Midnight phone calls.
Lack of specialist backup.
Big city wives.
Oh, the challenges of being an up-to-date doctor in a small town.
Of course, then there’s the great relationships with your patients, the tight-knit medical community, the community connections, the nice house, the acreage and fishing just down the road.
Ah, the joys of rural medicine.
Rim Country doctors balance the challenges with the joys, relying on a crucial relationship with Payson Regional Medical Center, innovations like telemedicine, a carefully cultivated network of specialists in Phoenix and elsewhere and a dedication to seemingly old-fashioned medicine, founded on patient relationships.
Still, keeping enough doctors practicing in Payson remains a challenge, said Dr. John Vandruff, head of the medical staff at PRMC.
“Some doctors are drawn to small communities with a rural atmosphere, others want all the amenities of the big city and there’s no way they would ever interview here. We don’t have a lot of specialty backup here in Payson, and that worries some doctors. It’s definitely harder to practice medicine in a small community.”
That’s one reason residents of small towns must make do with fewer doctors.
For instance, while 20 percent of Americans live in rural areas — only 9 percent of the nation’s doctors practice in those areas, according to a study of rural medicine published in the Journal of the American Medical Association.
Worse yet, only 3 percent of students in medical school say they intend to practice in a rural area, according to the JAMA-published study.
People living in rural areas generally have more medical problems, which reflects higher poverty rates — which in 2000 ran at 14 percent in rural areas and 11 percent in urban areas. Moreover, people living in rural areas are less likely to have medical coverage, which means their doctors more often find themselves treating patients without insurance.
Still, medical care constitutes a major portion of the economy in both rural and urban areas. In Arizona, health care in 2001 accounted for 7.2 percent of the economy — compared to 9.2 percent nationally, according to the U of A’s Rural Health Office.
Spending on health care has generally grown at about twice the rate of inflation and much faster than the rate of population growth for the past 20 years, and had declined less during the recession than almost any other sector of the economy.
On average, rural communities must deal with transportation problems that double the cost of emergency transport, lack of trauma centers that dramatically increases the risk of death in major accidents, a lack of many specialist physicians, fewer hospital beds and fewer nurses — all the while suffering from higher rates of chronic diseases and higher infant mortality rates.
Moreover, the complicated system MediCare uses to set prices for hospitals and doctors often works against rural hospitals. In effect, the formulas for the most complicated operations and treatments provide much higher rates for labor costs. As a result, the urban hospitals that treat more complicated cases like open heart surgery, transplants and other expensive procedures not only enjoy a wage index that’s 15 percent higher than rural hospitals and a case mix that gives them another 10 percent boost due to labor intensity.
That presents formidable challenges for rural hospitals and the network of doctors they support.
Fortunately, said Dr. Vandruff, the medical center and the region’s network of doctors have worked effectively together to provide broad coverage, with contract and referral networks to knit together the holes in the net of care spread for patients.
For starters, studies show that doctors living in rural areas generally make just as much as their urban counterparts in the same specialties. That money goes a lot further in a community like Payson than in an urban center like Phoenix.
Moreover, the medical center in recent years hired a staff doctor who specializes in taking care of patients in the hospital.
As a result, community doctors whose patients wind up in the medical center can have their care supervised by a staff doctor on the scene, reducing the need for the often hard-pressed community doctors to make frequent rounds in the hospital.
“The on-call issue is a big one for rural physicians,” said a Alison Hughes, a lecturer at the University of Arizona medical school and director of the Arizona Rural Hospital Flexibility Program.
She said the supply of rural physicians continues to shrink, despite the efforts of many medical schools to train doctors who will serve in those underserved rural areas.
The best way to recruit a doctor who will practice in a rural setting is to get into medical school someone who grew up in a place like Payson.
However, she noted, the dynamics of medical school also play a role. Almost all the medical schools are in the heart of big cities. And almost all medical students start their training unmarried and finish up married. Usually, they marry people they met in medical school in that big city.
“Doctors who want to locate in small towns often have spousal challenges,” said Hughes.
“I’ve asked physicians why they’re leaving rural areas and they’ll say their kids are growing up and they wanted to get them into other schools — or their spouses want to live in the big city.”
Dr. Vandruff agreed that keeping the spouse happy can pose a challenge.
“In a physician/nonphysician marriage, the doctor is often at the office or the hospital 40 or 50 hours a week and the spouse at home without the same level of job satisfaction. So quite a few doctors come to town — usually male —and their wives find themselves gravitating to Phoenix.”
On-call arrangements are also sometimes harder to arrange in rural areas.
“Young physicians these days want a life,” said Hughes of the challenges of recruiting doctors to practice in rural areas.
“They don’t want their job to overpower their lives.”
Large practices in urban settings provide enough doctors to cover overnight and weekend on-call requirements, so that doctors can have a semi-normal life after office hours.
Dr. Vandruff said the local medical community and the medical center have cooperated to provide on-call arrangements and recruit key specialists to the community.
Most of the doctors in town have privileges at the medical center, which benefits patients and satisfies the requirements of most of the private medical plans with which doctors contract.
Most doctors form alliances within their specialization with at least two other physicians, so that they only have to remain on call about one week in three.
“Some nights I’ll get four calls in one day, sometimes I don’t get a call for four days,” said Vandruff, referring to those times when he provides coverage on nights and weekends for the three primary care doctors who back up one another.
“Seems like it’s often that 1 a.m. call when I’m sound asleep for someone who needs a sleeping pill,” he joked.
The medical center and the medical staff then assess the community’s needs and actively recruit specialists to fill the gaps.
Generally, the medical center wants to have enough doctors in each key specialization so that no doctor has to provide on-call coverage for hospitalized patients more than once every third night.
Dr. Vandruff said the medical center now has only one full-time cardiologist on the medical staff, which means they’re actively recruiting for more cardiologists willing to take calls.
The center also lacks coverage for cardiac surgery, neurology, rheumatology and neurosurgery — and needs better coverage for plastic surgery and ear-nose-and-throat surgery. The center has thin-stretched coverage for internal medicine, urology and several other areas.
As a result, the relationship with the medical center provides essential backup and support for most of the doctors in town.
But that still requires most of the doctors in Payson to develop strong relationships with specialists in the Valley, whose proximity provides much more access to specialized care in Rim Country compared to most rural areas.
But for all those challenges, Dr. Vandruff and many other Rim Country physicians say they wouldn’t want to practice anywhere else.
“For me, it’s wonderful to always be bumping into patients. I’ve been here 22 years and most of my long-term patients are personal friends of mine. I enjoy seeing them — although sometimes I’ll be dashing to Walmart on a 30-minute lunch break and bump into three or four people — and they’ll all want to talk.”
And the connections offer other pleasures to a small-town doctor with a sly sense of humor.
Vandruff recalled the time a fellow in the market mistook him for another doctor.
The fellow called him by the other doctor’s name and complained “that medicine you gave me for my foot is not working.”
Vandruff nodded sympathetically, although he had no idea who the person was. Then he said, “I’m sorry that medicine didn’t work and I couldn’t help you on that last office visit — but come to my office tomorrow and I’ll give you a full refund.”
Ah. Small-town medicine.