The country doc. It’s a tired old stereotype, and one our society might well be rid of. It carries with it all the mid-century TV tropes our society knows so well: the black bag, the round hat, the grizzled air.
If there are elements of the old pigeonhole we might wish to keep, however, it’s the rural physician’s ability to make do. To trust their own well-informed judgment. To lead by example, earn the trust of patients and families, and make a difference in communities that matter.
These are the attributes that characterize Michigan’s rural health care landscape today. Despite the myriad challenges today’s rural physicians face, they continue to uphold the timeless value of care excellence that is the hallmark of the medical profession, no matter where it’s at work.
Rural Medicine in Michigan
With the state’s only true urban centers located in the bottom half of the Lower Peninsula, every community north of Clare falls into the “rural” category, along with many cities, towns and villages further south. In fact, 57 of Michigan’s 83 counties are classified as rural.
Generally speaking, the social and economic environments in Michigan’s rural areas are less robust than in more regions of the state. The U.P. and northern Lower Peninsula have been steadily losing jobs and population throughout the last decade, and its population is aging rapidly. Residents and businesses must go further to procure necessary resources, services and supports. And with limited broadband access, opportunities for learning and connection can be harder to come by.
Together, these factors paint a somewhat bleaker picture when it comes to the social determinants of health. And these more fragile social determinants, in turn, often can translate into reduced health outcomes for rural residents. From routine medical visits to ongoing disease management, it is often true that people in less favorable socio-economic circumstances often do not experience the same level of care as their better-resourced and -connected counterparts.
To help address these inequities and advance the overall quality of medical care statewide, a variety of pioneering initiatives have been set in motion. From physician recruitment and collaboration programs to the expanded use of telemedicine, an array of game-changing innovations are underway to help support Michigan’s rural communities more effectively.
Attracting More Physician Talent
Ask any practitioner in rural Michigan what their greatest challenges are, and the shortage of physician talent is sure to top the list.
“When you look at the state’s health professional shortage area designations, you see a lot of gaps,” says Rachel Ruddock, workforce development manager for the Michigan Center for Rural Health. “And while every state has rural shortage areas, a map of Michigan shows that we have a shortage of primary care physicians, we have a shortage of dentists, we have a shortage of psychiatrists, mental behavioral health providers. It’s a huge, huge, huge issue.”
Ruddock notes that 31 percent of all Michigan counties lack even one single obstetrician.
“MSU’s College of Human Medicine has done some research that classifies certain parts of the state as OB deserts,” Ruddock says. “Many rural communities have had to drop their OB service lines due to low volume and high staffing costs. Now, it’s not uncommon for women to have to drive 150 or 200 miles to get to a birthing hospital.”
Given the seven medical schools and numerous physician residency programs working in Michigan—and the thousands of students who travel from around the globe to participate in them—it is perhaps surprising that our state should experience such gaps in care.
“It’s simply maldistributed,” Ruddock says. “Physicians tend to stay where they train, so it’s not necessarily true that we have a huge shortage of them. It’s just that they all stay in a concentrated area.”
Andrea Wendling, MD, FAAFP, director of rural medicine for MSU’s College of Human Medicine, says there are proven strategies already in motion that are effectively increasing the supply of available talent in Michigan’s rural areas. Doctor Wendling operates one such pipeline program, which works to recruit and support undergraduate rural students with the hope they will return to serve in one of the state’s smaller communities.
“Rural students are underrepresented in medical school based on the population, but that’s the group that’s most likely to end up working in rural communities,” Doctor Wendling says. “If you look across the nation, about 20 percent of our nation comes from rural areas, but only four to five percent of our medical students are of rural origin.”
Doctor Wendling administers MSU’s Rural Premedical Internship Program, supporting rural undergraduates through the medical school admissions process.
“I work with them during the summer months, helping them gain the experiences they need for medical school and giving them admissions support,” she says. “They often end up training on one of our rural campuses, and I can begin to shepherd them through that experience while they’re in undergrad.”
The approach is already working. Today, MSU’s medical school admission rate for students from rural communities sits at around 20 percent, which is about the same as the state’s proportion of rural population.
Doctor Wendling’s efforts complement those of the Michigan Center for Rural Health, where Ruddock is fostering the creation and management of a more robust talent pipeline.
“I’m helping rural health care employers find providers, find staff, as well as working with providers who are interested in working in our rural communities,” Ruddock says. “At the same time, I’m helping students cultivate that interest in rural medicine so that they will hopefully go to those communities and practice someday.”
The Unexpected Impact of COVID-19
While the COVID-19 pandemic has had a huge negative impact on providers and employers, everywhere, there has been two surprising upsides for rural health care.
The first has to do with the aforementioned physician recruitment in rural communities.
“Those of us who recruit rural health care talent across the U.S. have just been deluged by the number of physicians from urban centers that now want to go to rural communities,” Ruddock says.
The reasons for the change are many.
“Some are tired of living in the city—they want property and to be outside and to quarantine on land essentially,” Ruddock says. “Others have been laid off, some have been furloughed, some of their hours have been cut, some of their contracts have been reworked. And so they’re looking for other opportunities.”
Second, the expansion of telehealth options under COVID-19 has improved access to health care options for many rural residents.
“With the public health emergency order and the policy changes, folks have been able to access telehealth a little more readily,” says Jill Oesterle, rural health clinics manager for the Michigan Center for Rural Health.
But still, issues remain.
“A lot of rural health communities don’t have access to internet,” Oesterle says. “And we know our rural communities tend to be much older and so you have technology barriers for individuals who aren’t familiar with these systems. So while use of the technology has advanced, we still have a lot of barriers.”
Most of today’s physicians are trained in a large metropolitan tertiary care center, with plenty of equipment, resources and support. Leaving these settings to practice in a small, isolated hospital or practice is, in a word, uncomfortable.
“Some of it is purely clinical,” Doctor Wendling says. “Most of the physicians who practice in rural communities have expanded scopes of practice. They’re generalists even if they are practicing within a specialty. Take, for instance, a general surgeon. She can’t just do appendectomy and gall bladders. She really needs to be able to do a full gamut of general surgery, because she’s the only person who’s providing those services, or her group is the only group providing those services in a rural community.”
Doctor Wendling notes there are fewer specialists on staff at rural hospitals.
“Working in a larger hospital, you have the support of many different types of physicians—ICU docs, cardiologists, pulmonologists, gastroenterologists. And so when a patient has a problem, it’s pretty easy to get that level of help from the different people who also work there,” she says. “If you’re a doc in a critical access hospital, there’s no cardiologist on staff often. There’s no pulmonologist, there’s no ICU doc. If somebody gets transferred to the ICU, you’re going to take care of them in the ICU as opposed to taking care of them on the floor.”
What does this mean for a rural physician? It results in a different way of assessing risk.
“You need to understand whether patients when they come in are in the right place,” Doctor Wendling says. “You need to be able to think ahead about what direction their condition might go and what supports they might need and how to manage available resources and logistics. These are skill sets that you don’t necessarily learn if you only train in a hospital where you can call cardiology when there’s a problem, and they show up.”
Doctor Wendling notes there are other problem-solving and communication skills that come into play.
“For the most part, you’re living in smaller communities that you are also serving as a physician, so you need to understand where to put boundaries up, so you can continue to treat people professionally while still having other relationships,” she says. “You don’t have the level of anonymity that you have in a metropolitan community, where some of that just doesn’t become an issue.”
She goes on to add, “There’s a lot of creativity and problem-solving that goes into serving distant and under-resourced communities. At the point you recommend a test or specialist, you also have to take a step back and think, ‘Okay. But do you have a car, or could somebody drive you? And is there a snowstorm?’ There’s a whole level of anticipatory problem-solving that I think physicians need to be thinking about.”
But when it comes together right, it makes all the difference—for providers and patients alike.
“To me, it’s most satisfying when we can make things work,” says Laurel Sawyer, practice manager at Sable Point Family Care. “I have personally picked up food from a local food pantry and delivered it to patients when there was a need. I have seen providers personally purchase equipment or medication and deliver it to patient homes, because that’s just what happens in rural medicine.”
Hidden Opportunities to Make Medical Magic
Despite the challenges associated with providing rural health care, there are opportunities for physicians who are keen to innovate.
Mark Hamed, MD, MBA, MPH, FAAFP, is medical director at McKenzie Health System in Sandusky, Michigan. Although he lives in the Metro Detroit area, he’s willing to make the 208-mile round-trip trek to the Thumb seven times each month to serve the community he’s come to love.
“Our CEO, Steve Barnett, is very pro-provider. He makes sure we’re comfortable, that we have whatever we need to provide the best care possible,” Doctor Hamed says. “Today, our institution has a very progressive nature as far as trying to advance and embrace new technologies and metrics. We are sharing services and consultants with other systems and working to provide telehealth consults in specialty services areas, like stroke and pulmonology.”
It was this progressive, highly interactive environment that helped Doctor Hamed’s institution respond swiftly to the COVID-19 pandemic.
“My CEO listens carefully to me and the other practitioners in our system,” Doctor Hamed says. “When we learned how transmissible the virus was, he was responsive to our urgent need to prepare. So very early on, we were able to secure four of our inpatient rooms as being negative pressure rooms. We actually secured extra ventilators. We even put in a request for rapid PCR testing, which we received in August. Because we were able to collaborate and be nimble, we were really, really prepared for COVID.”
Doctor Hamed says McKenzie has innovated in other important ways.
“We are the first hospital in Michigan to actually be an opioid free—we call it the Oxy Free—ER. We actually started that in February 2013, before the crisis was officially the opioid crisis,” Doctor Hamed says. “And a lot of these other things like acute heart attack and acute stroke care—we were offering that. We get a lot of, ‘Hey, what’s going on in a little place. It’s kind of buzzing there.’”
Other rural Michigan providers have found ways to collaborate for the good of their patients.
“We know a lot of providers are setting up hotspots in their parking lots where patients can pull into a space and get on their device and have their telehealth visit because they don’t have access to the internet at home,” Oesterle says. “Sometimes they even host patients in their primary care offices for telehealth visits with specialists elsewhere in the state, free of charge.”
Doctor Wendling says the advent of technology has added additional opportunities for collaboration.
“There are programs like MC3 out of Ann Arbor, which offers psychiatry services to children and adolescents in rural Michigan,” she says. “As physicians, we can call them and consult about our patient and they’ll talk to us, build a chart around that patient and we can call back later and continue that specialty dialogue. It helps me expand my scope of care in that area.”
A similar program, Project ECHO, is a multi-state effort working to support cardiology patients in similar ways.
And finally, new northern Michigan innovations are occurring as rural providers work to address an ongoing shortage of nurses and medical assistants.
“Rural Michigan hospitals and their partners are launching medical assistant apprenticeship programs modeled after other very successful initiatives,” Ruddock says. “The idea is that they’re going to essentially grow their own pipeline of medical assistants because it’s so hard.”
Similar programming is urgently needed, Ruddock says, as leaders grapple with a shortage of EMS and other workers.
But most of all, rural providers agree, there is a major need for widespread internet access.
“It’s a necessity. You can’t say today, ‘Oh, you don’t need internet access,’” Ruddock says. “Everyone needs some internet access in one form or another. We know that’s just how the world works.”
Michigan’s rural digital infrastructure remains weak. Strengthen it, and the economic viability of many rural communities takes a major leap forward. And so, in fact, do their social determinants of health.
In addition to this high priority for our state, there is one other change that can make an enormous difference for rural health care.
“It’s really hard for rural residents to have a voice,” Doctor Wendling says. “Rural populations are a minority of the population, and they have really different challenges and different solutions than urban or metropolitan places do. I think that we need more people who are willing to look at it with that lens, with a rural lens, sitting at the table with the people who are making the decisions.”
The Michigan State Medical Society is eager to ensure rural physicians are active in setting its policy agenda. By establishing regional seats on its board of directors and convening statewide conversations about the work we do, we hope to help erase the stereotype of the “country doc” and create a new way forward that’s grounded in the innovative strategies, technology expansion, and a future that’s brighter for all Michiganders, no matter where they live.