Off the Beaten Path

April 11, 2011
Don Shuwarger, MD, MBA, FACOG
Don Shuwarger, MD, MBA, FACOG

After practicing medicine in Antarctica and the western Pacific, it was time to come back to the US. Where would I practice? What size practice should I look for? What quality-of-life factors should I consider?

After practicing medicine in Antarctica and the western Pacific, it was time to come back to the US. Where would I practice? What size practice should I look for? What quality-of-life factors should I consider?

My experiences in Antarctica and the Marshall Islands taught me that one can have a fulfilling and rewarding life practicing medicine in very spartan conditions. The challenges of using only the history, physical exam, basic laboratory, and plain x-ray to make a diagnosis and effect treatment were daunting but rewarding. Before accepting the assignment in Antarctica, I was a general ob/gyn practicing in Lynchburg, VA. I was part of a busy practice with 3 physicians and 4 certified registered nurse midwives. Working continuously for 25 years with few vacations, I was ready for a sabbatical. I was accustomed to being inside the safety net of instantly available CT or MRI scans, consultants in all specialties, complex lab tests, well-stocked operating rooms, as well as having the support of a large hospital network. Still, when I began working in the small remote practice sites I found improved job satisfaction, less stress, and greater quality of life.

My experiences practicing medicine in remote and austere environments outside the country led me to seriously consider practicing in rural America. As attractive as overseas work can be, I realized that if I didn't return to the US and resume practice that I was at risk of losing skills or becoming increasingly unemployable. I described this possibility as "rusting" and I definitely didn't want to rust. With that settled, the search was on. Between recruiters and the Internet, it was relatively easy to identify rural practice opportunities. I knew that I could live, work, and play in any kind of climate, which kept many options open. One of the factors important to me was that I practice with more than one partner, which further narrowed my search.

After evaluating 4 domestic and 2 international opportunities, I chose a private independent practice in northwest North Dakota. The community is enjoying growth and prosperity thanks to the oil industry. The population growth has brought additional deliveries and gynecologic surgery-the practice recognized this trend, and 2 years ago began the search process that resulted in my employment. We are now close to hiring a fourth ob/gyn.

I work with 2 outstanding physicians, a certified nurse midwife, and an advanced practice registered nurse in a modern facility. The practice is fully electronic and has excellent in-office surgery suites. Across the parking lot is a small community hospital with a dedicated 10-bed labor and delivery as well as a well-staffed and supplied suite of operating rooms. They have an excellent full-service laboratory; CT, MRI, mammography, and bone densitometry scanners; and we receive mobile PET scan and lithotripsy services. There is a cancer treatment facility connected to the hospital. The medical community includes primary care, orthopedics, ENT, urology, general surgery, and visiting physicians in other specialties. We are very fortunate to have an excellent network for subspecialty referrals. The perinatologist and gyn oncologist are about 5 hours away in Billings, MT. We work closely with a reproductive endocrinologist 4 hours away so that the patients need only go there when it is time for their egg retrieval and embryo transfer.

Rural Doctoring in the Modern Age
One of the differences between rural, small, isolated communities and large cities is the distinction between needs and wants. In small towns you have everything you need, but maybe not everything you want. Forty years ago the isolation was overcome by travel. Now, electronic media brings the world to me. Our community has high-speed Internet, high-definition cable TV, and excellent 3G cellular coverage with 2 large national carriers. Continuing education, culture, movies, and video chats with friends and family are all now possible to a degree that was not available decades ago. FedEx and UPS do a great business in small towns. It’s easy to shop at your favorite stores over the Internet. Local merchants can capitalize by providing a personal level of service and custom goods not often available in “Big Box” stores.

Personal safety is another plus of living in small rural communities that I enjoy. Many people leave their doors unlocked. Nobody worries about being attacked in massive parking structures. There is hardly a stranger. Service people, like plumbers or electricians, can be trusted to come in, fix the problem, and send a bill. Try that in a big city!

Larger cities differ from the small towns in another important way: privacy. A lot is said about privacy. We are told to keep all the parts of our life private. There are laws to protect our financial privacy, health care privacy, Internet privacy, and social privacy. In small towns there is less social privacy and it has a name: community. I guess one way to look at it is to consider community to be the opposite of privacy. I still keep my financial affairs private, but I do enjoy the sense of community that I get in a small town. People know one another and go out of their way to help each other. There is a mutual reliance and camaraderie that can be seen and felt in smaller towns. I like that. And since I'm new in town, I am pleased to see patients when I am out. One time, I was unable to find something in Wal-Mart and happened to bump into a patient. She was able to direct me to the right aisle. We laugh about it ever since.

One of the factors that was important to me in making my choice to move to North Dakota was the economic viability of the town. I am fortunate to live in a small city that is prosperous, but many small towns across this country are not so lucky. Poverty can be pernicious in a small town, robbing it of growth and economic opportunities. When a physician considers small town life one of the considerations is often whether the community can reasonably support him or her, which is a valid concern. Some small rural hospitals are struggling in this economy. Sometimes barter and trade can be employed in small towns, which can benefit both parties.

Small Town Docs: Resilience Needed
It helps to have a lot of resilience if you are going to choose a small, rural, remote, and isolated community in which to practice. It will take some time to meet people and develop a social network. I found that joining clubs and attending community activities, plays, concerts, and sporting events helped me get to know people. I would often see the same people at different events-that recurring familiarity soon led to friendships. Physicians with spouses have the added benefit that there can be a second person scouting out friendships and social activities. One thing I enjoy is playing bridge. Regrettably, that is the one area in which I am having the most difficulty. A large city would probably have many more bridge players and maybe a few bridge clubs. In my town it has been very hard finding fellow bridge players and I have yet to play a single rubber.

Every so often one does need to get away-whether it is for cultural events, shopping, or just a change of scenery. The ability to fly to a major city is a big plus for me. We also have twice daily Amtrak service: west to Seattle and east to Minneapolis. I look forward to taking a long weekend for a train trip. The hard decision will be which direction to travel.

The differences and challenges of small rural practice may not suit everyone. But for me, it provides a lovely quality of life, excellent private practice position, supportive hospital, and a sense of community that makes me feel right at home.

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