The air is clean, the space is wide, and as the roadside signs say, the milk and eggs are farm fresh. Ahh, rural America.
What the signs don’t say is that while the pastoral view from a passing car may evoke hard work and healthy living, what are unseen are the health care challenges that can accompany a rural postmark. Doctors practicing in these communities typically encounter a higher concentration of complex health issues, fewer resources, and a lower-income population that may need to economize on care by choosing lower-cost options, delaying care, or just plain going without it. Whether rural care is defined by the buoyancy in patients, or a rugged individualism often found in rural populations, it is a type of care that calls upon the full range of a doctor’s diagnostic and negotiation skills.
Allen Millard, a primary care physician in rural family practice since 1989, says he is called to serve a much broader spectrum of health care needs than if he practiced medicine in the city. “It’s kinda funny. My wife and I went through the same residency program. She is an urban doctor in Olympia and doesn’t see patients in a hospital ICU. She doesn’t take care of ventilator patients. She doesn’t care for patients who have suffered heart attacks. I do all of those in the rural setting.”
In an urban setting, specialty care is often found in various clinics or facilities around town. But it’s not always possible for rural patients to drive 30 or more miles to a specialist. And if they don’t have a car, there are relatively few public transit options that make that type of route. So, while long distances mean some of the specialty care his patients require is difficult to obtain, Millard finds that the specialty care prescribed may be something he needs to do. Otherwise, the patient just won’t get it.
But the city has the advantage in an emergency, notes Millard. “If you have an acute heart attack in a Seattle neighborhood and need a cardiac catheter, the chances of you getting to one within that critical first 30 minutes is way higher than if you live in Humptulips.”
Because some of Millard’s rural patients may want to economize and not be a bother to their busy physician, they are prone to save up their ailments for a single 15-minute appointment. “It’s more difficult to diagnose when care is postponed and you’ve got several issues all at once,” he says. “And sometimes the next patient gets up and leaves because you took too much time with the first patient.”
Unique Challenges of Rural Health Care
The greater scope of care he must provide means Millard’s exposure is also greater. “Very few family practice doctors in Seattle have ventilator patients in the hospital. I do. That type of patient is more likely to suffer bad outcomes.”
Worse yet, in a bad economy, rural patients often refuse care entirely, or can’t afford it. Limited income patients might opt to not keep a regular doctor visit in order to save the $20 copay. Millard estimates that five percent of his patients modify their health care for economic reasons. Another 25 percent want a less expensive alternative, which means he spends more time negotiating care and looking for savings. “When a trip to a discount store nets the same medication at a third of the cost, patients want to know that.”
Millard says it also means keeping close records to minimize liability. “You have to carefully chart your patient visits. If a patient refuses to get a colon cancer screening, you need to document the reason why: ‘The patient refused a colon cancer screening due to cost. Risk factors were discussed.’”
Meticulous tracking is required, too, because of the higher number of physicians’ assistants and nurse practitioners used in rural practice. More oversight may be needed in reviewing their charts and notes, talking with them about their findings, and explaining how best to meet the care needs of a rural population.
Giving Patients Options for Care
Berdi Safford, MD, has spent 33 years seeing patients in Ferndale, Washington. Also the medical director of quality for the Family Care Network, she says that the difference between her rural constituents and those in the city of Bellingham, just seven miles away, is pronounced. Unlike many of her urban counterparts, she cannot limit the number of low-income patients that she serves.
Like Millard, she faces the conundrum of what health care her patients can afford versus the health care she thinks is best. She has become proficient in the art of negotiation and with finding less costly, yet workable, solutions.
“Thirty-five years ago, I trained in a very rural family medical practice in Maine where people always paid for their own health care,” she says. “I learned cost-effective habits I might not have learned in a place with less cost constraints.”
Demographics and socioeconomic factors play a significant role. Close to 50 percent of her patient population is on Medicare, welfare, or disability. Seniors are generationally prone to tough it out. “The perception is of a far greater distance than the reality,” she says. “Gas prices being what they are, though, my patients don’t want to get onto the freeway and go to the big city. They want their care from their local doctor.”
A higher concentration of complex health issues, fewer resources, and a low-income population have not dampened Safford’s optimism. She doesn’t fear adverse outcomes. “I’m trying to make the right health care decisions where there are a lot of gray areas. I remember one immigrant with very little money who complained of headaches. I wanted to get a scan, but he refused for lack of money. We negotiated. I was not so worried about being sued as I was worried that something bad for him would only get worse. Thankfully, the headaches got better. It’s a kind of dance we do.”
Innovations in Rural Care
According to the Bureau of Health Professions, “about 20% of the US population—more than 50 million people—live in rural areas, but only 9% of the nation’s physicians practice in rural communities.” This shortage of primary and specialty care physicians in rural settings is not new, but local programs today are addressing the issue head-on.
Safford and her colleagues have entered into a promising mental health pilot program with the county mental health clinic in Bellingham. Twice a month, a trained mental health counselor and a nurse practitioner trained in mental health medications see patients at Safford’s practice.
“It’s a resounding success,” she says. “Their schedules are full and there’s hope they will expand their hours. Patients we had difficulty getting to counseling in Bellingham are more willing to seek that help in our office.”
Ferndale Family Medical Center is also excited to be a participant in the University of Washington School of Medicine’s new TRUST program, which partners medical students with a rural community throughout their four-year medical training. The Targeted Rural and Underserved Track (TRUST) aims to train specially qualified and specially selected University of Washington medical students to be physicians who will work in underserved areas, including both rural and small-city community health centers. In essence, the program seeks to provide a continuous connection between underserved communities, medical education, and health professionals in our region. The hope is that by building relationships, the students will cement ties to the local community and, perhaps, return to establish their practice there.