Pros and Cons of a Physician Career in Rural Practice with Mary Wolf

How to set boundaries between work and home so that you can practice rural medicine in a sustainable way and prevent burnout in your physician career.

“Feeling like they can’t do enough for their patients, or that they’re falling short with their patients, (that) they’re disappointing their patients. And as you know, physicians can be very perfectionistic, want to fix things, and I often work with them on what are realistic expectations when you are in a rural setting.”

-Mary Wolf, MS, LPC-MH, BCC

Master Certified Coach Mary Wolf, president of Veritee Partners LLC, talks with the cohost of the podcast Master Certified Coach Jill Farmer about the benefits and drawbacks of practicing medicine in rural settings. Oftentimes with fewer resources in smaller communities, there can be significant physician burnout in rural areas, especially since the onset of COVID-19. How might physicians struggle to set boundaries in these communities where they often know their patients personally outside of the work office setting? Mary Wolf is able to offer valuable advice for physicians on how to set these boundaries between work and home so that they can practice medicine in a sustainable way. 

Mary Wolf, MS, LPC-MH, BCC 

Mary Wolf is the president of Veritee Partners LLC, a coaching and consulting business designed to promote wellbeing and success for physicians, executives, dentists, and the companies they serve.  Veritee Partners offers assessments and consultation for healthcare systems to build wellbeing programs and cultures.   

 Mary was the Program Director for the Avera Medical Group LIGHT Program, an award-winning wellbeing program for physicians and advanced practice providers. She led multi-strategy wellbeing services and provides executive coaching for physicians, nurse practitioners, physician assistants, residents, and executives. 

Before creating LIGHT, Mary was the director of multiple behavioral health programs at Avera including employee assistance program-EAP, addiction recovery, outpatient mental health, and day hospital.   

Mary earned a Master’s Degree in Counseling and Human Resource Development and is a Licensed Professional Counselor-Mental Health. Mary is a Board Certified Coach and holds certifications in executive, life, and spirituality coaching.    

Mary’s extensive work with the Coalition for Physician Wellbeing includes being published as a chapter author for their two books:  

• Transforming the Heart of Practice: 

An organizational and personal approach to physician wellbeing   

• Physician Well-being During Sustained Crisis: 

Defusing Burnout, Building Resilience, Restoring Hope

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Please enjoy the full transcript below

Mary: Feeling like they can’t do enough for their patients, or that they’re falling short with their patients, or disappointing their patients. And as you know, physicians can be very perfectionistic, want to fix things, and I often work with them on what are realistic expectations when you’re in a rural setting.

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Jen: Thank you for joining us here today on DocWorking: The Whole Physician Podcast. I want to take a moment and let you know that we’ve been working around the clock at DocWorking to bring you CME credit, so that now you can let your continuing education budget help you to prioritize your own wellness and get on the path to living your best life. Everything we do at DocWorking is specifically designed with you in mind. We hope you’ll head over to docworking.com today and take our two-minute quiz to find out where you are right now on the balance to burnout continuum. Take our burnout quiz and this simple step alone can put you in the right direction toward living your best life.

Jill: Hi, everybody and welcome to DocWorking: The Whole Physician Podcast. I’m Jill Farmer, one of the cohosts of the podcast and lead coach at DocWorking. Our podcast is brought to you by DocWorking Thrive, where you can get coaching, brain training for stress management, peer support, and all kinds of other resources to help you thrive in work and in life. Go to docworking.com to check it out today.

I am really excited about the conversation that we are going to have. Today, we’re joined by Mary Wolf. She is a licensed counselor, a certified executive and physician coach, and she’s created and directed a multi-strategy wellbeing program for 1400 physicians, nurse practitioners, physician assistants, and has won two national awards in that creation. She has an experience and style that allows you to understand each unique situation that healthcare providers are in to support them to achieve bigger goals and create lasting change. She also has been the designer of an employee assistance program that serves 150 companies and covers 80,000 lives. Mary Wolf, thank you so much for being with us today.

Mary: Thank you for having me. 

Jill: Mary, you’re an expert at supporting physicians and you also have deep knowledge and experience about the specific challenge physicians face, who are serving in rural communities. That’s really what our conversation is about today, because I think we sometimes forget how different physicians’ lives are based on the communities that they are serving. So, let’s talk a little bit about what you see as the difference for physicians serving rural communities versus those in more urban areas.

Mary: Absolutely. I very much have the honor of coaching physicians and advanced practice providers, who are working in rural locations all across the United States. They will tell you there are many, many benefits of being a rural physician or provider. For many of them, it’s going home, and they have parents and family close by.  For many of them, they chose a rural community because it’s safe, housing is less expensive, and there’s little commute, there’s little traffic, and it’s really a way for them to have amazing relationships with their patients, with their colleagues in a small community.

Jill: But those are the benefits. It’s a lifestyle choice, right?

Mary: It is.

Jill: So that would be a difference of recognizing that there’re benefits. What would you say are the challenges that you hear from the physicians in rural settings that you’re coaching that in some cases even makes them think they want to be practicing somewhere else?

Mary: Yeah, there are multiple challenges. I think one of them is, as I’ve worked with physicians and providers, I see more burnout. People go to small communities because they think they’ll have a better schedule and actually that’s not true in the cases that I’ve worked with physicians and providers many times, those physicians and providers are covering the clinic, the emergency department, the nursing home, hospice, a variety of different settings, but also, they have these other like, medical director roles such as the ambulance service or they’re the coroner, and they are really spread very thin in those rural settings.

One of the other aspects that are a big challenge for physicians and providers, I do a lot of critical incident processing and when I’m working with a physician or provider in a rural area, it’s much more difficult for them to process because they often know the patient or the patient’s family, whether it’s in the emergency department, or it’s an accident, or there’s a baby death, or a suicide. The impact is larger and the guilt is larger when the patient is known by the provider, and in a rural community, those incidents have larger impacts. I’ve been working with a physician who had a critical incident. There might be a potential lawsuit with the case and it really has affected their social network because they can’t talk about the case, there are rumors out there, the spouse has really been affected by this incident, she can’t defend her spouse, and they can’t even talk about the case, and it made them feel very isolated. So, those are a couple of the challenges.

Jill: Yeah, that’s really fascinating. It’s one of those situations, too. I think where one of the benefits of being in that community where you do have the connections, and the deeper roots, and where you get to know people, and you’re really having an impact on people that you know in your life outside of work, and your kids or friends within all those things is, as you said, when something challenging happens, there’s not a lot of anonymity. 

Mary: I felt a lot of moral injury during COVID, especially as I was coaching, and moral injury often happens when theres any events that violates our morals or our ethical code, and I saw this a lot with physicians and providers that they can’t practice medicine in the way that they want or with the quality that they want, either there weren’t enough beds, there wasn’t enough PPE. And also in small communities, there aren’t the resources for physicians to refer to. They don’t have access to mental health, or social workers, or navigators, or case managers as maybe in larger systems and even community resources are scarce. Domestic violence shelters, or even transportation, food or housing resources, all of those things, and physicians really have struggled with that moral injury in those rural areas feeling that they can’t do enough for their patients, or that they’re falling short with their patients, or disappointing their patients, and as you know, physicians can be very perfectionistic, want to fix things, and I often work with them on what are realistic expectations when you’re in a rural setting.

Jill: On that front, looking at just how that, not only was COVID challenging for every healthcare professional, we’ve said it many times on the podcast, and we need to say it again, we just can’t ever say thank you enough for the amount of work, and effort, and superhuman-ness that went into practicing medicine under those incredibly challenging conditions, and with a shortage of resources in many places, but even more exacerbated in rural settings, was particularly challenging. Having said that, we can’t just say, “Well, it’s too hard to be a doctor in a rural setting, so, you better choose somewhere else.” 

Mary: Yeah.

Jill: We need physicians serving more than ever, people who are in rural communities as well. What needs to change either through healthcare systems by communities in anything that needs to change to make it, so that it isn’t quite the harrowing experience of these challenges that feels so overwhelming for good doctors trying to practice good medicine.

Mary: You’re exactly right. I work with a lot of my clients around strategies on boundaries, boundaries, boundaries when you’re in a rural setting. I was just surprised as I talked with some of my clients. They have patients come up to them in the grocery store, in restaurants, and they want to show them their rash, and talk to them about their symptoms, and I encourage physicians and providers to have scripting. Good boundaries and scripting to be able to say, “Gosh, I’m sorry you’re not feeling good tonight. Please give my office a call in the morning. I’ll be sure to fit you in.” Have some of those scripts ready to go when you get into those situations where you’re at the soccer game or some of those things where you’re trying to just be a mom, or a spouse, or have a little downtime. So, boundaries are key for sure.

Another boundary is not giving out cell phone numbers to patients. In small towns, they often do that because they want to feel like they’re giving good care, but instead encouraging the patient to call the on-call person. That’s another boundary. In rural areas, also encouraging those providers to use virtual care, if they have those services. There is a lot of backups, e-care, virtual care, and sometimes rural providers will hesitate to use those- they don’t want to give up control, but to really utilize those resources as a backup, as a second opinion. And then also in talking with their administration about how can they set up some backup measures, maybe for taking on call when they’re sick, when they take vacations. 

Many times, physicians and advanced practice providers feel guilty for taking time off and one of the strategies is to talk with their administrators ahead of time about who will cover if they end up calling in sick, or needing to take some time off, or a vacation or a maternity leave, or some of those things. So, just working on a variety of strategies.

Jill: Yeah. I like how you just named a lot of individual strategies. I mean, we can talk about boundaries almost on every podcast, because it’s something in general that physicians often struggle with. I had a conversation with Tammy Chang, who’s a physician who wrote a great book on boundaries recently for women physicians, and she talks about it as protecting your life force. I love that reminder and especially, specific to rural communities, as you said, when there is more of that intermingling between work and life in a smaller community, boundaries are really important. So, let’s talk about the bigger picture from an institutional perspective. What do the rural healthcare providers, healthcare groups, organizations, hospital systems need to do a better job of to recruit and retain quality candidates in rural situations? 

Because we’ve named a lot of the challenges of why people would choose a different option. We know that there are benefits there, too. I know from working with a couple of my physician clients in rural settings. They really love the opportunity and the autonomy, and they’re looking for ways in their practices to fulfill needs that aren’t there systemically, and that’s inspiring to them, and that’s great. But how do we make it more attractive or how do organizations and healthcare institutions make it more attractive to bring in quality candidates and keep them there in rural communities?

Mary: You are exactly right with talking about recruiting. I wish recruiters and health systems would talk a lot more about expectations in a rural setting. What is it going to be when you’re covering four or five different settings all in one day, the nursing home, the clinic, the ED, and how are they going to manage on call? That is what I hear as one of the biggest burnout factors is, yes, they can handle busy days. It’s on call at night or weekends. As systems get really clear about what this looks like and I do a lot of coaching with residents, especially about negotiating what they want and what they want to do in those jobs ahead of time.

The other thing with recruiting as I talked with recruiters, they said one of the number one reasons that physicians leave is spouse unhappiness. Oftentimes, recruiters are really talking to spouses about what will this look like in this rural community as a physician spouse? Can they help with getting jobs, and hobbies, and get those spouses connected and how will it be if they look through a microscope in those small settings? So, really being upfront with expectations, but also, systems need to look at workload and how much can rural physicians and advanced practice providers actually cover when they are often the only one in the practice. 

I work with advanced practice providers, who are often running the whole show independently and how does the system really support them with their many roles. How are they going to bring in locums to let that one provider have time off? I think systems more and more are looking at developing a culture of wellbeing, and professional fulfillment, and really looking at culture of wellness, efficiency of practice, as well as resiliency as in the Stanford model. So, systems are using those kinds of models to really look at how can we make this a really good fit not only for the physician or provider, but also their spouse and family.

Jill: Yeah, and you mentioned locums being such an effective way and I’ve known clients and others in my life who use those opportunities to moonlight on the weekends in more rural communities as surgeons in other specialties and it was just a win-win situation in a variety of ways. I also just really love, I want to emphasize what you talked about, at DocWorking we do onboarding. It’s one of the services in addition to coaching and support we do. The reason that we do onboarding is because we understand that a lot of times very capable, wonderful physicians end up not staying in positions, because they haven’t had that support and the coaching they need to be able to get roots in a community to feel connected to have that life outside of work, feel fulfilling and meaningful for them. So, helping with onboarding in all the different facets that you’ve talked about and beyond can really help people feel a lot more overall fulfillment in their life and work.

Mary: Yes, that is an important service. I often work with clients on that first 90-day plan, and how do they not only work on that for their patients and with their colleagues, but how do they keep that open communication with administration from the very beginning? So, that is a big part of culture of wellbeing is that onboarding. 

Jill: Yeah. I think it’s so great that these conversations are being had because for so long, there was just so much what I would describe as linear or left brain thinking about all of this. It’s like, “Well, you take a job, you get your job, you go to work,” and then, all of a sudden there were all these consequences to not thinking about more proactive ways to help people feel involved in a community to help community support the important deliverers of their healthcare. I just love that these conversations are happening, because I think it bodes well for quality of care for people, whether they live five minutes from the city center or 500 miles from the city center. 

Mary: Yeah, I think that peer support that you mentioned is really important. I encourage that as well with clients of how do you stay in contact with your friends, you maybe went to med school with that are in rural practices? What are they using for strategies in their location, what are they talking to their administrators, how can we help them have that network where they can have that support, because they often do feel lonely in those communities? 

Jill: Yeah, and I think we talk about a lot of the downsides, and the COVID, and the challenges that that provided. But I’ve also heard from some of my physician clients and I’m curious if you have too, that the COVID in some cases for patients normalized telemedicine. And so, a patient that maybe wouldn’t have either the money or wouldn’t want to take the time to drive 50 miles in to get care might reach out to their family pediatrician, for instance, for a tele consult and something that is solved easily in that situation is taken care of as opposed to ignored until it becomes a bigger issue. Have you seen that as well?

Mary: Absolutely. I talked with almost every client about post-traumatic growth of COVID and, those are the things that they are talking about. In rural areas, the community rallied around me as the physician. They supported me, they appreciated me in a whole new way. They supported my family because they knew I was busy and away from family. We talk a lot about what are those things they learned. For many physicians and providers, their values shifted during COVID. We talk about that as their growth as well. Maybe achievement isn’t on their top value anymore, but maybe instead it’s relationships and connection. So, yes, I think COVID taught us all a lot.

Jill: I love that because it’s important to talk about the challenges and the places where there’s hard stuff and it’s important to remind all of us where resilience can be the shining star of the day as well and that was just a really good example. So, having had the expertise, you have both frontline of working with physicians as well as being policymaker in institutions and an influencer in this area as a consultant for a long time now, what do you see that makes you feel good about the future of medicine in rural America?

Mary: I think virtual is number one because it allows one person to run the emergency department in rural areas and have that virtual backup. It also allows for so many CMEs to do virtually, where many times getting to the airport is a challenge and a long road and I do see those virtual services, both being able to offer them, but also receiving them, as well as more virtual mental healthcare and that’s an area that we didn’t talk a lot about, but I know in our state, our senator is proposing some legislature to have additional dollars for virtual mental health. I think there are more grants, there are just more dollars available for mental health services not just for patients, but also for our physicians and providers, as well as other professionals. So, I do see those virtual services really being a key as we try and get people healed from COVID, and moving forward, and really focusing on that post-traumatic growth.

Jill: I agree I’ve heard from other rural providers that I’ve either coached with or spoken to that, when it used to be, ‘I can give you a referral as a pediatrician’, for instance, to when you need mental health support and you might be able to get into the regional area child psychiatrist in three months, now, because of the ability for people to get virtual care from people outside of their immediate area, that’s providing patients the opportunity to get that mental health care in a much more timely manner and that’s really huge. Okay, finally, Mary, I want you to leave us – you gave us some really positive changes that I think are helpful. What is an area that we all need to pay attention to and that we need to think about in terms of change? What is an area that is being ignored or that we need to focus on for positive change when it comes to rural health care in America?

Mary: Yeah, advocacy is a big area. And yes, it is lobbying for more dollars and for virtual services, things like that. It’s also self-advocacy. How are we going to step up and talk with our administrators, our local politicians, community leaders, and nationally about the importance of healthcare, of mental health care, recruiting physicians and providers into rural areas, and the wellbeing of those providers,  and just like the Dr. Lorna Breen legislation is really being focused on the mental health services and putting out grant dollars for that. I’d like the focus to turn to that advocacy and for communities to know those dollars are out there, and to start applying for those, and really focusing on advocacy and self-advocacy.

Jill: Powerful. Even if you’re not in a rural area, we need to be providing healthcare for everyone wherever they live, and to be able to provide opportunities for excellent doctors to practice if they want the benefits of practicing in a rural area to be able to do it in a sustainable way, so these conversations I think help make that happen. So, Mary Wolf, thank you so much for being here.

Mary: Thank you for having me. My website is www.veriteepartner.com, V-E-R-I-T-E-E. 

Jill: Wonderful. Thanks again for being here for giving us so much food for thought. It’s great to have you. Make sure that you share this with your friends and colleagues, and go to docworking.com today to check out all of the ways that we can help you thrive both in work and life. Until next time, on DocWorking: The Whole Physician Podcast, I’m Jill Farmer.

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