Ralph Riley, MD, Bought his practice in Saluda, South Carolina, after a 15-minute phone conversation and a handshake. “Nothing was ever signed; I bought the entire building and practice,” he says. While lawyers and practice management advisors would frown on such loose business practices, it fit Riley’s unique situation. He was coming home to his rural roots.
Riley was from Saluda, a town of about 3,000 people in central South Carolina. In the nearly 25 years since the handshake, Riley Family Practice Associates has grown with the addition of two full-time and two part-time nurse practitioners. A few years ago, he hired an additional physician. He knows that one of the challenges of rural practice is keeping the workload at a manageable level, but he wouldn’t trade it. “It was always my dream to go into family medicine and come back to Saluda,” Riley says.
In Houston, Missouri, Tricia Benoist, MD, is also living her dream. She works as a family practitioner with obstetrics for St. John’s Clinic and is on the staff at Texas County Memorial Hospital. Benoist has only been in Houston (population 1,995 according to 2004 census data) since September 2008, but word has already spread about the “only female who delivers babies” within a one-hour radius. Benoist has two young children and her parents live in St. Louis, which is about two and a half hours away. She could have stayed there to practice, but it’s not what she wanted, even from the time she entered medical school at Rosalind Franklin University of Medicine and Science in Chicago. “I always wanted to do the small town thing; that was always my dream,” she says.
Unfortunately, not every resident dreams of rural practice. According to the American Academy of Family Physicians (AAFP), 25 percent of the nation’s population resides in rural areas, but only about 10 percent of physicians practice there. The disparity is striking and can create a vicious circle of overworked physicians and an increasingly unhealthy patient base. Even defining what’s “rural” is difficult. The U.S. Census Bureau still uses a population definition of 2,500 or fewer people to define rural, but depending on the government agency or service measured, municipal boundaries or economic factors may be used. These varying definitions create an estimate of a rural population that ranges from 17 to 49 percent of Americans.
It’s no less complicated for health care. Medicare definitions may be used to designate a community hospital and rural health clinics. Medicare uses the medically underserved population formula for clinics and health professional shortage area designations, which include ratios of the number of physicians per 1,000 people in a given area. For the people who live in rural areas, however, rural is a feeling, a way of life.
Maybe that’s why Riley is more typical of the physician who chooses rural practice—he grew up in a rural area. Even so, there are transplanted physicians who choose topractice and live in rural areas and thrive there. Many people involved in rural health policy and physician recruitment, as well as the physicians, believe more medical students simply need exposure to rural medicine so they can make their own assessments instead of relying on hearsay and ever-growing myths about the practice. “We need to continue to emphasize training programs in rural areas,” says Tim Skinner, the executive director of the National Rural Recruitment and Retention Network (3RNet), based in LaCrosse, Wisconsin.
Martin Clements, MD, is an example of an urban transplant who chose rural practice after exposure to the small-town lifestyle. Clements, who now works as a family practitioner, who also does high-risk obstetrics for Lake Chelan Clinic in Chelan, Washington, grew up in Louisville, Kentucky, but went to a small college in one of Kentucky’s small towns—Danville. “It was a school of less than 1,000 students and a town of about 15,000. I started shadowing some of the family practice and internal medicine physicians doing hospital rounds and working in their clinics. That was just the kind of medicine I wanted to do,” he says.
The choices that Clements and Benoist made are more the exception than the rule. Aside from the issue of graduates not selecting rural care, many medical schools are not encouraging medical students to enter primary care fields. A study from the AAFP-affiliated Robert Graham Center, reported that less than one-fifth of medical students are interested in primary care as a specialty. “In medical school, too often students hear that the money’s not there for primary care, it’s too challenging, you have a tough call schedule, do extra work,” says Stacey Day, the director of recruitment for the South Carolina Office of Rural Health. “Medical schools want students to be successful; it’s not intentional, but they’re highlighting specialties,” she says.