The Challenges of Rural ENT Practice

Four years ago, Martin S. Trott, MD, was burned out on otolaryngology. He was managing partner of a large, private northeast Ohio ENT/allergy and immunology practice. He worked 80, sometimes 90, hours a week. He could perform 900 surgeries a year.

Then Dr. Trott made the decision to move to Jackson Hole, Wyo., a rural resort town 20 minutes from the Idaho border, to live a better life. He took a job as director of the Ear, Nose, Throat and Allergy Clinic at St. John’s Medical Center. Two months in, he added vice chief of staff to his CV. Now he’s landed a teaching position.

Professionally speaking, though, he simply traded in Cleveland Clinic-sized problems for the challenges of rural medicine—issues such as weather, travel and transportation challenges; roadblocks such as the implementation of wide-ranging reforms that revamp everything from coding to clinical care to computers; and, perhaps most vexing, lack of time for patient care, training, sick days and—dare it be said—personal time.

Rural physicians face a variety of challenges that their more urbanized counterparts rarely see. But with proper planning and recognition of the obstacles, most physicians easily overcome them, said Brock Slabach, MPH, senior vice president for member services at the National Rural Health Association and former rural hospital administrator at Field Community Memorial Hospital in Centreville, Miss. “I’ve seen some brilliant work being done in rural communities using meager resources and being creative and thinking outside the box in terms of how they address problems,” he said.

Isolation and Infrastructure

Isolation can be difficult to adjust to for rural otolaryngologists hundreds of miles from the nearest tertiary care center, Dr. Trott said. “I think that the biggest challenge for someone who’s coming out of training and going to a rural location is [finding] someone to bounce ideas off of,” he added.

Dr. Trott finds counsel in his former colleagues. He’ll soon begin to serve as an adjunct assistant clinical professor of otolaryngology-head and neck surgery at the University of Utah in Salt Lake City, so he can reach out to physicians there when he needs a consult. He can and does refer cases there when circumstances warrant, and those otolaryngologists fill in for him with enough notice.

Sigsbee Duck, MD, who practices at Memorial Hospital of Sweetwater County in Rock Springs, Wyo., approximately 200 miles south of Jackson Hole near the Utah border, set up an affiliation with the University of Utah when he left private practice in 2009. He wanted to set up a support system with the ENT doctors he would likely be referring complicated cases to, and, in return, he opened a line of communication with them.

But how often does a rural ENT need to tap the expertise, experience or resources of a big city colleague? That depends on their comfort and skill levels, Dr. Duck said. “There’s a lot of stuff that I feel like I can do as well as they can do,” he said. “But there’s a lot of stuff I can’t do as well as they can do—like, for instance, head-and-neck cancer. I don’t have time in a rural, one-man practice to do head-and-neck surgery for big head-and-neck cancers. And I have no business doing that, because I can’t make rounds two or three times a day, every day, on these people.” These patients are often more effectively treated in a university setting, he said. “You need residents, and you need a place where it’s done all the time because it’s in the best interest of the patients.” The transfer of patients in those situations depends on the self-confidence and comfort level of the provider, he added.

Another challenge for rural otolaryngologists is dealing with the current onslaught of medical reforms, many of which involve costly and complicated digital components.

Rural physicians are not as likely to adapt as quickly as their urban counterparts, said Dr. Slabach. However, he urges rural ENTs to embrace the technology and take advantage of their typically small practice size.

“Yes, it’s problematic, but because of their size … these changes can occur probably more quickly, assuming that they want to make that transition,” Dr. Slabach added. “Decisions could be made more quickly, and the process could move more efficiently.”

Rural physicians face a variety of challenges that their more urbanized counterparts rarely see. But with proper planning and recognition of the obstacles, most physicians easily overcome them.

—Brock Slabach, MPH

Time, Time and Less Time

Perhaps the ultimate challenge for small-town otolaryngologists is finding time to stop practicing long enough to learn how to do it better. Whether it’s time off for continuing medical education, a conference or just the breaks necessary to prevent burnout, how does an otolaryngologist stop working when he or she is the only game in town?

Realize you can’t do it all and build in time off, Dr. Duck advised. “You have to learn to realize that you can’t save the world, and that you’re needed, but you have to balance it. That’s all,” he said. “You can’t take calls 24/7, you can’t be available all the time and sometimes you have to say no.”

Scheduling days off, for any reason, requires planning, Dr. Duck said. Procedures that require follow-up shouldn’t be scheduled for a few days before you leave. Inform your patients that you’ll be out of town but available via pager or phone. Ensure coverage in your absence, using either a locum tenens physician or a stand-in from an affiliated practice. “Learn what procedures you can do so that people will be comfortable and safe in your absence,” Dr. Duck said. “And then you figure it out on your calendar, and then you do it that way.”

While the rigors of planning to take just a long weekend may seem like a challenge, rural physicians say they get used to the process. And, in the long run, the tradeoff is well worth the benefits that draw some otolaryngologists to rural practices in the first place. “I feel like I’m Marcus Welby, ENT, of Jackson Hole, Wyoming,” said Dr. Trott. “I’ve only been here for four years, but the good news is you know the governor, you know the mayor—you know everybody.”

Rural Health Care Facts

The obstacles faced by health care providers and patients in rural areas are vastly different from those found in urban areas. Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas:

• Only about 10 percent of physicians practice in rural America, despite the fact that nearly one-fourth of the population lives in these areas.
• Rural residents tend to be poorer. On average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty line. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24 percent of rural children live in poverty.
• Medicare payments to rural physicians are dramatically smaller than those made to their urban counterparts for equivalent services.
• Rural residents have greater difficulties finding transportation to reach health care providers, often traveling great distances to reach a doctor or hospital.

Source: www.ruralhealthweb.org