Greener acres: Some physicians bid goodbye to city life

Giving up the urban landscape for a practice in a rural area can be clinically and financially rewarding -- as long as you realize exactly what you're getting into.

By Mike Norbut — Posted July 5, 2004

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Family physician Saul Montelongo, MD, was looking for a new job earlier this year so his family could move closer to his wife's parents, who live in San Antonio.

But when an opportunity in the city came up -- complete with a good salary and plenty of physicians among whom to divide on-call work -- Dr. Montelongo turned it down.

Instead, he chose a practice in tiny Floresville, Texas, about 30 miles southeast of San Antonio, which offered a slightly lower salary but a chance to be a partner in a couple of years. The town, with about 8,000 residents, also offered those country living intangibles he couldn't get in the big city.

"It's friendly, with less stress, and the people are more appreciative," said Dr. Montelongo, who got used to rural living at his former practice in Alice, Texas, a town of about 20,000 residents in the southern portion of the state. "I got used to the laid-back attitude. I like picking up my daughter from school."

While the perception might be that urban and suburban opportunities always trump rural ones, doctors might be able to find solid jobs and practices in smaller communities across America. A shrewd physician willing to forgo some of the perks of city living can use the higher demand for medical care and the willingness of a hospital to assist in the recruitment to his or her advantage and actually get an enviable financial package, recruiters say.

Times have definitely changed. The days of a small town pooling its money to try to recruit a doctor who was willing to gamble his or her own financial security for a social mission are less frequent now. Instead, hospitals are taking the lead, and while there still isn't a rush to the country, spots are easier to fill because the positions have become more appealing.

With some incentives, including income guarantees, signing bonuses and fewer competitors than in more populated areas, doctors who choose rural locations certainly have a good chance to be successful, recruiters say.

"When you're recruiting to a rural community, you're filling a void," said Steve Korinek, vice president of recruiting of the southwest region for Merritt, Hawkins & Associates, an Irving, Texas-based physician recruitment firm. "You can get incentives in the form of signing bonuses between $10,000 and $50,000. You rarely find that in metro practices."

For example, a primary care physician in Dallas generally averages about $130,000 a year to start, But Korinek said he had seen rural opportunities that start at $180,000 per year.

Physicians either can join a practice as an employee of a local hospital, join a hospital-sponsored practice that would include a guaranteed salary for the first year or two in the new practice or join an independent group.

But to compete with urban and suburban practices, a rural group simply has to open its wallet and offer some incentives, recruiters say.

"What we're seeing is it may take longer to place a doctor in a rural practice, but their economic opportunities are in no way hindered," said Larry Stewart, president of CompHealth, a physician search firm with headquarters in Salt Lake City.

In addition to comparable or better salaries, rural practices can offer a quicker route to partnership with a less expensive buy-in, Stewart said. Physicians also can enjoy being a big fish in a small pond, with fewer established practices in the area, recruiters say.

"It all boils down to lifestyles these days," Stewart said.

Not all roses

Of course, not every rural opportunity is a golden one. There are definite downsides to practicing in a smaller community, just like there are to an urban or suburban setting.

For one, there are far fewer physicians to cover on nights and weekends. Doctors must keep phones on, and taking a vacation is a luxury some doctors don't have.

"In some ways, the lifestyle of a rural family physician may be more difficult," said Steve Richards, DO, a family physician in Algona, Iowa, and president-elect of the Iowa Medical Society. "You have more [emergency department] coverage, and you're delivering babies."

Dr. Montelongo said he got used to the extra time on call in his previous community, but since his resources were more limited than in the nearest cities, which had more technologically advanced equipment, he had to rely on his own knowledge to treat patients.

"The volume is not as high, but the acuity is the same," he said. "You learn as you go what you can do to keep them stable."

Low Medicare reimbursement rates can make practicing in a rural area very difficult as well. The pain physicians in more populated areas feel is amplified in rural locations because of more elderly patients and fewer good commercial insurance alternatives to help balance the losses.

Dr. Richards said Medicare payments were so poor more than 15 years ago that he wouldn't have stayed in his rural location, but a local hospital bought the practice in an effort to build a primary care network. The hospital took over the risk, and it has provided strong financial backing for the practice as it has grown over the years, he said.

A financially strong hospital is important for a physician to be successful in a rural setting. His or her own financial status is closely tied to the institution's, both because of the salary incentives and the impact its demise would have on the local economy.

"From our vantage point, you're looking for a welcoming medical staff, deep pockets and an up-to-date, modern facility," Stewart said. "They need to have some resources to recruit and support that doctor."

But hospitals' involvement in recruiting is coming under fire. Trial is set for October in the case of Alvarado Hospital Medical Center -- part of the Tenet hospital chain -- which is accused of paying more than $10 million between 1992 and 2002 in relocation agreements to doctors.

Federal investigators say the payments were nothing more than inducements to expand the pool of physicians referring to the San Diego hospital. Trever Fetter, Tenet president and chief executive officer at the time of the hospital's indictment in October 2003, said that government was making a broad attack on "a well-established, lawful and common means by which U.S. hospitals attract needed physicians to their communities."

Physician recruiting also has become more hazy recently, because of proposed changes in Stark regulations, health care attorneys said.

There are exceptions for regions that are deemed medically underserved. But for regions that don't fall under that category, the proposed changes could alter the way medical groups and hospitals collaborate on recruitment efforts, attorneys said.

The biggest change would restrict practices from adding noncompete clauses to employment agreements if the local hospital is supporting the group with an income guarantee.

In the past, physicians might have had to stay in a service area to fulfill those income guarantee obligations, but they would have been forced to move a certain distance away from the practice they were leaving because of the noncompete clause, attorneys said. Group expenses related to the new doctor will be under closer scrutiny as well, making it more expensive for the practice to employ that physician.

"In other words, if the hospital wants to help the group, the group cannot have a noncompete clause," said Claire H. Topp, a Minneapolis attorney who chairs the health care practice for Dorsey & Whitney LLP. "Groups might not recruit if they don't have the noncompete clause."

Selling strategies

Not having that protection certainly can be a concern for a practice, especially one that invests so much to bring a new physician to town. In rural locations, the courtship is the most important, and most difficult, aspect of the recruiting process, Dr. Richards said.

"After 25 years, you learn you have to go after families," said Dr. Richards, who grew up in Des Moines but sought out a rural location for its quality of life. "The young people have grown up in a different time. They want that balance between work and family demands. We have to compete in that total marketplace."

A limited access to cultural amenities, fewer vacations and a harder track for continuing education all weigh against rural locations. Add to that the fact there might be fewer people in a physician's income bracket, and it gets tougher to persuade people not familiar with a rural lifestyle to take that type of job, recruiters said.

In Iowa, for example, practices start their search with physicians who had rural residencies, Dr. Richards said, because many of those doctors came from smaller towns. There also has to be opportunities for the spouse; the recruiting effort is given a boost if the wife or husband can find enrichment in the small town.

"We search out people who already know what they're getting into," Dr. Richards said. "Most who come are from small-town Iowa. They go through the [residency] network, and their wife is from small-town Iowa."

A rural town will never be able to compete with cities when it comes to cultural opportunities, but the practice can make efforts to suit the doctor's lifestyle needs, Stewart said.

To accommodate vacation time, the group could hire locum tenens physicians. To make continuing education an option, it could use videoconferencing.

They might not be perfect solutions, but they show a commitment by practices and hospitals to making a situation comfortable for a physician.

"The degree to which these are drawbacks is up to each physician," Stewart said. "There are fewer cultural opportunities, but there are other aspects the city doesn't have."

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A physician's checklist

Points to keep in mind when you're considering a position with a rural practice:

Salary: How much? Recruiters say compensation levels are comparable between rural, urban and suburban practices.

Signing bonus: Does the practice offer one? Recruiters say you're more likely to see one in a rural practice.

Income guarantee: If the local hospital is involved in recruitment, is it giving a guarantee for your first couple of years in the community?

Hospital health: Does the hospital have deep-enough pockets to support you? What is its financial position?

Health care landscape: How many other practices are in the community? What are the partnership opportunities at the practice you're considering?

Size of the group: How big? The size will dictate how much time you spend on call.

Quality of life: What are the cultural opportunities? What are the job opportunities for your spouse? How are the schools? Will you get much time off?

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