"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 relationships to strike a workable balance." Rosenblatt and Moscovice, 1982
I’ve always learned mostly by my own mistakes and those that I have observed in others. So let’s move the clock ahead to 1997 or 1998. You’ve graduated and started practice. Sooner or later you realize that you made some errors. For example, you didn’t pay much attention during practice management talks (when you didn’t have a clue as to what you would do or where you were going). After the shock subsides that your residency training wasn’t perfect, then the denial, then the anger, you begin to accept and wish to deal with the situation.
See Building a Practice See Retaining Rural Docs Community role for rural docs
Self Assessment of Community Recruitment Effort also a useful retention tool
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The Problem Has Arisen |
How to Prevent It |
For the Future… |
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You didn’t negotiate as well as you should have with the docs/community and want: more pay, fewer hours, more control over personnel, better call coverage, more retirement pay, etc. |
You should have learned more negotiation skills or paid someone to help in this area. Not all is lost, you are more valuable there than elsewhere, just make sure you convince them and don’t burn any bridges in the process. Take your spouse, lawyer, consultant, office manager, or other who is likely to be a better negotiator with you |
Understand your style of communication and your practice style The number one cause of ex-rural doctors is management failure, personal management or professional. Reaping the superior rewards takes a lot of personal work. |
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You realize that your colleagues are way behind in practice management and other issues and you feel very incompatible. One of your partners has basically been forced into doing more and more administrative work to manage the group and your group must either hire someone or cut the administrative physician’s hours. Someone is coming to your practice to talk about buying out the practice. Managed Medicaid and Medicare have come to town, 50% of your patients could be impacted, and your group hasn’t got a clue where to turn. |
Do a more complete job of assessing the practice. Encourage and perhaps demand expertise to be hired or bought in this area. |
Always get the advice you need to make important financial and career decisions. |
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Your style of practice is slow and more detailed, offering a lot of support to patients but not rich in terms of income potential and now you find yourself staying later to see more patients to keep up. Or your colleagues are slow and you make most of the billings |
Understand this up front and negotiate this. Top rural practices know that they need a variety of types of practitioners to keep good market share and share call and otherwise meet the needs of all of their patients. |
Adjust to different practice styles What kind of persons are you attracted to for bosses, colleagues, patients? Learn about the value of having a variety of types of physicians - amiables, drivers, etc. |
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You and your spouse just can’t seem to find some friends who share your strange unpredictable hours and interests. |
Keep looking in various civic or church groups or through practice contacts. Good friends are the heart of rural practice. |
Devote time to this area, especially in the early years of rural practice. |
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Your house is a nightmare to fix/pay for/etc. |
Rural home sales are far more volatile, especially for larger homes. |
Buy smaller early and move up later. Make more contacts that way also. Don't build a huge new home that will antagonize people. A fancy car is also a bad idea. Blend in. |
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Your spouse is feeling the pull of family and you would like to visit more but.... Your spouse is feeling that there is more to life than taking care of the family while you work |
Often a symptom of too much time in practice and not enough time or valuable time at home. |
Achieve a balance between practice, marriage, and relatives. |
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You volunteer a lot, soon you are overwhelmed and it is easier to leave that deal with all of the overload. You are so involved that you are just not very efficient. |
What are your personal goals, ethics, positions, relationships in community, spouse and family, practice, patients, health system/hospital Make adjustments, read "The Road Less Traveled by Scott Peck or similar books, remember that you came so that you could make a difference. |
See the long term need to say no, carefully consider commitments in view of overall goals for self and family. Assertiveness improvement, say later which is a form of no Take special training in leadership, personal management at Academy events, national meetings Network with others, trusted others, in person or email. |
As a new solo rural doc in 1983, the times were interesting. The government specifically targeted new young doctors for lower reimbursement. An effort that even the courts found illegal, in a few years with no return of losses.
The first major contact with the community involved the bank, one that would not give me a loan based on my conservative and realistic practice plan. This was a shock since I thought banks would generally be supportive. I engaged a CPA firm to help out. They altered my business plan. It was not a plan that fit me, but I could do it if needed and I did get the loan.
The local bank also wanted 14% interest for my house loan (bad time in history to need money).
At this point I began learning the history of an oil plus agriculture town where bankers had been burned by fly by night operators for years. Having the chair of the hospital board as president of the bank did not help. Found a reasonable loan in another town and missed out on a great lobby and tellers, probably a mistake, but just could not work with them.
The CPA also gave advice - do nothing but practice medicine for the first 2 years. I took a community college course in accounting and the first lesson: if you don't use the info, don't pay for it. I fired him and did my own on an Apple IIe. His advice was also not good for himself. He soon was bankrupt. Seems that others shared my opinion. His advice was also not good about getting involved in the community. Within 6 months I was on the board of the Chamber of Commerce, also became secretary of Kiwanis, and worked on a number of health and education projects in the town, including initiating health fairs. The Kiwanis award would come in useful later. A 20 year experienced rural family doc was not sure if I was “rural” enough. When he saw the award, he no longer had these concerns.
Had another run in with the President of the Bank, or at least his wife. Seems that I did not consult her in her role as dictator in charge of health care projects for the county. I certainly could have done better. My rural advisor in the town (key support for a city boy like me), the newspaper publisher, kept me in the loop and out of most of these mistakes.
Nowata Ok was the greatest 2 years and worst 2 years, all about the economy. My most fun month was my busiest month and my best billing month and not my best procedure month. Had the best L and D nurse ever in Nowata, only later did I realize how much one person could do for outcomes, including my own. Took my only front page newspaper picture also, one of my colleagues was crazy enough to take on twins. I hung around just in case. Got the picture and he and the twins on the front page.
No matter the outside situation, I had the greatest office nurse, crazy but devoted patients, and the time of my life. Learned first hand that the nurse or RN-FP model is the best kept secret in health care. Most fun group was the Ministerial Alliance. Least fun group, Hospital Board and Medical Staff – a tie. Best learner in town – Homer Flora, DO who could pick the brains of any visiting speaker and expand his clinical and procedural expertise to serve his patients better. Did anesthesia, one of the best I ever saw. The most efficient office and records also. One of the least recognized and least well liked and the most important economic contributor that the town ever had.
The lessons were a challenge. My staff did embezzle from me, a computer “expert” was an idiot. Lab equipment was often a mistake and the county dropped from 12000 to 10000 population in a few years due to oil and agriculture declines and a hostile corporate takeover (phillips petroleum, T Boone Pickens). I gave them one of the first assisted living blueprints in the nation in 1985 but failed to have one of them present the plan as their own, so it was never adopted.
Points
1. Enjoy the experience and the people, all of the people
2. Learn all that you can in this best of all worlds FP environment
3. Get involved in all areas, chances are you will find 1 or 2 life long friends, just as you have had in college, med school, and residency
4. Work with others in town. You are a leader, you have been selected to lead. It probably led you to choose FP. You may not have been trained to lead or manage, but you will, so do it well. What you and others do in town will impact the entire future of the town and the area. You may never have this kind of opportunity
I also have given a final bit of advice to those I have trained. If the people don't treat you or your family well, despite your honest and best efforts to relate to them, pick up your mailbox and find a town that deserves you, needs you, and will become your town and you will become their doctor. There is no better mutual relationship for any physician.