It was recently reported that barely 10 percent of U.S. doctors work in rural health care. That number is continuing to shrink, while over 20 percent of the U.S. population lives in rural areas, and more than 80 percent of rural Americans are considered medically underserved.

There are many reasons why doctors, mid-levels, and other health care workers are avoiding rural practice opportunities.

The one I want to focus on today is “fear.”

Fear takes many shapes, but for doctors in rural practices, a chief and pervasive fear is the fear of not knowing enough clinically and thus making errors of omission, or not even recognizing a potential pitfall due to lack of access to knowledge.

For many non-medical persons, the “MD” degree is still seen as conferring some type of ultimate clinical knowledge, and many see physicians as medically all-knowing, or more accurately, wish and expect them to be. In today’s world, nothing could be further from the truth!

With the increasingly vast and exponential explosion of medical knowledge, no physician can ever hope to keep up with all the advances, even in their own field. For the generalist, the accelerating knowledge gap can be horrific. This is one reason why you see an increasing desire by many medical students for sub-specialty degrees or highly focused clinical specialties, where the knowledge expanse is something that can possibly be kept up with.

Now, apply that concern to a rural medical practice, where you may be the only general practitioner, OB-GYN, pediatrician, or mental health provider in your entire local area. You have no direct access to medical colleagues with whom you can confer or “curbside.”

Add to this dilemma the complication of many rural hospitals that, while facing increasing financial pressures with declining payer reimbursements and increasing difficulties in filling physician specialty slots, are having to cut back or close many service lines. These frequently include specialty, referral, or inpatient services. Over one-third of all U.S. rural hospitals are facing imminent threat of closure. These collateral complications leave remaining rural physicians with even less support, less access to consults and “curb-siding,” and an increasing loss of local referral capabilities!

It is well known that people living in rural areas die at higher rates than those living in urban areas. This fact only adds to the burden of fear among rural doctors that lack access to critical information and referral support prevents them from providing adequate health care.

A different story – urban centers

In urban and suburban medical practices with multispecialty services, there are numerous pathways and opportunities available to interact and receive on-site advice, information, consultations, and direction. I frequently avail myself of such opportunities. In my urban hospital doctor’s lounge, I hear conversations throughout the room almost every day about difficult cases, with others offering suggestions: “Have you thought of this?” or “You should consult Dr. Joe—she is the top expert on what you’re facing.” Many pundits now report that interprofessional collaboration, “curb-siding,” onsite access to referral specialists, and inpatient admission capability are critical factors in delivering optimal health care. These availabilities certainly provide the suburban or urban physician with a more secure sense of being able to deliver optimal health care.

While at rural facilities

In rural settings, as a doctor, you may have none of these opportunities and advantages. For independent-practicing mid-level providers, the isolation and fear can be even worse.

Thus, the fear of not knowing enough and having no readily available pathway for consultation and curb-siding, leading to clinical errors and possible bad patient outcomes, is a terrible fear, burden, and burnout accelerator (the opposite of a well workplace) for any physician or other provider.

That fear alone is more than enough to keep many physicians and others from entering rural practice.

Yes, some rural systems have been provided with potential referral patterns or linked to flagship or suburban and urban referral centers, but many others lack access to such resources. Even with potential access, it is often difficult to access support in real time, especially if you are only looking for advice or information, not necessarily to transfer a patient. Even more often, the rural physician may just have an undefined “gut feeling” or “hunch” that they may be missing something and need to just “talk it over” with a colleague who may be able to shed some light on these gut feelings and provide some insight or direction. None of this is available to the solo or isolated practitioner in many rural areas.

Thus, again, it is this fear of making medical omissions and errors, thus causing harm (“First, do no harm”), that leads many to shun rural practice. To add to this is the very real additional fear of a malpractice action and penalties for your medical “miss.”

Options to help reduce fear for rural doctors and increase rural practice attractiveness

Among options that states and other jurisdictions with large rural populations could create or expand to support decision-making and well-being among rural doctors, contributing to better patient outcomes and making rural clinical practice less fear-provoking and more attractive are:

• Provide platforms for peer-to-peer telemedicine (online “doctor’s lounge”) access for rural doctors to access consults and curb-siding opportunities.
• Provide access platforms to AI systems for obtaining curb-siding information and advice.
• Create, add, or expand state or regional referral center and teaching hospital on-site “outreach” clinics and visiting consultants to underserved rural areas and centers.
• Increase and support rural physician training programs.
• Enact malpractice tort reform for rural jurisdictions.
• Rural states and jurisdictions to create no-fault “bad outcome” patient expense coverage programs.

Summary

I am sure that there are additional options for improving support for rural doctors.

But if states and other jurisdictions with underserved rural populations want to retain the increasingly few rural doctors that they have and encourage more doctors to enter rural practice, they have to start taking more aggressive action in identifying and addressing issues that are keeping physicians from entering these rural practice areas and also work to provide optimal support systems to keep those few doctors that are currently in rural health care from continuing to leave.

Disclaimer: Opinions expressed are the author’s alone and do not necessarily represent the opinions of the author’s employers or affiliates.

Harry Severance is an emergency physician.