I have spent the bulk of my career working in a rural area. There have been chronic shortages of clinicians, but never shortages of patients. I’ve seen a variety of tactics used to bridge the gap — locum tenens, hiring bonuses, student loan repayments. I have even seen the creation of a family medicine residency to offset the staffing issues in the short term with resident physicians, and (fingers crossed) in the longer term with those residents staying in the area after completing residency. An expensive longshot.

But what if the reason for the staffing challenges is not about location? Maybe the proximity to recreational opportunities, how close/far it may be to airports, whether the schools are good or not, has very little to do with anything. Maybe it’s about what it means to work in these settings, and particularly what it means to work in these settings today.

Already burdened by an industry that challenges clinicians in all the wrong ways to an increasing degree, why would someone want to add all of the challenges of practicing in a rural setting on top of that? The challenges of rural health care are no secret. In many rural health care settings, there are openings for virtually every position at almost every level and department. The staff that are reporting for duty are stretched thin by their own responsibilities, and even more so as they either bridge the gap of unfilled positions or help to train and orient temporary staff.

Clinicians in rural settings are challenged to find solutions to problems that they were never trained for. I have talked with family medicine physicians who are diagnosing and treating skin cancers and other serious dermatological illnesses because of the lack of access to dermatology due to cripplingly low staffing levels. I have talked with new grad NPs who have huge panels of complex patients — without a medical assistant to room patients and get vitals. I have talked with PCPs who have places to refer their patients, but those places are 60 or more minutes away, and patients don't have transportation.

It’s no secret that diseases of despair, such as substance use disorder, are widespread in rural settings. When these patients come into the clinic and are ready to engage with treatment for their disorder, and the clinician has nowhere to send them — it’s scary, simply put. It leaves the patient in a vulnerable position, and leaves the clinician feeling powerless and defeated.

How are we supposed to bounce back from this?

In the wake of the peak of the pandemic, clinicians are more aware than ever of what works for them, and what really doesn’t. The bait that has been used to draw clinicians to rural practice settings doesn’t have the same power it had before (if it ever did). Bonuses? So what. If you are going to relocate, you might as well go the locum tenens route; you can get your big chunk of change without having to completely upend your entire life permanently. Student loan repayment? If the first question the clinician asks themselves is how long the commitment is so they don’t forfeit this benefit, then it’s really not that powerful. Sign-on bonus? You mean one that’s still taxed?

Rural health care systems have been chronically scrambling to plug the staffing holes. In my own rural backyard, that has meant a lot of travelers — clinicians of all stripes on a short-term assignment with pay significantly above baseline. Is it the higher pay that makes it attractive? Can you put a price on what it means to work in a setting without enough staff, enough access to specialty care, enough places to refer patients that need more than you are able to give?

Is the draw the shorter duration? Is it knowing that there will be a time limit, that you are only committing to this for 12 weeks? Is it knowing that you have the power to walk away at the end of the assignment? There are challenges to working in rural health, and there are challenges to working as a traveler. Yet, somehow, the gaps are able to be filled with travelers even when they cannot be with regular hires. Why is that?

We could redirect the premiums being spent on travelers and put them in the pockets of permanent staff and clinicians, but I am not sure that would make a compelling difference. Paying off student loans sounds like a good idea, but I’m not so sure that would make a difference, either. These things might be a start, but if they were a sustainable solution, they would have worked by now.

Could it be as simple as involving the people most affected by the decisions — the clinicians and staff — in the decision-making process? Giving them a voice, a seat at the table, and then allowing them to use it?

In order to commit to these under-resourced positions and workplaces, the clinicians that you are trying to recruit need reassurance that they are not going to be constantly pushing a rock uphill. I think of a former colleague who was promised a panel of 900 patients (working part-time) and who ended up with more than 2,000 patients on her panel. She quit.

Clinicians in rural, urban, or suburban settings all need realistic expectations of our work life, which can then feed into a realistic, sustainable, and dynamic work-life balance. We have done the work of thinking about what we need, what works for us, and what doesn’t, and we can tell you, in detail, at the drop of a hat.

If we are involved and invested in finding a solution, we are much more likely to be able to roll with changing priorities when asked. On the other hand, when we are simply notified of decisions made without our input, we are not invested, and much less willing to flex to meet someone else’s goal.

What could it look like if rural health workplaces shifted their perspective to include involving staff at the decision-making process at all levels? Could it change things from stopping the bleeding and instead attract not just staff but innovators who think and work differently, who may be attracted to working in this environment not because they love hiking, but because they love a challenge, they love being valued for their perspective, they love being a part of the solution? Could this hold the power to transform rural health care from a source of under-resourced stress to a lab for new ideas and new approaches to health care? The current model of rural health care isn’t working. Let’s change that.

What are your ideas to fix rural health care? Share in the comments.

Jessica Reeves is a nurse practitioner as interested in the well-being of her fellow clinicians as that of her patients — and she's on a mission to make the work world a better place to live. She writes, works, and lives in the town that holds the world record for most lit jack-o-lanterns (really). Follow her at jessicareeves.net. Jessica is a 2023–2024 Doximity Op-Med Fellow.

Illustration by Jennifer Bogartz