Careers in Family Medicine: Rural Practice

It's time to kick off my series on Careers in Family Medicine. 🎉 Each week over the next 3-4 months, I will highlight a family physician and their career paths. Each one will share their pearls. I hope you find this series helpful in expanding what's possible for you as a family physician and in giving you tangible aspects to consider when choosing your career path or pivoting. Dr. Murray Buttner has had a long career of experiences, so I felt he would make a wonderful example to begin our series with, representing primarily rural family medicine. (Plus, would I really be representing my state well if I didn't highlight rural medicine in Alaska?) Enjoy our written interview and discussion. 

Murray, Give the readers an overview of your career in family medicine.

Oh boy. Started in Med-Peds in NYC, where I thought I would spend my entire career practicing! Within two years I was living on a float house, 2 miles from the FQHC in Klawock, Alaska which hired me as their first physician. I paddled a kayak or motored a small skiff to work every day!  That year I got hooked on rural medicine and have never regretted for a minute leaving the big city. Finished FP residency in New Mexico, then returned to Juneau for 2 years at SEARHC doing full spectrum FP. Then 4 years in Cordova, AK- most of that time as the only physician.  After Cordova, we took a sabbatical in London and then spent the next 8 years living in the Northeast Corner of CT: depressed mill towns trying to reinvent themselves, small struggling dairy farms, and several posh boarding schools! I did 2 years in a group practice followed by 6 years in a solo DPC practice, which was awesome. 8 years was enough of the East Coast for my Alaskan wife, so we returned to AK in 2016, where I taught at the FP residency in Anchorage for 3 years until we moved to Unalaska/Dutch Harbor, where we have been working the last 4 years. 

Unalaska is a stunningly beautiful and very intense place.  Largest town in Alaska by far that doesn't have a hospital (several smaller ones do), we are 800 air miles from Anchorage (so our medivac distance is equivalent to Dallas/New Orleans/Jacksonville to Chicago!).  Outrageously diverse population, because of the enormous fishing industry.  65% urgent care, 30% primary care 5% real emergency medicine. It has been a trip!  Because we are not part of the native health service, we have a much smaller staff (provider, nursing, admin) than any comparable clinic. I won't say there haven't been stressful times, but the espirit de corps of our small team has been incredible. It is just us out here and we have to totally depend on each other. (Read more about life in Unalaska in an article written by Murray here). 

Which practice style fit you best and why? Low bureaucratic burden, high patient contact, minimal influence from the many perverse incentives of our health care delivery and payment system.

What lessons did you learn from your time in DPC?  It was incredibly satisfying. I had the analogy that it was as thrilling as rock climbing without ropes and gear (I have a serious fear of heights and don't climb, and if I did I would definitely be heavily geared up). But there was an incredible freedom to practice medicine without any third party (government or private insurer) between me and my patients.  But I underpriced myself and the first couple of years were really challenging financially. I also took on a partner without doing any due diligence. I wish I had talked to any of that provider's former colleagues before taking that plunge.  

What lessons did you learn from your time in academics? The students and residents start idealistic but sadly can become quite jaded by the time they have completed their training. But they are looking to be inspired, and they are generally extremely dedicated to their patients and eager to learn as much medicine as they can. Stoking their enthusiasm when it is flagging and feeding off their excitement to be becoming physicians when my own energy was waning is a virtuous circle.

What lessons did you learn from your time in rural practice?  

While many think of practicing out on the edge is scary, it is actually extremely rewarding.  

You are taking care of the community, and it can feel like a big responsibility. But at the same time, the community is taking care of you and your family.  And that is something that is really tangible. 

What three tips would you tell those who are looking at options for their first job in family medicine? 

1. Be honest with yourself about your priorities.  And if that doesn't come naturally, take advantage of whatever resources you can (a coach, a mentor, websites, etc.) to help you discern what your priorities actually are.

2. Go slow, don't rush the process of finding that first job.

3. Also, don't feel like the first job has to be perfect, your forever job, because it almost certainly won't be.

What common mistakes do you see in deciding on a job?  

Not asking questions of providers who have been working/have worked at the practice site to hear what they have to say, good and bad.

Picking a house before picking a job, and buying a house before trying out the town/city and job.  

What three tips would you give an attending who is looking to pivot?

Less is more!  Slow medicine beats industrial medicine.  

Small practice and rural medicine can be immensely rewarding.

Teaching can be a great way to get reinvigorated.

Anything else that you’d like to share?

Don't let medicine burn you out. If it is happening, take a pause, do a reset, make a change.  Those things can be hard to do when you are in the midst of it, but you aren't alone and there are a ton of resources and pros out there to help you. 

How do you create/find joy no matter what type of practice you’re in?

Try to keep a good sense of perspective.  We, professionals, can get super spun up by our own frustrations. We can lose sight of how lucky we are to be doing the work we are doing and getting paid quite well to do it. Most of our patients would consider our problems very first world problems.  

Try to keep the energy positive in your team (colleagues and support staff). Negative energy creates more negative energy.  

Great! Thank you for taking the time to share your wisdom with the readers. How can people find you if they want to talk more? 

Email is probably best to start, especially as my phone number may be changing: [email protected]

So many great pearls of wisdom dropped by Dr Buttner in this interview. I'd love to hear from you what you found helpful.  

Next week, we we'll dive into a Value-Based Care model by Dr. Erica Swegler. Don't miss any in this series; sign up to have them delivered to your inbox. 

Until then, have a joy-filled day!  Tonya