Rural Options

[Johnny Appleseed]

Hey all,

I am a pre-med student getting ready to take the MCAT in August and I am starting to think a little bit more about what I want to do in the future. My wife and I are both from very rural areas and we want to end up and raise a family in a rural area as well. I have shadowed physicians in our small hometowns (population ~5,000) and I noticed they often split time between the outpatient clinic, the county Emergency Room, and performing OB duties. Some of them also mentioned they leave one weekend a month to work locum tenens at other hospital's Emergency Departments.

My questions are what options do you have as a rural physician? For example can you do a residency in say Emergency Medicine or OBGYN and then work in an area with a population of ~ 5,000?

To phrase my question in another way.... Is it possible to function as a family doctor in a rural area as well as a specialist (OB, EM, or even Surgery)? Perhaps I am naive, but it seems a small population of <5,000 is not large enough to support a full-time OB, EM, or surgical physician. I imagine they would need to supplement their practice in other ways...

My favorite specialties to shadow have been OB, EM, and surgery, but I also know my wife and I will be much happier in a rural location so I want to pick a residency that can help us land a job somewhere rural. Is family practice the only option?

Any input you have is greatly appreciated. Thanks!

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[BlackDynamite]

You can definitely do OB, ER, inpatient/outpatient, and minor surgery. The general surgery/OB stuff would be limited to the three most basic procedures, and c sections.


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[cabinbuilder]

Family practice with OB would be your best bet. As far as doing C-sections it would depend on what the resources are available at the local hospital and if there is OB back-up in case of complications. Just because you know how to do a procedure doesn't mean the hospital will give you privileges to do said procedure. Just like knowing how to do scopes but what happens if you perforate a bowel and the patient has to go to the OR? Will there be a general surgeon there to fix your mistake or will the patient have to be shipped to the next facility? All ER's have to have someone on staff whether it a DR or PA. Most rural ER's are stabilize and ship the bad stuff or are treated mostly like urgent care. Patient's who are admitted are generally too old or are basic internal medicine cases: Pneumonia, cellulitis, COPD exac, CHF exac, etc. I think you will find as you get closer to finishing residency that it's nearly impossible to do all the different jobs anymore because time is limited and you will want a life too. When you are pre-med it's all dreams and glory. Flash forward 15 years and you just want to go home at 5 o'clock.

 

[Johnny Appleseed]

Thanks for the responses. So by doing a family practice residency you can expand and do some other things besides just outpatient clinic (OB, EM, some procedures, etc). Is the opposite true? Can you do a EM or OB residency and still run a basic outpatient clinic?

 

[HipsterLorax]

Thanks for the responses. So by doing a family practice residency you can expand and do some other things besides just outpatient clinic (OB, EM, some procedures, etc). Is the opposite true? Can you do a EM or OB residency and still run a basic outpatient clinic?

Your medical license doesn't limit what you can do--your training and your willingness to risk getting sued if you F up does. It would be hard to find an EM or OB that practices general outpatient medicine. That's mostly because they chose those fields specifically and that's what they want to spend their time doing (plus they probably make more $). For what you are asking, FM makes the most sense if you truly want a mix of outpatient/inpatient/EM/OB and you know 100% that you want to practice rurally. EM or OB residency would be much more limiting.

 

[cabinbuilder]

Thanks for the responses. So by doing a family practice residency you can expand and do some other things besides just outpatient clinic (OB, EM, some procedures, etc). Is the opposite true? Can you do a EM or OB residency and still run a basic outpatient clinic?

ER and OB don't run outpatient clinic. ER works in ER unless you are retiring and step down to urgent care a few days a week. OB has their own women's clinic and do scheduled surgeries ,deliveries, and C-sections ( schedule and emergent) They do not have a life generally and have worse quality of life than the surgeons in rural places since they tend to only have 1-2 back up help if that at all.

 

[apoptoaster]

I agree with the above posters- FP is your best bet. You'll find that not all FP residencies are the same and some will have more of a rural focus than others. I've started looking at the job market and can say for sure that there's a desperate need for docs willing to do what you're wanting to do, especially if you're willing to live in a remote area. Good luck with med school!

 

[CRED&PRIV-PRO]

Family practice with OB would be your best bet. As far as doing C-sections it would depend on what the resources are available at the local hospital and if there is OB back-up in case of complications. Just because you know how to do a procedure doesn't mean the hospital will give you privileges to do said procedure. Just like knowing how to do scopes but what happens if you perforate a bowel and the patient has to go to the OR? Will there be a general surgeon there to fix your mistake or will the patient have to be shipped to the next facility? All ER's have to have someone on staff whether it a DR or PA. Most rural ER's are stabilize and ship the bad stuff or are treated mostly like urgent care. Patient's who are admitted are generally too old or are basic internal medicine cases: Pneumonia, cellulitis, COPD exac, CHF exac, etc. I think you will find as you get closer to finishing residency that it's nearly impossible to do all the different jobs anymore because time is limited and you will want a life too. When you are pre-med it's all dreams and glory. Flash forward 15 years and you just want to go home at 5 o'clock.

I privilege providers in a rural, underserved setting. To accomplish what your goal(s) are currently, you should focus on Family Practice with OB. We have providers that have worked with that background previously before our facility "grew". We do have an ED; where EM Board Certified providers are granted clinical privileges, AND FP Board Certified providers are granted clinical privileges. The difference between the requirements for the two is an EM BC doc is not required to be ACLS, ATLS, BLS, PALS certified - as that was part of their core education/training. A FP BC doc IS required to maintain ACLS & ATLS in order to be eligible for privileges within the ED.
We have often been fortunate that our FPs have stepped up to help out in the ED during shortages; it has helped keep a much needed service line open, has been a benefit to the patients' access, and has reflected very nicely on the FPs RVU factor. Good Luck!

 

[cabinbuilder]

Yes, the ATLS certification is one of the reasons I stopped working in the ER.

 

[deleted6669]

I privilege providers in a rural, underserved setting. We do have an ED; where EM Board Certified providers are granted clinical privileges, AND FP Board Certified providers are granted clinical privileges. The difference between the requirements for the two is an EM BC doc is not required to be ACLS, ATLS, BLS, PALS certified - as that was part of their core education/training. A FP BC doc IS required to maintain ACLS & ATLS in order to be eligible for privileges within the ED.
We have often been fortunate that our FPs have stepped up to help out in the ED during shortages; it has helped keep a much needed service line open, has been a benefit to the patients' access,!

Does your facility credential PAs/NPs with acls, atls, pals, difficult airway, significant experience, etc? I work at 3 facilities similar to what you describe. 2 staff PAs or docs interchangeably for solo coverage and 1 staffs a pa and a doc for double coverage shifts with the providers alternating pts regardless of acuity.

 

[Smurfette]

Hey all,

I am a pre-med student getting ready to take the MCAT in August and I am starting to think a little bit more about what I want to do in the future. My wife and I are both from very rural areas and we want to end up and raise a family in a rural area as well. I have shadowed physicians in our small hometowns (population ~5,000) and I noticed they often split time between the outpatient clinic, the county Emergency Room, and performing OB duties. Some of them also mentioned they leave one weekend a month to work locum tenens at other hospital's Emergency Departments.

My questions are what options do you have as a rural physician? For example can you do a residency in say Emergency Medicine or OBGYN and then work in an area with a population of ~ 5,000?

To phrase my question in another way.... Is it possible to function as a family doctor in a rural area as well as a specialist (OB, EM, or even Surgery)? Perhaps I am naive, but it seems a small population of <5,000 is not large enough to support a full-time OB, EM, or surgical physician. I imagine they would need to supplement their practice in other ways...

My favorite specialties to shadow have been OB, EM, and surgery, but I also know my wife and I will be much happier in a rural location so I want to pick a residency that can help us land a job somewhere rural. Is family practice the only option?

Any input you have is greatly appreciated. Thanks!

Many rural hospitals have a general surgeon (or two, to help with call), who does scopes, bread and butter surgical cases (hernias, gallbladders, excisions, straightforward colon/bowel resections) and may be the one doing c-sections as well (because the volume in the town may not support an OB). I know of quite a few critical access hospitals in my state--in towns of less than 5000--who have general surgeons. I read an article a few years back that stated there was a high correlation between having a general surgeon and keeping a rural hospital open. There is a HUGE need for rural general surgeons, so if that is of interest to you, you will have plenty of lucrative job opportunities, especially since most grads want to stay urban/suburban. There are more rural surgeons retiring every year than there are younger surgeons willing to replace them. If the rural GS route is an interest to you, there are even several residency programs with a rural track specifically intended to teach the skills to succeed in a small town with small town resources.

 

[YoungDoc25]

Many rural hospitals have a general surgeon (or two, to help with call), who does scopes, bread and butter surgical cases (hernias, gallbladders, excisions, straightforward colon/bowel resections) and may be the one doing c-sections as well (because the volume in the town may not support an OB). I know of quite a few critical access hospitals in my state--in towns of less than 5000--who have general surgeons. I read an article a few years back that stated there was a high correlation between having a general surgeon and keeping a rural hospital open. There is a HUGE need for rural general surgeons, so if that is of interest to you, you will have plenty of lucrative job opportunities, especially since most grads want to stay urban/suburban. There are more rural surgeons retiring every year than there are younger surgeons willing to replace them. If the rural GS route is an interest to you, there are even several residency programs with a rural track specifically intended to teach the skills to succeed in a small town with small town resources.

This is incredibly motivating to hear. I am from a rural town (~2,500 population) and have the opportunity to sign a contract for a rural scholarship that will pay ~$12k-$16k (depending on funding for the year) towards my tuition each year. I have to work in a rural community in my state for 4 years after my residency. General surgery is included in the list of specialties I can pursue with the scholarship, and it has been my dream for quite a while now. It would allow me to graduate with <100k in loans (including undergrad), so I am taking it very seriously.

I guess my questions would be as follows:
Have you seen contracts offered for jobs that would be better opportunities (loan repayment)?
I'm not looking for a 'lifestyle' specialty, but are these lucrative opportunities laced with call every night?
How much better pay are we talking about? I was told that the average GS makes ~$330k a year, though I know that could be way off.

If it'd be better to discuss the details of those opportunities privately, just let me know!

 

[Smurfette]

This is incredibly motivating to hear. I am from a rural town (~2,500 population) and have the opportunity to sign a contract for a rural scholarship that will pay ~$12k-$16k (depending on funding for the year) towards my tuition each year. I have to work in a rural community in my state for 4 years after my residency. General surgery is included in the list of specialties I can pursue with the scholarship, and it has been my dream for quite a while now. It would allow me to graduate with <100k in loans (including undergrad), so I am taking it very seriously.

I guess my questions would be as follows:
Have you seen contracts offered for jobs that would be better opportunities (loan repayment)?
I'm not looking for a 'lifestyle' specialty, but are these lucrative opportunities laced with call every night?
How much better pay are we talking about? I was told that the average GS makes ~$330k a year, though I know that could be way off.

If it'd be better to discuss the details of those opportunities privately, just let me know!

I know there are places that will do loan repayment, but I don't know exact amounts. Many rural places will forgive certain amounts after a specified # of years of service, which is a rare perk to find outside of rural environments. It's all negotiable in your contract (regardless of which specialty you pick), so you shouldn't feel like you HAVE to take one of the contracts now. Keep in mind that if you change your mind on your career path, there are repercussions if you fail to meet the contractual obligations. If you want to do a subspecialty, some of these simply aren't compatible with rural life (like transplant or surg onc). Just consider all scenarios before signing something, and read the fine print.

Call in a rural environment IS more frequent, but the pace and volume are different from what you get exposed to in training. It's not like a big center where you're operating continuously and dealing with sick patients all the time. Most rural practices I'm familiar with do a week on call, week off, but some work it differently. This is call from home, and you get called only if something surgical comes in. If it can wait until morning (most things can), then you deal with it the next day. Really complicated or bad things are going to be transferred out to a large center.

$330K/year is lower than the average for GS, although I've been in practice a while and don't know the new grad data, which is lower than surgeons with experience. Academics pays below average, private practice or employed (but non-academic) makes more, and less desirable locations (i.e. rural) make even more. If you get a job offer for a rural surgery practice for only $330K, you should walk away. The east and west coast pay a bit less than the midwest and south from what I recall from MGMA data. However, if a job is advertising some crazy high salary, that may be because there is something very undesirable about that job or location.

 

[YoungDoc25]

I know there are places that will do loan repayment, but I don't know exact amounts. Many rural places will forgive certain amounts after a specified # of years of service, which is a rare perk to find outside of rural environments. It's all negotiable in your contract (regardless of which specialty you pick), so you shouldn't feel like you HAVE to take one of the contracts now. Keep in mind that if you change your mind on your career path, there are repercussions if you fail to meet the contractual obligations. If you want to do a subspecialty, some of these simply aren't compatible with rural life (like transplant or surg onc). Just consider all scenarios before signing something, and read the fine print.

Call in a rural environment IS more frequent, but the pace and volume are different from what you get exposed to in training. It's not like a big center where you're operating continuously and dealing with sick patients all the time. Most rural practices I'm familiar with do a week on call, week off, but some work it differently. This is call from home, and you get called only if something surgical comes in. If it can wait until morning (most things can), then you deal with it the next day. Really complicated or bad things are going to be transferred out to a large center.

$330K/year is lower than the average for GS, although I've been in practice a while and don't know the new grad data, which is lower than surgeons with experience. Academics pays below average, private practice or employed (but non-academic) makes more, and less desirable locations (i.e. rural) make even more. If you get a job offer for a rural surgery practice for only $330K, you should walk away. The east and west coast pay a bit less than the midwest and south from what I recall from MGMA data. However, if a job is advertising some crazy high salary, that may be because there is something very undesirable about that job or location.

So much good information. Thanks a ton!

 

[Johnny Appleseed]

Sorry to revive my old thread, but after doing some more shadowing and research I have decided I want to do either rural Family Practice w/OB and as many other things as possible or rural General Surgery.

Does anyone know of specific residencies in GS or FP designed for rural surgeons? I have found a few residencies that basically send you somewhere rural for a couple months, but nothing more than that.

I would like to find a few residencies focused on rural medicine so that I can research their requirements and learn what makes one competitive for their programs. That way I can have some direction when I start med school.

Also when picking a med school how much merit should I give to research opportunities provided by the school? I assume to match in GS, research would be required.

Thanks for your responses! It seems outside of Google there are not a lot of resources to use to find answers to some of these questions.


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[InternistDO]

This may have some helpful info: Rural Programs - The RTT Collaborative