The Hardships and Rewards of Rural Practice

A snap decision put us in Clare, Michigan. We have no regrets.

BY THOMAS CLARINGBOLD, D.O., F.A.O.C.O.

A single line, one stroke of a pencil, can turn a negative (-) into a positive (+). A single action can change your entire outlook on life. That's how I view my life and career in a rural, economically depressed area in northern Michigan. Aspects of my practice that I once used to think of as a detriment have now become a bonus. Life in small town America… you either love it or leave it. I love it.

How Did I End Up Here?

Growing up just outside of Detroit, I was a "city boy." Life was fast-paced, traffic was a fact of life and the quest for the competitive edge was foremost in everyone's mind. My first taste of a small town came when I entered Central Michigan University, a mid-size state college located in idyllic sounding Mount Pleasant. There is no mountain, but the town was pleasant enough. Here, I met my future wife, and prepared for a career in medicine. I never thought I would wind up living and practicing just 10 miles north of my alma mater.

After attending medical school at Michigan State University's College of Osteopathic Medicine, I once again ended up in the city for my residency — downtown Detroit, in an area with bars on the windows and homeless persons on the street. The main residency clinic was at the site of an inner city hospital, but we also covered five other urban/suburban hospitals and the emergency rooms. A daily commute of 90 minutes or more was the norm. At the time, I didn't realize how much of my life was spent waiting in traffic and what these lost minutes were truly costing me. That was the life that I was accustomed to up to that point.

Downtown Clare. The town is located in the center of Michigan's lower peninsula and is home to about 3,200 people.

An Amish buggy with handmade quilts for sale. Clare's Amish population has been a boost for tourism.

After my residency, I decided to take an opportunity to join a practice where the main office was located in South Bend, Indiana. I would also cover a satellite office in a smaller town. It was far from my initial dreams of practicing amongst the high rises of Chicago or New York, but it seemed to encompass the best of both worlds. However, like many other physicians just starting out, I found myself faced with the 2-year dilemma: Buy into the practice of my employer at his asking price or get out. Originally, the initial buy-in was to be structured over 5 years. However, when the senior partner decided to forego practicing ophthalmology for the more lucrative real estate market, I was left with the decision of having to buy the entire practice at once. The seven-figure asking price for the practice not only seemed excessive, but being just 3 years out of residency, I did not have the financial stability to take on that level of risk.

Through a family friend, I heard that there was an opening in Northern Michigan — a small town of about 3,200 people billed as the "Gateway to the North." By this time, my wife and I had two children. With car seats in tow, we ventured "Up North." In Michigan, north is not only a direction but a destination both physically, and perhaps more importantly, mentally. It just so happened that the weekend we visited Clare, the town was in the midst of its "halfway to St. Patrick's Day" celebration. Little did we know that this would become one of the many things that we love about this town. Any place that can throw a party 6 months in advance of the actual party must have some pretty interesting characters. Over a few green beers, my wife and I decided to make Clare our home.

Rural Bliss or Economic Suicide?

I think of myself as a "glass-half-full" type of person. In reality, every situation always has two sides. A move to a rural area can mean a more peaceful pace of life or limited opportunity for income and growth of a practice. A small town can be as friendly and inviting as Mayberry or it can be extremely clannish where you are still an outsider after 30 years.

Even before the recent economic downturn, the financial survival of an area like Clare was tenuous. There is no industry or manufacturing to speak of, with a majority of the county's income coming from tourism.

A disappearing icon of American culture — the small town movie house. No 16-screen multiplexes for Clare.

The hospital and the local community college collectively provide half of the area's jobs. Michigan as a whole has been hit especially hard and has the highest unemployment rate in the country. Clare County is the second poorest county per capita in the state, with the second highest unemployment rate in the state, a daunting 12.9%. Building an economically sound practice in this area was going to be a challenge.

To describe my current payer mix as "poor" is a gross understatement. Within the last 6 months, our percentage of Medicaid patients has increased to 24% and self-pay has jumped to 13%. This past October, my contractual writeoffs from Medicare, Medicaid and self-pay approached a whopping 69%. Fortunately, the physician group that I am a part of has constructed a compensation plan based on RVU production rather than a percentage of collections. While globally this payer mix affects the entire group, and certainly could have a devastating impact if these trends continue, individual practices can continue to thrive in economically depressed areas.

Practicing in Clare gave me the opportunity to join a multispecialty physicians group while being the sole ophthalmologist on staff. Being under the financial umbrella of the physicians group provides the economic stability necessary to build a practice from scratch. The area had not had a practicing ophthalmologist in more than 40 years (the last cataract performed at the hospital was an intracap!). This unique situation gave me the autonomy to build the practice the way that I wanted to, without the financial risks of practice ownership.

Being the sole practitioner in a rural area where there are no other practices to share call with can be quite demanding. As the only ophthalmologist on staff for the local hospital, I am essentially on-call 24/7. I realize that federal guidelines would allow me to specify a limited percentage that I would take call, but there is a team effort that is fostered in a small town that instills a sense of responsibility to provide the best care to our area. While my one-in-one call schedule is not nearly as demanding as the one-in-two call of both of our general surgeons, it can still be quite draining.

Clare's Irish Parade is a big event. The town got its name from County Clare in Ireland.

The Reality of Rural Practice

A rural patient population presents its own unique challenges. Travel can be very difficult, especially in the winter. Many of the back roads may not get plowed for 2 to 3 days after a snowfall. This past December was the snowiest on record for our area, with a snowfall total of over four feet.

Often, these storms strike after a day in the operating room, making it impossible for patients to come to the clinic for their first postoperative day visit. At least twice a year, I find myself packing up postoperative kits and a transilluminator and heading out in my four-wheel-drive vehicle to make house calls. It can also be difficult to convince patients to see a subspecialist. The nearest retinal surgeon is 45 miles away.

With shovels in hand, Dr. Claringbold and son Tom get ready to deal with a typical "small" Clare snowstorm.

This past summer, when gas prices soared above $4 per gallon, patients refused to travel that distance, regardless of the risk to their vision. Yet, on the flip side, I've had patients make tremendous efforts to keep their appointments. One morning, my receptionist stated that Mr. Jones had arrived at 11:00 a.m. for his 2 p.m. appointment and asked if we should see him earlier. At first, I was a little annoyed, squeezing him in to the morning schedule might be difficult. Then I found out why he had arrived so early. It had been a foggy morning, and his only means of transportation was a moped. He let us know that he lived 30 miles away from the office and was unsure how long it would take him to arrive due to the weather. Being a diabetic, he knew how important it was to have his eyes examined and would not mind waiting until his regularly scheduled appointment. Needless to say, we had no problem working him in before lunch.

In a rural area, it can also be difficult to provide what can be considered some of the more lucrative procedures to patients who have grown up with an extremely strong work ethic and subscribe to the belief that "less is more." A few colleagues questioned if I would be able to continue to build a refractive practice after I moved to Clare. Fortunately, with the reputation I had built, particularly with LASEK and Epi-LASIK, I was able to continue through local patients as well as referrals. Building a premium IOL component to the practice has been more of a challenge. After extensive chair time describing the pros and cons of multifocal IOLs more than one patient has responded, "That sounds nice, but aren't reading glasses two bucks at the dollar store?" It's a different mentality in a rural area. More isn't always better and the fastest way is not always the best.

Dr. Claringbold in the OR.

We Don't Lack for Local Color

A particularly unique aspect of practicing in Clare is that the county is home to a large Amish community. All of the medical offices, as well as the local grocery stores in the area, have hitching posts to accommodate the Amish buggies. There's something about seeing a buggy hitched up outside your practice that instantly makes you take pause and appreciate the simpler life that our residents have chosen.

Life in this rural community runs at a much slower pace than the hectic, breakneck speed of the city. Patients show up early to their appointments to socialize in the waiting room. It can be difficult coming into an area with such a close sense of community. Most of the people that I deal with grew up in the area, just as their dads did, and their grandfathers before them. Although we've lived here for more than 8 years, we're still the "new ones" in town (and probably will be for the rest of our lives). Generation after generation of folks return to or remain in this area to settle down and raise their families.

Everybody Knows Your Name

Growing up, I could go all around the metropolitan area and never see anyone that I knew. There was a certain safety and comfort in being anonymous. Now, I can't leave my house without running into patients — and I find that I value the sense of community that you get when "everybody knows your name." To my patients, I'm more than their ophthalmologist, I'm a real person. Someone who dresses up as the Grinch at Christmas to promote the local arts council. Someone who helps coach their kids' soccer team. And even though I'll probably be the "new doc in town" for a while yet, the community has opened its arms to me and my family and enchanted us with its charm.

Family is the driving force behind my decision to be a rural doctor. We're happy in Clare. Not only is it a terrific place to raise a family, but the pace suits us. When you're too busy to greet your neighbors, or too rushed to inquire about a patient's new little grandson, it's time to take a hard look at your life. Everything that I used to consider as negative about practicing rurally has become positive.

Many of my colleagues who reside in urban areas question my decision. When we lived in Detroit, my commute to the various clinics in the suburbs was 60 minutes or more. In Clare, I'm at my office in just over 90 seconds (unless I get stopped by the traffic signal). It's a quality of life issue. Do we miss the culture available in a larger city? Sure, but we deal with it by taking weekend trips downstate or by promoting those things here in town. We've recently resurrected an arts council and we're putting on our own play this Spring, during the annual St. Patrick's Day festival.

We recently took a family trip to Detroit to get a dose of "culture." We stayed at one of the city's new casino hotels, saw a play at the Detroit Opera House, took in an impressionist exhibit at the Detroit Institute of Arts and attended a Red Wings hockey game at Joe Louis Arena. I didn't run into anyone who I knew at any of these events. The anonymity I used to crave was actually a bit disconcerting.

Certainly the rural scene is not for everyone. Many physicians come here thinking that this is what they want, only to discover that they feel like they are living in a "fish bowl." But there is also truth in the old axiom about it being better to be a big fish in a little pond.

One little line can turn a negative into a positive, turning worst-case scenarios into the best that life has to offer, especially in rural America. To quote Thoreau's definition of city life: "millions of people being lonesome together." Loneliness certainly isn't a problem here in Clare. OM

Dr. Claringbold is chief ophthalmologist for MidMichigan Physicians Group and is in practice in Clare, Mich. He is assistant clinical professor, Michigan State University College of Osteopathic Medicine and associate clinical professor, Central Michigan University. He is also on the board of directors for Central Michigan's Driving Evaluation, Education, and Research Center. He can be contacted at eyeboy@tm.net