MRIs, and ultrasounds," he says. The practice does OB, including C-sections, and other surgeries. For care they can't provide, such as cardiac procedures, joint replacements, complicated bowel resections, or thoracic and vascular surgery, they refer to physicians in Fargo, 120 miles away. Southeast Medical Center has six satellite clinics, and Nagala owns a nursing home and an assisted living complex in Oakes.

He says the clinic occasionally uses telemedicine, especially for burn patients. "The nearest burn unit is in Minneapolis, five hours away, so we'll send patients there. Once they're back, though, we communicate with specialists by telemedicine so that patients don't have to travel."

Liability? Rural docs are just as accountable

"Rural FPs do surgical procedures because there's no one else to do them," the AAFP's Pat Harr says. Rural FPs also deliver babies—some do 30 to 40 deliveries a year—because OBs are rare in smaller rural areas. "Yes, these doctors expose themselves to malpractice suits, but they have no choice," he says. Harr's liability premium went up 300 percent this year to $54,000. "More than what I made in my first 10 years in practice."

"In recent years, it appears that rural physicians are increasingly held to the same standard of practice as their urban counterparts," says Paul Hattis, an attorney, physician, and assistant professor in the department of family medicine and community health at Tufts University School of Medicine. "Rural doctors continue to be sued."

The malpractice climate in West Virginia has gotten plenty of publicity. But, while many doctors are fleeing the state, James Blume says he has no intention of leaving. "I've gone through three malpractice insurance carriers in three years because they're leaving in droves," says Blume. He's been sued three times during his career, each time by uninsured patients.

"I didn't charge them for their care, and they sued me anyway," says Blume. "It's heartbreaking." One plaintiff told Blume she didn't want to sue him. She'd said to her lawyer, "Dr. Blume did everything he could for me." Her attorney reportedly said, "No, we have to name everyone. That way we get more money." Blume was dismissed eventually. But during one of those legal battles he developed colon cancer, and he's sure the stress of the ordeal didn't help the condition.

"If a patient dies in a rural hospital, people say we killed him. If we transfer him, and he dies there, people say 'They did everything they could,' " he says.

There aren't enough to go around

One American in five lives in the country, but only 1 doctor in 10 practices there. About 460 rural hospitals have shut their doors since 1980.

"During the '90s we saw an increase in numbers of FPs and therefore rural physicians, since FPs are more likely to serve rural communities," says Jack M. Colwill, former chair of the department of family and community medicine at the University of Missouri, Columbia, School of Medicine. "But there are shortages today."

Jefferson Medical College in Philadelphia is doing something about that with its Physician Shortage Area Program. Howard Rabinowitz, PSAP director since 1976, says the program admits roughly 15 students a year who typically have grown up in rural areas and are committed to practicing family medicine there.

Students follow a basic curriculum, but take some courses that focus on rural issues. Then they receive training in rural areas under preceptors. "Unlike the Northern Exposure [TV show] scenario where a physician is placed in a rural area in exchange for paying for his education, the PSAP identifies people who choose rural practice," says Rabinowitz.

"Jefferson's program is good, but it's one of a kind," says Roger Rosenblatt at the Rural Health Research Center at the University of Washington School of Medicine in Seattle. Rosenblatt says that if more medical schools had interested students do their postgraduate work in rural areas, the pool of rural physicians would be vastly increased. In the absence of more such programs, he expects the shortage of rural physicians to worsen over the next few years.

Programs like PSAP also serve to prepare those students who do choose rural areas, says Rosenblatt. "They get to recognize diagnoses common in rural areas and become aware of cultural, social, and economic issues that confront their patients," he says. "And they learn how to manage without high-tech resources, and be confident of their abilities. If a doctor's trained in an urban center, it's scary to be practicing in the country."

It's also less remunerative. Country doctors work longer hours yet earn less money than their urban counterparts. Reimbursement issues have been especially troublesome for rural FPs.

"I'll probably make $10,000 less next year," says Thane Turner, a 1993 graduate of the PSAP program. "Major health insurance companies just announced 5 to 10 percent cuts, my malpractice insurance went up by more than 50 percent, my staff got a cost-of-living increase of 3 percent, and my rent just went up," he says.

Turner says one of the biggest money drains is doing OB. He does about 40 deliveries a year, but to pay the malpractice premium in Pennsylvania, a doctor has to do 50 or 60. He continues delivering babies, though, because "in this community, it's the right thing to do. We have to care for the whole family."

Money, of course, isn't what motivates rural doctors. North Dakota FP Rup Nagala tells of a 47-year-old patient who came to his clinic in the middle of the night. "He was almost dead—BP so low we couldn't find a vein for an IV," he says. Nagala's team worked on him for six hours, and was able to bring him back, at which point they evacuated him to a hospital in Fargo.

"His family—good people—just called to thank me," says Nagala. "It makes you feel good. Things like that keep me going here."

 

Dorothy Pennachio. The changing country doctor. Medical Economics Aug. 8, 2003;80:61.