Rural Medicine and the Struggle for Patient Survival

In 1948, Life magazine published W. Eugene Smith’s landmark photo essay, “Country Doctor.”¹ The essay chronicled the life of Dr Ernest Ceriani, who served as the sole general physician for over 2,000 people across 400 square miles within the Rocky Mountains. As a generalist in rural America, he did a little bit of everything while frequently making house calls. His generalist practice included the usual infectious ailments, injuries, and obstetrics, but also the need to amputate gangrenous limbs, treat myocardial infarctions, perform his own lab studies, and even serve as patient transport.

Over time, Dr Ceriani developed generational ties with the communities he served. Anonymity was impossible, but so too was the community’s admiration for his unwavering presence and service. Such is the life of rural physicians, living and working in a rural community.

Today, rural America is struggling to sustain an adequate medical community to serve those who choose to live in nonurban spaces. In fact, 185 rural hospitals have closed since January 2005.² Nonurban patients and physicians represent a diverse and distinct group of an underrepresented population. Access to care is a significant barrier to patients in rural areas; racial and ethnic disparities, and underrepresentation further exacerbate outcomes for rural inhabitants.³

Almost 20% of the U.S. population lives in a nonurban location, while only 10% of physicians practice in these areas (see Table).⁴ Access to a urologist in nonurban areas is even more scarce. Approximately 10% of U.S. urologists’ primary practice is in nonurban areas.⁵

Table. Rurality Level of Primary Practice Location

A significant number of counties in the U.S. have no practicing urologist, with many contiguous counties without a primary site for a urologist. Figure 1 demonstrates the sparce nature of urologists in America.⁶

Furthermore, 50% of rural urologists are greater than 65 years of age, creating a situation where even fewer urologists will be available for rural care in the coming years.⁷ Serving this need requires innovative care models, but also more rural clinicians.

Life as a Country Urologist

I grew up in the late 1980s in rural America—Prairie du Sac, Wisconsin, to be exact. At the time, the village of Prairie du Sac and the adjacent Sauk City had a combined population of about 5,000 people, and they were primarily dairy farming communities.

After college, I lived in urban America and worked in the private nonprofit sector for 7 years before I found my way into medicine and urology. Twenty years after leaving, I was drawn back to my rural hometown, serving as the sole full-time urologist (Figure 2). Similar to Dr Ceriani, I find the connection with patients, colleagues, and the community as the bedrock to maintaining a strong physician-patient relationship with superb work-life balance. The environment promotes a sense of belonging by reducing the almost transactional patient interactions some of my colleagues lament. However, it is unlikely the rural location is what allows this to occur, rather it is the ethos we create by living and working in these nonurban areas.

Figure 2. Dr Grunewald pictured with two urology staff members, Kathy Greenwood, RN, and Lindsay Ortegren, RN, in rural America.

Other noteworthy benefits to rural practice tend to include improved air quality, easier access to green space, less traffic, higher pay with a lower cost of living, and less crime.⁸ You can also become intertwined within the community’s social structure, serving in a variety of leadership roles. You are valued.

Like any work experience, there are potential downsides, and nonurban settings are not immune. Younger physicians may prefer a more active nightlife that might not exist in a nonurban area. Anonymity may be diminished as you are often recognized within the community. Answering a random medical question or seeing a patient and their family at the grocery store is likely to occur. Your children will be known as the “doctor’s kid.”

Due to smaller practice sizes, call requirements are a common concern for rural practice urology. However, creative solutions can be structured to assist making coverage in rural systems reasonable and not burdensome. It is important to understand Emergency Medical Treatment and Labor Act (EMTALA) requirements regarding when call coverage is required. For some hospitals, call coverage for all specialties is also not required.

Case mix and colleague assistance are also concerns for individuals contemplating a rural practice. Rural urologists tend to provide more general urological care.⁸ Each individual must decide what types of cases they are willing to perform as resources may be more limited. For example, access to robotics, specialty services (interventional radiology, cardiology, colorectal, trauma, intensive care unit, pediatrics, etc), and even the skill set of other clinicians may limit what is best treated in a rural location. Personally, I have used these criteria in my solo nonurban practice to curate patients who will be successful in our system and refer those patients who need advanced care or would benefit from unavailable local technology.

Serving an Underrepresented Population

The country urologist serves a diverse role in the community we live and work in. Rural population size and the relative few degrees of separation amplify our community roles. As we consider diversity, equity, and inclusivity issues, it is important to view rural residents and clinicians as an underrepresented group requiring attention to meet their needs. One of the many ways we address disparities is by being present, supportive, and including the group within analysis to develop and implement specific action plans.

The AUA and others are working to address the diverse issues noted within the rural practice climate. At the basic level, recognition has been created. Data are accumulating. Action is occurring.

My work-life situation is not for everyone. I’m thankful for my tertiary-care colleagues who help manage complex cases and admit patients when I am not on call. They are also thankful that I manage patients locally, freeing up their time. However, making the decision to practice in a rural location can be difficult, particularly if students and trainees lack exposure to rural practice environments to better understand clinical and community dynamics. Continued action is needed to expand access to learning in these environments.

America needs more rural clinicians, including country urologists. Take a moment to ponder if rural medicine might be an option for you or individuals you help train. If so, reach out to a rural urologist to learn more—we might just be willing to make a house call.