I am apparently in the minority. According to the 2015 AAPA salary report, 51.7 percent of physician assistants work in an urban setting of more than 1 million people. Further, 12.4 percent work in an area where the closest town has a population of 20,000 people or less. I am in the remaining 2.5 percent. I serve about 2,000–3,000 people who do not live near a metropolitan area.
When I was in school, being a rural PA was my dream. Now that I’m living it, I wanted to tell you a little about my experience.
You May Be the Only Show in Town
When I first fled Kansas City for a small town in western Kansas, I joined another PA in a family practice clinic. Myriad locum tenens physicians supervised us, sometimes for a week or two, sometimes for only a weekend. The owner of the locums group occasionally supervised us via phone from Kansas City. There were weekends where the other PA was out of town, my supervising physician was in a neighboring state, and I was the only provider for more then 30 miles. I was the guy, and I had only been out of school for little more than a year.
Besides being in charge of an entire hospital, the rural PA or APRN is going to be the primary care provider (PCP) for dozens of people. Word spreads about your practice, and soon there are people calling, asking for you by name. They want to see you, and they will drive hours for the opportunity.
In my first month, not a week went by where I did not learn of a new Kansas town I had never heard of before. These towns were often so remote I had never even been close to them, despite being raised in the area.
How Supervision Works When the Doc Is Away
In the first six months I practiced family medicine/ER, we had no long-term physician. It was great when we hired one, but he could not be there around the clock. If he was unavailable for a short time, he might line up a colleague to cover me via phone.
In such a situation, you learn how to paint a clinical picture quickly so your supervising physician can understand the case. Even more fun is calling an unfamiliar physician in the middle of a crisis, then skipping introductions and going right into the patient history and physical exam (H&P). It kicks you right back into 90-second-or-less presentation mode real fast.
Regardless of where your doctor is when a heart attack or stroke hits the door, you are in charge. Code blue? That is your code, and you might just save a life. When I took Advanced Trauma Life Support in Oklahoma City, the PAs and APRNs far outnumbered the physicians.
In rural areas, if your patient meets the trauma surgeon, it may be because you put them back together enough for them to survive the helicopter ride. Even then, they might only make it if there isn’t a severe thunderstorm or tornado that grounds air transport.
While this may sound like a challenging adventure, it’s also a steep learning curve for a new graduate, one where you learn on the fly. There is a huge difference between the first time you do a knee injection on a real person and the first time you place a large-bore intercostal needle just before tube thoracostomy for a tension pneumothorax.
You’ll See Hard-to-Explain Emergencies
There are some challenges I do not even know how to describe. Who knows what a thresher is? How about a grain auger? Ever seen a grain elevator blow up? All these things can annihilate the human body in the blink of an eye. The survivors are always critical and suffer from impressive injuries, and whether they live or die may depend on how fast you ran to the trauma bay to meet them and whether a nurse heard you yell for the life-team helicopter.
Just when you think you’ve imagined all the crazy things that can happen in a farming community, you hear a new over the EMS scanner. Motorcycle vs. deer. Tractor rollover. Crush injury under a horse. There’s never a dull moment. Farming accidents are so prevalent out here that some of the medium-size hospitals have trailers with mocked-up disasters to help train first responders and hospital staff alike.
When the EMTs are local farmers, mechanics, and maybe even your IT guy, it’s not just the nurses and you that save lives — some days, it’s pretty much the whole community.
It’s Totally Worth It
This is just the beginning. I have many more adventures to regale you with in the coming months, and they’ll help you understand why I would not give up rural medicine for anything.
What else do you want to know about rural care? Tweet @bartonlocums, or throw out questions in the comments section below. You can also pick up a copy of my book, Through the Eyes of a Young Physician Assistant.
