Practicing in the Heartland: How Where You Practice Affects How You Practice

Plenty of data show that a greater share of physicians practice in urban than in rural areas. The Council of Graduate Medical Education called it geographic maldistribution, "one of the most enduring features on the American health landscape," and said that it is likely to continue until universal health care is enacted.¹

According to the Center for Studying Health System Change, there are 53 primary care physicians (PCPs) per 100,000 rural residents, compared with 78 PCPs per 100,000 urban residents. For specialists, the disparity is much greater: 54 versus 134 specialists per 100,000 residents, respectively.²

Factors that influence retention of rural physicians include the physician's ability and desire to handle both emergencies and busy outpatient practices without consultants or high-level technology; his or her involvement in teaching; and the quality of rural school systems. Surprisingly, physicians raised in an urban area who move to practice in a rural area are more likely to remain in their practice than those raised in rural areas.³ In this newsfeature, we profile 2 neurologists who have found the recipes for success in their rural Midwest practices.

FROM NIH TO THE IRON RANGE

Robert W. Van Boven, MD, DDS, is in private practice at the Northern Neurology Care Center in Virginia, Minn. His practice is adjacent to the Virginia Regional Medical Center, an 83-bed hospital and 116-bed convalescent center with a staff of 43 physicians, dentists, and podiatrists. Van Boven is one of 53 physicians and dentists who hold courtesy and consulting privileges at the hospital.

Virginia Regional Medical Center is one of the larger health care facilities in northeastern Minnesota, providing services to 44,000 people in the region, including a dozen smaller mining towns. Van Boven is the only full-time neurologist within a 50-mile radius and the first neurologist that the community has had in 5 years. Virginia is 3 hours north of the Twin Cities of Minneapolis and St Paul, and 1 hour north of Duluth. The area is adjacent to the Boundary Waters Canoe Area Wilderness (BWCAW), renowned for its outdoor recreation and wildlife.

Wooed by the regional hospital and community leaders, Van Boven, originally from Chicago, liked the idea of returning to the Midwest with his wife and then 2-year-old daughter. He had been an annual visitor to the nearby BWCAW town of Ely. He was excited to set up his own practice and to have a "ripple effect on a community that hasn't had neurological services for over 5 years." After a little more than a year in northeastern Minnesota, Van Boven said he's found "a different set of rewards, not better or worse, just simply different."

Before moving to Virginia, Minn., Van Boven was at the NIH's Laboratory of Brain and Cognition as a clinical associate focusing on functional MRI studies of perception and brain plasticity. "If NIH is the heart of research, now I'm in a peripheral vessel," says Van Boven. An ongoing volunteer research position with NIH helps maintain his connection to the federal research and policy center.

Van Boven originally set out to be a dentist, earning a DDS from the University of Illinois. While completing a fellowship at Johns Hopkins University, he became passionately interested in multifacial pain research, as well as neurologic injury and recovery. That led to more years of medical training at the University of Maryland Shock Trauma Center, the University of Missouri-Kansas City, and Rush-Presbyterian-St Luke's Medical Center, as well as residencies at Harvard University's Beth Israel Deaconness Medical Center and at Northwestern University in Chicago.

At Johns Hopkins, he collaborated on several inventions, including a device for diagnosing gratings for somatosensory deficits. Now under license with Stoelting Co., Wood Dale, Ill., the grating device is used by numerous other investigators.

DEALING WITH PRACTICALITIES

Although the research was always rewarding, "You can't eat prestige," said Van Boven about his decision to leave NIH. Was he prepared to work in a rural area? "Well, prepared technically, but I had zero training for running a business." Another thing he was not prepared for was the local politics and bureaucracy of a smaller city. "Federal government employment did not prepare me for local politics or working with a city-owned hospital governed primarily by nonphysicians." He acknowledges that there have been times when he's encountered "attempts to influence how I practice medicine."

He has enjoyed working with patients on the "Iron Range," named after the vast iron ore deposits in the region. "They have a strong basic education, engage in health decisions regularly, and with their doctors take a team approach in their health."

Van Boven said that being the first neurologist in the area in several years has proved rewarding. "Many of the cases are like low-hanging fruit. It's easy to look like a hero when you're seeing things that have not been appreciated and detected for weeks, months, or even years." He added, "I have had a patient who was told she had a terminal disease when it was simply a slipped disk. Another patient thought she had [multiple sclerosis]. Another believed he had [Parkinson disease], when in fact it was essential tremor. Conversely, I have had patients who were told their problem was 'all in their head,' and we discovered that this was literally the case in 2 individuals. Imaging revealed a subdural hematoma and an aneurysm, respectively."

Van Boven has championed the use of clot-busting treatments and newer treatments for seizures and dementia. Furthermore, he's been featured on local television and in the newspaper, The Mesabi Daily News, in the company of grateful patients receiving treatment for stroke and dementia. Other satisfaction comes from his involvement in public education, which he views as a high priority. He gives frequent public presentations on coping with Alzheimer disease (AD) and other dementias and with stroke, and on living with epilepsy and other seizure disorders.

Current secretary of the Minnesota Society for Neurological Sciences, Van Boven said that Minnesota neurologists, like those across the country, are concerned about the rising costs of health care and medical-error reporting. Minnesota's adverse events health care laws lack enforcement, he said. Many errors, although reported, undergo long delays before resolution--or are never investigated--often because of confusion about state and federal accountability. "As it stands right now, there are no apparent punitive actions incorporated in the state statute if the law is broken," said Van Boven.

After meeting recently with Minnesota Attorney General Mike Hatch, Van Boven hopes the scope of reportable events will be broadened, that the law will be better enforced, and that reporting safety concerns will be encouraged so that the "culture of shame for whistle-blowers" will be eradicated. Van Boven also will work with Hatch's office on a pilot program to stem methamphetamine use. "Methamphetamine is an epidemic in northeast Minnesota," said Van Boven. "We've got to reduce the demand for drugs in the first place, as addiction after the fact is a great challenge."

One of his goals for the pilot prevention program is to have first-time methamphetamine use offenders given community service requirements to speak out about how the drug has affected their lives. Van Boven also believes that there needs to be a greater overall focus on prevention in future health care strategies. "Part of our mission is to teach people to care for their own health," he said.

FROM NEW DELHI TO HASTINGS

Pushpa Narayanaswami, MBBS, DM, a native of Madras, India, trained in Bangalore and practiced in New Delhi as a neurologist for 4 years; then, she completed a residency in neurology and a fellowship in clinical neurophysiology and neuromuscular diseases and practiced 2 years in Memphis, Tenn. She landed in Hastings, Neb., in 2003.

A community of 23,500 residents, Hastings may seem distant both culturally and climatically from Memphis, and even further removed from Bangalore. Hastings has a mixed economy of agriculture, manufacturing, retail, and tourism. It's home to 2 of Nebraska's largest corn ethanol manufacturing facilities. ConAgra has a great presence, as do smaller meat packers and soybean refiners.

Narayanaswami learned of the opening at Hastings' Mary Lanning Memorial Hospital from her mentor, Ronald F. Pfeiffer, MD, a native Nebraskan and the vice chair of the Department of Neurology at the University of Tennessee. She is 1 of 2 neurologists out of about 80 physicians serving the immediate community and 50,000 additional residents in surrounding counties.

Speaking on the second-year anniversary of her move to Hastings, Narayanaswami, who resides in the area with her husband, 12-year-old daughter, and 4-year-old son, said she didn't have much trouble adjusting to the smaller town and slower pace. "It was not hard to adjust on both personal and professional levels," she said, noting that a residency equips a physician to see almost any neurologic case.

Narayanaswami believes that she sees a wider range of patients than her urban counterparts. "I'm referred a lot more cervical and lumbar spondylosis that in a larger city would go to a neurosurgeon," she said. That's partly because physicians and patients are familiar with her background in neuromuscular disease. She treats the full range of neurologic disorders--from stroke, AD, and Parkinson disease in older patients to migraine and epilepsy in younger patients. Having a neurologist in the community means that patients don't have to travel up to 2 hours to Lincoln or Omaha.

ANYWHERE IN 2 MINUTES

Not having a long commute to work is a benefit for anyone who's fought morning and evening traffic congestion. "It's nice not to drive--it's 2 minutes to go anywhere in town. It's also safer for kids to walk to school," said Narayanaswami. She found it easy to adapt to the closeness and familiarity of a smaller community. In a small town, physicians are better known. "People know your kids so they can't get into trouble," she added with a laugh.

She considers the things she does miss minor inconveniences. One example: "We don't have an Indian grocery store." Another: Traveling out of the region is more challenging. Lincoln, the closest large city with a major airport, is 90 miles away.

Narayanaswami said that it is difficult to say whether her work schedule is more demanding now than it was in Memphis, where she worked as part of a team of 8 neurologists. There, neurologists were on call every 1 out of 8 days, "and we were really busy." Now she's on call every other day and every other weekend, but on-call days are less busy, "so it probably evens out."

From talking with patients and colleagues, she gets the sense that practices are full but there's ongoing recruiting. "Most patients seem to get in to see their doctors when they need to, however," she said. "We work very hard. Does that mean they [patients] need more? I don't know." She admitted that the hospital "could do with more specialists." The closest neurosurgeon is in Lincoln, and no gastroenterology practices are nearby.

Narayanaswami said that her office would benefit from adopting more electronic medical record (EMR) technology. She said, however, that the country "needs a national standard for EMR. I worry about safety and privacy issues. You're not doing it on your own. EMR requires coordination. Hospitals and clinics must be connected to referring doctors and pharmacies." (See "The March Toward Paperless Health Care," Applied Neurology, March 2005.)

A hospital that was founded 8 years ago, Mary Lanning Memorial has developed a sound infrastructure, including MRI and electroencephalographic (EEG) technologies. "It helps me give quality 'neurocare.' The trouble is when I need neurosurgeons," she said. She views emergency neurosurgery as the major challenge facing the community hospital.

Some cases, such as those involving head trauma and spondylolisthesis, would typically be handled by a neurosurgeon. Each case referred to Narayanaswami requires more timely and careful evaluation. Is it something you can handle without emergency neurosurgery? "You don't want to move sick patients un-less they really have to be moved," she said. "I try to anticipate potential problems." Patients who require video EEG evaluation must be referred to Omaha's University of Nebraska Medical Center or the children's hospital there.

A report from the Center for Studying Health System Change² argues that the disparity between rural and urban physicians shouldn't be attributed to income, because urban and rural practitioners earn roughly the same amount, thanks in part to changes in the Medicare physician fee schedule. As a bonus, rural physicians enjoy more buying power when adjustments are made for cost of living.

Medical reimbursements are not an issue either. "I do look at my reimbursements, and I think they are comparable to, or a little better than, Tennessee's. I don't see too much of a problem," said Narayanaswami.

The medical liability crisis doesn't extend to Nebraska--yet. "I'm lucky. Nebraska is a yellow state," which refers to the color alerts created by the AMA in its ranking of state medical liability. Although malpractice insurance has increased slightly in Nebraska, it does not approach that of the approximately 20 "red" states, or those in crisis. "We have a state cap here. Not all states have the cap. So far, so good. But we can't afford to be complacent. We'll be in the red in 5 years if we let it go."

Narayanaswami's society memberships and advocacy work add to her satisfaction. "You feel you're not alone. You're not the only one worried about these issues." She's active in the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), the American Academy of Neurology (AAN), the American Clinical Neurophysiology Society, the AMA, and the Nebraska Medical Association.

When she was 1 of 2 physicians running a neuromuscular clinic in Memphis, Narayanaswami led a support group for patients with amyotrophic lateral sclerosis (ALS). This led her to participate in a national ALS day in Washington, DC, where she spoke as an advocate for more ALS research. She's also participating in the AAN's Neurology on the Hill Day in Washington, DC, this year.

Narayanaswami appreciates the advocacy work of the associations and says that the AMA, AAN and AANEM are collaborating strongly on Medicare and tort reform in particular and that these organizations provide opportunities for physicians to get involved. "They tell you what they're doing and what you can do to help."

Like Van Boven, Narayanaswami finds it "very gratifying to diagnose and manage even routine neurological disorders" in her rural community. "The visibility that I have as a neurologist in a small community helps me make a greater impact," she said.

When you're a big fish in a small pond, that's a lot easier to do. *

Editor's Note: This article is the first in an occasional series, "How Where You Practice Affects How You Practice," on the geography of neurology.

REFERENCES

1. Council on Graduate Medical Education. Physician Distribution and Health Care Challenges in Rural and Inner-City Areas. US Department of Health and Human Services. February 1998. Available at: www.cogme. gov/10.pdf. Accessed May 17, 2005.

2. Reschovsy JD, Staiti A. Physician incomes in urban and rural America. Issue brief no. 92. Center for Studying Health System Change. Available at: www.hschange.com/CONTENT/725/. Accessed May 17, 2005.

3. Costa AJ, Schrop SL, McCord G, Gillanders WR. To stay or not to stay: factors influencing family practice residents' choice of initial practice location. Fam Med. 1996;28:214-219.