	I practice in a 5-physician group. We are not the only practice in town, but we are the largest. Sadly, oncologists rarely suffer from lack of patients, so it is probably just as easy to have a full patient roster in a small town as it is in New York City. Additionally, we have 10 satellite offices in the communities surrounding Council Bluffs.

	Even in Corning, Iowa, the site of our farthest satellite, where the town population is about 2000, we have a local oncology-trained nurse who works with us and a local hospital to support our patients. The community is grateful for the care we provide, so treating those patients is especially rewarding. The other small communities we serve are similar in their support of the practice and the services available for patients. And for the patients who would never make the drive to Council Bluffs (a big city by their standards), providing local care is an ideal solution.

	regularly see my patients outside of the office. Almost once a day I run into a patient—at the gas station, post office, or a high school football game. If I am in the smaller communities, I’m almost guaranteed to cross paths with a patient. My life as a rural physician is not an anonymous one.

	My longest commute is the 3-hour drive to and from our farthest satellite office. I could have a driver and use the time for paperwork (though my nature would be to talk rather than work), but most often I drive myself and listen to books on tape. When I arrive home, I am rested; I no longer need to “decompress,” and the remainder of my day is mine. When my children, who are now in college, were younger, I did not miss a concert, sports event, or parent-teacher conference. I even have the option of flying my small plane to an outlying office, which likely would be a financial and logistical impossibility in an urban practice.

	I consult with my partners when developing a treatment plan for a patient or when a patient is not responding as I had expected. With the advent of the Internet, imaging results online, and electronic medical records, I can also easily consult with a colleague hundreds or thousands of miles away.

	My rotation on call is less frequent now, but it was not unreasonable even in the early days. I spoke recently with a colleague who is a solo practitioner in Wyoming. He has been on call for 8 years because he is the only oncologist in his town. When asked how disruptive it was to his family life, he remarked that it was a problem when he wanted a vacation. Beyond that, there were calls that came at inopportune times and calls that were no disruption at all.

	Some patients in rural communities will travel to the large, famous cancer treatment facilities around the country, often for a confirming diagnosis. My experience has been that when a patient receives a confirmation of the diagnosis I have made, he or she is reassured and our relationship improves. I have never felt minimized.

	So then, if being an oncologist in the country or city is similar once the examination room door closes, what is the difference? The difference is lifestyle. In Council Bluffs, for example, a $250,000 house is a big house. Dinner for 4 at one of the better restaurants is under $100. The numbers may be smaller, but the life is not smaller. If you want to live on an acre or more of land but do not want the longer daily commute that it would require in Chicago or Denver, a rural practice may be for you. However, I would be remiss if I didn’t mention that there are trade-offs. While on the popular culture front, books and magazines are as available in a small town as they are anywhere else, movies may open in the theater a week or two later, and finding legitimate theater may be a challenge. Regarding practical issues, worries about traffic, parking space availability, and long commutes are not daily concerns.

	As mentioned, a physician practicing in a remote corner of America has easy access to the medical community far beyond his or her town via modern technology. The days of a rural physician being isolated are long gone.

	A professor once told me, “When you are deciding on where to practice, bring your spouse. You will close the door and could be anywhere, but your spouse will have to live each day in the community you choose.” That may be one of the more important lessons I learned in medical school. The choice of where to practice is a family decision, not an individual one.

	Local education is a big consideration. It’s important to investigate the schools in a town that you’re considering relocating to if you have a family or plan to have one in the future. However, the days of small-town education being small or inadequate are gone. Medical schools are full of the sons and daughters of rural physicians who received a quality education at small-town high schools, attended first-class universities, and went on to some of the best medical schools in the country. My daughters are both at a nationally ranked university with plans to go to medical school; I have no doubt that they will get in. (I have not asked where they intend to practice, but I can guess.)

	A bigger issue may be employment for a physician’s spouse. Depending on his or her field of expertise, this may present the most significant logistical issue. Fortunately, many universities are in smaller cities and towns, telecommuting has made working from a remote office a viable option, and opportunities are more plentiful than they once were. It was not the case for me, but I suspect that for some, asking one’s spouse to give up a career is a lot to ask. Perhaps too much to ask. I doubt that there are any hard data on the subject, but the high incidence of a spouse (more often wives than husbands) working as practice managers, at least in the early days, may represent a common solution to the career question.

	Just as visibility for a physician in a small town is greater, so is visibility for a physician’s spouse and family. For my family, it’s simply been a fact of life that hasn’t had a negative impact on their daily lives. At least, not any that I’ve heard about!

	Economics also can play a role in choosing where to practice. Many rural practices, especially oncology practices, are experiencing difficulties because of under-reimbursement and patients’ inability to pay deductibles and co-pays. These issues are compounded for an oncology practice because of the high cost of cancer drugs and can often be so severe as to threaten the financial survival of the practice. When finances interfere with the ability to deliver care or with a patient’s ability to pay for care, physicians can find themselves dealing with issues beyond that of a clinical nature. Recent healthcare reform legislation does not provide any relief to this problem.

	An important factor to consider is pace—the pace of your practice and the pace of your life. If you view rural/small-city oncology and rural/small-city living as slow, dull, and lacking more than it offers, it’s not for you. However, if city life leaves you feeling breathless and stressed, the nonurban option may be a good fit.

Federal and State Incentive Programs for Rural Physicians

	The US Department of Health and Human Services (HHS) estimates that 50 million Americans lack ready access to primary healthcare, and that number is expected to increase in coming years.1 To help address this critical shortage, both federal and state incentive programs offer full or partial repayment of student loans to physicians agreeing to work for specified periods of time in underserved locations, known as health professional shortage areas (HPSAs). Most programs are open to physicians who serve patients in both rural and urban HPSAs.

	Programs vary by the amounts awarded, the number of hours and weeks a physician must practice to earn the award, and may require employment with a nonprofit healthcare facility, establishment of a sliding-scale fee schedule, or acceptance of specific insurance coverage options, such as Medicare or Medicaid, in order to be eligible.

	The National Health Service Corps, part of HHS, offers $50,000 in exchange for a 2-year full-time service commitment or a 4-year part-time commitment. Physicians must be employed by, or have applied to, an approved site. Individual states or healthcare agencies also may offer additional incentive programs.

Articles

There are multiple factors to consider when deciding whether to practice in an country or a city setting

Robert W. Warner, MD

Articles

City Oncologist or Country Oncologist?