Sept. 17, 2014 – By Peter I. Buerhaus, Ph.D, RN, FAAN

Not long ago, I was working with a colleague on a project aimed at determining the areas in the U.S. that are likely to be most impacted by the Affordable Care Act’s health insurance expansions and to assess the capacity of the primary care workforce in these areas. The analysis indicated that much of the rural areas of western mountain states would experience growth in the newly insured that would challenge the area’s existing primary care workforce. This result made me realize how little I understood about the health-related challenges that people living in rural areas face and, similarly, the challenges facing rural health care clinicians. As a health care workforce researcher, I was aware of the longstanding maldistribution problem and knew about some of the policies and programs that have been in place to increase the supply of practitioners in rural areas. But, fundamentally, I did not have a strong understanding of the challenges faced by rural populations and clinicians alike, and I did not have a mental image that would come to mind whenever I heard “rural workforce.” In short, I did not see “faces behind the numbers.”

To address these gaps, I spent the month of May in Laramie, Wyoming, at the University of Wyoming, College of Health Sciences, in the Faye Whitney School of Nursing. The school graciously offered me the use of an office and the dean introduced me to university faculty who helped me learn about the health needs of residents living in rural Wyoming. Additionally, I took two road trips throughout the state to meet with clinicians – physicians, nurse practitioners, nurses, physician assistants—community leaders, business groups, and others to observe first-hand what a primary care practice “looks” and “feels” like in rural Wyoming. These trips and meetings also allowed me to learn how health care is interrelated with the local culture, including employers. I drove hundreds of miles, often crossing endless sage brush desserts (green from Spring rains but not yet in bloom), passed through dozens of “towns” and communities of less than 100 people, walked around small communities in the mountains that rely on tourists, visited the Wind River Reservation, and traversed long stretches of highway where there were no radio signals and the only the prong horn antelope to keep me company.

So, what did I learn? Let me offer five insights.

First, anonymity can be a problem for both people and clinicians in rural areas. Because towns are so small, when someone parks his or her car at the clinic, everyone knows…gossip flies, and some people might even suspect that their friend might be seeing a psychiatrist using that “internet gadget they have at the Clinic.” Clinicians told me they suspect that the lack of anonymity deters some people from coming to the clinic. The other problem with lack of anonymity extends to clinicians themselves. Some told me they are often reluctant to go the grocery store or walk downtown for fear of being spotted and asked for their clinical opinion on “who knows what.” One clinician commented, “People have pulled down their pants to show me things right in the middle of the grocery store, and sometimes I’ll be asked to treat the family pet that is waiting outside. I try to realize that people don’t mean to invade my space, but sometimes I need my privacy, and I don’t need to be told by every patient I see that they heard I had a few beers at dinner at the local bar last night.”

Second, a good number of clinicians said the long distances people have to drive to see a health care provider, combined with a “cowboy culture” and a sense of suspicion toward doctors (and lawyers), means that too many people do not come back to the clinic for follow up care. “Getting blood tests and measurements for conditions that aren’t yet visible don’t make sense to many people. You gotta remember that many people won’t come to the clinic for a broken finger or hand, or get sutured for cuts.” I heard clinicians describe their patients as having a “cowboy culture”  that seems to cause people to be willing to bear the pain and “cowboy or cowgirl up” rather than see a clinician. And, I was told, “Many people think my asking them to come back for follow up is more about me charging them a fee, versus improving their health. My staff is increasingly challenged by this attitude, let alone the distance some people would have to drive to get examined.” This clinician went on to state his worry that “all those quality measures that are being developed will not take these factors into account, and I’ll end up getting held accountable just the same.”

Third, and once again this is based on a limited number of conversations, but the clinicians who seemed to enjoy their work the most, who struck me as the most connected with their clinic and community, and those who expressed the most optimism, were the clinicians who had grown up in the community or similar rural area. I thought of all the studies on barriers to clinicians moving to rural areas, and the interventions aimed at overcoming these barriers. What stood out most was the contrast between talking to the clinicians who could tell me the number of days before their obligation to serve in a rural underserved areas was over versus the clinicians who couldn’t dream of ever leaving the area. The sincerity in the voice was compelling listening to clinicians speak about not missing the city, the shopping malls, or the traffic but instead spoke at great length about the reasons they loved being in a rural area – a higher quality of life, sense of community, knowing your neighbor, the lack of violence, a connection to the outdoors, a healthier and more satisfying way of life.

Fourth, resources. I won’t forget the exasperation on a physician’s face who went through a long list of insurance and government requirements the clinic must comply with. Not only were some of these requirements of limited relevance to the reality of providing care, but all of these compliance issues cost money in an environment where margins are razor thin. If not for private citizen contributions and foundation donations, the clinic would be out of business. On top of that, one physician extolled, “we are being forced to implement an EMR or face penalties. Well, an EMR might be fine, but we don’t have the IT people readily available to install such systems, even if we could afford to buy them. People don’t realize that it can take weeks before we can get a techy to drive out here and fix our lap tops, and I can’t imagine affording to hire or train someone to be help us implement an EMR and keep it functioning. I don’t think people in Washington understand the scarcity of resources in this area and what it will mean for many rural clinics.”

A final observation concerned teamwork. Several clinicians asked me why there seems to be so much “fuss about teamwork.” “That’s all I hear about. I don’t understand this. Teamwork is what we do here. We don’t have a choice. If we aren’t working as a team, we couldn’t possibly stay alive. Everyone jumps in and helps as needed. Many of our staff are cross-trained to do other functions, and our doctor, NP, and PA work like a hand and glove with everyone. Everybody counts here and we are all focused on the patient.” Indeed, I was taken aback by this comment, but can understand it. In several clinics, I observed what appeared to be effective teamwork occurring among administrative staff and clinicians in the waiting room, in patient treatment areas and in helping patients in the parking lot. Everyone seemed to be aware of what others were doing and interacted openly with each other. I sensed an absence of hierarchy and a freedom to approach the physician, the NP, or the PA with clinical information that would support the care delivery process. I left several clinics very much aware of a strong team and patient focused environment, and thought to myself that perhaps the rest of the care delivery system could learn about teamwork from some of the clinics I visited.

Influenced, in part by this experience, I thought the Center’s first edition of themed webinars would focus on rural workforce challenges and issues. Please join us on September 24th, at 2:00 PM EST for the first installment of our three part, fall webinar series. Douglas Staiger, Ph.D., John French Professor in Economics, Research Associate at the National Bureau of Economic Research at Dartmouth University, and Davis Patterson, Ph.D., Deputy Director for the WWAMI Rural Health Research Center, will present insightful research focusing on rural physicians, followed by a Q/A session. The webinar is free and will last approximately 60 minutes. For more information and to register, click here.  Slides for selected presentations will be made available within the event listing on the event calendar once the presentation has concluded. Please note some presentation slides may not be made available due to pending publication sensitivities or at the presenter’s discretion.

We hope to “see” you there!