I sometimes wonder how much of me is the last of the old traditional country doctor and how much of me is the doctor of the future. Can you be both? - —John Berger, A Fortunate Man: The Story of a Country Doctor
Despite the regional successes of programs designed to encourage students to choose rural medicine over the past several decades,1–3 rural family medicine residencies and practices continue to have difficulty attracting applicants and practitioners. In 2004 alone, 25 of 51 rural training track (RTT) positions offered in the National Resident Matching Program went unfilled in the Match. From October 2002 to present, a dozen RTT family medicine residency programs have closed. Innovative, effective, and affordable strategies to foster students’ interest in rural practice are more important than ever.4
One of the difficulties many students face in choosing rural training or practice is a lack of understanding about the nature of either, and a tendency to focus more on potential risks rather than rewards. Rural training and practice are often viewed as isolating, marked by long hours, and financially unrewarding, although studies document relatively high levels of physician satisfaction with rural living, and in comparison to urban practice, greater clinical autonomy, a wider variety and complexity of medical conditions, a relationship with patients more personal in nature, and greater opportunity to fill a need or provide a critical service.5–8
An Innovative Retreat
We wrote this report to relate how we used literary sources to trigger discussion and reflection among a group of learners participating in The Ohio State University College of Medicine’s Rural Health Scholars Retreat, an annual gathering of medical students with an interest in learning more about rural generalist practice. The goal of this particular retreat was to enable participants to listen, through readings, to the voices of practitioners who had preceded them, reflect on the relevance of these voices to their own possible futures, and explore, through writing, their own impressions of doctoring in rural settings, acquired either during rural clerkships or from personal experience.
In 2004, 11 medical students (two in their fourth year, four in their third year, two in their second year, and three in their first year) from three of Ohio’s medical schools attended an annual two-day retreat, the second in the Rural Health Scholars program, a series devoted to developing rural generalist leadership. Five of these students intended to specialize in family medicine; four were considering specializing in family medicine; four, obstetrics–gynecology; two, internal medicine; two, internal medicine–pediatrics; one, emergency medicine; one, pediatrics; and one, psychiatry. (As these numbers suggest, some of these students expressed interest in several specialties.) Nine of the students were women, an encouraging distribution given many female physicians’ concerns regarding rural practice.9,10 Also interesting in light of data showing rural origin to be a strong predictor of student interest in rural practice,11,12 only four of the 11 had been born or even raised in rural places. Two faculty members (including RL), a family nurse practitioner, the residency coordinator, four residents from the Mad River family practice residency program, and a guest speaker (JS) also participated.
Participants attended a two-hour talk on rural medicine based on a review of narratives by and about country doctors presented by one of us (JS). The purpose of this presentation was to summarize the texts and identify passages of potential relevance to retreat participants; demonstrate a connection between the accounts offered in literary sources and the participants’ own experiences; and show how personal writings of rural physicians can open up discussion of sensitive lifestyle issues and doctor–patient dynamics in a small community. Next, learners participated in small-group sessions where they directly studied excerpts from the texts, identified major themes, and compared them to their personal knowledge about rural practice. Finally, learners completed a writing exercise in which they were asked to reflect on a significant personal experience involving rural medical practice.
In total, we studied 17 sources: seven memoirs,13–19 three biographies,20–22 three fictional accounts,23–25 one book-length essay,26 an Internet article,27 the classic Life Magazine photojournalism essay on a country doctor,28 and a collection of medical students’ prose and poetry.29 Geographic regions represented in these texts were rural areas of the Northeast, Midwest, South, Canada, and Great Britain. In the texts, the physicians’ times in practice ranged from two to 50 years (with a mean of 19.87 years). Practice time spans stretched from 1937 through 2001, and six of the texts were published between 2000 and 2004. Each of the doctors in these texts had a practice of about 2,000 patients, saw between 15 and 40 patients daily, and was responsible for the health care needs of several villages and towns. The types of practice were often solo, but also included partnerships and small-group practices of three or four physicians. House calls were common. The patients in these practices were often poor and worked as farmers, fishermen, laborers, and factory hands. Their illnesses were typical of those seen in any family practice.
The students’ discussions focused on two main themes: characteristics and attributes of rural communities and patients, and the “nature” of rural practice and rural practitioners. Below we present a brief summary of students’ conclusions. However, it is important to note that we intend neither to assert that all rural communities, patients, and physicians are characterized by the qualities noted below; nor to claim that only rural communities, patients, and physicians evince these attributes. Rather, we merely present what the students themselves recognized in the texts as important and relevant to their experiences in rural practice, and what they felt differentiated rural from urban and suburban practices.
Students expressed deep-seated loyalties toward and identification with rural communities. A minority were concerned about the potential narrow-mindedness and insularity they might also encounter. In the text-based discussions, learners were surprised and pleased to see that authors mirrored both their appreciation for “rural folk” and their apprehensions. Students concluded that their views of rural inhabitants as self-reliant, proud, resilient, hard-working, God-fearing,13,27,29 generous despite widespread poverty,14,20,22 and helpful toward both neighbors and strangers,14,15 as well as unemotional, self-deprecating,24 sometimes stubborn, suspicious of outsiders, even cantankerous23,29 were fair assessments supported by the readings.
Students also recognized in these texts patients’ attitudes toward illness that they had personally encountered on rural rotations: minimization and endurance of even the most serious injuries and disease,16 reluctance to ask for help,13,16,26 resistance to being asked personal questions,14 reliance on the “family doc” rather than specialists,13 and valuing the ability to function in one’s family and work over valuing personal health.15,26 However, students agreed with the texts’ authors that, over time, it was possible to interpret signs and symptoms within a framework of patients’ stoicism, negotiate treatment and hospitalization around work and harvest requirements, and slowly but steadily win patients’ trust.
Above all, students were attracted to rural practice because of the opportunity it offered to form uniquely intimate and multidimensional relationships with patients, a perspective reflected in the texts and confirmed by more recent reports.30,31 One faculty participant expressed it as “Less people, more connections.” Students looked forward to true continuity of care—for example, the possibility of caring for whole families across generations—and were encouraged to see precisely this kind of care represented in their readings. Students also believed that rural practitioners had more leadership potential within their communities than did urban practitioners, but at the same time were required to make significant personal sacrifices of time and privacy, a view for which they found textual confirmation.17,20,28 In the words of another faculty member, “You have to be comfortable living in a glass house.” It was this dimension of in-depth, interwoven, multifaceted, and overlapping relationships that students felt most strongly distinguished rural from urban or suburban practices, and their readings tended to corroborate this perception.
In reflecting on the texts, learners noticed that, with two exceptions, they described the practices of male physicians, and wondered how the experiences of these ruggedly independent men might apply to women who, as noted, composed the majority of retreat participants. But both male and female participants identified with the qualities of ingenuity, self-sufficiency, boldness, and creativity they were reading about.16,17,23 They also were drawn to the willingness of these medical practitioners to be comfortable with a larger range of procedural competencies and clinical responsibilities than is generally the case in urban practices.32 Further, students identified with the rural lifestyle described, the sheer beauty of the natural environment,18,26 the chance to enjoy outdoor sports18,21 and engage in activities such as farming, raising livestock, and generally living closer to the earth.21 Finally, students appreciated and were reassured by accounts of “outsiders” (foreigners,14,15 Jews,17,26 single women at a time when the lack of a husband was frowned upon,22 and medical students from the suburbs and cities29) who seemed to find places in supposedly xenophobic rural America.
For all the rewards of rural practice, students were apprehensive about its costs. They mentioned the fear of being chronically overworked to the point of mental, spiritual, and physical exhaustion and noted that the physician–authors also complained of such pressures.13,17,22,28 Other texts described periodic deep depressions in their authors.18,19 Alcoholism was mentioned,17,25 and a few sources referred to the potential inferiority complexes of local medical doctors.18,26 The honesty of the authors proved extremely useful in helping students to articulate their doubts, enabling authentic discussion. To some extent, students were reassured by comments from more experienced residents and faculty at the retreat. Equally powerful, the physicians who wrote about their experiences in rural practice agreed that, no matter what the stresses, it was in this environment, among these people, that they learned to become true doctors.13,15,17,18,20
Finally, students concluded that there seemed to be considerably more continuity than discontinuity in the practices described. Whether a text portrayed rural medicine five or 50 years ago, and despite advances in medicine and medical technology, the essential nature of the practices seemed to change surprisingly little over time. This conclusion of retreat participants is substantiated post hoc in a recently published book about contemporary country doctors.31 Its themes of multilayered, deeply caring doctor–patient relationships, ruggedly independent living, and the valuing of family and community parallel with little disparity the texts we studied. The notable exceptions are consistent references by present-day rural practitioners to their overall financial stability despite the inevitable inroads of managed care. Perhaps because they were at an early stage of their training, students did not appear to have many questions about financial issues, although they did comment that they expected to have more freedom from managed care constraints in rural practices than in urban ones.
During the retreat, learners also generated personal poems and essays in response to prompts from retreat faculty about rural doctoring, which they then shared with their fellow participants. This process produced a lively discussion, and learners appeared to find the exercise enjoyable and engaging. Several of the poems were explicitly situated in rural contexts. Others portrayed patients who bore many of the characteristics of independence, stubbornness, and stoicism exemplified by the patients in our readings. Participants’ writings also emphasized the importance of physicians’ emotional connectedness and sense of commitment to patients.
Program evaluations indicated a high level of satisfaction. On a scale of one to five, with 1 = strongly disagree that the retreat was useful and 5 = strongly agree that it was useful, students rated their mean overall satisfaction 4.7. They reported that their expectations for the retreat had been met or exceeded (mean = 4.9); they had a deeper appreciation for the relevance of literature to professional development (mean = 4.8); they had a more refined understanding of the challenges and rewards of rural practice (mean = 4.4); and they had acquired new personal insights as a result of this experience (mean = 4.4). There were no responses lower than “3.”
Written comments about the retreat revealed that it had helped solidify participants’ commitment to rural practice:
[I learned] that I am not alone! [in wanting to pursue a career in rural medicine]. What a relief!
Throughout the retreat my desire to become a rural physician was strongly deepened by all that we read and talked about.
Another important theme expressed in participants’ comments was the value of reflection in rural practice:
In order to deal with my emotions and concerns with my life as a physician, I really need to take time to reflect either through writing or just moments of pause.
I also realized more of the expectations that I will be faced with in the future as a country doctor and feel that through reflective insight and through the power of writing, I will better meet and even exceed all that will be expected of me.
A Promising Approach
From this novel marriage of the humanities and rural medical education, we and our colleagues involved in the retreat learned that narratives about country doctors can provide a revealing and intriguing entry into psychological and social aspects of rural life and rural medicine that might not otherwise be accessed in more formalized, academic approaches. Most important, learners were able to engage in an extended reflection on the nature of the relationship between physicians and patients in rural settings and why the experience of rural practice may be challenging, but also uniquely gratifying.
Based on our experience, we conclude that similar programs could be mounted without great difficulty and might offer rural residencies an additional tool for attracting students or confirming the decisions of those already leaning in a rural practice direction. Interesting texts describing rural practice abound. While it was helpful to have a facilitator (JS) familiar with techniques for integrating literary sources into discussions about medical practice and doctor–patient relationships, the richest and most insightful aspects of the retreat consisted of the small-group discussions among the participants themselves, and the opportunity to reflect in writing on specific incidents and occurrences in their own lives relevant to rural practice. What did seem helpful structurally was advance identification of pertinent portions of texts to be used as the basis for reflection and exchange, as well as demonstrating for participants how even historical works could speak directly and meaningfully to present experience. Future programs incorporating these types of first-person accounts should include contemporary versions that address important issues such as the impact of managed care, the financial viability of rural practices, and how social changes in rural parts of the country are affecting core aspects of rural medicine.
The authors would like to acknowledge support for this project from the Rural Health Scholars Program. The Rural Health Scholars Program is made possible by proceeds from the Dr. J. Martin Byers Memorial Endowment Fund at The Ohio State University College of Medicine. This fund was established by the family of a physician who practiced in rural Ohio.
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