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By Joe Cornely

John Duffy's job eats up a lot of hours, but he doesn't mind. He knows he could make more money if he took a job in the city, but he’s not really motivated by the chance to earn big bucks. He sticks it out in the country because, he says, "It's a way of life."

Duffy's mindset is the same as you'll find in countless farmers. Except he's not a farmer. He's a doctor. And he's one of a shrinking number of general practitioners who choose to hang out their shingles in rural America.

Fifty of Ohio's 88 counties have a shortage of primary care physicians according to the Ohio Department of Health (ODH). The agency said many of the doctor-deficit areas are rural. That statistic is backed up by the National Rural Health Association (NRHA) that said 20 percent of Americans live in a rural area while less than 11 percent of the nation's doctors practice in these areas. Said another way, the doctor-patient ratio in the country is about half what it is in the city.

John Duffy has bucked the trend. He’s a resident at Mad River Family Practice in Logan County and is part of an Ohio State University medical college program that places two resident doctors each year in a rural setting. Duffy comes from an urban area of Northern California, but took the Logan County residency because "I wanted to practice true family medicine: delivering babies, nursing home care and everything in between." He likes connecting with patients. "It’s nice to see the affect of your work," he said.

If the job satisfaction can be so high, then why are so few of the country's doctors willing to become "country doctors?" Dr. Randy Longenecker, who administers the OSU program at Mad River Family Practice and is Duffy’s mentor, said it’s because of "myths" about practicing in small towns. He said those misperceptions include being constantly on call with no time for family and a feeling that "you can’t possibly know enough (medicine) to do a good job without having specialists right there at your elbow." Another concern that’s common is that small towns provide little in terms of privacy. Longenecker said that's a worry that is balanced by some advantages of being in a close-knit community. "It’s true everyone in town knows when you’re on vacation," he said. "But it’s also true they’ll keep an eye on your house for you while you’re gone."

One roadblock to attracting doctors to rural areas definitely isn’t a myth, according to Longenecker. The pay typically isn’t as good. NRHA’s studies support his belief. The association said rural doctors "on average work more and earn less that their metropolitan counterparts." NRHA said the lower income results from rural doctors having a higher percentage of their patients who receive Medicare and Medicaid benefits. These public programs pay less for doctors’ services than private insurance, which is more common for patients in metropolitan areas. Longenecker disputed another bias that appears to be built into Medicare and Medicaid: that health care, like eggs, is cheaper in the country. "My office supplies, examination tables and medicines don’t cost any less than they do in town." The staff doesn’t cost any less either. He talked of a recent hiring. "I had to pay a first-year salary that was about the same as what a doctor with 15 years of experience was earning." But such is the competition created by managed care companies who hire what Longenecker called "docs in a box" to staff their corporately owned practices. Still, he doesn’t fault graduating doctors for going where the money is better because, he said, "Students often leave medical school with debt in excess of $100,000."

Ironically, that tough financial situation for a young doctor might be leveraged to the benefit of rural communities that need doctors. Students can get their medical school loans paid off by agreeing to practice in what’s called a Health Professional Shortage Area (HPSA). The program is a federal one, but the Ohio Department of Health (ODH) is engaged in putting it to work.

That’s part of Joel Mariotti’s job. He’s ODH’s program administrator of primary care and rural health. He explained what an HPSA is and how it works. "It's a self defined geographic area by a local entity. It could be a group of farmers who would say I want these specific townships to be an HPSA. And they could contact my office and we would help them define the geographic area that they want to be the HPSA. The local entities would have to survey all the local primary care physicians to find out how many there are in the geographic area, what their hours are, and what their specialties are. That would become the basis on which our review would be conducted here to determine whether or not we could recommend to the federal government that the area is in fact an HPSA." Whether or not the federal government designates an area as an HPSA is based primarily on the doctor-to-patient ratio. There are currently 73 HPSAs in the state. "We have a fairly good success rate at getting these areas designated," Mariotti said.

Applying for the designation is only the first step. If HPSA status is approved, the community needs to come up with funding for salaries, staff and office space. "A local group has to sponsor the physician," Mariotti said. "They have to create a facility and a structure for that physician to practice. Our end of the proposition is to either pay back the physician’s medical school loans or to pay the physician to go to medical school or to allow a foreign born physician to stay in this country."

Along with university, federal and state programs to recruit doctors to rural areas, the American Farm Bureau Federation (AFBF) also is involved. Most recently AFBF supported legislation that allows foreign citizens who are U.S. medical school graduates to apply for a waiver to their visas. Without the wavier, the graduates are required to return to their home countries within three years of finishing medical school. Other Farm Bureau policies support efforts of medical schools to train doctors who intend to practice in rural areas, and support a reduction in medical malpractice insurance costs including limitations on certain punitive and noneconomic damage awards.

Regardless of what kinds of incentives are used, it's clear that rural Ohio needs more doctors. As anecdotal evidence, ODH's Mariotti cites his conversations with farmers where he's learned that a shortage of physicians leads to a lot of "self-treatment." He said of farmers, "If they cut themselves, if the burn themselves or they're exposed to fertilizer or some other chemical, they typically downplay the injury. They treat it themselves or their spouse treats it, and they go back to work." But there's a cost to that approach, Mariotti added. "The literature is complete with studies that show if individuals ignore their health and they self treat themselves, that creates a stress on the body. So when you do become ill or need to be hospitalized, it costs more to treat that individual." That's one reason Mariotti said a primary mission of ODH is to recruit doctors to under-served areas.

Mad River's Randy Longenecker hopes the practice’s rural residencies help in that recruiting. He said, "It's imperative that we expose more medical school students to this kind of medicine."

John Duffy got the exposure and liked what he saw. When his residency in Logan County ends, he's setting up practice in Wallace, N.C., a town of 4,000. He figures it will be similar to his rural Ohio experience, of which, he said while laughing, "I don't get a lot of sleep." But that's more than offset by the advantages of living and working in a rural setting. "It's nice to have a little elbow room." He also said he likes the diverse nature of the community. "I get to play basketball with farmers and Honda workers and businessmen." But the personal attraction is accompanied by a professional one. "It's rewarding to help people. It gives you a good feeling."