PE R S PE C T IV E
be unfamiliar to them: What staff round providers, including physi-
members are on island and on
call? Is orthopedics here? Whats
the current volume? Will the
weather prevent MedFlight from
getting here?
Assembling the summer ED
team became increasingly diffi-
cult. The usual cadre was aging,
and some clinicians chose not to
return. Seeing that the model
that had evolved wasnt serving
us and couldnt be sustained, we
began to think about an alterna-
tive. Our chief medical officer
identified an emergency staffing
group MEP Health, now called
U.S. Acute Care Solutions
that, far from being daunted by a
new problem, was intrigued by
Nantucket and its unusual cir-
cumstances. Aiming to balance
delivery of high-quality medicine
an ever-evolving goal with
continuity provided by a core
team that understands the puz-
zle we face, we negotiated a trial
agreement. MEP Health became
the employer of the existing year-
Rural Health Care
Rur al He alth C are
And How Long Will You Be Staying, Doctor?
Heather Kovich, M.D.
Have I told you that Im
converting my garage into
a workout room? my friend asks.
We are roaming the compound,
our eyes fixed on the enormous,
changing sky, oblivious to the
tumbleweeds and empty plastic
bottles skittering across our path.
Im hiring one of the mainte-
nance guys to put down laminate
floors. Theyre even installing a
window.
The sun, down behind the
The New England Journal of Medicine
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Copyright 2017 Massachusetts Medical Society. All rights reserved.
whose quality we have no way of
cians and physician assistants, as
well as some longtime summer
team members, and supplement-
ed them with rotating clinicians
from its higher-volume hospitals.
It took on responsibility for sched-
uling, peer review, and quality
metrics, while building awareness
of Nantucket-specific aspects of
clinical judgment, so that we no
longer have to constantly reorient
personnel. This model forces a
careful comparison between the
cost of subcontracting ED staff-
ing and the cost of directly hir-
ing six or more ED physician and
PAs, even if we could recruit
them to the island and figure out
how to enable them to buy into
the housing market. Most of all,
it takes advantage of the continu-
ity and stability of our year-round
ED base, while allowing us to
stay current as medicine evolves.
Now we dont have to worry
about filling our schedule for
next summer or about depending
on a locum agency for physicians
Carrizo Mountains, streaks the
sky in a saffron finale. Our dogs
chase a curious prairie dog back
into its den.
My mind turns over the impli-
cations of my friends home-reno-
vation project, and I am filled
with happy relief. We circle the
hospital and return to our street.
I cant voice my feeling shed
be disappointed that Id doubted
her commitment. Instead, I say,
Thats a lot of money to put into
n engl j med 376;14 nejm.org April 6, 2017
thirty miles at sea
judging in advance. Instead, we
can focus on becoming fluent in
the type of medicine that best
serves our island.
Disclosure forms provided by the authors
are available at NEJM.org.
From Nantucket Cottage Hospital, Nan-
tucket, MA.
1. ODonnell J, Unger L. Rural hospitals in
critical condition. USA Today. November 2014
(http://www.usatoday.com/story/news/nation/
2014/11/12/r ural-hospital-closings-federal
-reimbursement-medicaid-aca/18532471/).
2. Wishner J, Solleveld P, Rudowitz R, Para-
dise J, Antonisse L. A look at rural hospital
closures and implications for access to care:
three case studies. Kaiser Family Founda-
tion, 2016 (http://kff.org/report-section/a-look
-at-rural-hospital-closures-and-implications
-for-access-to-care-three-case-studies-issue
-brief/).
3. Massachusetts Department of Public
Health. Lyme disease surveillance in Massa-
chusetts, 2014 (http://www.mass.gov/eohhs/
docs/dph/cdc/lyme/lyme-disease-surveillance
-2014.pdf).
4. Collins M. Staffing an ED appropriately
and efficiently. American College of Emer-
gency Physicians, 2009 (https://w ww.acep.org/
clinical---practice-management/staffing-an-ed
-appropriately-and-efficiently/).
DOI: 10.1056/NEJMp1701449
Copyright 2017 Massachusetts Medical Society.
Rural Health Care
the hospitals house, but it sounds
awesome. I cant wait to see it.
This tension defines our lives
as rural primary care physicians.
Our patients put it the most
bluntly: And how long will you
be staying, doctor?
Over the past decade, efforts to
increase access to health care in
the United States have focused
on insurance coverage. Meanwhile,
a shortage of physicians is still
the limiting factor in rural com-
1307
PERS PE C T IV E
munities. Twenty percent of the
U.S. population is rural, but only
11% of physicians practice in rural
settings,1 even though residents
of rural areas are older and have
worse health indicators than their
urban counterparts.2 Programs
like the National Health Service
Corps and state loan-repayment
arrangements lure physicians to
rural settings, but these physi-
cians churn like lottery balls in a
drum.3 The winning combination
is a good doc who stays.
My patients asked me The
Question at every visit for several
years, and it irritated me every
time. I would paste on a smile
and answer with some version of
Im not sure, dodging the follow-
up inquiries about what my hus-
band does and whether he likes
the area. Their questions implied
what the Dartmouth Atlas made
explicit: physician supply is driven
by where physicians want to live,4
not by the health needs of the
community. If we like it, maybe
well stay.
Before moving to rural New
Mexico, I had been itinerant. Med-
ical school on the East Coast.
Residency on the West Coast.
Locums abroad. So I expected to
stay for 2 or 3 years a tenure
that seemed respectable to me. It
was not the answer my patients
wanted. I rationalized my defen-
siveness. Why did turnover mat-
ter if the care was good? My col-
leagues in big cities changed jobs
after a few years, too.
As I started my practice, the
patients seemed complicated: dia-
betes, rheumatoid arthritis, cirrho-
sis, often all three. I was grateful
theyd had a series of very good
doctors. Their problems had been
worked up, and the plans were
clear. Theyd had their cancer
screenings. When it was indicated,
1308
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Copyright 2017 Massachusetts Medical Society. All rights reserved.
they were on aspirin and statins.
Hardly any were on long-term
opiates.
In my first month I diagnosed
a patient with hyperthyroidism.
Wheres the nearest endocrinol-
ogist? I asked a veteran internist.
She was puzzled. Why would
you refer? Cant you order the ab-
lation?
I learned to adjust my care to
the geography. Some of my pa-
tients live hours from our hospi-
tal, on dirt roads that become im-
passable in thunderstorms or
snow. The nearest tertiary care
hospital is another 3 hours away.
We dont refer often. If my pa-
tients do need a specialist, they
go for a visit or two I can al-
ways e-mail the rheumatologist or
cardiologist if I have a question
about adjusting their treatment.
I appreciate the continuity. I see
my patients in our hospital and
back again in clinic. I dont need
to request stacks of records from
when they were septic, with dia-
betic ketoacidosis. I was in the
ICU with them, ordering their
antibiotics and insulin drip, ex-
plaining their condition to family
members who are also my patients.
Caring for entire families helps
me understand my community. I
know that a patient is stressed
because her son struggles with
alcoholism: Ive admitted him
several times with pancreatitis. I
know another patient cant focus
on her diabetes because she is
still grieving her mothers death:
for years she wheeled her mother
into my clinic for monthly ap-
pointments. When a teenager re-
turns from a first year at college
and asks for birth control, I re-
member her mother crying in my
office months earlier, overwhelmed
with pride and worry at having
her first baby move so far away.
n engl j med 376;14 nejm.org April 6, 2017
The New England Journal of Medicine
how long will you be staying?
The patients weary of explain-
ing all this their tragedies, tri-
umphs, and transformations
to a new face every few years, no
matter how bright or kind that
new face is. Seven years in, I un-
derstand why my patients would
be disappointed if I left. As their
doctor, I would be, too.
Ive seen plenty of doctors cy-
cle through. Smart, sincere, and
hardworking, they came for a year
or two or four to pay back
loans, to gain experience before
fellowship, to have an adventure
before settling down. Their ser-
vice is no small thing: we depend
on them. When I see Dr. C.s
copperplate handwriting in patient
charts, I remember her warmth
and meticulousness. When I use
the clinic ultrasound, I see the
reams of forms Dr. W. used to
justify its purchase. I wistfully
think of Drs. B. and D., a married
couple of fun, razor-sharp clini-
cians who taught me a lot about
medicine and parenting over
2years. And I have a small, dusty
bottle of sweet-teaflavored vodka
on my shelf from Dr. H. He left
6 years ago and gave it to some-
one else, who left and passed it
along to me. Although the vodka
is not to my taste, I like the re-
minder of Dr. H. He still recruits
for us, sending us residents from
his academic post.
Like my patients, I weary of ex-
plaining my history to new col-
leagues year after year. Also like
my patients, I am immensely grate-
ful for the physicians who have
been here longer than I. We doc-
tors are a close group. We rent
housing from the hospital on its
adjacent compound. We gather
for potlucks and barbecues. Our
children play together. I have
knocked on a neighbors door at
10 p.m. to borrow a cup of sugar.
PE R S PE C T IV E how long will you be staying?

So, like my patients, I tire of
saying goodbye. When doctors
leave a remote practice, they go
far away. Getting together with
them involves airlines, time zones,
and unsettled feelings. There is
guilt for the person who left, inse-
curity for the one left behind. I feel
it acutely: Are they really happier
somewhere else? Should I leave
too? It sounds nice to live in a
neighborhood with Trader Joes,
high-speed Internet, and baby-
sitting grandparents.
Now, before I make friends, I
gauge how long someone will stay.
I learned this move
An audio interview
with Dr. Kovich is
from my patients,
available at NEJM.org though Im not yet
as blunt. I remem-
ber how much How long will be
you staying? irritated me. Instead,
I observe: Do they plant a garden,
spruce up the hospitals house,
adopt a stray dog? I hesitate to
pull up a chair unless theyre go-
ing to lay down some laminate
floors and stay awhile.
Patients still ask me The Ques-
tion at least twice a day. Youre
not leaving soon, are you? My
smile comes naturally. I feel val-
ued. I tell them honestly, I have
no plan. I dont tell them that Im
undecided about buying a new
dining-room table. Mine is fall-
ing apart, but Im torn between
buying a nice one that fits this
space and getting a cheap one. If
I move, I might want something
different in a new house.
I talk it over with my friend as
we walk our dogs in the evening.
Her eyes widen slightly, but she
hesitates only for a second. Buy a
nice one for this space, she says.
Disclosure forms provided by the author
are available at NEJM.org.
From the Northern Navajo Medical Center,
Shiprock, NM.
1. Rosenblatt RA, Chen FM, Lishner DM,
Doescher MP. The future of family medi-
cine and implications for rural primary care
physician supply. Seattle:WWAMI Rural
Health Center, August 2010 (https://depts
.washington.edu/uwrhrc/uploads/R HRC_
FR125_Rosenblatt.pdf).
2. Institute of Medicine. Quality through col-
laboration: the future of rural health. Wash-
ington, DC:National Academies Press, 2005
(http://www.nap.edu/catalog/11140.html).
3. Pathman DE, Konrad TR, Dann R, Koch
G. Retention of primary care physicians in
rural health professional shortage areas.
Am J Public Health 2004;94:1723-9.
4. Goodman DC. Linking workforce policy
to health care reform. Invited testimony to the
United States Senate Committee on Finance,
March 12, 2009 (http://www.dartmouthatlas
.org/downloads/press/Goodman_Sen_Fin_
2009.pdf).
DOI: 10.1056/NEJMp1613899
Copyright 2017 Massachusetts Medical Society.
Rural Health Care

n engl j med 376;14 nejm.org April 6, 2017 1309

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Copyright 2017 Massachusetts Medical Society. All rights reserved.