I'm just getting around to the August AFP and have just finished your excellent article in Medicine and Society. One point in particular I would like to agree with and expand on.
Rural North Dakota is like rural Nebraska: lots of little towns 30-40 miles apart each with a 15 bed hospital, 120 bed nursing home and 2-4 FP's. I practiced in one for 11 years- 500 OB deliveries, nonstop 80 hour workweeks and almost no guilt-free vacations. Two years ago I totally burned out and quit it all. I worked part time on an Air Force base for 6 monthes, to regain my senses, then went job hunting, hoping for a 40-50 hour week, one night of call a week, and one weekend a month.
I had many start-immediately offers from the larger clinics in our towns of 30,000+ (Minot, Bismark, etc), but the small towns simply would not even consider it. There are no FP's under the age of 50 working in ND small towns as described above and the reason is obvious- no one in my age group (40) is going to work 40 hours a week in clinic and take another 40 hours of call a week. The FP residents in our state seem to be 40% women, and they sure aren't. The clinic I left still has 3 FP's - ages 53,62,62. they haven't had the slightest nibble from any prospective replacements.
The rural situation will not change until some old attitudes change. Younger FP's want time with their families. The old standard of working 80 hours a week until your MI at age 65, won't cut it with young FP's.
I now do locums in ND, including one weekend a month at my old practice. My old partners are still waiting for Marcus Welby to walk in and sign on with them.
Former Rural Physician in ND
Also one rural doc retired, left for Florida, couldn't stand not being with his patients and town. Came back a year later, and made 5 times as much doing the same work in the same town under locums contract. Sad commentary on national support for continuity primary care.
See Adjusting to Rural Practice