How Small Practices Are Surviving and Thriving, Part 2

Rural and small-town physicians serve a vital role in their communities, where approximately 20% of the US population live. However, only 11% of physicians practice in these regions, according to a report by the Health Policy Institute at Georgetown University, Washington, DC. 

Medscape discussed low reimbursements, difficulties recruiting talent, and limited access to resources in Part I of this series. But there are other compelling issues facing doctors who practice outside the sphere of a large hospital system. Here, three physicians in small towns around the country share more of their unique pain points. 

Organizations reported more physician vacancies and longer time to fill than ever before, particularly in rural areas. 

The pandemic only worsened this statistic, says Amber Hairford, MD, a family medicine physician who has practiced in King, North Carolina, for 9 years. 

“We’ve lost a lot of providers from our office in the last 3.5 years,” says Hairford. “We’re the cornerstone of health in this part of the state and cover three counties, but we still have our limitations since several doctors wanted to join practices in larger cities rather than keep working in a rural area.” 

While all of the doctors Medscape spoke with love their small communities and feel fulfilled providing care in a small practice, the issue of physician vacancies is just one of the challenges they face.

Burnout Can Be More Severe for Small-Town Docs 

While burnout has become a buzzword industry-wide, physicians working in small practices and rural areas risk the fallout from more extended hours, less time off, and a lack of doctors to share their workload in many places.

Exhaustion and grueling call schedules are just two factors leading to physician burnout when you run a rural or small-town practice, says Bradley Serwer, MD, an interventional cardiologist and chief medical officer at CardioSolution, which currently helps 39 rural hospitals in 21 states keep their cardiac units open by bringing in interventional cardiologists.  

“If you’re a solo practitioner in a small town, you’re handling call all of the time, and if you’re sharing a practice with one other physician, you’re dealing with call half of the time, and neither is sustainable,” he says. “This isn’t conducive to anyone’s lifestyle, and you won’t be able to maintain any kind of work-life balance.” 

Serwer credits CardioSolution’s 1 week on (24/7) and 1 week off schedule (during which time he’s entirely off work) for reducing burnout, despite the long hours he works during his “on” week. 

“If I work 90 hours in a week, and that’s not uncommon, I know I will have 7 days to recover,” says Serwer, who spends every other week at Wayne Memorial Hospital in Honesdale, Pennsylvania, population 4000. “We swap out on Mondays and that’s when my partner comes in. By doing this, we’ve kept rural units open and saved lives in the process.” 

For Robert Haas, MD, a family medicine physician in Olean, New York, who is also fellowship trained in maternal and newborn care/surgical obstetrics, the work hours are long since he has his own practice and also sees patients at a rural satellite clinic in this part of New York state, located 70 miles from Buffalo. 

“I’m on call 12 to 15 days out of the month,” says Haas, who has been practicing in Olean for 4 years and works at a federally qualified health center. “I’m doing rounds when my patients are in the hospital and I deliver my own patients, too, so that adds to the schedule. It’s certainly challenging at times.” 

Patients Shun Lengthy Travel for Care 

For small-town physicians, another big obstacle involves encouraging patients to travel long distances to get the care they need. 

“Our closest specialty care doctors are in Winston-Salem and some of our patients aren’t willing to make that 45-minute drive,” Hairford says. “That’s why we end up being part cardiologists, part dermatologists, and part sports medicine doctors.” 

So, while Hairford can do skin biopsies, if the biopsy comes back as melanoma or if a patient has a larger cyst, they must go to a dermatologist’s office. 

“The same goes for cardiology,” she says. “If a patient comes in with chest pain and their EKG is normal, that’s one thing. If they come in with chest pain and have an abnormal EKG and need a stress test or further workup, we’re not able to do that here — and we don’t have a cardiologist nearby.” 

Hairford says that one of the crucial things to keep in mind about rural family medicine is the need to “realize our limitations.” 

“We recognize what we can and cannot handle here, but we have to convince the patient of the same,” she says. “While we’re able to cover a lot, there comes a point where seeing a patient in our office isn’t in a patient’s best interest, and we have to get them to see a specialist.” 

Convincing patients to see specialists adds a challenging layer to patient care that doctors in larger cities usually don’t have to contend with. Specialists can be hours away from small towns, and patients, who don’t always understand the need to be referred, often prefer getting their care locally.

Retaining Talent Is Tough

While Medscape reported that it’s challenging to attract talent to practice medicine in particularly remote or rural locations in Part 1 of our series, it can be even more difficult to retain that talent and encourage doctors to build a life in small towns. 

“It’s difficult to uproot your life and family and move to these small communities on a gamble,” Serwer says. “People may be initially afraid their kids won’t get a good education or that there will be a lack of diversity and resources. That may be a challenge they face when they get to a rural town, and may make it a tough decision to stay and put roots down.” Small-town areas may also offer fewer opportunities for working spouses.

Since research shows that medical students who grew up in small towns are more likely to return to small communities to practice, many medical schools now try to identify those doctors early.

Efforts are underway to place more physicians in rural and underserved communities with programs such as Compadre (California Oregon Medical Partnership to Address Disparities in Rural Education and Health), an effort between Oregon Health & Science University, Portland, and University of California, Davis School of Medicine, Sacramento, to support medical students and link them to one of 31 residency programs in rural areas. Research shows that over half of all residents end up practicing medicine in the state they trained.

Serwer offers some tips if you’re a small-town doctor trying to retain physicians:

1. Recognize your doctors’ hard work. “There are a thousand ways to make physicians feel wanted,” he says. Show gratitude by routinely recognizing their hard work and inspiring them to keep it up. Once they know that they are valued members of the practice and the community, that’s harder to walk away from.

2. Get out into the community. “By doing outreach in the town, either via speaking to local groups or EMS workers, your presence becomes known — and it will help keep your colleagues feeling connected,” he says. When you show how much your practice cares about the community, they reward you. “Even when I’m shopping in the grocery store people come up to me all the time and tell me, ‘You saved my brother’s life. We’re so glad you’re here.’ That sense of reward is better than any financial incentive.” 

3. Make work schedules reasonable. “To the best of your ability, make sure your colleagues have a balanced work schedule,” says Serwer. “When I first got to this hospital there was only one interventional cardiologist, and he was on call 24/7. For him to take any time off was very difficult.” After a few short years, he resigned and joined a larger group practice elsewhere. When doctors don’t end up getting the work-life balance they need, they won’t be inclined to stick with their small-town practice.

Lambeth Hochwald is a New York City-based journalist who covers health, relationships, trends, and issues of importance to women. She’s also a longtime professor at NYU’s Arthur L. Carter Journalism Institute.

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