The Next Step
Robert C. Bowman, M.D. rbowman@unmc.edu
9/11/02
Do you know enough about your planned practice to be able to anticipate the problems that you will have?
Theory is that if you know more about yourself, the practice, the people, the town, then you will be able to choose better. If you have already chosen, then you can adapt more quickly when you know more. Recruitment and orientation are big investments, estimates range from $150,000 to $250,000 to recruit and orient a primary care physician.
Medical training can retard your personal development and abilities in these areas. Medical education tends to be passive, sequential, set in place. Practice is real life with variations. By personality Amiables, tend to not probe for information, lack of work experience
Carl Hammerschlag, M.D., was asked by a Navaho patient if he could dance. Carl shuffled his feet a bit self consciously and the patient said, Thats good. Realizing that there was some purpose to the request. Carl asked him if he would dance also. The patient adjusted his oxygen cannula and stood up on the bed and danced vigorously. Carl paused for a moment, then asked, Can you teach me to dance like that. The Navaho, a healer by profession as well, noted, I can teach you my steps, but you must hear your own music.
What are some of the areas that you have discovered to be difficulties for you (Personality issues, assertiveness regarding personal needs, easily taken advantage of, personal skills such as delegation, negotiation, learning to say no. Passive aggressiveness, resentment)?
Research on Search Process of Residents Basic problem solving in practice. Consider up to 5 diagnoses, question and test to rule out the least likely. Works good if the right one is in the top 5. In selecting a residency or a practice, where there is so much more to know and it is so much out of the normal scope of experience, it is not uncommon to miss with the top 5. The best thing to do is to reset and add to the 5 selections, but current activities such as learning or family interfere.
Techniques, adding to your ability to choose
1. Comparison
2. Checklist
3. Spouse likely a bit different personality, often good with details or assertiveness.
4. Faculty or friend more info, background, history of town or practice or main players
Free consultations
Adapting to a Practice Balance between Physician, Personal, Practice, Community
The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship. For the rural community the trauma is almost as great: it is easier in most instances to be perennially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again. Bruce and Norton, Improving Rural Health
Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationship to strike a workable balance. Rosenblatt and Moscovice, 1982
Adapting is a part of all primary care practices. Retention and Effectiveness =
support + experience + preparation
Stress workload, uncertainty, relationships
Two Way street Communities do not have the luxury of remaining ignorant about the intricacies of medical practice. Unless they understand the tribulations and rewards of country practice, they will be unable to attract and retain people with the spectrum of skills that rural areas require. Rosenblatt and Moscovice 1982 Rural Health Care. John Wiley and Sons, New York, 1982 Are your future colleagues, those in your practice, and those in the community willing to support you?
For further assistance
Establishing Yourself in a Rural Community table with various scenarios, anticipate problems. Recommendations for amiables.
Resources at UNMC for those looking for a practice or needed information about the site that they have chosen
Responsive Practices - more control, more fun!
Using Your Residency - info for residents on how to use resident training more effectively
Searching for a Rural Practice - research about the search process
Self Assessment of Community Recruitment Effort - if you are choosing a community, you better know how well they will do to recruit someone to join you later when you need help.
Ultimate Recruitment Experience
RECRUITING NEW RURAL PRACTITIONERS
A Family Doctor Affair - by Rowley
By the numbers - rural doctors are of great value
Building a Rural Practice - Article in JRH - cooperative vs competition
In What Types of Communities Do Rural Women Physicians Practice
Summaries of Practice Changes and the Potential Impact on the State of Nebraska
Current Concerns of Rural Physicians
Physicians that stay in rural communities
Complaining Physicians - Student Questions
Complaining Physicians - Primary Care Only?
Questions By Students and Other Info about Programs
Rural and Procedural Electives
Fam Med Res Prog and Grad of RFP
Dealing with Change in Nebraska
IMPLEMENTING A COMMUNITY BASED APPROACH
Checklist for Recruitment prepared for rural communities, but turn the tables and see how well they do in recruiting you. Eventually you will need to recruit someone to join you and better know up front.
Retain Rural Doctors various pages on aspects of retention
Building a Practice article by Bowman published in Journal of Rural Health based on interviews of 10 long term rural physicians in Nebraska.
