Heather Kovich, M.D. N Engl J Med 2017; 376:1307-1309April 6, 2017DOI: 10.1056/NEJMp1613899
“Have I told you that I’m converting my garage into a workout room?” my friend asks. We are roaming the compound, our eyes fixed on the enormous, changing sky, oblivious to the tumbleweeds and empty plastic bottles skittering across our path.
“I’m hiring one of the maintenance guys to put down laminate floors. They’re even installing a window.”
The sun, down behind the Carrizo Mountains, streaks the sky in a saffron finale. Our dogs chase a curious prairie dog back into its den.
My mind turns over the implications of my friend’s home-renovation project, and I am filled with happy relief. We circle the hospital and return to our street. I can’t voice my feeling — she’d be disappointed that I’d doubted her commitment. Instead, I say, “That’s a lot of money to put into the hospital’s house, but it sounds awesome. I can’t wait to see it.”
This tension defines our lives as rural primary care physicians. Our patients put it the most bluntly: “And how long will you be staying, doctor?”
Over the past decade, efforts to increase access to health care in the United States have focused on insurance coverage. Meanwhile, a shortage of physicians is still the limiting factor in rural communities. Twenty percent of the U.S. population is rural, but only 11% of physicians practice in rural settings,1 even though residents of rural areas are older and have worse health indicators than their urban counterparts.2 Programs like the National Health Service Corps and state loan-repayment arrangements lure physicians to rural settings, but these physicians churn like lottery balls in a drum.3 The winning combination is a good doc who stays.
My patients asked me The Question at every visit for several years, and it irritated me every time. I would paste on a smile and answer with some version of “I’m not sure,” dodging the follow-up inquiries about what my husband does and whether he likes the area. Their questions implied what the Dartmouth Atlas made explicit: physician supply is driven by where physicians want to live,4 not by the health needs of the community. If we like it, maybe we’ll stay.
Before moving to rural New Mexico, I had been itinerant. Medical school on the East Coast. Residency on the West Coast. Locums abroad. So I expected to stay for 2 or 3 years — a tenure that seemed respectable to me. It was not the answer my patients wanted. I rationalized my defensiveness. Why did turnover matter if the care was good? My colleagues in big cities changed jobs after a few years, too.
As I started my practice, the patients seemed complicated: diabetes, rheumatoid arthritis, cirrhosis, often all three. I was grateful they’d had a series of very good doctors. Their problems had been worked up, and the plans were clear. They’d had their cancer screenings. When it was indicated, they were on aspirin and statins. Hardly any were on long-term opiates.
In my first month I diagnosed a patient with hyperthyroidism. “Where’s the nearest endocrinologist?” I asked a veteran internist.
She was puzzled. “Why would you refer? Can’t you order the ablation?”
I learned to adjust my care to the geography. Some of my patients live hours from our hospital, on dirt roads become impassable in thunderstorms or snow. The nearest tertiary care hospital is another 3 hours away. We don’t refer often. If my patients do need a specialist, they go for a visit or two — I can always e-mail the rheumatologist or cardiologist if I have a question about adjusting their treatment.
I appreciate the continuity. I see my patients in our hospital and back again in clinic. I don’t need to request stacks of records from when they were septic, with diabetic ketoacidosis. I was in the ICU with them, ordering their antibiotics and insulin drip, explaining their condition to family members who are also my patients.
Caring for entire families helps me understand my community. I know that a patient is stressed because her son struggles with alcoholism: I’ve admitted him several times with pancreatitis. I know another patient can’t focus on her diabetes because she is still grieving her mother’s death: for years she wheeled her mother into my clinic for monthly appointments. When a teenager returns from a first year at college and asks for birth control, I remember her mother crying in my office months earlier, overwhelmed with pride and worry at having her first baby move so far away.
The patients weary of explaining all this — their tragedies, triumphs, and transformations — to a new face every few years, no matter how bright or kind that new face is. Seven years in, I understand why my patients would be disappointed if I left. As their doctor, I would be, too.
I’ve seen plenty of doctors cycle through. Smart, sincere, and hardworking, they came for a year or two or four — to pay back loans, to gain experience before fellowship, to have an adventure before settling down. Their service is no small thing: we depend on them. When I see Dr. C.’s copperplate handwriting in patient charts, I remember her warmth and meticulousness. When I use the clinic ultrasound, I see the reams of forms Dr. W. used to justify its purchase. I wistfully think of Drs. B. and D., a married couple of fun, razor-sharp clinicians who taught me a lot about medicine and parenting over 2 years. And I have a small, dusty bottle of sweet-tea–flavored vodka on my shelf from Dr. H. He left 6 years ago and gave it to someone else, who left and passed it along to me. Although the vodka is not to my taste, I like the reminder of Dr. H. He still recruits for us, sending us residents from his academic post.
Like my patients, I weary of explaining my history to new colleagues year after year. Also like my patients, I am immensely grateful for the physicians who have been here longer than I. We doctors are a close group. We rent housing from the hospital on its adjacent compound. We gather for potlucks and barbecues. Our children play together. I have knocked on a neighbor’s door at 10 p.m. to borrow a cup of sugar.
So, like my patients, I tire of saying goodbye. When doctors leave a remote practice, they go far away. Getting together with them involves airlines, time zones, and unsettled feelings. There is guilt for the person who left, insecurity for the one left behind. I feel it acutely: Are they really happier somewhere else? Should I leave too? It sounds nice to live in a neighborhood with Trader Joe’s, high-speed Internet, and baby-sitting grandparents.
Now, before I make friends, I gauge how long someone will stay. I learned this move from my patients, though I’m not yet as blunt. I remember how much “How long will be you staying?” irritated me. Instead, I observe: Do they plant a garden, spruce up the hospital’s house, adopt a stray dog? I hesitate to pull up a chair unless they’re going to lay down some laminate floors and stay awhile.
Patients still ask me The Question at least twice a day. “You’re not leaving soon, are you?” My smile comes naturally. I feel valued. I tell them honestly, I have no plan. I don’t tell them that I’m undecided about buying a new dining-room table. Mine is falling apart, but I’m torn between buying a nice one that fits this space and getting a cheap one. If I move, I might want something different in a new house.
I talk it over with my friend as we walk our dogs in the evening. Her eyes widen slightly, but she hesitates only for a second. “Buy a nice one for this space,” she says.
Disclosure forms provided by the author are available at NEJM.org.
From the Northern Navajo Medical Center, Shiprock, NM.
1 Rosenblatt RA, Chen FM, Lishner DM, Doescher MP. The future of family medicine and implications for rural primary care physician supply. Seattle: WWAMI Rural Health Center, August 2010 (https://depts.washington.edu/uwrhrc/uploads/RHRC_FR125_Rosenblatt.pdf).
2 Institute of Medicine. Quality through collaboration: the future of rural health. Washington, DC: National Academies Press, 2005 (http://www.nap.edu/catalog/11140.html).
4 Goodman DC. Linking workforce policy to health care reform. Invited testimony to the United States Senate Committee on Finance, March 12, 2009 (http://www.dartmouthatlas.org/downloads/press/Goodman_Sen_Fin_2009.pdf).