Attracting Physicians to Rural Medicine

 

“American medicine is probably the best in the world, but they rush too much and do too much unnecessary surgery.”

Dr. Bohdran Hordinsky (1991)

 

Having written about the problems with one-doc towns in rural areas, specifically rural North Dakota, I thought it would be helpful to provide an example of how the town of Drake, ND, dealt with their need for a physician.

True, this happened many years ago, but Drake residents attracted a skilled physician who chose to practice the rest of his life in their community. At that time a town of 600 people, their success offers some clear contrasts at to what’s missing in our efforts today to attract physicians to rural communities.

There are many ways the state of North Dakota, for example, could attract physicians, physicians who would stay in the community, possibly until they retired. The existing programs help, such as the J-1 visa for physicians from foreign medical schools, but these J-1 physicians, as a rule, do not stay in a community any great length of time. Some medical schools do encourage students from rural communities to return to rural areas to practice, but usually not with any prolonged efforts. The University of Iowa’s Carver College of Medicine Rural Iowa Scholars Program (CRISP) was specifically designed to keep students, especially students from rural areas, involved in rural medicine throughout their training.

North Dakota legislators and those organizations involved in attracting physicians to rural areas need to look at what really keeps rural areas without physicians. This would include taking a good, close look at the workings of the one-doc town syndrome. The usual response is that physicians now days refuse to be on call 24/7. This is about as convincing as the excuse that malpractice insurance is too expensive for rural hospitals to offer obstetrics. In reality, rural physicians are often not on first call 24/7, but rather often on back-up phone call a good bit of the time, which does not require appearance in the ER. Nonetheless, they are on-stage, as it were, 24/7, even if not on first call. Patients will approach the physician at a restaurant table, on the street, or in the grocery store, often to just let them know how glad they are to have a physician in town. Some physicians may find this kind of attention disconcerting.

Besides the generally required one-day-a-week and one-weekend-a-month call to retain hospital privileges, extra first call is often paid for by the hospital, and in North Dakota, paid well. With paid call, rural primary care physicians can substantially increase their income. Indeed, rural family practice physicians, at least in most of North Dakota, are paid remarkably well.

If North Dakota legislators looked at how the city of Drake, a town of 600 people, attracted a well-known physician to their community, they might find some clues to how they could create very good programs to actively recruit physicians to rural areas. People in the Drake area still talk about Dr. Hordinsky. There is a limited amount of information about he and his family on-line, but the historical details of how he came to the United States can be found in his Ukrainian Weekly obituary.

In 1991, the town of Drake produced a cookbook in honor of Dr. Hordinsky’s 40 years of serving their community. This is the one source of detailed information of his childhood, his family, and his circuitous route to a small rural town in central North Dakota (and the source of most of my data and quotes). Unfortunately, there are no copies of this cookbook available anywhere except in the homes of people who still remember with great warmth Dr. Hordinsky and his wife Irene.

There is one blog post online by a woman who had the honor of interviewing Dr. Hordinsky while he was still alive. She is candid that much of the background information came from the cookbook, but she does report on her conversation with him as well.

Bohdan Z. Hordinsky was born in 1911 into a Ukrainian family of artists and scientists. His cousin discovered the cause of Parkinson’s disease. Before coming to the United States, he developed a protocol using terpenes to dissolve gallstones. Several physicians continued his research in the use of terpenes. In 1971, Minnesota Medicine, published his paper describing his technique. The paper can now be found on PubMed.

Dr. Hordinsky was born in the Ukraine into a family of remarkable relatives. His family moved to what is now Austria, which became part of Poland after World War II. He graduated from medical school in Lviv in 1935 and spent two years in Berlin where Sigmund Freud was one of his teachers. Dr. Hordinsky recounts how Freud warned his students to concentrate on the patient: “Take as much time as you need with each patient. Don’t look at your watch, but if you have to, take his pulse and then look.”

Dr. Hordinsky remained in Europe until after World War II. Married and with two children, he moved from one place to another during World War II to avoid working in environments he would not tolerate. In 1946, he managed to become chief of the medical department for a displaced persons hospital started by the United Nations in Salzburg. Shortly after, President Truman began a program to admit 200,000 displaced persons into the United States. On Christmas Day 1947. Dr. Hordinsky, his wife Irene, and his two children arrived in New York City.

In the United States, his first job was as house physician at St. James Hospital in Newark, NJ. In 1949, the North Dakota Legislature agreed to accept 24 foreign doctors who would go to towns where no other physicians practiced. He and his family were happy to leave New Jersey, where he said he was considered a German regardless of his Ukranian heritage, and move to a state which had weather much like his home in the Ukraine. He was often asked why he stayed in Drake, North Dakota, practicing until he was into his 80s:

“Sometimes people don’t understand why I stay here, but to be two years in the Soviet Union and then to be under Hitler, you are glad you survived. After years of war, I looked for a quiet place to live. I could make twice as much money other places, but we got more from living here than in a big city. I can spend plenty of time with my patients, and it gives me satisfaction that these people are happy.”

At that time, the North Dakota legislature took at least this one action to attract physicians to rural North Dakota. But the town of Drake, at their own expense, provided him with a clinic, a place to live, and even a car. In a discussion with a rural business owner, I once expressed the notion that there’s no reason rural communities couldn’t do much of what Drake had done to get Dr. Hordinsky to become their rural physician and stay in the community so many years. The response: “We don’t do that any more.” And perhaps that’s one reason we don’t have many rural physicians opening practices in rural towns.

The clinic and house the people of Drake provided Dr. Hordinsky and his family were modest by today’s standards. Indeed, Dr. Hordinsky would tell about how his physician friends from urban areas would ask him how he managed with a simple clinic without a lot of high-tech equipment:

“You can trust machines too much. Of course, machines are good, but they make mistakes…some physicians rely so much on sophisticated equipment that they forget to listen to the patient.”

The state of North Dakota could initiate many programs to attract physicians to rural areas. It could develop a self-insuring pool to provide malpractice coverage to incoming rural physicians. It could develop programs, possibly in cooperation with the United States Department of Agriculture, to help rural communities build clinics and housing for rural physicians. The University of North Dakota School of Medicine could develop a program similar to Iowa’s CRISP approach.

There’s much that could be done to revitalize rural medicine, but it will take some thinking outside the box. Indeed, at the University of North Dakota Doctors Aaland and Sticca realized that surgeons tend to avoid rural practices because of the difficulty getting coverage when they need time off. They devised a plan to provide coverage for rural surgeons as needed to encourage surgeons to locate in rural areas. Many of the excuses bandied about for why physicians avoid rural medicine are off the mark. To date, with the exception of Carver Medical College’s CRISP approach or Doctors Aaland’s  and Sticca’s the Rural Surgery Support Program at the University of North Dakota, there isn’t much substantial programming to attract and keep physicians in rural areas, at least in North Dakota. Certainly cooperation between various government and medical school entities need to come together and do some outside-the-box program development before there is a critical mass of successful innovative approaches to the problem of attracting physicians to rural communities.

“I have had many offers to go to bigger cities like Chicago and New York…but these are wonderful people here and I am quite in love with North Dakota.”

dhaugen

Some young HR person once looked at my CV and asked me, quite seriously, if I had really done everything I had listed there. Well, yes. Because I am someone who can’t sit in a Morris Miller cubicle every day, much less for any great stretch of time. Once the problem is solved, I get bored and I’m ready to move on to the next challenge. This hasn’t afforded me any great stability in my work life. I simply arrive in places about ten years ahead of time. So far, at least, that penchant for early arrival hasn’t been accompanied with a pocketbook full of door knobs.

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