Some Student Perceptions of Rural Practice

If you're wondering how medical students in 2001 perceive rural practice, here are a few comments heard at a recent FMIG meeting at UW that featured a panel discussion talking about specialty choice -

One M-1 reported that a specialist told him that "all you do is wipe kids noses in a rural area"

You're not really doing real medicine in a rural area

You don't need a knowledgable physician in a rural area - they just transfer the patients to the city anyway

I might lose my aggressive, high tech edge if I moved to a rural area

I'm forwarding these comments so that we can be thinking about responses to these perceptions as we plan recruitment fairs and special events for students. What would you say to these students? If you email the group list with your thoughts, I can collect them for a report at our April 4 Statewide RTT meeting.

Carrol C

I have lots of ready answers to these questions based on my opinion. It would be quite helpful to have refernce DATA to back up our answers. I'll put my "answers" below in ALL CAPS. Can anyone lay hands on relavent data?

Louis Sanner, MD

Residency Director

Madison Family Practice Residency

608-263-1731

One M-1 reported that a specialist told him that "all you do is wipe kids noses in a rural area"

RIDICULOUS. RURAL PRACTICE IS INHERENTLY MORE FULL RANGE THAN URBAN/SUBURBAN PRACTICE BECAUSE THERE IS MUCH LESS TENDENCY FOR PATIENTS TO SELF-REFER TO SPECIALISTS (TOO FAR AWAY) OR GO TO URGENT CARE CENTERS (MOSTLY DON'T EXIST IN RURAL AREAS). MOST RURAL PATIENTS THINK ABOUT SEEING "THE DOCTOR" FOR WHATEVER PROBLEMS THEY HAVE - NOT A PARTICULAR KIND OF DOCTOR.

You're not really doing real medicine in a rural area

UNSURE WHAT IS MEANT BY "REAL" HERE. IF "REAL" MENAS CUTTING EDGE EVIDENCE BASED COGNITIVE PRACTICE THAN ACCESS TO INFORMATION IS JUST AS AVAILABLE IN RURAL AS URBAN AREAS THANKS TO THE INTERNET, ETC. IF REAL IS HIGH TECH PROCEDURES THEN RURAL FPS TEND TO DO MORE PROCEDURES THAN THEIR URBAN COLLEAGUES - THE QUALITY OF THEIR EQUIPMENT DEPENDS ON PRACTICE FINANCIAL VIABILITY WHICH COVERS THE SAME RANGE IN RURAL SETTINGS AS URBAN.

You don't need a knowledgable physician in a rural area - they just transfer the patients to the city anyway

YOU NEED TO BE AT LEAST AS KNOWLEDGABLE - PATIENTS DON'T WANT TO TRAVEL LONG DISTANCES OR BE AWAY FROM HOME AND COMMUNITY. I THINK ALL PHYSICIANS MUST BE "KNOWLEDGABLE" REGARDLESS OF SETTING. YOU CAN MAKE MISTAKES, NOT CONSIDER RELAVENT DIAGNOSES, ETC. JUST AS EASILY WHEN PRACTICING NEXT DOOR TO A TERTIARY CENTER AS WHEN PRACTICING IN REMOTE AREAS AND HAVE JUST AS BAD AN IMPACT ON YOUR PATIENT.

BECOMING LESS "AGGRESSIVE" OR EVEN LESS "HIGH TECH" IS PROBABLY A GOOD THING FOR MANY PHYSICIANS AND THEIR PATIENTS. WE NEED TO MAKE APPROPRIATE USE OF TECHNOLOGY AND NEW TREATMENTS AND REPLACE "AGGRESSIVE" WITH WORDS AND ATTITUDES LIKE "ATTENTIVE" AND "DEDICATED" AND MAYBE EVEN "WISE" AND "COMPASSIONATE".

I DON'T PERCEIVE RURAL PRACTICE AS CAUSING ANYONE TO LOSE THEIR EDGE - THE MOTIVATION CERTAINLY IS THERE FOR LIFELONG LEARNING. YOUR PATIENTS COUNT ON YOU. THEY ARE YOUR NEIGHBORS. THAT'S A VERY SUSTAINABLE MOTIVATION.

This really makes me livid. We will never dispell these myths by working

only with students interested in primary care and rural practice. In

additon, we need to educate all medical students so that when they are

eventually practicing in a different discipline and not in a rural

practice, they are knowledgeable and respectful of what primary care rural

physcians really do. And, more importanly, we need to start educating our

specialist, tertiary care center colleagues that they are dead wrong. How

about a grant that funds two weeks rotations of our academic specialist

colleagues to shadow and work with some of our finest rural colleagues?

This is probably the next best alternative to them experiencing first-hand

the work of a rural doctor, i.e personally developing a major,

life-threatening illness while traveling in a rural community and being at

the "mercy" of great rural physicians. There was an apocraphyl (sp?) story

at University of California, San Diego when I was there, that the dean

(name unmentioned) changed his phylosopy, language, and to some degree

program funding support when he experienced a major MI in a rural mountain

area and was coded, received thrombolytics, was stabilized and

air-transported to a tertiary care setting, all the while being attended to

by a family physician, aka "another LMD from the boonies." Undoubtedly a

life-changing experience but probably not a feasible plan on a large

organized scale!

Lee Vogel

I had applicants I interviewed this year in Baraboo who told me they were

told the same things at UW. They said internal medicine and surgery at UW

are the worst at family practice and rural doc bashing. I have been around

23 years practicing and teaching in southern wisconsin. I have seen this

attitude persist for all 23 years from University Hospital but never change.

Things have not changed with the referral process there either (personal

experience). The only way to change these myths is to let these limited care

subspecialists feel it through the pocketbook and/or feel repercussions for

their actions. The Dean of the Medical school and other leaders need to take

this stuff seriously. These comments should be investigated similar to a

sexual harrassment case. These allegations are untrue. They are usually

stated by people with NO rural or even private sector experience. People who

say these statements should be mandated to speak with the Dean or other

leaders about what they said. Federal grants and other funds should be cut

to medical schools who do not have certain numbers of graduating medical

students going into primary care.

Just to let people know, this week I had 2 people in with ruptured

diverticula requiring surgery and triple antibiotics, 2 eldery people in

with pneumonia, one in with urosepsis, took care of a pediatrician with

kidney stones, evaluated and sent someone to madison with a complete

placenta praevia who had bled (gave first dose of steroids here), ran a code

blue on someone who collapsed in the next hospital room, and saw patients in

the office all week. Tim Deering (3rd yr Baraboo family practice RTT

resident) helped with the hospital patient load, Stuart Hannah (1st yr

Baraboo resident)did the defibrillation on the successful code and Stuart

did a thoracentesis on another patient of mine. I don't think we have seen

one snotty nose to blot all week.

Learning Issues and Questions for Investigation

What type of access does the rural population have to specialty physicians (ie, cardiologists, urologists, neurologists, etc.)?
How many choices do rural residents have when choosing a primary care physician? In other words, what is the typical ratio between physicians and town/county population in rural Nebraska?
Is access to technology and newer equipment a problem in rural Nebraska?
Is it more difficult for clinics and hospitals in rural Nebraska to find competent medical staff-workers (i.e., nurses, clerical, technicians) than in Omaha or Lincoln?
Are rural residents more likely or less likely to have health insurance? What are the implications of this?
Do rural hospitals have more problems receiving funds and staying afloat than do urban hospitals?
Does rural Nebraska have more Medicaid and Medicare patients than does Omaha or Lincoln? What are the implications of this for a Medicaid patient in rural Nebraska? Are "critical access" hospitals (hospitals that are allowed to see more Medicaid patients than is normally allowed) ethical and fair?
Do doctors have enough time away from medicine to prevent burnout? Is over-working a problem with quality of care given to patients? Are there any solutions to the problem (i.e., locum tenens)?
Do rural patients wait longer before they come and see their doctor (i.e., the farmer who waits a month before he sees the doctor for his hernia), and if so, what implications does this have for the successful treatment of patients in a rural setting? (Modification: question was not addressed in the review)

Does the emergency room in a rural hospital go through different cycles of emergencies based on the time of the year (i.e., harvest season, flu season, planting season)? If so, how does this affect a rural patients’ access to quality emergent health care? (Modification: question was not addressed in the review)

Is confidentiality a big problem in a small town, where everyone wants to know everything about everybody (psychosocial problems for patients)?
Is there a large shortage of female physicians in rural Nebraska? If so, how does this affect a female’s (or male’s) choice for a physician?
Is physician privacy a problem in the rural setting, where they seem to be one of the leaders in town and are constantly being "observed"?
Do small towns have a greater number of "incompetent" primary care physicians and/or surgeons? (Modification: question was not addressed in the review)
What type of physician shortages are there in rural Nebraska?
What are some ways of improving the shortages? Are there programs out there that are helping recruit new physicians to the rural area?
How do most rural citizens feel about their hospital/clinic/economy in town? (Modification: question was added but not addressed in the review)

What affect has satellite clinics had on a rural residents access to health care?
What type of long-term care (i.e., nursing homes) and rehabilitation care (i.e., physical therapy, occupational therapy, etc.) is available in smaller towns? (Modification: question was not addressed in the review)

Is there a large non-English-speaking population in rural Nebraska? If so, how is the rural healthcare system dealing with the language barrier? How does it affect the healthcare of this population? (Modification: question was not addressed in the review)

Do the politics and rivalries of small town clinics and hospitals affect a person’s healthcare access?
Is transportation a big problem for people accessing health care in rural Nebraska (i.e., long distance to the clinic, lack of public transportation, etc.)?
What role does telemedicine and other technologies have in the present and future of rural health? (Modification: question was added and used in the review)

What is the incentive for a physician to choose rural practice? (Modification: question was added and used in the review)

How does the hospital influence the rural economy? (Modification: question was added and used in the review)