Backyard lakes and a bucolic lifestyle are two of the attractions to practicing orthopaedics in rural America.

AAOS Now

Published 6/1/2012
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James B. Stiehl, MD

Why I Choose to Practice in Rural America

The advantages of moving from a city to a country practice

About 3 years ago, I closed my orthopaedic specialty practice in adult reconstructive surgery in Milwaukee, Wisc., and moved to a remote farming community in southern Illinois. I was 59 years old and beginning to think about my future options. Although I was not ready to make major changes, my wife had inherited a home and farm and dreamed of living there.

In addition, the Milwaukee market was changing, and I realized that I soon might have to give up my independent practice and affiliate with a health maintenance organization or a joint venture. The neighborhood where I practiced was extremely competitive, and I had watched several small practices be gobbled up.

Thus, we decided to move to this rural community. We created a plan that met both my patients’ needs and our needs. Closing down my practice in Milwaukee took some effort, because several patients decided to have their surgery before I left town. I arranged for one of the local hospital systems, which had recently hired some of my best friends, people I would want my patients to see, to take over my charts.

So off I went to my new life, and I hope these observations and advice will be beneficial to others in a similar position.

Getting established
Before we moved, I identified some orthopaedic practices in the area and developed a working relationship with a local orthopaedic surgeon. His group practice (three orthopaedic surgeons) was located in a community about 30 miles from our new home. I was assigned to a community about 13 miles away from home.

The 160-bed local hospital had no orthopaedic surgeons on staff and was delighted to have one come on board. But being the only orthopaedic surgeon in a county of 41,000 people was challenging. I was seeing orthopaedic trauma—including femur and spine fractures—for the first time in several years. Soon, I was seeing more than 100 patients per week.

My associate’s office controlled the referrals, however, so more than 60 percent of my new cases were public aid patients, while he kept the better insured patients in his practice. I eventually decided to build my own referral network and to establish my own office.

Another challenge I faced was to get the hospital up to speed with current equipment and trends of treatment, particularly for orthopaedic patient safety. I insisted that the hospital equip two operating rooms with laminar flow before I agreed to schedule a total joint arthroplasty procedure. I introduced the standardized orders that I had developed while practicing in Wisconsin and quickly acquainted the nursing group with my system and style of practice.

The general surgeons on staff were very active, providing safe, quality patient care. Because several different orthopaedists had served in this hospital over the years, I found that the hospital had a variety of instruments on hand. These factors helped me quickly establish the same level of practice that I had enjoyed in a major urban hospital.

Know your limits
I enjoy a privileged status with local physicians, who view me as a dependable and available orthopaedic surgeon. But despite my extensive background in joint reconstruction and trauma, I found that a rural practice also required skill in several general areas such as arthroscopic knee and shoulder surgery. The challenge and opportunity to learn new technologies and skills are among the aspects of my new practice that I enjoy the most. Over the past 20 years, technology in the areas of arthroscopic rotator cuff repairs and other diagnostic work has made extraordinary leaps, forcing me to rethink how and what I do.

I avoid performing spine, hand, and foot surgery because I know nearby surgeons who perform these surgeries much better than I ever could. I have a number of academic friends in St. Louis who are more than willing to receive referral patients from my practice.

This raises another important point about practicing in rural areas. Simply stated, you just can’t do all of the complex and demanding cases that you may have done as a specialist in an urban practice. During my last year in Milwaukee, I saw patients who had traveled 300 miles to see me and I had referrals from 28 orthopaedic surgeons. Now, I am the one referring and sending patients. I select my surgical patients carefully and refer complex cases. With the large volume of patients who are underserved in general, this has been very easy to do.

Making ends meet
The practice has been financially rewarding, and my income, despite a 2-year “break-in period,” now matches my last year in Milwaukee. I find reimbursements are generally higher in the rural area where I practice than in the city. I am told that rural medicine accounts for less than 2 percent of an insurance company’s business. As a result, the companies are reluctant to spend a lot of time forcing fees down.

This is not the case in most metropolitan areas. I witnessed medical reimbursement go down nearly 20 percent in one year in Milwaukee. It is strictly supply and demand. If you have far too many hospitals and doctors for a given volume of treatment, carriers can force the issue.

Green acres
Finally, it is so great to live in Southern Illinois. Instead of a 20-minute drive through the city to a hospital, I have a 20-minute drive through rural farmland. Morning scenes can be breathtaking.

I love to play golf but could never find the time when I was practicing in Wisconsin. With my rural practice, I can play golf or tennis weekly. I joined the local Elks club because they have the best food in town on Tuesday and Friday nights.

My wife and I have a 25-acre private lake behind our home, which is a great source of joy and relaxation with fishing, jet skiing, and the like. My cell phone message is “I am cutting down a tree so just leave your number,” which is not far from the truth. We have reliable internet service and satellite TV and can drive into St. Louis for the airport, shopping, and nights out.

I could keep doing this for quite a long time. Most doctors in the country keep active in some sort of medical practice; the need for medical care is just too great to stop practicing completely. It’s a great way to end a career.

James B. Stiehl, MD, practices at St. Mary’s Hospital in Centralia, Ill.