The saying goes: “Home is where the heart is.” And for many physicians, this holds true when it comes to deciding where to practice. That was certainly the case for Amanda Mooneyham, M.D., MPH. No matter where school or work took her, she always planned to return to the Northern California town of Redding, where she grew up, to serve the medically underserved in her community.
“When I started medical school, a community health needs assessment showed that Shasta County, California, needed an additional 17 primary care physicians just to meet the existing needs of the community—and [that] didn’t account for those leaving the workforce through migration or retirement,” says Mooneyham.
This was in 2009, and Mooneyham says the needs of her community have not improved since—even though many more people in the area have been able to access care through the Affordable Care Act. In fact, this is the pattern nationwide. As residencies and high-paying specialties lure physicians to big cities, rural areas like Shasta County, which encompasses the city of Redding, are experiencing a shortage of health care providers.
Many states are trying to attract doctors to rural areas with financial incentives, such as federal- or state-funded student loan reimbursement or repayment programs. But among physicians who grew up in these areas, many need no convincing. Plenty of doctors return to their hometowns to join family practices, rural practices or the practices where they did their residencies.
Returning to your residency
After graduating from UC Davis Medical School in 2014, Mooneyham returned to Redding with her husband, a civil engineer. She had done her residency in Redding and ended up taking a job there as a teaching faculty member at Shasta Community Health Center Family Medicine Program. She’s also one of four core providers in their Medically Assisted Therapy clinic. There, she practices full-spectrum family medicine, including obstetrics and addiction medicine.
Mooneyham enjoys filling the need for providers in a rural area, and she also enjoys the rural pace of life. “My commute to work is all of seven to eight minutes each way,” she says. “The hospital is less than 10 minutes from the clinic. Most of the providers at our FQHC work four days per week, which helps me maintain a healthy work/life balance.”
Brandon Allen, M.D., also chose to stick to his roots. Born in Fort Lauderdale, he attended medical school at Florida State University College of Medicine and residency at the University of Florida. He completed his residency and final year as chief resident in 2013 and joined the University of Florida as an assistant professor in the department of emergency medicine and the assistant medical director of the adult emergency department.
Allen says his transition from chief resident to assistant professor was mostly seamless because he was already familiar with the university. “I knew the environment, and I wouldn’t be starting over in a new place,” he says. “I had created strong relationships with nurses, staff and providers outside of the ED over my residency that would be hard to replace or recreate.”
However, he says he did face an initial challenge in figuring out new working relationships with residents who had previously been his peers. “One day I was a resident, and the next I was an attending physician and faculty member,” Allen says. “How would I be perceived by residents who I had shared a seat with in conference or the same shift schedule? Would they listen to me as an attending? Could I be effective?”
He also had to figure out new relationships with his staff, since he became an assistant medical director following his last day of residency.
Allen says he worked through these challenges by modeling the traits of an attending faculty member whom he had always appreciated and respected. He always tried to be the first to see patients, so he could take advantage of teachable moments. He also took the time to review charts and send regular feedback emails on performance.
“I made a conscious decision to be effective over being popular,” explains Allen. He adds that transitioning to his new role as medical director has taken time. Some faculty members embraced him with open arms while others waited for him to prove himself.
“One of the ways I did that was to focus on standardization of practice with evidence-based protocols and pathways,” says Allen. By working to improve provider satisfaction and patient care, he earned other faculty members’ respect.
Joining a family practice
The opportunity to join a family practice is what attracted Drew Schmucker, M.D., back to his hometown of Olney, Illinois. “I was attracted to the idea of practicing in a small town so that I could have the scope of practice I wanted,” says Schmucker. “I do both inpatient and outpatient medicine as well as OB.”
Schmucker graduated from Southern Illinois University School of Medicine and completed his residency at Memorial Hospital of South Bend in Indiana before joining Carle Richland Memorial Hospital in Olney as a family practitioner. Carle Richland is a not-for-profit facility, part of the Carle Health System, which serves eight southeastern Illinois counties with a population of over 109,000 individuals.
Schmucker says there were quite a few advantages to heading home. Being close to family and friends was a big one. “I spent a lot of time away from home, family and friends because of school and residency,” he recalls. “I missed some birthdays, weddings, family get-togethers, etc.” Now that he’s closer, he says it’s been great to be present at these special events. And it’s nice to have family around since he and his wife now have a 10-month-old.
As a family practitioner, Schmucker has patients ranging from newborns to adults, and he offers obstetrics services to expecting patients. Practicing medicine in a town as small as Olney has given him the chance to diversify his skills and connect with his patients. When he started his career there, one of his biggest concerns was getting too busy, since there was such a great need for primary care in the area. He says he was afraid of getting overrun with too many patients and too much call, especially because he wanted to have a broad scope of practice.
But those fears have been put to rest. “I’ve been really fortunate to have a great first year of practice so far,” Schmucker says. “The hospital system I work for keeps my office running smoothly, and there is a great group of doctors here to share call with.”
He says it helped that he knew some of his office staff before he began working with them. They have developed close-knit relationships and have a lot of fun while seeing patients. Schmucker has also noticed he has a lot of flexibility working for a small hospital in a small town. If there are ever any problems with workflow or patient care, he says it’s easy to find the right person to talk to and get the issue resolved.
“I love taking care of patients here,” he raves. “Oftentimes, people have been waiting to get in for appointments or driving out of town. It’s so rewarding to deliver good care in a place where it is really needed.”
Patients are very appreciative of his work, and Schmucker says in some cases, these patients are people he has known for years. He even went to school with some of them. Knowing a bit about patients before they visit helps him provide better care. “It also keeps me grounded as I practice,” he adds. “Patients aren’t just cases of pneumonia or diabetes here. They may be old classmates, family members of old classmates, former teachers, coaches, family friends, etc.”
Practicing solo rural medicine
While moving to a small rural town may not be a top choice for many physicians, others wouldn’t have it any other way. One month after finishing his residency, J. Scott Litton, Jr., M.D., returned to his hometown of Pennington Gap, Virginia—which has a population of just over 1,700—to open a solo family practice. This year marks the 15th anniversary of Litton Family Medicine, P.C.
“It was always my plan to practice in my hometown,” says Litton, who attended medical school at the University of Virginia, then completed his residency at the Spartanburg Family Medicine Residency Program in South Carolina. “I was very blessed to have exposure to wonderful mentors, both as a volunteer before medical school and with my attendings in medical school and in residency.”
These mentors gave Litton perspective on rural family care. He says, “I was able to see how a small-town family physician can connect with patients and truly have an impact on modifying their lifestyle behavior and medical outcomes.”
Litton believes one of the biggest benefits of practicing in your hometown is getting the chance to care for people you have known and loved for many years. Several of his childhood teachers, athletic coaches, church members and family now use his practice.
“My initial concern was that everyone in town has either known me since I was a kid or grew up with my parents,” he adds. “Everyone has always referred to me as ‘Scotty’ as a child, and ironically enough, many of my patients still call me Scotty, rather than Dr. Litton.”
He says that in a small town where everyone knows everyone, physicians have to politely and firmly draw certain lines about providing care. Whether he’s working as the varsity sideline doctor at a high school football game or simply attending church, people often expect him to answer their medical questions about anything at any time. Over the years, he’s learned how to handle people who get too pushy.
“I simply tell them that I practice medicine in the office, and I am happy to go over all their concerns or questions, but they must make an appointment and continue the discussion in a confidential setting,” says Litton. “Everyone has pretty much grown accustomed to it.”
He always finds it rewarding to help people but says it’s especially meaningful when you’re helping people with whom you have an emotional connection. The flipside of this is that people he cares about inevitably become sick or ill. “When I have to deliver bad news or comfort a grieving family, I just sit there and cry and pray with them,” says Litton.
A passion for his community also led David O. Barbe, M.D., MHA, to open a solo practice in his hometown. As he finished his residency in family medicine at the University of Kansas, Barbe says he and his wife had an easy decision in front of them. They had both grown up in the same small town of Mountain Grove, Missouri—with a population under 5,000—and as a nurse, she shared his conviction that the area needed more providers.
“We both knew that we wanted to return to our area of rural southern Missouri, and we saw it as a mission. That area has been underserved for as long as I can remember,” says Barbe, who attended the University of Missouri–Columbia School of Medicine.
Barbe had seen firsthand that the area never had enough physicians. He says the health care facilities there were few and far between, and there was no hospital. He knew he wanted to serve that population. “We went in eyes wide open,” he adds. “And although there were physicians in that community, joining with one of them wasn’t quite the right fit. So we opened a solo practice from scratch.”
Barbe established a solo practice in traditional family medicine, including obstetrics, endoscopy and minor surgery. “That was daunting, but we managed to pull together a simple one-physician office,” he says. “We opened our doors on August 1, 1983 and had essentially a full panel of patients the very first day. I have never regretted it or looked back.”
Over time, Barbe expanded his independent practice to two sites with several physicians. “I practiced solo for four years before I recruited my first partner,” he recalls. “She and I built that practice as an independent practice. In fact, we established a second office in a community about 25 miles away.”
After 15 years in independent practice, Barbe joined Mercy Clinic in Springfield, Missouri, a 650-physician multi-specialty integrated group. He saw merging as a way to bring more resources into his community and serve them better than he could as an individual physician.
Barbe is now vice president of regional operations for Mercy and oversees five hospitals, 90 clinics and more than 200 physicians and advanced practitioners. “But despite that growth and success, my practice eventually came full circle,” he says. “The physician who’d been with me for 22 years retired and another who’d been with me for 18 moved, leaving me as a solo practitioner, back to how I started.”
At first, he didn’t succeed in recruiting another physician to join him, but then his own son chose family medicine as a specialty and began seriously considering coming back home to practice. “He’s now decided to do just that,” says Barbe happily. “It wasn’t because of my pushing or encouragement. It was because he saw some of the merits of a rural practice that I experienced throughout my career.”
Advice for going home
Whether you’re excited about moving back home or just contemplating the idea, physicians who have done it have advice to share. They say it’s important to think carefully about the decision. Allen, who returned to work where he completed his residency, says a physician returning home should expect some people to struggle to embrace your new position.
“Having the self-awareness to understand your role and how your strengths and weaknesses may affect that will hopefully assist with prevention of burnout and/or dissatisfaction with your decision,” he says.
And Schmucker says physicians returning home to join an existing practice or hospital should talk with administrators about their expectations.
Let your employer know what you hope for in your role and address any concerns ahead of time. He also recommends talking with area doctors to see what the environment is really like. When he did this, Schmucker says, “I could tell they were happy and felt like the hospital was receptive to their concerns.”
Having this discussion ahead of time has allowed Schmucker to do all the things he wanted to do in practice while maintaining work/life balance.
He says one big help has been that the hospital arranged for some hospitalists to come in and share call on the weekends. “That gives me most weekends to spend more time with family, catch up on work at home and travel,” says Schmucker.
Litton, who opened a solo practice in his hometown, says no matter what specialty a physician chooses, he or she shouldn’t ignore the benefits of family medicine. “Sure, you won’t make as much money as a neurosurgeon, but if you start out and keep your practice small, then you can have a very good lifestyle with a very comfortable living,” he says.
The one mistake he says he made many years ago was not saying no enough. “Our practice is pretty much covered up on a daily basis,” he says. The heavy workload results in long hours and less free time than he would like, so now he’s trying to find balance by not accepting new patients for a time.
When Barbe opened his solo practice 35 years ago, he says he had to learn a lot on his own. Then, as now, medical students and residents weren’t taught about running a business as part of their training.
He says that’s something the American Medical Association—of which he’s president until June 2019—is trying to address. The AMA Accelerating Change in Medical Education Consortium is finding better ways to coach and prepare students for the future.
But whether physicians choose to pursue a solo practice or join a practice, Barbe says more physicians need to consider practicing in a smaller area.
“I want to debunk the myth of professional or social isolation in a rural community,” he adds. “Many physicians fear that in a rural community they’ll be too far from a good restaurant or sports or activities for their children.”
While it may take a little more effort to access some of those social amenities, most small communities are within driving distance of a larger community or metro area.
“I don’t think enough physicians give careful consideration to their opportunities in that regard,” Barbe says. “Rural America is a wonderful place to practice and raise a family.”
Mooneyham has found that to be true.
Her relocation to Redding—where her parents and brother still live—turned out to be a smooth move for her and her husband. The firm where her husband was working in Sacramento had a large corporate office in Redding. Now, her husband’s new office is only a quarter mile from her hospital.
Her advice for physicians considering moving home is simple: Do it. She believes it is especially important for those from underserved communities to return because they have insider knowledge of those areas and will be welcomed with open arms.
“There is a certain intimacy when working with other health care providers who have a connection to who I was before becoming a physician,” says Mooneyham. “It is likewise also rewarding providing care to those who know me as ‘Amanda,’ before I became ‘Dr. Mooneyham.’”