Can you go home again? How to practice medicine where you grew up

Family physician Alan DeWitt, MD, returned to his hometown of Snowflake, Ariz., right after residency to start a practice with three other doctors. He'd always wanted to practice in the small town of 6,000 but found himself unprepared and a little uncomfortable one day when he looked at his appointment list and saw the name of an ex-girlfriend.

"It felt like it would be a little strange keeping the professional distance," Dr. DeWitt said. "Those embarrassing conditions do come up, and the idea of having old girlfriends as my patients [was uncomfortable]. I referred her to my partners."

Awkward as it may be, such situations often are unavoidable for physicians practicing in their hometowns. For some doctors, the prospect is so daunting that it dictates where they locate their offices. Medical schools often hear it from students as an excuse not to practice in their hometowns and sometimes as a reason to avoid the medical field altogether.

But experts, as well as physicians who have returned home, say that once you get over the initial discomfort of treating people from your past, the experience can be fulfilling and successful if you set ground rules that protect your personal life and ensure that you're compensated correctly.

Doctors who grew up in small towns are likely to return there or a place like it after residency.

A study by the Indiana State Dept. of Health and Indiana University found that doctors of all specialties who came from a non-metro hometown were 4.7 times more likely to locate their practices in a non-metro location, said Terrell Zollinger, DrPH, one of the study's authors. The study, published in the April Family Medicine, followed 2,400 Indiana medical students over 10 years.

"Rural people have a culture," Dr. Zollinger said. "People who come from that background understand that culture and are comfortable living in it. If you grew up in a metro area, maybe you're not comfortable in a rural culture."

Richard Glehan, a physician recruiter in Danbury, Conn., agrees. "Physicians who come from smaller communities like to go back," said Glehan, also a board member of the National Assn. of Physician Recruiters. "I don't think anybody goes back for economic reasons. The appeal is lifestyle, and the sense of things were good when they left. There's usually a matrix of relatives and grandparents there for the kids."

Where everybody knows your name

That close-knit feeling is appealing for some, but for others it's a turnoff. John Brandon, MD, medical director of the University of Alabama's Rural Medical Scholars program, said the anxiety and pressure of returning to a place where everyone knows you often makes students reconsider a move home. In rare cases, it makes them consider leaving medicine altogether.

"We hear it almost universally from students," Dr. Brandon said. "We have a session we do with our premeds about things like how you deal with family who request a prescription on Thanksgiving Day." The program stresses the ethical dilemmas of treating family members and how to deal with patients with whom there is a past. One key is to tell the patient if you feel uncomfortable, because he or she deserves to know, he said.

"Whether it's your first-grade teacher or your basketball coach, if you're uncomfortable, then the patient is uncomfortable," he said.

Glehan, the recruiter, said physicians should set ground rules to help themselves enjoy the advantages of practicing in a hometown without falling prey to the disadvantages, which might include old friends thinking they're entitled to free care or after-hours care because they played Little League baseball with their physician.

"The doctor has to train his or her patients," Glehan said. "There have to be guidelines, because they do not serve at the whim of the local patients. They're providing a service just like a plumber or electrician or any other business."

Charles McKee, MD, a family physician who's practiced in his hometown of Appleton, Wis., for 30 years, said he used to give in to acquaintances who called in the middle of the night asking for prescriptions. He said he understands that young physicians might be afraid to be firm with friends and family.

"I wouldn't tell them it's inappropriate. I didn't want to be disliked. You don't want it to be interpreted as, 'I'm sorry, I know we used to be friends, but that's changed,' " Dr. McKee said. "I've gotten better at that. The reality is, 'You're taking advantage of me, and I don't appreciate it.' "

Dr. DeWitt has perfected a response for those who ask for discounts on services or prescriptions. "I tell them this is a shared venture with my partners, and we have a large staff of employees that the expense will spill down to, and I'm not in the position to cost my partners money."

Dr. DeWitt said that when acquaintances with money problems often ask him to waive bills, he tries to implement a payment plan. If that's not possible, he gently suggests that the patient use another practice. It's important "not to pour salt on the wound," because these are people he still has to see around town. "They're our neighbors. We go to church with them. We see them at the grocery store. They're relatives of other patients. But we're not in a position to carry them for thousands of dollars."

Adjusting to home

Richard Cecconi, MD, has been a general surgeon in his hometown of Iron Mountain, Mich., for 20 years. He came back after residency. It was an attractive option because he loves the outdoor feeling of the Upper Peninsula and because a lot of his family lives there.

Dr. Cecconi has turned down several requests from friends to perform their surgeries -- but the logistics of practicing in a small town sometimes make it impossible to avoid an emotional situation.

Six years ago, his father needed immediate surgery, and Dr. Cecconi was the only surgeon available to do it. "As a physician, you learn to compartmentalize, but it's difficult to do with somebody close to you," he said. "If something goes wrong [during surgery] you want to have a clear head" rather than feeling anxiety over whether you'll harm someone you love.

Maurice Ramirez, DO, an emergency and family physician in his hometown of Kissimmee, Fla., remembers having to tell his elderly former neighbor he had lung cancer that spread to the brain. "It was horrible and heartrending."

Sometimes treating patients in your hometown is a sobering reminder that people get old, they get sick and they have flaws, because you remember them when they were young and healthy, said Appleton's Dr. McKee. He remembers the day the town's former insurance agent came to him for treatment of alcoholism. "I had to get over this feeling of this place being like Pleasantville," Dr. McKee said. "It took a year or two."

Drake Lavender, MD, a family physician just outside his hometown of Eutaw, Ala., felt awkward when he treated his younger brother's best friend for depression. "You wonder as a physician, is the patient telling me everything? I think that's especially a concern with someone you've known before you were physician. You have to let them know this is not gossip, this is not talking to your friend -- this is a doctor-patient privileged conversation," Dr. Lavender said.

Another time, he performed a colonoscopy on an elderly man who lived across the street when Dr. Lavender was a boy. This time he was concerned that the man would view him as the kid next door, not as a professional with serious medical advice to dispense.

"If it's to the point where they can't comply [with your recommendations], you have to recommend they see someone else. Otherwise it's not doing their health care any justice."

Arizona's Dr. DeWitt not only has had former girlfriends come to him as patients, he also has seen a former teacher and an old neighbor.

He said the key to dealing with these situations is simple: Remember what you learned in medical school.

"There's a job to be done, and you don't have the option of leaving the room," he said. "Use your training of appropriate professionalism. You just try to push the past aside and deliver the care."