By Theresa Chan

This is the first part of a series that first appeared on the blog Rural Doctoring, where Theresa Chan writes about her experience working as a family physician and hospitalist in a rural Northern California community.

I’ve been reading the blogs of medical students and residents with some interest lately. Their stories about the trials and tribulations of learning to stay awake night and day and how to deal with cranky attendings and even crankier patients take me back to the bad old days of my own residency.

I’ve also had a few glimpses of the osteopathic medical students (OMS) who are rotating in rural California as they assume their new roles as clinical learners. Hearing about and witnessing these experiences makes me reflect on my own training and the steps I took to become a doctor in a rural community. This post series will examine these steps in more detail, and I hope it will be helpful to trainees who are considering a career in rural health care.

This is going to seem obvious but it bears repeating: Rural communities
are different than metropolitan or suburban communities. Any survey of
economic or political demographics of the United States will highlight
various aspects of the distinction, but  the differences that I
encounter most frequently in health care are these:

Poverty. Every corner of the world feels the impact of poverty. I do not mean to minimize the magnitude of the problem in urban or global communities, but I am particularly concerned with the problem of poverty in the rural U.S. There are various definitions of poverty, but the face of the poor looks different in the country than it does in the city. For example, the rural poor are a bit more likely to live in a broken-down fifth-wheel trailer than a building project, and that fifth-wheel is often parked off a country road and has no telephone or electricity attached to it. Pay-as-you-go cell phones, which have provided a lot of low-income adults with reliable communication, are not a solution for the remote rural poor who live beyond cell tower range.

Distance. Policymakers often refer to distance as a barrier to accessing health care. The distances rural citizens must travel to obtain basic care in our community range from 5 to 60 miles. Some of the roads leading into town are treacherous in winter — windy, covered with black ice, often closed down due to mudslides or like this summer due to wildfires. It is important to remember that distance comprises more than mere miles or kilometers. And, in this era of high fuel costs, even 10 miles may be too far for a cash-strapped patient to travel for care. Unlike urban communities, public transportation is spotty and infrequent. People must often hitch-hike just to get to a bus depot in some communities in.

Industry-specific impact. Not all rural economies are alike. In my community, the major industries are construction, lumber, hospitality, commercial agriculture, and fisheries. In the past 10 to 20 years, lumber and fisheries have dwindled and haven’t been replaced by any new industries, so unemployment is a persistent problem. Young people usually leave the area when looking for work, which creates a demographic shift common to many rural communities. Furthermore, some of the more dangerous occupations — construction, lumber mills, and industrial fishing — means that a certain significant percentage of mid-life adults are living with sequelae from industrial injuries. My impression of the local 40 to 50 male population is that at least 20% of them are missing fingers from these types of accidents, and that’s only considering one limb. A related problem, the impact of which we haven’t fully grasped, is the disproportionate military recruitment from rural communities. As young people return from Iraq with injuries and stress-related illnesses, these will inevitably change the face of rural health care.

Few doctors means breadth of practice. Because doctors are few and far between in rural communities, the breadth of practice is greater for doctors, especially among primary care specialties. For example, a beloved local pediatrician regularly assists surgeries; family physicians and their midwife colleagues provide most of the maternity care; and primary care internists perform colonoscopies. Many of these services would be provided by specialists and subspecialists in metropolitan areas.

Few specialists means even more breadth of practice. Not to sound redundant, but when there are fewer specialists and fewer doctors in general, there is more need for existing community doctors to shoulder a greater range of medical care. Rural California does not have a perinatologist so the family doctors manage gestational diabetes, autoimmune illnesses, and multiple gestations in their practice (the latter get referred to obstetricians in the 3rd trimester). There are only two critical care doctors in the area, and they cover both hospitals, so both primary care internists and family doctors assume critical care responsibilities in the hospitals.

Magnification of local politics. Politicking is not unique to rural communities — I used to live in the big city, I know — but in a small community, the disagreements tend to color every interaction with hospital administrators and medical staff who straddle the divide.

Obviously, the commonalities between urban and non-urban medicine outweigh the differences, but I would argue it takes a certain kind of doctor to thrive in a practice environment such as the one I’ve described above. In subsequent posts in this series, I will discuss a number of elements in such a doctor’s training, including:

* Specializing for rural practice    * Evaluating medical schools    * Approach to medical school curricula    * Personal attributes of a rural doctor    * Useful procedures    * Residency training    * Job-seeking    * Joining a rural community    * Online resources for physicians in remote locations

Ultimately I hope this series will be helpful to students and residents who are considering work in a rural community. Your input about other topics not listed above is valuable. Please don’t hesitate to comment.