The rural healthcare landscape is tremendously varied. For the many physicians practicing in metropolitan areas, I suspect it is hard to imagine practicing in an environment in which you are the only physician within a 50-100 mile radius. You may have NPs and PAs to assist you in seeing patients and cover some of the call, but whatever happens, you are 100 percent responsible for it whether you have any control over the outcome or not.
There is now finally some recognition that one of the primary reasons physicians refuse to locate in rural areas is that taking call 24/7 is a recipe for an early death. And many times the call is unpaid. While it’s common for rural hospitals to pay for locums tenens coverage for their primary care physician, it’s much harder to find a locums tenens coverage for a surgeon, for example. This creates rural health care systems with a single primary care doctor supported by PAs and NPs. Increasingly, this is becoming rural health facilities with only NPs.
There is an elephant in the room, though, that no one talks about. The rural one-doc town.
In rural areas where a single primary care physician has practiced, even for only a few years, there is no way to bring in a second physician to help carry the load without a horrendous territorial fight. This may sound bizarre, but most practicing physicians, if they are old enough, have seen the collegial nature of their profession ebb away as bean counters and non-physician owners of medical facilities have taken over control of what physicians do.
Often the existing rural physician doesn’t want the competition of the incoming physician. After all, there is this notion that the patients belong to the existing practicing doctor. The physician can tell the PAs and NPs what to do, but this doesn’t work well with a new incoming physician. Physicians have differing practice modalities. In the days before doctors began eating doctors from the pressure of corporate medicine, physicians were tolerant of the practice of other physicians and could often benefit by learning from each other. Some rural communities do manage to attract and maintain several physicians who will work together, but these practice environments are relatively rare.
Rural hospital and clinic CEOs seldom have the strength or abilities to force the existing one-doc town physician to play nice. In short, it doesn’t take very long for a single doctor in a rural hospital and clinic setting to rule the roost, often not in the best interest of either the hospital and clinic or the patients. The hospital boards, CEOs—and patients—become hostages to whatever doc is willing to stay in a rural area and run the show, often at the expense of the patients.
This is especially true in Critical Access Hospitals (CAHs) , where rural hospitals have been given the job of “stabilizing and sending patients on” to the larger hospital centers. CAH hospitals have evolved into band-aid stations, with the local physician often sending anything and everything on to the larger medical centers. Not because the condition can’t be handled locally, but because keeping the patient in the local hospital means more work for the nurses and more work for the physician.
While this may be hard for physicians working in an environment with numerous other physicians to comprehend, I have observed this pattern now in four different rural one-doc communities.
There are extremely harmful ramifications to the quality of health care available to patients under these conditions. First, patients who don’t like the local doctor will travel 50 to 100 miles to see doctors they do like. Second, patients will not complain of any care they receive because they might accidentally wind up in the emergency room under the care of the very physician they have complained about. And thirdly, rural hospitals are considered small enough to seldom merit full scale investigations by Medicare and regulating agencies.
The assumptions made by many of the studies of why rural hospitals are closing at alarming rates seem to universally miss this deadly mix of dynamics.
It’s time to address the real problem with rural health care—the elephant in the room.