The Benefits of Practicing Neurology in a Rural Setting
When you think of practicing medicine in a rural setting, what comes to mind? For neurologists who have lived and trained in densely populated urban areas for most of their lives, the mental image can be full of misconceptions. But you may be surprised to learn that salaries for rural neurologists frequently exceed those of their colleagues in the city. Another surprise might be the flexibility that rural neurologists often experience, in both the subspecialties they can pursue and the conditions of their work. Even the stereotypes about the towns themselves may turn out to be false, with many “country” locations offering amenities that rival those of the big city—albeit in lesser quantities. With those stereotypes out of the picture, read on to discover the realities of practicing neurology in a rural setting.
Practicing one’s specialty immediately
For Saurabh G. Shukla, MD, there was never a question of whether he would practice in a rural or underserved area, since that was a condition for maintaining his visa. Even so, he admits the prospect was somewhat daunting for both him and his wife. Having completed medical school in India before taking post-graduate roles in Boston, New York City, and Miami, Shukla was used to highly populated cities. But once he understood that his first employer would likely be situated in an under-served area, he threw himself into a strategic and methodical job search. Shukla’s process took 18 months to complete, partly because of the administrative process with his visa paperwork and partly because he was being extra selective. In the end, he accepted an offer from the University of Mississippi Medical Center in Jackson, joining the staff in January 2019 as assistant professor of neurology.
“One thing that really drove me here was the work factor,” Shukla says of his decision. “Here I’m able to practice neuromuscular neurology, which is really difficult for a new doctor in large centers. Because in bigger centers, those positions are saturated, and people stay for decades.”
Indeed, not only is Shukla able to devote nearly full time to his specialty in neuromuscular neurology, but as it turns out, he’s the only academic neuromuscular specialist in the entire state. This provides a unique opportunity for someone so new to the university, as patients come from the states bordering Mississippi in search of a second opinion on complex diagnoses. “I get all the challenging cases, which is amazing,” he notes. In addition to seeing patients, Shukla has begun classifying his cases for research purposes, with the support of his chairman and division chief. “They all want research to happen here,” he explains. “I’m looking forward to collaborations and presenting at conferences.”
Fewer resources but less bureaucracy
For James Dorman, MD, FAAN, FACP, one of the defining features of working in a rural area after his post-doctoral training was the immediate connection he was able to make with everyone from the hospital staff to members of the community. Working now as a general neurologist at Stroger Hospital in Chicago—commonly known as Cook County Hospital—Dorman currently practices at one of the nation’s busiest medical facilities. But from 2004 to 2006, he was employed as one of two neurologists in a multi-specialty practice serving the town of Dixon, IL, population 20,000, and the nearby towns of Sterling and Rock Falls. The overall community of 70,000 supported two hospitals, so Dorman and his partner each served one, but covered at the other. To handle call, they each took a week, with the hospitals transferring patients out every third week.
Dorman remembers that period as a balance between limited resources and lessened bureaucracy. For example, he rarely had to wait more than an afternoon to receive a patient’s MRI results from the radiology technician. And one of the hospitals didn’t even require the doctors to show ID. When Dorman inquired about a badge, he was told, ‘No, it’s okay. We put an ad in the paper. Everyone knows you’re coming.’ “And it was true,” he says. “When I walked in the door on the first day, everyone was saying ‘Hello, Dr. Dorman.’ And I had never set foot in there before.”
On the other hand, it could sometimes be nerve-wracking having fewer options for treating patients. For example, those needing a tPA medication would require transfer to larger facilities with a neurosurgeon available in case of intracranial hemorrhaging—and the transfer process could involve hours on the phone. “There were a lot of gray areas where it wasn’t really clear about whether to keep the patient or transfer them,” Dorman recalls. “And with the training wheels just off—and being a little isolated—that in itself could be intimidating.”
Small town amenities
Every physician knows that there’s more to life than practicing medicine, which makes the community surrounding one’s workplace very important. On the one hand, as Dorman notes, “People in a rural area have a reputation for being relaxed and friendly, which is true. But it’s easier to be that way if your idea of a traffic jam is three people at a stop light—which it was.” Shukla has also experienced the traffic patterns unique to a rural setting, but from a different perspective. Having never needed an American driver’s license, he and his wife are now a two-car family. While she needs to bring their daughter to activities, he needs a car to travel between clinic locations.
As for socializing—neither Dorman nor Shukla found that difficult, although Dorman missed the variety of restaurants he and his wife had been accustomed to. For their part, Shukla and his wife were delighted to find other families originating from the same region of India, providing them with an instant sense of extended family far from home.
Perhaps the most vaunted amenity of small-town living is the lower cost of living, which can sometimes be much lower compared to urban rates. For Dorman, one other amenity that stood out was the smaller community’s attitude toward physicians. “I got the impression that they hold doctors in high esteem,” he recalls. “It reminded me of the traditional Marcus Welby attitude. Where, in the urban area, if you’re a doctor, it’s more like you’re a dime a dozen.”
Future prospects for rural neurologists
With telemedicine and other advances in health care, one could wonder if there’s still a place for small-town doctors, not to mention their specialist colleagues. Jason Hermanutz, neurology search consultant for RosmanSearch, Inc., believes the future is rosy for rural neurologists. “More and more in the last decade we’ve been seeing programs that maybe 15 years ago wouldn’t have thought of supporting neurologists locally. There are more people being treated and that’s creating opportunities for neurologists in rural areas.” Specifically, Hermanutz notes that most of the work in the rural setting is happening in hospitals, with the biggest demand for general neurologists.
Even so, Hermanutz also sees flexibility offered by rural employers that isn’t being matched in urban centers. “One big advantage,” he says, “is that rural programs can create an opportunity or even build a program around a physician, instead of stating, ‘This is the position. You have to do this.’ The physician can say, ‘This is who I am; how can we make the position fit what I’m looking for?’” As an example, Hermanutz cites the recent placement of a neurologist who also wanted to use his MBA. The new job will start out at 25 percent administration, with the percentage increasing as the doctor gains experience. “That’s an incredible package that probably would have been out of reach in an urban program,” Hermanutz notes.
Not only do the rural employers work hard to accommodate the doctor, but they also extend themselves to help the physician’s family. Hermanutz has seen communities provide assistance on everything from house hunting and school searches to finding work for the doctor’s spouse.
Perhaps the most quantifiable differences between employment offers for rural and urban settings are rooted in the salaries, with Hermanutz consistently seeing rural compensation land in the 75th percentile for neurologists. When relatively rich loan repayments and leadership bonuses are included—to the tune of $150,000 or more—the packages offered by small communities frequently eclipse those of larger organizations.
If you’re interested in exploring opportunities to practice neurology in a rural area, Hermanutz, Shukla and Dorman all have advice for you. Based on his experience, Shukla advises doctors needing a J-1 visa waiver to first identify the specialty or type of neurology they want to practice, and then start early to make connections with the programs. “Rural America needs doctors,” he says. “When they really need you, they’re very supportive.”
Dorman notes that the doctor’s personality will play a role in determining the best opportunities to pursue. “So much of it comes down to lifestyle and career goals,” he says. “I think the main need is for general neurologists because they can handle 95 percent of what comes through the door.”
And Hermanutz says, “The biggest advice I could give someone is to be really open to exploring options that you might consider to be outside your usual comfort zone. Going on two or three site visits during your job hunt is not too much. There’s a very wide world out there with opportunities you wouldn’t be able to see if you only looked at academic or large settings.”