City Oncologist, Country Oncologist

Robert Warner, MD
Published: Monday, Mar 07, 2011
The story of the city mouse and the country mouse is a popular Aesop’s fable for children that concludes, “A modest life of peace and quiet is better than a richly one with danger and strife.” Is that the choice an oncologist makes when he chooses where to practice? Is the life of a country oncologist quieter and less intense, while the city oncologist’s life is noisier and more stressful?

First, it’s important to note that few oncologists have practiced in both an urban and a rural practice, so it is difficult to find one physician who can tell both sides of the story. I have practiced in Council Bluffs, Iowa, (population 60,000) for almost 25 years, and my office is about 20 feet from where I was born, so I can tell you what it is like to be a country oncologist.

The view from my “porch”

I practice in a five-physician group. We are not the only practice in town, but we are the largest. Sadly, oncologists rarely suffer from lack of patients, so it is probably just as easy to have a full patient roster in a small town as it is in New York City. Additionally, we have 10 satellite offices in the communities surrounding Council Bluffs.

Even in Corning, Iowa, the site of our farthest satellite, where the town population is about 2000, we have a local oncology-trained nurse who works with us and a local hospital to support our patients. The community is grateful for the care we provide, so treating those patients is especially rewarding. The other small communities we serve are similar in their support of the practice and the services available for patients. And for the patients who would never make the drive to Council Bluffs (a big city by their standards), providing local care is an ideal solution.

I regularly see my patients outside of the office. Almost once a day I run into a patient—at the gas station, post office, or a high school football game. If I am in the smaller communities, I’m almost guaranteed to cross paths with a patient. My life as a rural physician is not an anonymous one.

My longest commute is the three-hour drive to and from our farthest satellite office. I could have a driver and use the time for paperwork (though my nature would be to talk rather than work), but most often I drive myself and listen to books on tape. When I arrive home, I am rested; I no longer need to “decompress,” and the remainder of my day is mine. When my children, who are now in college, were younger, I did not miss a concert, sports event, or parent-teacher conference. I even have the option of flying my small plane to an outlying office, which likely would be a financial and logistical impossibility in an urban practice.

I consult with my partners when developing a treatment plan for a patient or when a patient is not responding as I had expected. With the advent of the Internet, imaging results online, and electronic medical records, I can also easily consult with a colleague hundreds or thousands of miles away.

My rotation on call is less frequent now, but it was not unreasonable even in the early days. I spoke recently with a colleague who is a solo practitioner in Wyoming. He has been on call for 8 years because he is the only oncologist in his town. When asked how disruptive it was to his family life, he remarked that it was a problem when he wanted a vacation. Beyond that, there were calls that came at inopportune times and calls that were no disruption at all.

Some patients in rural communities will travel to the large, famous cancer treatment facilities around the country, often for a confirming diagnosis. My experience has been that when a patient receives a confirmation of the diagnosis I have made, he or she is reassured, and our relationship improves. I have never felt minimized.

Lifestyle differences

So then, if being an oncologist in the country or city is similar once the examination room door closes, what is the difference? The difference is lifestyle. In Council Bluffs, for example, a $250,000 house is a big house. Dinner for four at one of the better restaurants is under $100. The numbers may be smaller, but the life is not smaller. If you want to live on an acre or more of land but do not want the longer daily commute that it would require in Chicago or Denver, a rural practice may be for you.

However, I would be remiss if I didn’t mention that there are trade-offs. While on the popular culture front, books and magazines are as available in a small town as they are anywhere else, movies may open in the theater a week or two later, and finding legitimate theater may be a challenge. Regarding practical issues, worries about traffic, parking space availability, and long commutes are not daily concerns.

As mentioned, a physician practicing in a remote corner of America has easy access to the medical community far beyond his or her town via modern technology. The days of a rural physician being isolated are long gone.

A family decision

A professor once told me, “When you are deciding on where to practice, bring your spouse. You will close the door and could be anywhere, but your spouse will have to live each day in the community you choose.” That may be one of the more important lessons I learned in medical school. The choice of where to practice is a family decision, not an individual one.

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