Dr. Nancy W. Dickey is a family physician in College Station, Texas. She’s also president of the American Medical Association. She knows rural, she knows health care, she had some important things to say about the intersection of the two during a visit to Maine this week.

Recruiting country doctors remains a challenge; keeping them even more so There may be enough physicians overall — general practitioners and specialists — in the nation and even in Maine, but distribution between urban and rural is skewed. The problem, Dr. Dickey says, is a combination of practical public-policy issues and less tangible sociological obstacles.

On the public policy side, rural physicians are at a distinct disadvantage. Medicare payments to rural providers are less, as much as 10 to 15-percent less, than to urbanites, thanks to a formula based upon the largely theoretical assumption that it’s that much cheaper to run a rural practice. Time-consuming, annoying and somewhat humiliating Medicare audits for fraud and abuse are disproportionately targeted at rural providers, not because they are more likely to cheat, but again thanks to a formula with no grounding in reality. Small rural hospitals do not the financial resources to help new physicians pay off student debt that large urban hospitals have. Rural physicians who try to consolidate their practices to gain some economy of scale often run into anti-trust difficulties.

These are issues that can and must be addressed by legislators and policy-makers at the federal and state levels. The sociological nuts will be tougher to crack, but they are just as crucial.

Increasingly, Dr. Dickey notes, the spouse of a physician also is a highly educated professional who may not find sufficiently rewarding opportunities in a one-doc town. Young physicians often train in technologically advanced teaching hospitals and often are shocked and dismayed at the not-so modern conditions they find in the country. The isolation — from cutting-edge research, from resources, specialists and colleagues — can be oppressive. And (this one of particular relevance to Maine, which just happens to rank 50th among the states — dead last — in sending college students on to medical school) the decline of rural schools, the gutting of education programs to below bare bones, makes the rural setting totally unacceptable to the family physician with a family to raise.

Thus, the same deteriorating conditions that make economic development, the attraction of new businesses, an idle dream for rural regions does the same for stability in health care. The effective practice of medicine, especially at the family practice level, requires a level of confidence and confidentiality between physician and patient that cannot be reached when young physicians come and go through a revolving door. New businesses will not locate in communities with uncertain health care any more than they will locate in communities with substandard schools. It’s a vicious cycle and it’s entirely correct to look at creating conditions for stable medical practices as economic development: Oregon, which offers an attractive income tax credit to country doctors, estimates that a physician in rural practice generates a payroll in support services in excess of $250,000 a year.

Oregon isn’t the only state to have recognized the importance of continuity in rural health care and to have developed programs to obtain it. West Texas is an extremely rural place, yet it is extremely well supplied with physicians, most trained on location at Texas Tech in Lubbock, all kept in touch and up-to-date afterward by a substantial state investment in a tele-medicine network. North Dakota has addressed the isolation issue by developing a hub-and-spoke system in which 10 or more physicians form a central practice and fan out far into the countryside on regular, rotating schedules. In Minnesota, medical students spend their entire third year training in rural hospitals and clinics.

The common thread among successful efforts to boost rural medicine, Dr. Dickey says, “is that the best way to keep doctors in small towns is to train them there and the best place to recruit them is in small-town high schools. The message we have to get out to our brightest rural students is that medicine is a fabulous profession. You won’t get rich as a rural physician, but you’ll do very well. Most importantly, you can do this. Far too many of brightest young men and women in small towns simply see becoming a doctor as something beyond their reach. It’s not; we have to help them see it.”