Why Are There So Few Doctors in Rural America?

Christian Rubio, Sermo's community director, says "it's not just the highbrow ballet stuff" that contributes to physicians' reluctance to move out to the bush.

"It might be the lack of diversity of food options," he said. "One rural doctor said he goes once a month with his wife to a big city to get food and go to movies and just get out."

Though some country doctors cite unusual perks—high schools with just 50 students in each grade, for example—others say they've faced prejudice in small towns. 

Bryon Harbolt treats a patient in his
clinic in Altamont, Tennessee. (Harrison McClary/Reuters)

Rubio said one gay psychiatrist responded that, while she liked the closeness she had with her rural patients, she also experienced homophobia. Another pediatrician said he moved back to the city after his small town's school principal prohibited his son from being on the cheerleading squad. 

Even if they do hear the call of the wild, providers might find that there aren't enough patients to support a private practice. People in some rural regions are more likely to use Medicaid, the government health insurance program for the poor, which does not reimburse doctors for medical services as much as private insurance does. 

What's more, doctors working in the hinterlands face geographic struggles that a Dupont Circle dermatologist can't fathom. In Alaska's villages, community health aides work out of single-room clinics, relying on shaky phone and Internet connections for back-up. Many Native Alaskans speak rare tribal tongues as their first language. Overt complaining is not customary among some of the tribes, making it difficult for doctors to understand their symptoms. Transfers of patients to specialists or emergency rooms depend on the schedules of rickety charter planes, which often get "weathered up," or prevented from flying because of rain, snow, or some combination of the two.

Butler, from the Tribal Health Consortium, was once working out of a clinic on St. Lawrence Island, which floats just below the Bering Strait. One morning, there was a knock at the door and a local resident brought in a 14-year-old with a massive facial wound and cerebrospinal fluid pouring out of his nose. After the boy was stabilized, a blizzard rolled in, and Butler and the health aide spent the next six hours waiting for the weather to clear before a plane could come collect him.

And of course, having one doctor in a village means that doctor never gets a day off. “Country doctors doing family practice is kind of a 24/7 job,” Dave Jones, board president of the California State Rural Health Association, told the California Health Report. Doctors told Sermo that many country colleagues get burned out quickly, and some eventually come to resent most of their patients.

I asked several healthcare workers whether they'd be willing to move to Bethel. One Kansan dental hygienist said she wouldn't want to relocate this late in her career. A female dentist said she couldn't do her work in such a place because she has a faculty job.

Ji Choi, a dentist in Seattle who grew up in a small town, said he would consider moving to Bethel. His more cosmopolitan wife, though, probably not so much. "She needs her Barnes and Noble," he said.

"Sometimes dentists show up [in a rural area], and the wife hates it," McClellan said. "They'll stay a year and end up leaving. What's more common is for dentists to think they'll earn enough to travel to far-off places, but they don't necessarily want to live there."

Choi points out that dentists who are saddled with loans when they graduate might take jobs in clinics for underserved or needy populations because many such programs offer loan forgiveness plans. But after a few years, most move on.

"To stick with it, they really have to have the heart for it," Choi said. "And that has to come from within."

Reporting for this story was sponsored by the W.K. Kellogg Foundation.

Presented by

Olga Khazan is a staff writer at The Atlantic, where she covers health.

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