Healthcare Musings For April 28, 2023

April 28, 2023

Dear Interested Readers,

 

The Challenges of Medical Practice in Small Towns and Rural Environments 

 

Last weekend my wife and I enjoyed attending my sixtieth high school reunion in South Carolina. The class of 1963 at Dreher High School was small because if you were born in 1944 or 1945 it was likely to be true that your father was either too old to be in military service or was employed in some critical homeland activity. My father was a seminary student. I think that he always regretted that he was not in military service like his brother who was a decorated paratrooper in the 507th regiment of the 82nd Airborne and parachuted into France the night before the D-Day landing to capture the bridge over the Merderet River near Sainte-Mère-Église in one of the bloodiest battles of World War II.

 

Because of the dad thing my class had only about 240 students. My brother was in the class of 1965 and his class had over 450 students. There was a lot of boom in the baby boom. In my class, there were six future doctors, a cardiologist, an orthopedic surgeon, a gastroenterologist, an ophthalmologist, a dermatologist, and a pathologist. We should have also had a Nobel Prize winner. Kerry Mullis, who was originally in the class of 1963 chose to graduate a year early in the class of 1962, and then he won the Nobel Prize in chemistry in 1993. Perhaps, the best-known graduate of Dreher High is Alex English, class of 1972, who is in the Basketball Hall of Fame. There were no African American students in the class of 1963. Change is a slow process in South Carolina. It took many years for them to act on the outcome of Brown v. The Board of Education of Topeka which the Supreme Court decided in 1954. South Carolina is one of the ten states that has still not implemented the Medicaid extension of the ACA.

 

My best friend in high school, who is the orthopedic surgeon mentioned above, went to West Point before he went to medical school as an army captain. After a year in combat as a green beret Ranger in Vietnam where he was given medals for his valor, he got the army to send him to medical school. After over twenty years of service as an army orthopedic surgeon including serving as chief of the hand service at Walter Reed, he retired from the army as a colonel and became a solo practitioner of orthopedics in a small South Carolina town. 

 

As you might expect, my wife and I spent a lot of time with my friend last weekend. We have intermittently stayed in touch over the years. He spent the first week of his leave back in the States after a year in Vietnam in my apartment in Cambridge. At that time, after a year on patrol in the jungle, he was almost vegetative. Over the years he occasionally came to Boston for medical meetings and to visit his son when he was a student at Harvard. We even did one Boston Marathon together back in the early nineties. We always connected at reunions. 

 

Time has taken its toll on both of us and our class. About a third of the class has died. There were a few men in my class who did die in Vietnam. Of those who attended the reunion, there were some who were leaning on canes, including my friend. My friend and I both limp. He uses a cane after a recent stroke, and I have a slowly improving footdrop after a fall two years ago. The stroke did end his long years of practice at age 76, but except for his cane, and some difficulty getting out of a chair, he is the same old guy that I have always admired for his intelligence, strength of character, patriotism, and commitment to practice and patient care. 

 

Over the weekend we spent one night and most of two days with him which gave us a lot of time to talk about what we think we have learned through our personal experiences in healthcare and in life. I was eager to hear the latest presentation of his many stories about his service in Vietnam, his years of medical practice in the Army which included several years at Landstule Army Hospital in Germany, and his participation as a doctor in the US military involvement in Grenada as a member of the 82nd Airborne in 1983. 

 

Most of all I was interested in hearing about recent events in his life as a doctor in small-town South Carolina since we had not communicated since the last reunion five years ago. I am sensitive to the increasing challenges facing patients and medical professionals in small towns and rural environments. I live in a small town. I served for ten years on the board of Guthrie Clinic which provides care in a small-town and rural environment in north-central Pennsylvania and south-central New York state. Tertiary care in South Carolina usually requires that patients go to Greenville, Charleston, Florence, or Columbia. South Carolina is geographically the smallest southern state and no town is much more than two hours from the capital in Columbia which was sighted by design to be located at the geographical center of the state. 

 

As I expected, my friend’s description of the last few years of his practice was quite different from what I experienced in a large multispecialty group practice nestled in a city that sports three outstanding medical schools and multiple world-class hospitals that are filled with trainees destined to be some of the future leaders in academic medicine. The best parts of my friend’s experience were the sense of community that he experienced in practice and the challenges that he loved to address in the operating room. There are pros and cons of not having the relative anonymity of practice in a large urban area or the surgical support and equipment that were available in the army or would have been his in an academic environment. In a small town, there is a former patient or a family member of a patient around every corner and at the grocery store, and a good surgeon learns how to make do with what is available and he develops the support he needs to get a good job done.

 

My friend is a conservative by nature who places great value on personal responsibility. That may be an explanation for why he enjoyed the relative freedom and autonomy of private practice. The flip of those joys was that he had little privacy and many business concerns. He was frequently at war with hospital administrators whose agenda was to optimize finance and not patient care, and he was always vulnerable to an urgent phone call. I got the feeling that sometimes the gratitude that he would hear from his patients as he saw them about town was not quite enough to positively balance the cost he experienced in his own life. Years of practice took a high toll. In a state where many patients have no ability to pay for their care, he did not enjoy the seven-figure annual compensation that orthopedic surgeons in more affluent communities often enjoy. He provided a lot of uncompensated (free) care. If a patient needed help, he/she got it. If they had no insurance, as is true for many South Carolinians, or couldn’t pay, so be it, he gave them the care they needed pro bono.

 

My friend had very close relationships with his office staff and with the team that he took to the OR. His former office manager still assists him with the details of his life, and she came by to make breakfast for us! The big shadow on his practice experience was that he was always working. He had close to thirty years of eighty-hour-plus weeks and was essentially always on call for his own patients. He was also on call for the hospital every other night and weekend for orthopedic emergencies.

 

The stress of his work had an impact on his family life. He had other explanations for his stroke, but I wondered if he experienced some form of burnout and that stress and fatigue were factors in why he had a stroke. If burnout was not a factor for him it has become an epidemic among other caregivers. I have imagined that the risk of burnout must be high among medical professionals that work in small towns and rural environments.

 

Whether or not he actually experienced burnout, it was obvious from his reflections that the positives outweighed the negatives. He was satisfied with the choices he had made and the positives of his professional life. The negatives seemed to be just the price he had to pay for the positives and the satisfaction of knowing that he had done his best to answer the call of service that had provided direction for his whole life. He had been where he felt he belonged. There were several times over the years when larger institutions in urban areas tried to recruit him, and he turned them down.

 

Whether or not burnout was an issue that impacted my friend, burnout should be one of our greatest concerns when we think about the future of healthcare. I was shocked by the estimate of a 50% prevalence of burnout that has been reported among medical students. I would imagine that the numbers are probably worse for interns, residents, fellows, and practitioners. When I searched for burnout percentages for physicians practicing in rural environments in America, I was surprised to find articles reporting on small studies that suggested that rural and small-town doctors had significant but lower rates of burnout compared to doctors in urban environments.  Perhaps, the positives in my friend’s experience confirm a surprising fact that there is less burnout in a small-town medical practice. In our joy let’s notice that better was not perfect. In small towns, burnout is still a significant concern. In the reference, we read:

 

Twenty-five percent of rural FPs reported burnout, compared to 37.5% of those in medium-sized towns and 51.4% in metropolitan areas, a finding the authors called statistically significant…

 

The burnout prevalence in Canadian medicine is reversed with rural physicians experiencing more burnout than those working in cities. In Canada, burnout in small towns and rural environments may be a function of working for the government.

 

Given my recent positive experience with Chat GPT, I decided to go to the well again. So I asked my new colleague a question:

 

Can you discuss some of the possible causes of burnout in physicians working in rural and small-town environments?

 

Certainly, burnout is a significant concern for physicians working in rural and small-town environments. Some of the potential causes of burnout in these settings include:

• Workload: Physicians in rural and small-town environments often have a high workload, which can lead to burnout. They may have to see more patients due to a shortage of healthcare providers in the area.

• Isolation: Rural and small-town environments can be isolating, both professionally and personally. Physicians may feel disconnected from the medical community and lack the support they need.

• Limited Resources: Rural and small-town hospitals and clinics may have limited resources, which can put a strain on physicians. They may have to work with outdated equipment or lack access to certain medications or specialists.

• High Expectations: Physicians in rural and small-town environments may feel pressure to be available at all times due to the limited healthcare resources available. This can lead to a lack of work-life balance and burnout.

• Emotional Exhaustion: Physicians working in rural and small-town environments may experience emotional exhaustion due to the close-knit nature of the community. They may be treating patients they know personally, which can be emotionally draining.

• Lack of Professional Development: Rural and small-town physicians may have limited opportunities for professional development and career advancement, which can lead to burnout.

• Financial Pressures: Physicians in rural and small-town environments may face financial pressures due to lower reimbursement rates and higher costs of living.

It’s important to note that burnout is a complex issue, and the causes can vary from person to person. Healthcare organizations and policymakers can take steps to address these factors and provide support for physicians working in rural and small-town environments.

 

As I read the response from the chatbot, I realized that during our conversations over the weekend, my friend had spoken to every point the “bot” raised. 

 

I am sensitive to the concern raised in many discussions of AI that perhaps the “bot” was just making things up so I decided to ask for references.

 

Can you give me references for the causes of physician burnout in small towns and rural environments that you listed?

 

Sure, here are some references that support the causes of physician burnout in small towns and rural environments that I mentioned:

• Shanafelt TD, Hasan O, Dyrbye LN, et al. Intensive Care Unit Physician Burnout and the Risk of Clinician-Reported Medical Errors. Crit Care Med. 2016;44(7):e737-e743. doi:10.1097/CCM.0000000000001652

• Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. doi:10.1001/archinternmed.2012.3199

• Rathert C, Ishqaidef G, May DR. Physician burnout in rural healthcare organizations. J Rural Health. 2019;35(2):212-221. doi:10.1111/jrh.12301

• Shanafelt TD, Boone SL, West CP, et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc Innov Qual Outcomes. 2017;1(1):79-87. doi:10.1016/j.mayocpiqo.2017.06.005

• Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. Stress and Health Care Professionals. Updated November 2021. Accessed April 25, 2023. https://www.cdc.gov/niosh/topics/healthcare/healthcare-professionals.html

• American Medical Association. Professional satisfaction and physician well-being. Updated 2021. Accessed April 25, 2023. 

• https://www.ama-assn.org/system/files/2021-03/professional-satisfaction-physician-well-being-2020.pdf

These references provide evidence and insights into the various factors that can contribute to physician burnout in rural and small-town environments.

 

I checked out all of the references and came away with the realization that most of the numbers reported in studies are derived from the Maslach Burnout Inventory, a brief set of questions that were first developed in the early 80s and have evolved as MBI has been used in multiple industries and professions. As I tried to use the bot’s list, I discovered that most of the references were “doors” to more specific reports. Following the thread in reference number six, I found a startling number from the AMA.

 

Physician burnout is an epidemic in the U.S. health care system, with nearly 63% of physicians reporting signs of burnout such as emotional exhaustion and depersonalization at least once per week…

 

I was reassured that there are some facts behind the “bot’s” comments. My guess is that much of the stress that leads to burnout in rural and small-town practice is directly related to the shortage of doctors. The MBI is an imprecise tool, that may contain some biases, but I believe that it does indicate that we have a problem. It was a shortage of orthopedic surgeons who wanted to practice in a little town in South Carolina versus Charleston, Columbia, or Greenville, the cities of South Carolina, that contributed to the long hours my friend endured for so many years. Perhaps there is a subtle selection process that attracts some physicians, just not enough, to work in small towns and rural environments even when there are huge personal challenges. To underline the reality of a true doctor shortage in small towns and in rural America I decided to ask Chat GPT one more question to see what it knew about primary care panel sizes in small towns and rural environments. 

 

Thanks! Do you know what the shortage of primary doctors is in rural and small-town environments? What are the panel sizes for doctors working in small towns and rural environments?

 

Yes, I can provide some information on the shortage of primary care doctors in rural and small-town environments.

According to the National Rural Health Association, approximately 20% of the U.S. population lives in rural areas, but only about 10% of physicians practice in those areas. This shortage of physicians is particularly acute in primary care specialties like family medicine, internal medicine, and pediatrics.

The Health Resources and Services Administration (HRSA) has identified many rural and small-town areas as Health Professional Shortage Areas (HPSAs) based on criteria such as population-to-physician ratios and other factors. These areas have a shortage of primary care providers and may struggle to attract and retain healthcare professionals.

Regarding panel sizes for doctors working in small towns and rural environments, there is no set standard as this can vary depending on factors such as patient acuity and healthcare resources available. However, some studies suggest that primary care physicians in rural areas may have larger patient panels than those in urban areas. For example, a 2017 study published in the Journal of the American Board of Family Medicine found that rural family physicians had an average panel size of 2,380 patients, compared to 1,679 patients for urban family physicians.

It’s important to note that panel size is just one factor that can contribute to physician burnout, and other factors such as workload, work-life balance, and access to resources are also important considerations.

 

Considering the source, those are probably reliable numbers. I have been concerned that much has been said about physician burnout, but little has been done to improve it. The numbers seem to be getting worse. We can’t order extra orthopedic surgeons, primary care physicians, or nurses to immediately resolve the workforce shortages that are huge problems everywhere, especially in small towns and rural environments. In the organizations that I have observed, there have been efforts to offer counseling and emotional support, but little or no effective organizational attempts to change the factors that seem key to diminishing satisfaction and increasing personal distress from practice. I decided to see what AI had to say about a problem where AI might be one of many potential sources of relief. I thought that an inventory of things tried might be helpful. So, I asked again.

 

What treatments or changes have been offered to manage burnout in medical professionals?

 

Burnout is a common problem among medical professionals, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Burnout can lead to reduced job satisfaction, increased medical errors, and even physical and mental health problems.

Fortunately, there are a number of treatments and changes that have been offered to manage burnout in medical professionals. Some of these include:

1. Mindfulness training: Mindfulness training can help medical professionals learn to focus on the present moment and reduce stress and anxiety. Mindfulness-based interventions have been shown to be effective in reducing burnout and improving well-being among healthcare providers.
2. Cognitive-behavioral therapy (CBT): CBT is a form of therapy that focuses on identifying and changing negative thought patterns and behaviors. CBT has been shown to be effective in reducing burnout and improving mental health outcomes among healthcare providers.
3. Supportive supervision: Supportive supervision involves providing regular feedback and support to healthcare providers, as well as opportunities for professional development and growth. Supportive supervision has been shown to be effective in reducing burnout and improving job satisfaction among healthcare providers.
4. Workload adjustments: Adjustments to workload, such as reducing the number of patients seen per day or providing more flexible scheduling, can help reduce stress and burnout among healthcare providers.
5. Team-based care: Team-based care involves working collaboratively with other healthcare professionals to provide comprehensive care to patients. This can help reduce the workload and stress on individual healthcare providers, and improve job satisfaction and patient outcomes.
6. Organizational change: Organizational change, such as promoting a positive work culture, improving communication and teamwork, and addressing systemic issues that contribute to burnout, can be effective in reducing burnout and improving well-being among healthcare providers.
7. Self-care: Self-care involves taking steps to prioritize one’s own physical and mental health, such as getting regular exercise, practicing stress-reduction techniques, and seeking social support. Self-care can help healthcare providers better manage stress and prevent burnout.

In summary, there are a variety of treatments and changes that can be effective in managing burnout among medical professionals. These include mindfulness training, cognitive-behavioral therapy, supportive supervision, workload adjustments, team-based care, organizational change, and self-care. By implementing these strategies, healthcare organizations can help reduce burnout and promote well-being among their providers.

 

I was surprised and pleased to see suggestions 4, 5, and 6. I have felt that there has been too much of 1,2,3, and 7. I have been interested in “practice improvements” since the 80s. That’s why I became active in the internal “politics” of my group and eventually became the CEO. There were many improvements to support the practice that we tried. Before computers had enough power we made attempts to get our practice to employ “Dragon” speech recognition as an add-on to Epic. After I became CEO, the efforts intensified. Among other supports, we introduced Lean to improve workflows, offered Shared Medical Appointments to improve access, promoted the use of the Internet to reduce unnecessary appointments and improve communications, and enhanced our team-based practice with mental health and clinical pharmacists embedded into primary care. 

 

I have felt that burnout was more a systems issue than evidence of individual deficiencies. I have felt that mental health support and behavior modification techniques can be helpful after we have traumatized individuals, but those efforts seem like palliative care for clinicians and do not feel to me like the long-term solutions to the growing imbalance between the demands of practice, the increasing workforce shortages, and the inadequate supports that are provided to practice.

 

Dr. Ebert said that we needed a better operating system and better finance mechanisms, and time has proven him to be so right. Almost sixty years have passed since Dr. Ebert put his shoulder to the necessity of healthcare reform. We have made progress in some areas, but I must believe that like global warming and poverty, our efforts to support our medical practices in ways that do not damage professionals while lowering the cost of care, expanding access, and improving quality need the sort of attention and resources that require more insight and better tools will than we have applied to far. There is much work to do. 

 

Patiently Waiting For Spring

 

The downside to my trip to South Carolina was returning from temps in the eighties to temps in the forties and low fifties. The deciduous trees and flowers seem to be at a mid-summer level in South Carolina. The camellias and azaleas have come and gone in the south while we are just seeing our first red buds on the maple trees and there are five or six brave daffodils and one skimpy forsythia bush in our front yard. The leaves on trees and bushes are just beginning to think about coming out, but the bears are out, so I brought in the bird feeders. 

 

Today’s header was taken from a spot on the road that approaches the Trapp Family Lodge in Stowe, Vermont. We gave our daughter-in-law a ride up to the Trapp Famly Lodge and back this week because she had flown in from her job as a librarian at the University of California at Santa Cruz to attend a management conference for librarians at the lodge. I love the mountains of Vermont, but visiting Stowe always reminds me that I lost my right ACL while skiing on an icy trail at Stowe back in 1981. I did not get to run the Boston Marathon that year. ACL surgery was not that good back then and a colleague who was a very good orthopedic surgeon advised me just to do PT and wear a brace if I was skiing or doing something that required lateral movement. That knee is now my “good knee.” 

 

My Stowe experience has made me a conservative when it comes to being a candidate for orthopedic surgery. I turned down an offer of a total knee on the left in 2010 and a rotator cuff repair of my right shoulder in 2016. With PT both joints are pain-free and totally adequate for a pretty active lifestyle for a guy my age. My experience makes me wonder just how much unnecessary reconstructive surgery gets done every year. I have decided that pain that prevents sleep or loss of function that can’t be improved with vigorous PT should be my personal indication for orthopedic surgery. It seems that everything that is “broke” doesn’t need fixing by surgical intervention. 

 

The forecast for the next ten days in Vermont and New Hampshire is for mostly cloudy days with occasional sun and frequent showers. I guess that is spring. Between showers, I hope to catch my first fish of the season. Wherever you are, I hope that you will find a way to take advantage of any outdoor opportunity that Mother Nature offers.

Be well,

Gene