Pros and Cons of Being a Country Doctor

In the past few years, as I went along my days as a country doctor, I have been writing down the pros and cons about this unique job. I’ve also received some very good questions on my social media platforms from medical students and residents. I’d like to compile a Pros and Cons list here for the readers who are, or know somebody who is, considering this career. I wish this was readily available when I was pondering about this career path as a resident.

A Country Doctor is a physician who works out in the country, or rural areas. The term was popularized by W. Eugene Smith in his photo essay in 1948 LIFE magazine. He shadowed Dr. Ernest Ceriani in Kremmling, Colorado, who was the only provider for an area of about 400 square miles, with over 2,000 people. The intimate photos taken by Smith showed Dr. Ceriani’s incredible and tireless duties as the country doctor, where he saw people in his clinic, patient’s homes, back of the cars, and the hospital. The country doctor didn’t seem to have many days off, and was always on call for emergencies even on his days off.

“His income for covering a dozen fields is less than a city doctor makes by specializing in just one,” LIFE’s editors noted, “but Ceriani is compensated by the affection of his patients and neighbors, by the high place he has earned in his community and by the fact that he is his own boss. For him, this is enough.”

Medicine as a whole has changed since then. So has country medicine. Today, us rural full-scope family docs are the closest thing to the original country doctor: attending clinic, delivering babies, performing C-sections, admitting and taking care of people in the hospital, conducting nursing home rounds, and providing hospice care. But unfortunately, we are a dying breed. In 2016, for instance, only 21% family medicine graduates wanted to deliver babies, but only 7% currently do. Similar situation exists for hospital/inpatient medicine. As 46 million people live in rural America, country doctors are not only essential, but also habe been shown to produce the same fetal and maternal outcomes.

Now that we have established the importance of country doctors, let’s dive into the Pros and Cons of being one. Warning: I am being very real in this list, don’t proceed if you aren’t ready for the truth!

Pro: Clinic is never boring, if you like to solve problems. People come in for all sorts of interesting problems: anything from a cockroach in the ear, to IUD placement, to a retained bullet they want you to dig out (true story). You see all the organs of the body in all the sexes, and you talk about sex, a lot. People tell you about their deepest trauma, and they also share exciting good news with you. You get to put stuff in, and take stuff out. You work people up for hyponatremia, you cast broken arms, you perform circumcisions (if you would like), and you help kids come out of their shell by treating their acne (with Accutane if you want).

Con: People bring up too many issues with you, precisely because of the broad scope of your practice. While you really want to, and can help, the “oh, otra cosa” when your hands are on the handle of the door at the end of a visit, gets old very fast.

Pro: You get to take care of pregnant people, deliver their babies, and take care of the babies, too.

Con: While others who deliver babies (midwives, OB/GYN providers) during their shifts only, you do it while maintaining a full clinic schedule. And when others are post-call after their shift, and can enjoy a beer, you still go to work the next day even if you spent all night delivering a baby. There is no post-call days for you. And if you have pregnant people over 36 weeks, as a general rule, which you will all the time, you probably shouldn’t drink any alcoholic beverage even after work, because you are on-call for your patients, 24/7. (I haven’t turned my phone off or had a drink after work unless away on vacation for about 3 years now. But I am also a light weight when it comes to ETOH.)

Pro: You form longitudinal relationship with a whole family as their family doctor. And you are one of the most respected members of your community.

Con: You can’t go to the grocery store without seeing a dozen of your patients. And some of them might want to stop to ask you questions, and some might be embarrassed to see you, depends on what you saw them for. Small town life isn’t for everyone. For somebody like me, who grew up in one of the biggest cities in the world (Beijing), it was definitely an adjustment.

Pro: A large proportion of patients who come to your office will get better without intervention, and sometimes, just reassurance alone is good enough. (Less is more.)

Con: But you still have to worry about (infuriating) prior authorizations, (totally useless) quality measures, and (absurd) Medicare wellness exams. This is a good place to point out that it’s important to work for an organization whose leadership are medical people, not just strictly business. So that the leadership understands, outside of all the numbers and charges, what it means to practice good medicine. In other words, they see you as a provider, not as an quality measures/RVU producer.

Pro: You are “The Doctor” in your community, no one really cares where you are from, where you went to school, did residency, and published how many papers. Patients and colleagues see you for you, and your reputation depends on the qualify of care you provide.

Con: (This is a big contributor to burnout.) The rest of the world still cares about all of the above. The outside providers from the academic centers whom you try to consult, oh the prestigious outside providers! Talking to them is like talking to your attending for the first time in medical school: you have to prove yourself to not be smart or else you are assume to be an imbecile. It’s really not them, it’s the culture of medicine. They are in this academic world where the hierarchy and the shame culture are still alive and well. While you live in a world where people treat you like equals, they don’t. They also like to assume you have all the time of the world to wait on the phone to speak to them. The reality is, you are the one who is seeing 30-40 patients a day, on call, delivering babies and admitting patients on your lunch break. Some outside consultants like to “badmouth” you in front of your patients when they see them (true experience). Little do they know, your patients probably will take your side, because after all, you have taken care of their entire family, and have had a much stronger relationship with them.

Pro: Despite common belief, you CAN make good money as a country doctor, probably more than the urban family docs, and even pay off your loans much faster than others because you work in rural America. Generally, naming numbers is frowned upon in medical careers (which needs to change, really). So I don’t want to be too explicit. But I have some colleagues who make the higher half of a six figure each year by just being a country doctor.

Con: The productivity model enables you to make good money, and primary care is very well positioned to adopt this model. But a high RVU count doesn’t equal good quality of care, and it might even be inversely correlated to work-life balance. The more you produce, the more notes and work you will do, and the less time you get to spend outside of your job.

Pro: You have very few people to report to as the country doctor of the community, most people around you look up to you for the ultimate medical decisions. Sometimes you get to precept advanced practitioner colleagues, and teach medical students and residents, if you are lucky.

Con: There is probably no back-up for you when things go south. When you are on-call, you are probably the solo doc on call for that day. That can be a little scary sometimes.

Pro: Your country nurses in your country hospital treasure you as a doctor and care about your sleep, and they try very hard to not call you in the middle of the night, or at all. Most of the time, when I have to get woken up at night to catch a baby, I literally roll out of bed, drive to the hospital, step in the room, and catch a baby. The nurses have managed the patient on their own until crowning.

Con: Home calls are not for everyone. If you are the type of person who cannot fall back to sleep after being woken up for a brief conversation with a patient in the middle of the night, or if you are too anxious to go to sleep knowing your phone might ring any time, this job might not be for you.

Pro: You can find a job anywhere you want. There simply aren’t enough of people like you. You just choose a geographic location, and cast your net. And you probably will have a lot of autonomy of your schedule and your practice, which contributes to work satisfaction.

Con: Your colleagues might not practice to the same standard as you do. While big academic centers have clear practice guidelines and algorithms, your organization might not. You might find yourself frequently disagreeing with the practice of another provider, because the upkeeping of medical knowledge in rural medicine is almost entirely up to each individual practitioner. This can become frustrating.

Lastly, here are some other commonly asked questions:

Q: Do I need a fellowship to be comfortable with vaginal deliveries and/or C-sections?

A: If your residency prepares you well for low risk vaginal deliveries, with some instrument-assist delivery experiences, you might not need a fellowship for this part. Some FM residencies are unopposed, with lots of deliveries, all of which are for FM residents. Usually these are pretty good at preparing you for non-surgical obstetrics. But if you are interested in C-sections, you should consider a fellowship.

One thing I’d like to point out is, once you are OB fellowship trained, in rural medicine, you are regarded more like an OB/GYN than a FM-OB. So an organization might ask you to take OB calls, not FM calls. This might mean you have to give up inpatient medicine. OB calls are a totally different beast. I don’t have enough experience in that to comment on it, but I can’t imagine being on call for emergency C-sections.

Q: Work-life balance?

A: What work-life balance? (Sorry)

Q: What about research?

A: You CAN do research while in rural medicine. In fact, as the provider who sees the one of the highest volume of patients for the broadest scope of complaints, it’s almost your academic/moral responsibility to be collecting data. However, it’s not easy. You most likely don’t have allotted time for academic activities like in tertiary centers, and you might not even have access to an IRB. I don’t. In the past 3 years, I have published a few studies, all are utilizing a commercial IRB that luckily my work paid for. Even though I am on the faculty of a well known medical school, I am not able to utilize their IRB easily because I am not on site of their campus. And, I had to do research on the side, utilizing my own time. Although my work takes pride in my academic activities, I also know that they didn’t hire a scientist, they hired a practitioner.

Q: I am interested in administration/leadership role in my organization, do I need an extra degree like MPH or MBA?

A: It would be nice if you had one. But remember, you are a rare and valuable good, who is willing to practice, teach, and even lead in rural America. People would appreciate your willingness even if you don’t have a degree. You can always get one while practicing, and I bet you your work will sponsor you for this education if they know you are committed to working for them in the long run. Come to rural medicine willing to do and learn, this is more important than all the letters you might have already had behind your name!

This is by no means a complete list, and it’s based on my own experiences as a rural full-scope FM-OB provider. Another awesome blog post is by Dr. MaryAnn Dakkak on AAFP’s Fresh Perspectives. Comment below if you have more questions about the life of a country doctor, or if you would like to help me complete this list!