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Monday Sep 25, 2017

Rural Practice Stretches Our Skills, Supports Our Families

My wife turned to me with her eyes brimming and said, "That's what I want!"

I have practiced in Valdez, Alaska, which has a population of about 4,000, for more than 20 years.

We had been visiting Valdez, Alaska, the community we would eventually settle in, while pursuing a third-year elective rotation away from my residency program. My daughter was 3, the same age as our host's daughter, Maggie. As our families walked through town, people everywhere greeted Maggie by name and with a smile. The warmth of the community was palpable and so different from what we were used to. We were so sold on the community during that visit more than 20 years ago that we moved here and never left.

Sadly, not nearly enough medical students and residents have had an eye-opening experience like ours. A recent Merritt Hawkins survey(www.scribd.com) suggested that few residents are interested in rural medicine. In fact, only 3 percent of final-year residents said they would prefer to practice in communities of 25,000 or less, and only 1 percent would prefer communities of 10,000 or less.

That is unfortunate, because rural communities have much to offer, especially for family physicians with young families. Rural medicine itself is fun, challenging, never boring, and allows family physicians to stretch their capabilities and talents. For a physician's family, it offers a safe place for kids to grow up and to build strong relationships within the community. It is also easier to be closer to nature and to enjoy the recreational opportunities that nature affords.

When I first moved to Valdez, the greatest challenge I faced was seeing my patients in settings other than the clinic or hospital. In a large metropolitan area, this happens occasionally. In a rural community, it happens all the time. I remember giving testimony in the AAFP Congress of Delegates that you know you live in a small town when you're standing in line at the grocery store and realize that you have examined every single person in front of you, including the cashier.

I've gotten used to it. I realized long ago that everyone pretty much looks the same from the neck down. Our brains remember faces, but not much else unless there is something that stands out, like an abnormal finding or a really cool tattoo. This makes living in a small community easier. Physicians in rural communities do not have the luxury of not taking care of friends or neighbors.

The kids complained when they were growing up that everyone knew what they were doing. This was true, and as a parent I found it incredibly reassuring. When my son was being dangerous on his bicycle, a concerned neighbor drove behind him in her car to keep him safe, then told my wife about it. When my other son held hands with a girl for the first time, I heard about it several times before I left the office. There is a saying that it takes a village to raise a child. In our case, it was a real village, not a metaphorical one. My kids and my neighbors' kids were watched over by our whole community.

I have heard students' concerns that there is less to do in a small town. My community may be unusual, but there are always things to do here. My wife and I enjoy nature and feel fortunate to have found a community that other people travel to because it's on their bucket list. We have wildlife in our backyard, mountains and rivers within city limits, fishing and kayaking that can be enjoyed after work. I have never understood why some physicians work in a place they hate so they can go somewhere they enjoy during their time off. Why not live and work in the place you go to appreciate nature?

Tonight, I am going to an art opening at the local museum, followed by a book club gathering. We have a high-school homecoming football game tomorrow. I delivered many of the boys on the team. Most everyone in town will be there. For me, the greatest part of my experience in my rural community has been delivering babies and watching them grow into adults, caring for them on the way, and being with them as they grow older.

Living and working in a rural community is a deep lesson in understanding human existence. Last night, I ran a code on a friend, and immediately after that I helped a woman I had taken care of since she was 3 deliver a healthy newborn.

The intensity of the experience of a rural family physician is not often discussed, but encompasses incredible joy, sorrow and love. It is not unusual to save lives as a physician, but unless you work in a rural community, you don't get to see those lives surrounding you at the grocery store.

So how do we get more physicians to communities like mine? We know physicians who train in teaching health centers are nearly twice as likely to practice in underserved settings(www.graham-center.org) compared to their peers who train in hospital-based programs. Since its inception in 2010, the Teaching Health Center Graduate Medical Education program has grown from 63 residency positions to more than 400 in family medicine and 700 in primary care. Unfortunately, the program will expire Sept. 30 unless Congress takes action.

The National Health Service Corps(www.nhsc.hrsa.gov), which puts health professionals in underserved communities through scholarships and loan repayment programs, faces the same deadline.

We can't afford to let these invaluable programs end. According to the Health Resources and Services Administration, there are already nearly 7,000 areas designated as having a shortage of primary care clinicians(datawarehouse.hrsa.gov). That number is staggering but not surprising when you consider that roughly one-fifth of Americans live in rural areas, but only one-tenth of physicians practice in such locations.

You can tell your legislators to support extending the teaching health center program using the AAFP's Speak Out tool. Please speak up for our small towns.

John Cullen, M.D., is president-elect of the AAFP.

Posted at 05:23PM Sep 25, 2017 by John Cullen, M.D.

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