USAF Maj. Kaitlin Peace MD (CAMED’14) is stationed at a 25-bed military hospital in Anchorage, Alaska. Photo by Joshua Corbett

Health & Medicine

The Rewards of Working as Rural Docs

Doctors enjoy playing a vital role in the lives of underserved rural residents

For most physicians, the next step following residency is a position at a hospital or private practice in an urban or suburban area, sometimes paired with a career in academia. Only an estimated 11% of all physicians choose to work in rural areas, and as a result, the United States is approaching a crisis point in rural medicine. Many physicians are retiring or moving away, with diminishing replacements and a population whose health is decidedly worse in all the major benchmark diseases than populations in metropolitan areas. 

Boston University Chobanian & Avedisian School of Medicine alumni who serve in rural communities say that too few doctors have experienced the reality of healthcare work in nonmetropolitan settings, and they dispute the characterization oflower pay, longer hours, and a less challenging career path. They are convinced that the benefits of being part of a small community-living among those you serve and being appreciated for making the choice to play a vital role in their livesoutweigh the drawbacks.

The Many and Varied Rewards of Rural Practice

“I think a lot of people think a rural practice means I’m living in the middle of nowhere for lower pay,” says Frederick Powell (CAMED’ll, PhD’ll). He points out that his pay as an anesthesiologist at Moultrie, Georgia’s Colquitt Regional Medical Center is better than what was being offered in larger, urban hospitals; the cost of living is lower, the hours are less taxing, and his commute is a relaxing, two-mile drive.

Powell also was pleasantly surprised by the level of community involvement made possible due to his increased free time. “Most of us are so busy in our medical practice that we do medicine, go home, wake up the next morning, and try to recharge,” he says. “But I’m on a variety of boards, and I meet with community leaders. People are appreciative that I choose to spend my time practicing medicine in their town, and they try to do their best to make sure that I recognize that it’s my town, too.”

Serving the Underserved and Maintaining Work/Life Balance

Not everyone wants the fast pace and busy lifestyle of an urban physician. Alumni say they choose rural locations for a range of reasons, one of the most important being what drew many to BU as medical students in the first place-the sense of purpose that comes with directly addressing the disparities in healthcare for marginalized and medically underserved people.

The benefits of an improved work/life balance, easy access to nature and the outdoors, and sometimes, the financial incentives of better pay and a lower cost of living than what metropolitan practices or hospitals offer are also considerations.

“One of my goals going into medical school was to treat underserved populations,” says David Veltre (CAMED’13), an orthopedic surgeon at Southwestern Vermont Medical Center, a regional 99-bed hospital in Bennington with five operating rooms.

Family considerations weighed heavily when Veltre and his wife Julia Keosaian (SPH’ll) decided he would accept his present position and live in the nearby college town of Williamstown in western Massachusetts.

“I took the job because we loved the area,” he says. “Just being in the proximity of the mountains, lakes, and parks, with outdoor activities like skiing and hiking so close by, has been wonderful for our family.”

“People come to rural areas because they want to have a good work/life balance,” he adds. “We all want to work hard, but we also realize that there are other important things in life.”

Veltre is the only hand surgeon in the lower third of Vermont, from New York State on the west to New Hampshire on the eastern boundary. He knows there is a shortage of primary care physicians and that long waiting periods to become a patient of a primary care practice leave many so discouraged that they stop seeking medical care for health problems that, ultimately, are much worse when treated at the hospital.

Health Challenges Disproportionately affect Rural Areas

All but one of Vermont’s 14 counties have a federally designated Health Professional Shortage Area (HPSA) where there are insufficient providers-MDs, DOs, physician assistants, and advanced-practice RNs-to care for the population. The HPSA designation allows providers working in those areas, as well as Federally Qualified Health Centers and Rural Health Clinics, to access benefits and incentives such as bonus payments for Medicare services, National Health Service Corps (NHSC), the State Loan Repayment Program (SLRP), and the J-1 Visa waiver program. 

With fewer people, one would expect scaled-back services, but the difference is starkly disproportionate when it comes to healthcare. According to the Health Resources and Services Administration, there are just 13.1 providers per 10,000 people in nonmetropolitan areas, and 31.23 per 10,000 in metropolitan areas.

For specialists, the disparity is much more pronounced, with 30 per 100,000 people in rural communities as compared to 263 per 100,000 people in metropolitan areas.

“I think our hospital does the best they can, but for specialized care, people are travelling long distances,” says Emily Nelson (CAMED’14). Nelson lives with her husband Ben (CAMED’l6) and their two children in the woods of Camden in rural midcoastal Maine, “where the mountains meet the sea.” Like Veltre, the Nelsons wanted to find a better work/life balance.

“I’m a little too laid back for the city and academia,” says Emily. “It’s really a wonderful place to raise a family. Very idyllic. The kids spend summers swimming the lakes. The shoulder season we hike; the winter we ski.”

“We are not rural heroes. Thanks to our degrees from Boston University, we are able to live in a spectacular part of the world and have consistent, meaningful work,” she adds.

Even in such an idyllic setting, healthcare challenges exist. The US is still a profoundly rural nation, with nearly 81% of the population living in urban areas that take up only 3% of the country’s land area; the remaining 20% occupies 97% of the land. Nonmetropolitan areas have higher rates of death from cancer, heart disease, and other major causes, yet have one-third the number of physicians per 100,000 compared to metropolitan areas. Coincidentally, nearly 62% of HPSAs in the US are in rural areas.

Treating Generations of Families

Emily Nelson is a physical medicine and rehabilitation specialist helping patients with stroke, spinal cord injury, and neurological conditions reach their functional goals at a clinic in Rockport, Maine, a town with a population under 4,000. Primary care in her area is difficult to access, and it’s hard to recruit and retain specialists, nurses, medical technicians, and other staff.

“I’m a one-woman show, really,” she says. “It’s a bit of a struggle to do the things I do. I see things in a much more unmanaged state than you do in Boston.”

Since the availability of specialists varies depending on who the hospital has been able to recruit, Emily occasionally reaches out to the BU alumni network for medical specialty advice.

“You’re at the mercy of who the hospital has been able to hire and what those doctors are comfortable treating,” she says. Some physicians will take on cases beyond their specialty, read the literature, seek advice from specialists outside their practice, and widen the scope of diseases and injuries they’ll treat. Others just ship them out.”

Ben Nelson is a general surgeon at the 25-bed Waldo County General Hospital, a Critical Access Hospital (CAH) in Belfast, Maine, a city with around 7,000 residents. A rural hospital designation made by the Centers for Medicare & Medicaid Services (CMS) in response to the closure of over 400 rural hospitals nationally during the 1980s and early 1990s, a CAH is designed to reduce the financial vulnerability of rural hospitals and provide higher levels of Medicare reimbursement, flexible staffing, grants, educational resources, and technical help.

Ben is one of three surgeons at the hospital. Lacking a lot of surgical subspecialties, they perform a wide variety of operations-and the locals are grateful they are there.

“Patients don’t want to travel for surgery. They want to stay in their community, and we feel very fortunate to be able to provide many of the services they need,” he says. “A lot of the families up here have been here for generations, and we see a lot of people with the same names by treating generations of one family.”

He finds building relationships within a small rural community to be very rewarding. When patients call the hospital, the surgeons answer the phone. The heartfelt ways their patients show their appreciation-jars of maple syrup, pickled green beans, apple butter, knitted items for him and his family-are especially touching.

He’s on call more often than he would be in a city rotation, but the daily hours tend to be better, providing opportunities for him to occasionally drive his daughter to school and be home to help with dinner. Still, the job can be stressful.

“There’s less help than in the city, especially with surgical cases that happen in the middle of the night,” he says.

Trading urban roots for the desert Vardan Papoian (CAMED’l4, SPH’l4), lives in Helendale, California, a small high desert town of around 6,000 whose population center is twin subdivisions of relatively new homes clustered around two small adjoining lakes and surrounded by a brown flat desert landscape ringed by mountains.

But Papoian is not a returning son of the desert, having grown up in decidedly urban Hollywood, California. Following his residency at Georgetown University, he and his wife wanted to move back to California with their four children to be closer to their families in Los Angeles. Establishing a practice in the high desert of San Bernardino County allowed him to care for a medically underserved community.

“[The high desert] had a big population boom over the past 10 years as the [California coastal home] prices kept going up, but the healthcare infrastructure that supports that population has been slow to catch up,” Papoian says. “We have only a handful of specialists.”

A Struggle to Attract and Retain Specialists

“We have the population, but we don’t have the appeal of a city,” he said. “When you try to get younger, new graduates from their residency to come establish a practice here, it’s not appealing to them because it doesn’t have the nightlife or the extra advantages of a city.”

Others, accustomed to the urban hospitals they trained in with specialists always available for consultation, are put off by the lack of experts they can call on when they encounter a difficult case.

“They think about who’s going to help them out if they run into a complication,” he says.

The only general surgeon for hundreds of miles, Papoian works out of nearby Barstow. Where there were once three specialists working in the city, he’s now the only one. There are just three urologists in the entire high-desert area serving over 300,000 people, and a desperate need for primary care physicians.

He enjoys the challenge oflearning new skills and taking on cases that involve research and consultation with other specialists, welcoming the opportunity to return to what a general surgeon used to do. Papoian was one of the few in his class who chose to become a general surgeon, a reflection of that role diminishing in recent years as specialists have assumed many of the operations the general surgeon once performed. 

In such a small community, Papoian is widely known and recognized. He recalls standing in line in the local department store in his scrubs-which would hardly draw a glance in Boston-when a father looked his way and told his daughter that if she studied hard and went to college, she could be a doctor. He sees patients at work at the local shop, gas station, and post office. “People see you in the community, going to the store, getting your car washed,” he says. “They have to consult with me about anything surgical because I’m the only one here.”

Exposure to Unique Cases

“There’s definitely more that falls into the wheelhouse of a general surgeon [in rural areas] than elsewhere,” notes Kaitlin Peace (CAMED’l4), a general surgeon in the Air Force who is currently stationed at a 25-bed military hospital in Anchorage, Alaska. “The number of things that you are able to do is going to be minimized in a big city because the referrals go to a subspecialty.”

Peace also is an on-call surgeon at the nearby Alaska Native Medical Center, a large hospital complex that solely serves indigenous Alaskans, many of whom hail from “The Villages,” isolated locations so remote that patients are flown in for treatment. Aside from the endemic problems of obesity, diabetes, and cardiovascular problems, she has seen unusual cases like the 10-year-old child with a large chainsaw wound that required a reconstruction of the chest wall.

“That was some of the excitement, for me, of going into general surgery-that I would be exposed to a breadth of things that I would be able to help treat,” says Peace.

Eliminating Financial Barriers to Rural Practice

Studies have shown that most rural doctors practice in the areas in which they grew up, or similar settings. They appreciate the values, strong sense of community, and natural beauty of such surroundings-and also understand the isolation, poverty, and chronic poor health that comes with decreased access to healthcare.

“It comes as no surprise that one of the best predictors of who’s going to practice in a rural area is that they come from a rural area,” says Joshua Wyne (CAMED’71, CAS’71), since 2010 dean of the University of North Dakota (UND) School of Medicine & Health Sciences and vice president for health affairs at the university.

Wynne is at ground zero for the multitude of issues impacting rural healthcare. Although the school, which sits on the border of Minnesota, is in a city of 59,000, it is surrounded by farmland and a third of the county is a designated HPSA, as are 41 of North Dakota’s 53 counties. About half of the state’s 784,000 residents live in nonmetropolitan areas, including 38 counties that are considered “frontier” with fewer than seven people per square mile.

“There are challenges no matter where you live, but one of the things that’s important [in a career in rural medicine] is a real commitment to, and excitement about, being in rural areas,” says Wynne, who was not born into a rural lifestyle himself. Originally from New York City, he moved to Long Island with his family, attended BU for six years in a combined undergraduate and medical school program, followed up with a residency in internal medicine and a fellowship in cardiology at Brigham and Women’s Hospital, then joined Harvard as an assistant professor before being named chief of cardiology at Wayne State University in Detroit.

Wynne had spent his entire medical education and career in urban settings when he decided to shake things up in 2004 by accepting an administrative post at UND and ultimately, the university’s medical school deanship.

“This would be a real change,” he recalls thinking. “I liked learning about rural medicine, the challenge of rural healthcare delivery, and what we, as a state-based school, could do.”

Wynne’s goal as an administrator was to remove any roadblocks, particularly financial, that might discourage medical students and residents from taking a rural post. He took the lead in developing a program that required medical students to experience rural healthcare as part of their medical education and created rural residencies that sent surgeons into needy communities as needed. The school also introduced the incentive of 100% forgiveness for medical school tuition debt after five years serving a rural community.

“We want to remove barriers so that someone who has a passion for rural life and practice can actually do it,” he says.